Montrose Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montrose, California.
- Location
- 2123 Verdugo Blvd., Montrose, California 91020
- CMS Provider Number
- 055135
- Inspections on file
- 24
- Latest survey
- July 1, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Montrose Healthcare Center during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
Surveyors found that two residents were not provided safe medication storage: one was allowed to keep and self-administer Flonase without authorization, and another had Lorazepam, a controlled drug, stored with non-controlled medications instead of in a separately locked compartment. Additionally, a resident with diabetes received insulin from pens that were not labeled with expiration or discard dates and were administered past their effective period, contrary to facility policy.
Surveyors identified improper food handling practices, including staff plating food without gloves or handwashing and failure to label potentially hazardous foods in the refrigerator and freezer with use by dates. The Dietary Supervisor confirmed that use by dates were not routinely applied, contrary to facility policy, increasing the risk of foodborne illness.
A resident with cognitive impairment and multiple medical conditions was left waiting for her meal tray for at least 20 minutes after others at her table had been served, resulting in her eating alone. Staff could not explain the delay, and the dietary supervisor noted that the dining room resident list was not always updated, leading to the deficiency in providing dignified and equal care.
A licensed nurse documented the administration of multiple medications, including aspirin, for a resident before actually giving them, resulting in the resident not receiving the prescribed aspirin dose. The MAR was signed prior to medication administration, contrary to facility policy, and the omission was later acknowledged by the nurse and confirmed by the DON.
A resident with significant medical needs and requiring maximal assistance with ADLs was left in a wet, foul-smelling incontinent brief for over eight hours without being changed. Staff failed to communicate during shift change, resulting in the resident not receiving timely perineal care as outlined in the care plan and facility policy.
A resident with a history of Stage 4 pressure injury did not receive required daily and weekly skin assessments or consistent repositioning, as documented in the care plan and facility policy. Staff failed to document skin condition changes and left the resident in the same position for extended periods, resulting in significant skin redness and increased risk for pressure injury recurrence.
A resident with dementia, Alzheimer's disease, and a history of falls was observed walking unsupervised with eyes closed and hands outstretched, repeatedly running into a wall without staff assistance. Despite being identified as high risk for falls and requiring increased supervision due to new behaviors related to eye irritation, the care plan was not updated and interventions were not implemented, resulting in inadequate supervision and increased risk of harm.
A resident with a suprapubic catheter was not properly monitored for signs and symptoms of UTI, and staff failed to document specific symptoms or interventions when issues were noted. The catheter was observed unsecured and leaking, with pinkish, foul-smelling urine, and staff did not consistently report or follow up on these findings as required by facility policy and physician orders.
A resident with dementia and atherosclerotic heart disease did not receive physician-ordered ASA 81 mg for CVA prophylaxis when an LVN overlooked the order during medication administration, despite the resident questioning the omission. The error was confirmed through observation, interview, and record review, and facility policy required medications to be administered as prescribed.
Staff did not document vital signs, updated care plans, or provided treatments for a resident with dementia and diabetes who was in declining condition and being considered for hospice care. Despite frequent monitoring reported by the LVN, there were no recorded vital signs or progress notes for several days before the resident was found unresponsive, leaving the clinical record incomplete and not in accordance with facility policy.
A CNA did not wear required PPE while entering the room and touching the belongings and person of a resident on Enhanced Barrier Precautions for a history of MDRO infection. The CNA was aware of the resident's EBP status but failed to follow facility policy, which required PPE for contact with potentially contaminated surfaces and the resident. Facility leadership confirmed that PPE should have been used in this situation.
The facility failed to ensure call lights were within reach for two residents at risk for falls. Both residents had care plans requiring accessible call lights, but observations revealed the call lights were placed out of reach. Staff acknowledged the issue and the importance of accessible call lights for resident safety.
The facility failed to ensure a homelike environment for two residents due to the disruptive behavior of their roommate, who frequently yelled and cursed, disturbing their sleep and well-being. Despite complaints, the issue persisted, impacting the residents' ability to rest and function daily.
The facility failed to post actual worked nursing hours at the start of each shift, resulting in an inaccurate reflection of the number of staff providing direct care to residents. The Director of Staff Development admitted to posting projected numbers the night before and not updating them for call-offs or staffing changes.
The facility failed to ensure the medication room was free from expired medications. Two bottles of undated opened Gabapentin oral solution were found in the medication refrigerator, labeled for two residents. The MDSC and DON confirmed that the facility's policy requires opened medications to be labeled with the date they were opened and discarded after 30 days to ensure resident safety.
The kitchen staff failed to follow infection control policies by not wearing a hair net in the food preparation area. The Dietary Supervisor admitted to forgetting the hair net, which is required to prevent food contamination. The facility's policy mandates wearing a hair net at all times.
The facility failed to provide information about Advance Directives to a resident readmitted with dysphagia and prostate cancer. The Social Service Director admitted forgetting to screen the resident for AD, violating the facility's policy and potentially leading to treatment against the resident's will.
A facility failed to follow professional standards and its own policy on documenting medication administration immediately after administering Ceftriaxone IV to a resident. The RN did not sign the MAR immediately, which was acknowledged as a lapse by both the RN and the DON. The resident had diagnoses including dysphagia and hypertension and was prescribed Ceftriaxone for a bacterial infection.
A facility failed to provide appropriate care for a resident with an indwelling catheter, resulting in the catheter tubing being cloudy with white sediments and touching the trash bin. The resident's care plan required monitoring for signs of UTI, but observations and interviews revealed that the facility did not follow its policy on urinary catheter care, leading to potential delayed care and treatment for a UTI.
A resident receiving Ceftriaxone IV for a bacterial infection had an unlabeled IV site, contrary to the facility's policy requiring rotation every 96 hours. The registered nurse confirmed the importance of labeling and rotating the IV site to prevent infections.
A resident received oxygen therapy without a physician's order, and the nasal cannula tubing was observed touching the trash bin, posing an infection risk. The facility's policy requires a doctor's order for oxygen and proper storage of tubing to prevent contamination.
A facility failed to protect a resident's personal and medical information by leaving a computer screen unattended and logged on in a hallway. The LVN admitted to forgetting to log out, and the DON confirmed the requirement to protect resident records at all times.
The facility failed to ensure that a resident with cognitive impairments, including schizophrenia, Alzheimer's disease, and bipolar disorder, had the capacity to understand and make an informed decision before signing a Binding Arbitration Agreement. The Business Office Manager and Director of Nursing acknowledged that the staff should not have allowed the resident to sign the document, and the facility lacked a Policy and Procedure for such agreements.
The facility failed to follow infection control practices by not placing a resident with a PICC line on Enhanced Barrier Precautions (EBP). The resident had multiple diagnoses and was dependent on staff for daily activities. The Infection Preventionist admitted to forgetting to implement EBP, which could lead to the spread of infection.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of medications for several residents. One resident, with diagnoses including dementia and atherosclerotic heart disease, was found to be storing two bottles of Flonase nasal spray in his nightstand drawer and self-administering the medication without a physician's order or assessment for self-administration. The resident reported using the medication more frequently than prescribed, and staff confirmed there was no care plan or interdisciplinary team discussion regarding self-administration. The facility's policy required medications to be stored in locked compartments and only accessible by authorized staff, which was not followed in this case. Another resident, with epilepsy and psychosis, had Lorazepam, a controlled medication, stored in a medication refrigerator alongside non-controlled medications. Although the refrigerator and storage room were locked, the controlled medication was not kept in a separately locked compartment as required by facility policy and federal regulations. The DON acknowledged the importance of separate storage for controlled substances to prevent diversion and ensure proper tracking. Additionally, a third resident with diabetes was found to have insulin pens (Novolog FlexPen and Glargine) stored in the medication cart without expiration or discard dates labeled, despite being opened beyond the recommended 28-day period. The pens were administered past their effective date, and staff confirmed that expired medications had been given to the resident. Facility policy required proper labeling and immediate disposal of expired medications, which was not adhered to in this instance.
Improper Food Handling and Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in food handling practices within the facility's kitchen. During a tour, it was noted that plastic cups containing whole milk and juice were labeled only with the date they were poured, lacking any use by or expiration date. Similarly, items in the freezer, such as a bag of green beans and a chocolate cream pie, were labeled with only the date they were stored, without any indication of when they should be used by. Lunch meat boxes also lacked use by dates. The Dietary Supervisor confirmed that the facility does not routinely apply use by or expiration dates to food items, despite the facility's policy requiring all refrigerated and frozen items to be properly covered, dated, and labeled. Additionally, during meal preparation, a kitchen staff member was observed plating food without wearing gloves or washing hands. The staff member acknowledged that gloves are required for food safety and to prevent contamination. These practices were inconsistent with professional standards and the facility's own policies, potentially exposing residents to foodborne illness due to improper food handling and inadequate labeling of potentially hazardous foods.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a resident was not provided with respect and dignity during a meal service. The resident, who was moderately cognitively impaired and required supervision or assistance with eating, was observed waiting for her lunch tray for at least 20 minutes after other residents at her table had already received their meals and begun eating. The resident expressed dissatisfaction and stated that this was not the first time her tray was served late. Staff present in the dining room were unable to explain why the resident's tray was delayed, and the dietary supervisor acknowledged that the list of residents eating in the dining room was not always updated, which contributed to the delay. The resident's medical history included heart failure, schizophrenia, and hypertension. Facility policy required that residents at each table be served together and that all residents be treated with kindness, respect, and dignity. However, the failure to deliver the meal tray in a timely manner resulted in the resident eating alone, after the others had finished, and did not honor her right to dignified and equal care.
Failure to Accurately Document and Administer Scheduled Medication
Penalty
Summary
A licensed nurse failed to accurately and timely document medication administration for a resident with diagnoses including dementia and atherosclerotic heart disease. The resident was prescribed several medications, including daily aspirin (ASA) for stroke prophylaxis. On the morning in question, the nurse prepared seven medications for the resident's scheduled 9 AM administration, but did not include ASA among them. Despite not administering the ASA, the nurse signed the Medication Administration Record (MAR) at 8:53 AM, indicating that all scheduled medications, including ASA, had been given. The nurse later admitted to signing the MAR before actually administering the medications, which was not in accordance with facility policy. The nurse also acknowledged overlooking the physician's order for ASA and failing to double-check the orders before documenting administration. The facility's policy requires that the individual administering medications initials the MAR after giving each medication and before administering the next. The Director of Nursing confirmed that signing the MAR before medication administration could result in inaccurate documentation and medication errors. As a result of these actions, the resident did not receive the prescribed ASA as scheduled, and the MAR inaccurately reflected that it had been administered.
Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Facility staff failed to provide timely assistance with activities of daily living (ADLs) and incontinence care for one resident who was unable to perform these tasks independently. The resident, who had a history of sepsis, obstructive and reflux uropathy, and anemia, was cognitively intact but required substantial to maximal assistance with toileting hygiene, bathing, and personal hygiene due to muscle weakness and other medical conditions. The resident's care plan specified the need for assistance with toileting and incontinence care after episodes of incontinence. On the day in question, the resident was observed wearing a wet incontinent brief with pink-colored urine and a foul smell that had not been changed from 7 a.m. to 3:10 p.m. The resident confirmed that the last change and cleaning occurred around 7 a.m. and sometimes had to remind staff for care. Staff interviews revealed a lack of communication between CNAs during shift change, resulting in the resident being left in soiled conditions for several hours. Facility policy required that residents unable to perform ADLs independently receive necessary assistance to maintain hygiene and grooming, which was not followed in this instance.
Failure to Prevent and Monitor Pressure Injuries
Penalty
Summary
A deficiency occurred when staff failed to provide necessary care and interventions to prevent the development or recurrence of pressure injuries for a resident with a history of a Stage 4 pressure injury. The resident, who was cognitively intact and required partial to moderate assistance with mobility, was identified as being at risk for pressure injuries based on a Braden Scale score and care plan. The care plan required daily and weekly skin assessments, regular repositioning, and use of a low air loss mattress, but documentation and implementation of these interventions were lacking. Record reviews revealed that after an initial skin assessment in December, there were no further documented skin assessments, and the Braden Scale was not updated after December. The weekly nurse note only referenced the use of a low air loss mattress as an intervention, omitting other required measures such as regular repositioning and skin checks. Observations and staff interviews confirmed that the resident was left in the same position for extended periods, with one instance where the resident remained on her back from morning until afternoon without repositioning. Staff were unsure about the frequency of repositioning and failed to document skin assessments or interventions when redness was observed. The facility's policy required daily skin inspections, individualized repositioning schedules, and documentation of any changes in skin condition. However, these procedures were not followed, as evidenced by the lack of documentation, inconsistent repositioning, and failure to assess and report skin changes. These actions and omissions led to the resident developing significant skin redness and placed her at risk for further skin breakdown.
Failure to Provide Adequate Supervision for High-Risk Resident with Visual Impairment and Dementia
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure adequate supervision and monitoring for a resident with significant fall risk and cognitive impairment. The resident, who had diagnoses of dementia, Alzheimer's disease, and a history of fractures, was assessed as being at high risk for falls due to unsteady gait, poor safety awareness, and impaired cognition. The care plan identified the need for interventions such as regular fall risk assessments and supervision, but these were not consistently implemented. On observation, the resident was seen walking unsupervised in her room with her eyes closed and hands outstretched, repeatedly running into a wall near the restroom area. No staff were present to assist or redirect her, and no bed or chair alarm was heard during the incident. Interviews with staff confirmed that the resident had recently developed new behaviors, including walking with her eyes closed due to eye irritation, which further increased her fall risk. Staff acknowledged that the resident required increased assistance and supervision, including 1:1 supervision for safety, but this was not provided at the time of the incident. Review of facility policies indicated that maintaining resident safety and providing adequate supervision are facility-wide priorities, with individualized interventions required to address specific risks. However, the care team did not update the care plan to address the resident's new behavior of walking with eyes closed, and interventions to mitigate the increased risk were not implemented or documented. This lapse in supervision and failure to modify interventions as needed led to the resident being left unsupervised despite her high risk for falls and injury.
Failure to Monitor and Document Catheter Care and UTI Signs
Penalty
Summary
The facility failed to provide appropriate monitoring and care for a resident with a suprapubic catheter, as required by both physician orders and facility policy. The resident, who had a history of sepsis, obstructive and reflux uropathy, and anemia, was identified as being at risk for urinary tract infection (UTI) due to the use of a suprapubic catheter. The care plan and physician orders specified that staff should monitor and document urine characteristics such as color, consistency, odor, and presence of blood, as well as secure the catheter with an anchor to prevent dislodgement. However, documentation in the Treatment Administration Record (TAR) indicated signs and symptoms of UTI on multiple dates, but did not specify what symptoms were observed or what interventions were provided. Additionally, there was no evidence in the nursing progress notes or catheter assessment that these symptoms were followed up with appropriate care or physician notification. Direct observations and staff interviews revealed further lapses in care. On one occasion, the resident's suprapubic catheter was observed to have pinkish urine output and a foul smell, and the catheter was not secured with an anchor, resulting in leakage. The resident reported being unable to monitor her own urine output and was not informed by nursing staff about her condition. Staff members, including a CNA and treatment nurse, confirmed that the catheter was not properly secured and that the odor was noticeable, but the treatment nurse was unaware of the pink urine until later in the day. The Director of Nursing acknowledged that the catheter should have been anchored at all times and that staff should have reported abnormal findings immediately. Interviews with nursing staff indicated a lack of detailed documentation and follow-up regarding the signs and symptoms of UTI noted in the TAR. Staff admitted that documentation was incomplete and that interventions were not clearly recorded. Facility policy required that catheter care include securing the catheter, observing for complications, and recording detailed information about urine characteristics and any unusual findings. These requirements were not met, resulting in a failure to accurately monitor and respond to potential UTIs and catheter-related complications for the resident.
Failure to Administer Ordered Aspirin for CVA Prophylaxis
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer aspirin (ASA) 81 mg as ordered by the physician for a resident with diagnoses including dementia and atherosclerotic heart disease. The resident was admitted with a physician's order for daily ASA for cerebrovascular accident (CVA) prophylaxis, and the medication was scheduled to be given at 9 AM. During medication administration, the LVN prepared and administered seven other medications but omitted ASA. The resident noticed the omission and questioned the LVN, who incorrectly stated that ASA was not part of the regimen. The LVN later acknowledged overlooking the physician's order in the Medication Administration Record (MAR) and did not double-check when the resident raised the concern. Further review revealed that the licensed nurses did not check the physician's order and were unaware that the resident was supposed to receive ASA. The facility's policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time. The failure to administer ASA as ordered resulted in the resident not receiving the medication as prescribed, as confirmed by observation, interview, and record review.
Failure to Document Vital Signs and Care for Resident with Declining Condition
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with dementia and diabetes who was experiencing a declining condition and was being considered for hospice care. The staff did not document vital signs, updated plan of care, or the treatment and services provided to the resident, despite the resident being in a critical state that required frequent monitoring. The assigned LVN reported checking the resident every hour and performing vital sign checks every two hours during the night shift, but admitted to not documenting these assessments or the resident's condition in the progress notes. There were no recorded vital signs from the morning prior to the resident being found unresponsive, and no progress notes documenting the resident's condition or care for several days before the resident's death. The facility's policy and procedure on charting and documentation required that all services, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, interviews with facility staff, including the MDS nurse and DON, confirmed the absence of documentation regarding the resident's deteriorating condition, the plan for comfort or hospice care, and the care and services provided to the resident and family. This lack of documentation meant that the resident's clinical record did not accurately reflect the care delivered or the resident's status prior to being found unresponsive.
Failure to Implement PPE Use for Resident on Enhanced Barrier Precautions
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow the facility's policy and procedure regarding the use of personal protective equipment (PPE) while in the room of a resident placed on Enhanced Barrier Precautions (EBP) due to a history of multidrug-resistant organism (MDRO) infection. During an observation, the CNA entered the resident's room, which had an EBP sign posted, and did not wear PPE while touching the resident's nightstand, table, and the resident, who was sitting in a wheelchair. The CNA acknowledged being aware of the EBP status and that PPE should have been worn, as instructed by the Infection Preventionist Nurse (IPN). The resident involved had diagnoses including Parkinson's Disease, difficulty walking, and dysphagia, and required substantial to maximal assistance with daily activities. The facility's policy required staff to perform hand hygiene and wear gowns and gloves for any care activity involving contact with environmental surfaces likely contaminated by the resident. The Director of Nursing (DON) confirmed that PPE use was necessary not only for direct care but also when touching the resident's bedside and surroundings, as these areas were likely contaminated.
Failure to Ensure Call Lights Were Within Reach for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide reasonable accommodation for two residents, Resident 27 and Resident 14, who were at risk for falls. For Resident 27, the facility's records indicated a history of falling and a care plan that required the call light to be within easy reach. However, during an observation, the call light was found placed at the head of the bed, out of Resident 27's reach. Resident 27 confirmed the inability to reach the call light and expressed a need for assistance. Registered Nurse 1 acknowledged that the call light was not within reach and emphasized its importance for Resident 27's safety. Similarly, Resident 14, who had Alzheimer's disease and a history of falling, was also found to have the call light placed out of reach, hanging on a cabinet next to the bed. Resident 14 confirmed the inability to reach the call light. Certified Nurse Assistant 1 and the Director of Nursing both acknowledged that the call light was not within reach and stressed the necessity of having it accessible to ensure Resident 14's safety. The facility's policy and procedure also mandated that call lights should be within the resident's reach, which was not adhered to in these cases.
Failure to Maintain Homelike Environment Due to Disruptive Resident Behavior
Penalty
Summary
The facility failed to ensure a homelike environment for two residents, identified as Residents 51 and 54, due to the disruptive behavior of their roommate, Resident 12. Resident 12, who was admitted with multiple diagnoses including a fracture of the right femur and difficulty in walking, exhibited frequent outbursts of yelling, cursing, and swearing. These behaviors were observed to disturb the sleep of Residents 51 and 54, who both reported feeling tired and frustrated as a result. Despite repeated complaints to the staff, the disruptive behavior continued over several days, affecting the residents' ability to rest and their overall well-being. Interviews with the affected residents and staff confirmed the ongoing issue. Resident 51 and Resident 54 both expressed their frustration and the negative impact on their sleep and daily functioning. The Social Services Designee (SSD) acknowledged that the behavior of Resident 12 did not provide a homelike environment and was not conducive to the well-being of the other residents. The facility's Policy and Procedure on maintaining a homelike environment, which includes ensuring comfortable sound levels, was not adhered to in this case, leading to the deficiency noted in the report.
Failure to Accurately Post Nursing Hours
Penalty
Summary
The facility failed to post actual worked nursing hours at the start of each shift in the nursing stations visible to the residents and visitors, as required by the facility's Policy and Procedure. During an interview and record review with the Director of Staff Development (DSD), it was found that the Daily Staffing Posting for the morning shift indicated only 7 Certified Nursing Assistants (CNAs) were working, while the staffing assignment showed 10 CNAs were actually assigned. The DSD admitted to posting the projected number of staff the night before and not updating the posting if there were call-offs or staffing changes. This discrepancy resulted in inaccurate reflection of the number of staff providing direct care to the residents.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure the medication room was free from expired medications. During an inspection of the medication storage room, two bottles of undated opened Gabapentin oral solution were found in the medication refrigerator. One bottle was labeled with Resident 40's name and the other with Resident 13's name. The Minimum Data Set Coordinator (MDSC) confirmed that the prescribed medication should have a label indicating the opened date to ensure it is not used past its expiration date. The facility's policy requires that opened medications be labeled with the date they were opened and discarded after 30 days to ensure resident safety. Resident 40, who was readmitted with diagnoses including dysphagia and hemiplegia, had severely impaired cognition and was dependent on staff for daily activities. Resident 13, readmitted with diagnoses including dysphagia and cerebral infarction, had moderately impaired cognition and was also dependent on staff for daily activities. Both residents were prescribed Gabapentin oral solution for neuropathic pain. The Director of Nursing (DON) confirmed that all opened medications should be labeled with the date they were opened and discarded after 30 days, as per the facility's policy, to protect resident safety.
Infection Control Policy Violation in Kitchen
Penalty
Summary
The facility's kitchen staff failed to follow infection control policies by not wearing a hair net in the food preparation area. During an observation, the Dietary Supervisor (DS) was seen working without a hair net. In a concurrent interview, the DS admitted to forgetting to wear the hair net and acknowledged that it is required to prevent hair from falling into food and causing contamination. The facility's policy, revised in 2019, mandates that food service employees wear a hair net or head covering at all times to maintain sanitary conditions.
Failure to Provide Information on Advance Directives
Penalty
Summary
The facility failed to provide information about Advance Directives (AD) to a resident, which is a written preference regarding treatment options and a process of communication for future healthcare decisions. This deficiency was identified during an interview and record review of a resident who was readmitted with diagnoses including dysphagia and malignant neoplasm of prostate cancer. The resident's Minimum Data Set indicated that the resident had clear speech and was able to make themselves understood. However, the Social Service Director (SSD) admitted that they forgot to screen the resident for AD and acknowledged the importance of providing this information to respect the resident's medical treatment wishes. The facility's policy and procedure on Advance Directives, revised in September 2022, states that residents have the right to formulate an AD and that this should be inquired about prior to or upon admission. The SSD's failure to provide this information to the resident or their responsible party was a direct violation of this policy. This oversight had the potential to result in medical or surgical treatment being administered against the resident's will, thereby violating the resident's rights.
Failure to Document Medication Administration Immediately
Penalty
Summary
The facility failed to follow the professional standard of care and its own policy on documenting medication administration immediately after administering the medication. During an observation on 4/20/2024, RN 2 administered Ceftriaxone intravenously to Resident 6 but did not sign the Medication Administration Record (MAR) immediately afterward. RN 2 acknowledged this lapse during an interview, stating that the MAR should be signed right after administering medication to avoid errors and potential harm to the resident. The Director of Nursing (DON) confirmed that medication administration should follow the 'five rights' including right documentation, and that staff should sign the MAR immediately after giving medication to prevent errors such as double dosing. Resident 6, who was readmitted with diagnoses including dysphagia and hypertension, was prescribed Ceftriaxone 1 gram IV every 24 hours for a bacterial infection in the urine. The resident's Minimum Data Set (MDS) indicated that they had clear speech and the ability to understand and make themselves understood. The facility's policy on administering medications, revised in 3/2023, also required that the date and time of medication administration, along with the signature and title of the person administering the drug, be recorded in the resident's medical record immediately after administration.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, as evidenced by the presence of white sediments and cloudiness in the urine, and the catheter tubing touching the trash bin. The resident, who was admitted with diagnoses including a urinary tract infection (UTI) and urinary retention, had a care plan that required monitoring for signs and symptoms of UTI, such as changes in urine character and the presence of sediments. However, during an observation, it was noted that the catheter tubing was cloudy and contained white sediments, and was in contact with the trash bin, which could lead to cross-contamination and infection. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the catheter should be monitored every eight hours for signs of infection and should not be in contact with the trash bin. The facility's policy on urinary catheter care, which aims to prevent catheter-associated complications, was not followed. The policy specifies using aseptic techniques and ensuring that catheter tubing and drainage bags are kept off the floor. The failure to adhere to these guidelines resulted in the potential for the resident to receive delayed care and treatment for a urinary tract infection.
Failure to Label and Rotate IV Site
Penalty
Summary
The facility failed to ensure that a resident received care and services for parenteral antibiotic administration consistent with professional standards of practice and the facility's policy. During an observation, it was noted that the resident's IV site was not labeled with the date of insertion, which is necessary for staff to know when to change the IV site to prevent infections. The registered nurse confirmed that the IV site should be labeled and rotated every three days to control infections, and failure to do so could lead to infection and worsen the resident's health condition. The resident, who was readmitted with diagnoses including dysphagia and hypertension, was prescribed Ceftriaxone IV daily for a bacterial infection. The facility's policy indicated that IV peripheral sites should be rotated at least every 96 hours, with extensions not recommended to exceed seven days. However, the resident's IV site was not labeled, and there was no indication that the site had been rotated as required, leading to a potential risk of infection.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that Resident 49 received oxygen therapy in accordance with the facility's policy and procedure. Specifically, Resident 49's nasal cannula tubing was observed touching the trash bin, which poses a risk of infection. Additionally, Resident 49 was receiving oxygen therapy without a physician's order, which is against the facility's policy that requires a doctor's order for oxygen administration to ensure accurate oxygen therapy. These observations were confirmed by interviews with CNA 2, RN 1, and the Director of Nurses (DON), who all acknowledged the importance of keeping oxygen tubing off the floor and the necessity of a physician's order for oxygen therapy. Resident 49 was admitted to the facility with diagnoses including acute respiratory failure with hypoxia and pneumonia. The Minimum Data Set (MDS) indicated that Resident 49 had intact cognition and required supervision for various activities of daily living. Despite these needs, the Order Summary Report (OSR) did not include an order for oxygen therapy. The facility's policy and procedure for oxygen administration, which was reviewed during the investigation, clearly stated that oxygen use requires a physician's order and that oxygen tubing should be stored in a clean bag when not in use to prevent cross-contamination and infection.
Unattended Computer Screen Exposes Resident Information
Penalty
Summary
The facility failed to follow its policy and procedure titled 'Management and Protection of Protected Health Information' by leaving a computer screen unattended and logged on, exposing a resident's identifiable, personal, and medical information. This incident involved a resident who was admitted with diagnoses including anemia and neoplasm-related pain. The resident's Minimum Data Set indicated moderately impaired cognition and total dependence on staff for various daily activities. During an observation, a computer screen displaying this resident's information was left unattended in a hallway, accessible to unauthorized persons. The Licensed Vocational Nurse (LVN) responsible for the computer admitted to forgetting to log out, acknowledging it as a HIPAA violation. The Director of Nursing (DON) confirmed that staff are required to protect residents' personal records at all times to prevent unauthorized access. The facility's policy, revised in 2014, mandates that all personnel ensure the management and protection of resident information to prevent unauthorized release or disclosure.
Failure to Ensure Resident Capacity for Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident, who signed a Binding Arbitration Agreement, had the capacity to understand and make an informed decision. Resident 14, who had multiple diagnoses including schizophrenia, Alzheimer's disease, and bipolar disorder, was admitted to the facility and was found to be moderately impaired in cognitive skills according to the Minimum Data Set (MDS). Despite this, Resident 14 signed the Binding Arbitration Agreement, which was not appropriate given their cognitive impairment as indicated in their History and Physical (H&P) record. The Business Office Manager (BOM) acknowledged that the staff should not have allowed Resident 14 to sign the document, as residents who lack the capacity to understand and make decisions cannot comprehend what they are signing. The Director of Nursing (DON) confirmed that staff should not ask residents to sign arbitration agreements if their H&P indicates they do not have the capacity to understand and make decisions. Additionally, the facility did not have a Policy and Procedure (P&P) in place regarding having residents sign arbitration agreements. This oversight had the potential to result in Resident 14 being unable to make an informed decision and having their rights denied.
Failure to Implement Enhanced Barrier Precautions for Resident with PICC Line
Penalty
Summary
The facility failed to ensure infection control practices per the facility's Policy and Procedure (P&P) were followed to prevent the transmission of disease and infection for one of five sampled residents. Specifically, the facility did not place a resident with a Peripherally Inserted Central Catheter (PICC) on Enhanced Barrier Precautions (EBP), which involves wearing a gown and gloves during high-contact resident care activities. This oversight was identified during a review of the resident's Admission Record and Minimum Data Set, which indicated the resident had multiple diagnoses, including peritonitis, stomach cancer, and surgical aftercare following stomach surgery. The resident was also moderately impaired in cognitive skills and dependent on staff for daily activities such as toileting, dressing, and bathing. The care plan for the resident indicated the need for enhanced standard precautions, but these were not implemented as required. During an observation and interview with the Infection Preventionist (IP), it was confirmed that the resident had a PICC line and should have been on EBP to protect against multidrug-resistant organism (MDRO) infections. The IP admitted to forgetting to place the resident on EBP, which could potentially lead to the spread of infection. The facility's P&P on Enhanced Barrier Precautions clearly stated that residents with indwelling medical devices, such as a PICC line, should be assessed for EBP upon admission and as needed. However, this protocol was not followed, resulting in a failure to protect the resident from potential infection risks.
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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