Mountain View Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mountain View, California.
- Location
- 2530 Solace Place, Mountain View, California 94040
- CMS Provider Number
- 055316
- Inspections on file
- 36
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mountain View Healthcare Center during CMS and state inspections, most recent first.
Two residents did not receive anti-seizure medications as prescribed due to errors in order entry, timing, and MAR management. For one resident with epilepsy on a lamotrigine titration schedule, the original bedtime order from the hospital was discontinued, a new morning order was entered with a delayed start date, and no lamotrigine doses were documented on two consecutive days; the resident later experienced a seizure during PT and was sent to the hospital. For another resident with epilepsy on lacosamide, two overlapping lacosamide orders were active in the EHR, resulting in administration of the drug three times on one day and four times on the next, exceeding the maximum daily dose; the resident developed dizziness and requested transfer to the hospital. Staff interviews revealed uncertainty about why the lamotrigine timing was changed, that nurses followed the MAR even when duplicate lacosamide orders existed, and that nurses could enter medication orders without oversight, contrary to the facility’s medication administration policy requiring adherence to the six rights and administration as prescribed.
A resident with multiple complex medical conditions was discharged AMA after not returning from a pass, without proper discharge planning, timely notice, or an interdisciplinary team meeting. The facility did not follow its own policies, failed to provide a discharge summary or address the resident's post-discharge needs, and did not ensure safe transition or appropriate placement.
Facility staff did not obtain required signatures from a resident and staff member on the personal effects inventory form at discharge, as mandated by facility policy. The form was left unsigned and there was no documentation of refusal to sign, despite the resident being discharged with personal belongings and the policy requiring signatures to acknowledge receipt of items.
Two residents did not receive required quarterly fall risk assessments, despite one having respiratory disorders and mobility issues and the other having dementia. Both experienced incidents involving falls or near-falls, and the DON confirmed the assessments were not completed as per facility policy.
The facility did not follow physician orders for specialized care and medication administration. A resident's void trial was performed without required urology supervision, leading to complications and transfer to acute care. Additionally, three residents did not receive blood pressure medications as ordered, with doses missed or given inappropriately based on blood pressure readings, as confirmed by the DON.
The facility released medical records of two residents to unauthorized individuals, violating their privacy rights. One resident with dementia had records released to her son, not her designated health care agent. Another resident's records were given to a daughter who was not the substitute decision maker. The DON confirmed these breaches, which contravened the facility's policy on medical record release.
A resident's MDS was inaccurately completed, indicating the use of a walker despite no documentation or observation supporting this. The resident, with conditions including cerebral infarction and morbid obesity, was confirmed by the MDS coordinator and director of rehabilitation to be unable to use a walker due to weakness, violating federal assessment accuracy requirements.
A facility failed to provide a baseline care plan summary to a resident and her representative, as required. The resident, with multiple health conditions, was admitted without the necessary signatures on her care plan, indicating a lack of communication and involvement in her care planning. The DON confirmed the oversight, which contradicted the facility's policy to provide such documentation in an understandable language.
A facility failed to develop a care plan for a resident with morbid obesity, despite it being identified in their assessment. The resident had a BMI of 59.7, indicating severe obesity, but no care plan was created to address this. Interviews with the ADON and DON confirmed the oversight, acknowledging the need for a person-centered care plan as per facility policy.
A facility failed to follow infection control practices when a CNA placed soiled linen on a resident's room floor instead of in a plastic bag, and a janitor walked in the hallway with gloves on, contrary to policy. Both staff members acknowledged their errors, and the infection preventionist confirmed the non-compliance with facility policies.
A bariatric resident with impaired mobility fell off the bed when only one CNA was assigned to reposition her, contrary to the facility's policy requiring two staff members for such residents. The incident highlights a failure to adhere to staffing guidelines, resulting in the resident's fall.
The facility failed to provide proper respiratory care for three residents on oxygen therapy. One resident's BiPAP orders were incomplete, and there was no documentation of oxygen administration or equipment cleaning. Another resident received oxygen without documentation of the liters per minute, and the MAR lacked nurse signatures. The third resident's BiPAP orders did not match hospital discharge orders, and there was no record of equipment cleaning.
A resident with hemiplegia, hemiparesis, and obstructive sleep apnea developed a new productive cough and low blood oxygen levels. A stat chest X-ray was ordered to rule out pneumonia, but it was not performed in a timely manner. The resident was later transferred to the hospital due to increased oxygen needs, highlighting a failure to adhere to the facility's policy for urgent diagnostic services.
The facility failed to comply with CFR 483.15(c) by inappropriately transferring five residents without valid reasons or proper documentation. These facility-initiated discharges were conducted under the false pretense of improved health, despite residents continuing to require long-term care. The transfers led to potential psychosocial harm due to increased distance from support networks.
The facility failed to provide timely written notifications of transfers or discharges to residents, their representatives, and the LTC Ombudsman. Four residents were affected, with notifications made only days before discharge, primarily verbally. The Ombudsman was notified late, hindering advocacy efforts.
The facility exceeded its licensed bed capacity of 123 without approval from the CDPH after an emergency program flex expired. The facility had a total bed count of 136 and a census of 130, with rooms previously used for other purposes converted into resident rooms. Despite submitting an application to increase bed capacity, the facility did not have documented approval, leading to a deficiency noted by surveyors.
Failure to Administer Anti-Seizure Medications as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as prescribed and in accordance with professional standards for two residents receiving anti-seizure medications. For the first resident, admitted with epilepsy and on a titration schedule for lamotrigine, the hospital SNF orders dated 10/6/25 directed lamotrigine 25 mg, 2 tablets (50 mg) by mouth at bedtime for 5 days, with a detailed 8‑week up‑titration schedule. The facility’s clinical physician orders initially reflected lamotrigine 25 mg, 2 tablets at bedtime for 5 days, but this order was discontinued on 10/7/25. A new order dated 10/7/25 changed lamotrigine to 25 mg, 2 tablets in the morning for one week, with a start date of 10/8/25 at 9 a.m. The RN documented that admission orders and diagnoses were reviewed with the NP and updated, and the NP’s progress note stated to continue lamotrigine titration as recommended by neurology and to continue all home medications as prescribed by the discharging physician. Review of the medication administration record for this resident showed lamotrigine 25 mg, 2 tablets was given on 10/6/25 at 9 p.m., but there was no documentation of administration on 10/7/25 or 10/8/25. The DON explained that when orders are changed in the EHR, the next dose starts the next day, and that the lamotrigine was scheduled for 10/8/25 at 9 a.m. but was not given because the resident was at therapy; the DON stated medications could be given within one hour before or after the scheduled time, and the resident should have received morning medications between 8 a.m. and 10 a.m. On 10/8/25, PT documentation indicated the resident consented to therapy between 10:15 a.m. and 10:30 a.m., and during use of an Omnicycle, jerky/dystonic movements worsened, therapy was stopped, nursing was notified, and a seizure was identified. A change in condition note documented that at approximately 10 a.m. the nurse went to administer morning medications but the resident was in therapy, and at approximately 10:50 a.m. the therapist reported the seizure, after which 911 was called and the resident was transferred to the hospital. A neurology consult from the hospital recommended facility education regarding the importance of not missing anti‑seizure medications and giving all as prescribed. The RN, NP, MD, DON, and consultant pharmacist each stated they were unsure why the lamotrigine timing was changed, and the consultant pharmacist stated that changes in medication administration timing should be ordered by a provider. For the second resident, admitted with a wedge compression fracture and epilepsy and later readmitted after a hospitalization, the hospital SNF orders dated 10/20/25 specified lacosamide 150 mg, 1 tablet by mouth twice daily, with the last hospital dose given at 9:31 a.m. on 10/20/25. The facility’s physician orders contained two active lacosamide orders: one for 150 mg, 1 tablet by mouth twice a day for seizure starting at 8 a.m. on 10/21/25, and another for 150 mg, 1 tablet by mouth every 12 hours for seizures starting at 9 p.m. on 10/21/25. The MAR showed one lacosamide order scheduled at 8 a.m. and 5 p.m. and another scheduled at 9 a.m. and 9 p.m. The controlled drug record indicated lacosamide 150 mg was correctly given twice daily from 10/11/25 to 10/16/25, but on 10/21/25 it was given once, on 10/22/25 it was given three times, and on 10/23/25 it was given four times at 8 a.m., 9 a.m., 5 p.m., and 9 p.m. Progress notes on 10/23/25 documented that at 6 p.m. the resident complained of dizziness, evening medications were given at 8 p.m., and at 9 p.m. the resident again complained of dizziness and requested transfer to the hospital; 911 was called and the resident was transported. The DON confirmed the multiple lacosamide administrations on those dates. LVNs involved stated they did not remember giving lacosamide twice on the same shift and indicated they followed what was in the MAR. The consultant pharmacist stated the maximum daily dose of lacosamide is 400 mg and that the resident received 600 mg on 10/23/25, described this as an error due to failure to discontinue the first order when the second was entered, and noted that nurses could input orders without oversight. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, following the six rights of medication administration and comparing the medication source with the MAR, and to administer within 60 minutes before or after the scheduled time unless otherwise ordered.
Failure to Provide Safe and Appropriate Discharge Planning for Resident Discharged AMA
Penalty
Summary
The facility failed to provide sufficient preparation and orientation to ensure a safe and appropriate discharge for a resident who was discharged against medical advice (AMA) after not returning from an authorized pass. The facility did not follow its own policy regarding AMA discharges, as the policy did not support automatic discharge for failing to return from a pass, and staff admitted that the resident did not initiate a request to leave or intend to be discharged. The resident was discharged without timely written notice, and the required discharge notice was not provided in advance or as soon as possible. Additionally, the resident's care plan did not include a discharge plan addressing needs such as medication management, home health referral, or durable medical equipment (DME), and there was no interdisciplinary care team (IDT) meeting to discuss or plan for the resident's discharge needs or placement. The resident had multiple complex medical diagnoses, including polyneuropathy, acute on chronic systolic heart failure, COPD, obstructive sleep apnea, hypertension, and a pacemaker, and required assistance with personal care and supervision for transfers. Despite these needs, the facility did not identify the location of discharge, complete a referral to an appropriate community agency, or provide a discharge summary that included the assistance needed for the resident to adjust to a new living environment. The post-discharge plan of care did not address the resident's limitations or ability to care for himself, and the resident's whereabouts were unknown after discharge. Interviews with facility staff confirmed that the resident was considered discharged AMA solely due to exceeding the allowed hours for being out on pass, despite the facility's policy stating that extended therapeutic leave is not grounds for discharge. The resident was not provided with medications at the time of discharge, only a medication list, and was not given the opportunity to appeal the discharge decision. The facility's own policies required an IDT-developed discharge plan and summary, which were not completed. The lack of proper discharge planning and communication endangered the health and safety of the resident, who was unexpectedly discharged without appropriate preparation, placement, or follow-up care.
Failure to Complete Personal Effects Inventory Documentation at Discharge
Penalty
Summary
Facility staff failed to follow established procedures for documenting a resident's personal belongings at the time of discharge. Specifically, the inventory list of personal effects form, which is used to record a resident's possessions, was not signed by either the resident or facility staff upon discharge. There was also no notation indicating that the resident refused to sign the form. This omission was confirmed during interviews with both a registered nurse and the assistant director of nursing, who acknowledged that the form should have been signed according to facility policy. The resident involved had been admitted with multiple diagnoses, including osteomyelitis, depression, diabetes mellitus, and generalized muscle weakness, and was discharged to an assisted living facility. Review of the medical record indicated that personal belongings were discharged with the resident, but the required documentation acknowledging receipt of these items was incomplete. Facility policy requires both the resident or responsible party and a staff member to sign and date the inventory on admission and discharge, which was not done in this case.
Failure to Complete Quarterly Fall Risk Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two out of three residents reviewed, specifically regarding the completion of quarterly fall risk assessments. One resident, admitted with respiratory disorders and difficulty walking, did not have any quarterly fall risk assessments documented in their clinical record. This resident experienced an incident where they slid down from the commode and ended up on the floor, as noted in a change in condition evaluation. Another resident, admitted with dementia, also lacked a quarterly fall risk assessment during a specified period. This resident was found sitting on the floor next to her bed after attempting to ambulate to the bedside commode and feeling weak. During an interview, the DON confirmed that both residents did not have the required quarterly fall risk assessments completed, as stipulated by the facility's Fall Prevention Program policy, which mandates a fall risk assessment every 90 days and upon changes in a resident's condition. The absence of these assessments meant that the residents' fall risk and prevention strategies were not updated in accordance with their current conditions.
Failure to Follow Physician Orders for Specialized Care and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services as ordered for several residents. One resident with a history of benign prostatic hyperplasia and obstructive and reflux uropathy was admitted with a Foley catheter and had discharge orders specifying that a void trial should be performed under urology supervision. Despite this, the void trial was conducted at the facility without urology supervision, and the resident subsequently experienced a high post-void residual and discomfort during repeated unsuccessful straight catheterizations, ultimately requiring transfer back to acute care for Foley catheter placement. The director of nursing confirmed that the void trial should have been supervised by urology as per the discharge orders. Additionally, the facility did not administer blood pressure medications according to physician orders for three residents. One resident received hydralazine when their systolic blood pressure (SBP) was below the ordered threshold and did not receive it when their SBP was above the threshold on multiple occasions. Another resident did not receive hydralazine when their SBP exceeded the ordered limit, and a third resident was given losartan potassium despite an SBP below the hold parameter. The director of nursing reviewed the medication administration records and confirmed these discrepancies. Facility policy and job descriptions require that medications be administered according to practitioner orders, which was not followed in these instances.
Unauthorized Release of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of medical records for two residents by releasing their records to unauthorized individuals. Resident 1, who was admitted with a diagnosis of dementia, had her medical records released to her son, who was only listed as an emergency contact and not her legal representative. The Health Care Power of Attorney for Resident 1 designated her husband as her health care agent, yet the Authorization for the Release of Protected Health Information was signed by her son, with the section for the authorized individual or organization left as 'Not Applicable.' The medical records director confirmed the release of Resident 1's records to her son. Similarly, Resident 2, who was self-responsible with one daughter as a substitute decision maker, had his medical records released to another daughter, who was only listed as an emergency contact. The director of nursing confirmed that the records for both residents were released to individuals who were not their legal representatives, which was against the facility's policy. The facility's policy clearly stated that medical records should only be released to the resident or their legal representative, and the authorization should be reviewed to ascertain access rights.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately assess and complete the Minimum Data Set (MDS) for a resident, which compromised the ability to develop and implement resident-centered care plans and interventions. The resident, who was admitted with diagnoses including cerebral infarction, type 2 diabetes, hypertension, and morbid obesity, had an MDS dated 3/08/24 that inaccurately indicated the use of a walker. The MDS coordinator confirmed that the resident's MDS was not accurate as there was no documentation or observation of the resident using a walker during the specified time frame. Interviews with the MDS coordinator and the director of rehabilitation revealed that the resident was not able to use a walker due to weakness, and there was no supporting documentation in the therapy records. The inaccurate assessment was a violation of federal regulations requiring that assessments accurately reflect the resident's status, as outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident and her representative, which is a requirement to ensure continuity of care and inform them about the initial plan for care and services. The resident, who was admitted with diagnoses including cerebral infarction, type 2 diabetes, hypertension, and morbid obesity, had a baseline care plan effective from early March 2024. However, the plan lacked the necessary signatures from both the resident and her representative, indicating that they were not informed or involved in the care planning process. Interviews and record reviews revealed that the resident's responsible party, her daughter, was not informed about the care plan and did not receive a written summary. The Director of Nursing confirmed the absence of signatures and acknowledged the facility's failure to provide the required documentation. The facility's policy mandates that a written summary of the baseline care plan be provided in a language understandable to the resident and representative, which was not adhered to in this case.
Failure to Develop Care Plan for Obesity
Penalty
Summary
The facility failed to develop and implement a care plan for a resident diagnosed with morbid obesity, despite this being identified in the resident's comprehensive assessment. The resident, who was admitted with multiple diagnoses including cerebral infarction, type 2 diabetes, hypertension, and severe obesity, had a BMI of 59.7, indicating severe obesity. However, a review of the resident's care plans revealed that no care plan was developed to address the obesity diagnosis. Interviews with the assistant director of nursing (ADON) and the director of nursing (DON) confirmed the absence of a care plan for the resident's obesity. Both acknowledged that a care plan should have been developed to address the resident's specific needs related to obesity. The facility's policy on the care and treatment of bariatric residents emphasized the importance of developing a person-centered care plan to ensure the resident's highest practicable well-being, which was not adhered to in this case.
Infection Control Lapses in Linen Handling and PPE Use
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey. A certified nursing assistant (CNA) was seen placing soiled linen on the floor of a resident's room instead of in a plastic bag, as required by the facility's policy. During an interview, the CNA acknowledged that the linen should have been placed in a plastic bag. Additionally, a janitor was observed walking in the hallway with gloves on and using a wiper to clean the wall, which is against the facility's policy that states gloves should not be worn in the hallway. The janitor also acknowledged this mistake during an interview. The infection preventionist confirmed that these actions were not in compliance with the facility's infection control policies.
Inadequate Staffing Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safety of a bariatric resident, resulting in an accident where the resident fell off the bed. The resident, who was admitted with a severe obesity diagnosis, had impaired range of motion on one side and required maximal assistance for repositioning in bed. Despite these needs, only one CNA was assigned to reposition the resident, which led to the resident rolling off the bed and onto the floor during a care routine. The assistant director of nursing confirmed that the CNA worked alone with the resident, contrary to the facility's policy that mandates two staff members for bariatric residents. The facility's policy, dated 6/1/23, clearly states that bariatric residents require special care and that adequate staffing is necessary to ensure their safety. The incident occurred because the CNA did not call for additional assistance, as required by the facility's guidelines.
Deficiencies in Respiratory Care Documentation and Equipment Maintenance
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents on oxygen therapy. For the first resident, there was no documentation of education on the risks and benefits of refusing to use the BiPAP device. The BiPAP orders were incomplete, lacking specific airway pressures, and there was no record of the amount of oxygen administered. Additionally, a PRN breathing treatment was not administered as ordered, and the resident's respiratory care plan was not individualized. There was also no documentation indicating that the BiPAP was cleaned weekly as per the manufacturer's instructions. The second resident was provided oxygen without documentation of the liters per minute administered. The MAR for May and June did not have nurse signatures indicating the administration of PRN oxygen. The assistant director of nursing confirmed the lack of documentation and stated that the amount of oxygen should be included in progress notes. For the third resident, the BiPAP orders did not match the hospital discharge orders, with the EPAP and IPAP pressures being switched. There was no documentation that the BiPAP was cleaned weekly according to the manufacturer's instructions. The facility's policy required obtaining an order for BiPAP use and settings from a practitioner and following the manufacturer's cleaning instructions, which were not adhered to in these cases.
Failure to Provide Timely Radiological Services
Penalty
Summary
The facility failed to provide timely radiological services for a resident who required a stat chest X-ray. The resident, who had diagnoses including hemiplegia, hemiparesis, and obstructive sleep apnea, developed a new productive cough and experienced an episode of de-saturation. A nurse practitioner was notified of the change in condition and ordered a stat chest X-ray to rule out pneumonia. Despite the urgency of the order, the X-ray was not performed, and the resident was later transferred to the hospital due to increased oxygen needs. The Quality Assurance Director confirmed that the stat order for the chest X-ray was placed but not completed within the expected timeframe of four hours. The facility's policy stated that stat diagnostic orders should be completed as soon as possible, but this was not adhered to in this case. The lack of timely radiological services had the potential to delay necessary treatment for the resident.
Inappropriate Resident Transfers Without Adequate Justification
Penalty
Summary
The facility failed to adhere to the regulations outlined in CFR 483.15(c) regarding the transfer and discharge of residents, resulting in inappropriate facility-initiated discharges for five residents. These discharges were conducted without adequate reasons or proper documentation, as required by federal regulations. For instance, Resident 1 was transferred to another facility without a valid reason, as the facility claimed her health had improved, yet she continued to require long-term care. The social services director admitted to selecting this reason because no other option applied, despite the resident still needing the same level of care at the new facility. Similarly, Resident 2 was transferred under the pretense that her health had improved, although her primary physician was not involved in the decision and assumed the transfer was requested by the resident or family, which was not the case. The facility's documentation did not support the claim that the resident no longer needed the services provided. Resident 3 was transferred without her consent or a documented request from her family, despite being her own responsible party. The facility claimed the transfer was requested by the resident's family, but no evidence was provided to support this claim. Residents 4 and 5 were also transferred without appropriate justification or proper documentation. Resident 4's transfer was allegedly requested by a family member who was not the designated power of attorney, and Resident 5's transfer was initiated by the facility without a selected reason for discharge. In both cases, the residents continued to receive the same level of care at the new facility, contradicting the facility's claim that their health had improved sufficiently to warrant a transfer. These actions led to potential psychosocial harm for the residents, as they were moved to facilities farther away from their support networks, resulting in decreased visits from friends and family.
Failure to Provide Timely Discharge Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the State Long-Term Care Ombudsman regarding transfers or discharges. This deficiency was identified for four residents, none of whom received the required 30-day notice prior to their discharge. Instead, notifications were made only a few days before the discharge, primarily through verbal communication, which is not compliant with the regulatory requirements. For Resident 1, the facility did not provide a written notice 30 days prior to discharge, and the notification to the Ombudsman was delayed by six days after the discharge. Similarly, Resident 2 was informed in person rather than in writing, and the Ombudsman was notified 14 days post-discharge. Resident 3 was also notified in person, and the Ombudsman received the notice 24 hours after the discharge. Resident 4's family was informed via phone, and the Ombudsman was notified 29 days after the discharge. The facility's policy and procedure on discharge planning were not followed, as evidenced by the lack of timely written notifications and the absence of documented exemptions from the 30-day notice requirement. The failure to adhere to these procedures deprived residents of their rights to be informed and to appeal the discharge, and it hindered the Ombudsman's ability to advocate on their behalf.
Facility Exceeds Licensed Bed Capacity Without Approval
Penalty
Summary
The facility failed to comply with state regulations by having more residents and/or beds set up for use than the number for which it was licensed, which is 123 beds. This occurred without prior temporary permission or approval from the California Department of Public Health (CDPH) after the expiration of an emergency program flex that had been approved during the COVID-19 pandemic. The facility's Assistant Administrator confirmed during an observation and interview that the facility had a total bed count of 136 and a census of 130, despite being licensed for only 123 beds. The Administrator admitted that the facility had submitted an application to increase their licensed beds to 135, which was still under review, and acknowledged that the facility's census fluctuated above the licensed capacity after the program flex expired. Further investigation revealed that certain rooms, which were previously used for other purposes such as dining and activities, were converted into resident rooms after a change of ownership. The facility's census records indicated that the number of residents exceeded the licensed bed capacity from time to time. Despite having the capacity and staffing for the current census, the facility did not have documented evidence of an approved application for a bed change or capacity increase. This lack of compliance with federal regulations was noted as a deficiency by the surveyors.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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