Mount San Antonio Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 900 E. Harrison Ave, Pomona, California 91767
- CMS Provider Number
- 055016
- Inspections on file
- 19
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mount San Antonio Gardens during CMS and state inspections, most recent first.
Two residents with dementia, gait/mobility impairments, history of falls, and high Morse Fall Scale scores had care plans that included motion sensor alarms as fall-prevention interventions. Surveyors observed that the room sensors were positioned facing each resident, but when an LVN triggered the sensors, the CNA carrying the paired wireless alarm device did not respond, no audible alarm was heard, and the CNA did not communicate being occupied. The CNA was later found in the staff lounge, and testing showed the pocket alarm did not sound until a button was manually pressed, after which the CNA stated the alarm might have turned off in the pocket, demonstrating that the facility failed to ensure the alarms were functioning and that staff responded as required.
A resident with COPD and heart failure experienced a significant change in condition, including confusion and shortness of breath. Although a CNA reported the symptoms and an LVN administered oxygen and a breathing treatment, the LVN did not immediately notify the physician as required by facility policy. Staff interviews and documentation confirmed this delay in notification.
A resident with a history of UTIs and total dependence on staff for hygiene was not provided adequate perineal care, as staff reused wipes for multiple cleaning passes instead of using a new wipe for each stroke, contrary to facility policy. This practice was observed and confirmed by staff interviews, and the resident's family expressed concern about recurrent UTIs.
A resident with severe cognitive impairment and total dependence on ADLs was found with all four quarter bed rails raised, but the facility's assessment, physician's order, and consent form each described different rail configurations, none matching the actual setup. The facility also failed to document that the risks and benefits of the bed rails were explained to the resident's representative, resulting in unclear and incomplete informed consent.
A resident with severe cognitive impairment and multiple diagnoses was found with all four quarter bed rails raised, but the facility's documentation was inconsistent. The side rail assessment, physician's order, and consent form each described different rail configurations, and staff confirmed these records did not match the actual setup or each other, resulting in unclear documentation regarding the use and consent for bed rails.
The facility failed to follow proper food storage practices by not labeling or dating food items in Kitchen 1, including spices, fruits, and frozen goods. This was observed during a survey, and staff interviews confirmed the facility's policy required labeling to prevent serving expired food, which was not followed.
A facility failed to accurately assess a resident for elopement risk, despite the resident's history of leaving the facility and attempts to do so without assistance. The resident, diagnosed with dementia, was found outdoors without staff assistance and had an ankle monitor to alert staff. Interviews with staff confirmed the resident was an elopement risk, but the assessment was incorrect, contrary to the facility's policy.
A resident with multiple diagnoses, including atrial fibrillation and hypertension, did not receive adequate care for a skin tear and edema. Despite orders for Geri sleeves to protect the skin, staff failed to apply them, and necessary skin assessments were not conducted. The resident's condition worsened, leading to concerns about neglect and inadequate treatment.
A resident's dirty laundry was improperly stored on a toilet seat by hospice staff, contrary to the facility's infection control policy. The resident, with cognitive impairments and dependent on assistance, had their laundry left inappropriately, risking contamination. Staff interviews confirmed the hospice staff's failure to follow proper procedures.
Failure to Ensure Functioning Motion Sensor Alarms and Staff Response for High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that motion sensor alarms used as fall-prevention interventions were functioning and appropriately monitored for two residents identified as high fall risk. Resident 2 was admitted with dementia, gait and mobility abnormalities, and was assessed on the MDS as dependent in ADLs with short- and long-term memory problems. A Morse Fall Scale dated 1/8/2026 showed Resident 2 was at high risk for falls, and the care plan, revised the same day, included a motion sensor alarm in the room as an intervention due to impaired balance, impaired mobility, and attempts to get out of bed unassisted. Resident 3 was admitted with a history of falling and muscle weakness, had a care plan indicating risk for recurrent falls related to impaired balance and mobility, and had an assisted fall on 12/23/2025 when attempting to walk without calling for staff. Resident 3’s MDS showed intact cognition with a need for maximal assistance, and a Morse Fall Scale dated 12/30/2025 also identified high fall risk; the care plan likewise included a motion sensor alarm. Surveyor observations and staff interviews showed that the wireless sensor alarm system was not being used as intended and was not reliably functional. CNA 2 reported having two alarms for these residents and produced two white alarm devices from a pocket. CNA 1 explained that the facility practice was for CNAs to carry a white device paired with the room sensor and to respond visually to the resident when the device sounded after motion was detected. The DON stated that CNAs needed to carry the sensor alarms at all times and that response to an activated alarm should be immediate, with CNAs expected to leave the alarm with nursing staff if they were too busy to respond. Despite these stated practices, subsequent testing of the alarms and staff response revealed failures. During observations with LVN 2, the motion sensors in both residents’ rooms were positioned on tables facing the residents in bed. When LVN 2 moved in front of Resident 2’s sensor to activate it and then waited in and outside the room, CNA 2 did not respond, and there was no audible alarm sound heard between 2:37 PM and 2:41 PM; CNA 2 also did not communicate being busy. A similar test in Resident 3’s room showed no audible alarm and no response from CNA 2. CNA 2 was later observed in the staff lounge. When CNA 2 then moved in front of both residents’ sensors, the alarm device in CNA 2’s pocket did not sound until a button was pressed, after which an audible alarm was heard; CNA 2 stated the alarm might have turned off while in the pocket. The facility’s product description for the alarms indicated they are wireless bed alarms intended to alert staff when a patient gets up so staff can assist to prevent falls, and the facility’s fall prevention policy described a program to identify fall risk and implement interventions, but the alarms for these two high-risk residents were not functioning or being monitored as required at the time of surveyor observation.
Failure to Promptly Notify Physician of Resident's Change of Condition
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to promptly notify the physician of a resident's change of condition (COC). The resident, who had chronic obstructive pulmonary disease (COPD) and systolic congestive heart failure, was admitted with severely impaired cognition and required maximal assistance with daily activities. On the morning in question, the resident was observed to be confused, less responsive, and experiencing shortness of breath with increased fatigue. The Certified Nursing Assistant (CNA) reported these symptoms to the LVN, who checked the resident's oxygen level and administered a routine breathing treatment and oxygen, but did not immediately notify the physician of the change in the resident's condition. Further observations throughout the day confirmed the resident continued to have fast, shallow breathing and remained on oxygen. Interviews with staff, including the CNA, Activities Assistant, Registered Nurse (RN), and Director of Nursing, confirmed that the resident's symptoms were not typical and constituted a significant change in condition that required immediate physician notification according to facility policy. The facility's policy and procedure also required prompt reporting of any change in condition to the physician to ensure proper treatment, which was not followed in this instance.
Inadequate Perineal Care Provided to Dependent Resident with UTI History
Penalty
Summary
A deficiency was identified when staff failed to provide adequate perineal care for a resident with a history of urinary tract infections (UTIs) and total dependence on staff for activities of daily living, including personal and toileting hygiene. The resident, who was frequently incontinent of urine and bowel, had documented episodes of E. coli and yeast present in urine cultures. During observation, a certified nursing assistant (CNA) cleaned the resident's perineal area from front to back using wipes, but reused the same wipe for multiple passes instead of using a new clean wipe for each stroke as required by facility policy. This practice was confirmed during interviews with both the CNA and a registered nurse (RN), who acknowledged that reusing wipes could lead to contamination of the perineal area. The facility's policy and procedure for perineal care specified that a new section of the washcloth or a new disposable wipe should be used for each stroke, particularly when cleaning the urethral meatus and vaginal orifice, to prevent infection. The observed deviation from this protocol was corroborated by staff interviews and was inconsistent with both facility policy and CDC guidance on UTI prevention. The resident's family member also expressed concern about the resident's recurrent UTIs, further highlighting the importance of proper perineal care in this case.
Failure to Ensure Accurate Assessment, Consent, and Documentation for Bed Rail Use
Penalty
Summary
The facility failed to ensure the safe and appropriate use of bed rails for a resident with severe cognitive impairment and total dependence on activities of daily living and mobility. The resident was observed with all four quarter rails raised and locked, but the facility's documentation did not align with the actual bed rail configuration in use. Specifically, the side rail assessment indicated full side rails on two sides, the physician's order called for bilateral half rails times four, and the consent form referenced quarter rails on two sides. None of these documents accurately reflected the four quarter rails that were actually in use for the resident. Additionally, the facility did not obtain informed consent that matched the physician's order or the actual bed rail setup. The consent form signed by the resident's representative described a different rail configuration than what was implemented, and there was no documented evidence that the risks and benefits of using all four quarter side rails were explained to the resident's responsible party. This created a lack of clarity regarding the intervention to which consent was given and whether the resident's representative was fully informed. Interviews with facility staff, including an LVN and the DON, confirmed these inconsistencies and acknowledged that the documentation did not accurately reflect the resident's needs or the actual intervention in place. Facility policies reviewed required that the risks and benefits of side rail use be explained and that documentation be complete and accurate, but these requirements were not met in this case.
Inaccurate Documentation of Bed Rail Use and Consent
Penalty
Summary
The facility failed to ensure accurate and consistent documentation regarding the use of bed side rails for one resident. The resident, who had diagnoses including dementia, hypertension, and dysphagia, and was assessed as having severe cognitive impairment and being dependent in activities of daily living and mobility, was observed with all four quarter rails raised on their bed. However, the side rail assessment documented in the medical record indicated the use of full side rails on two sides, which did not match the actual configuration in use. Additionally, the physician's order specified bilateral half rails times four, while the side rail consent form signed for the resident indicated quarter rails on two sides, further contributing to the inconsistency. Interviews with facility staff, including an LVN and the DON, confirmed that the documentation in the resident's record did not accurately reflect the physician's order or the actual bed rail setup. The discrepancies between the side rail assessment, the physician's order, and the consent form resulted in a lack of clarity regarding the type of side rails to be used and whether the resident's representative had consented to the correct intervention. The facility's policy required that documentation be objective, complete, and accurate, but this was not followed in the case of this resident.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to safe and proper food storage practices as per professional standards and its own policy and procedure. During an observation and interview, it was noted that several food items in Kitchen 1 were not labeled or dated. Specifically, an unlabeled 20 oz Lawry's Salt-Free 17 Seasoning, a 16 oz Sysco Imperial Ground Nutmeg, and a 26 oz Sysco Imperial Granulated Garlic were found on the preparation counter. Additionally, an unlabeled orange and apple were stored in a fruit basket, and inside Refrigerator 10, there were unlabeled bags of frozen potato wedges and onion rings. Refrigerator 3 contained unlabeled boxes of fresh apples, oranges, lemons, onions, and two 1-gallon Sysco Ultra Premium Lime Juice containers with varying contents remaining. Interviews with the Purchasing Clerk and Cold Food Prep staff revealed that the facility's practice was to label food items with the arrival date to track expiration and prevent serving expired food, which could lead to foodborne illness. The facility's policy and procedure on labeling and dating required all foods to be wrapped, labeled, and dated according to storage guidelines, with use-by dates monitored and followed. The Food Safety Management System policy provided specific storage guidelines for various food items, but these were not adhered to, leading to the deficiency.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The facility failed to accurately assess a resident for elopement risk, which could lead to inadequate treatment and care services. The resident, who was admitted with diagnoses including dementia and a history of repeated falls, had a documented history of leaving the facility. Despite this, a recent elopement risk assessment indicated the resident was not at risk. However, records showed the resident had been outdoors without assistance and had attempted to leave the facility multiple times. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the resident was considered an elopement risk due to their behavior and history. The facility's policy required elopement risk assessments for residents with certain risk factors, but the assessment for this resident was found to be incorrect. The resident's care plan and medical records indicated a need for monitoring and interventions, such as an ankle monitor to alert staff when the resident was near exit doors.
Failure to Provide Adequate Skin Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care according to the facility's policies and procedures. The resident, who was admitted with multiple diagnoses including atrial fibrillation and hypertension, had a care plan that included interventions for assessing skin integrity and applying Geri sleeves to protect against skin breakdown. However, the facility did not adequately monitor or care for the resident's skin tear and edema, leading to no improvement in the resident's condition. Observations and interviews revealed that the resident's legs were swollen and discolored, with a skin tear on the left ankle that was not healing. The resident expressed concern and disappointment over the lack of care, stating that the swelling had worsened since admission. Despite physician orders for Geri sleeves to be applied daily, the resident was not wearing them, and staff failed to carry out the order, which was crucial for protecting the resident's fragile skin. Interviews with staff, including a Quality Assurance Nurse and a Registered Nurse, confirmed that the necessary skin assessments were not conducted, and the physician's orders were not followed. The Assistant Director of Nursing acknowledged that a skin assessment should have been performed due to the worsening condition and that the Geri sleeves could have minimized further skin breakdown. The facility's policies and procedures emphasized the importance of recognizing changes in residents' conditions and providing appropriate treatment, which was not adhered to in this case.
Improper Storage of Dirty Laundry by Hospice Staff
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by the improper storage of dirty laundry for a resident. During an observation, a closed bag of dirty laundry, including bed linen, was found on top of the toilet seat in the resident's restroom. This was contrary to the facility's policy, which requires all soiled laundry to be placed directly into a closed laundry hamper bag. The incident involved a resident who was admitted with diagnoses including cerebral infarction, hypertension, and atrial fibrillation, and who was moderately impaired in cognitive skills and dependent on assistance for toileting hygiene. Interviews with staff revealed that hospice staff, who were assisting with the resident's care, were responsible for leaving the bag of dirty laundry on the toilet seat. The Certified Nursing Assistant (CNA) and the Infection Preventionist Nurse (IP) both confirmed that the hospice staff should have placed the dirty laundry in the designated dirty linen barrel to prevent contamination and ensure infection control. The facility's infection prevention and control program, as well as the personal laundry policy, were not adhered to in this instance, leading to a potential risk of cross-contamination and infection transmission.
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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