Niles Canyon Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Fremont, California.
- Location
- 38650 Mission Boulevard, Fremont, California 94536
- CMS Provider Number
- 055562
- Inspections on file
- 18
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Niles Canyon Post Acute during CMS and state inspections, most recent first.
A resident with type 2 DM, malnutrition, and severe cognitive impairment was admitted on oral sitagliptin but did not receive physician orders for HbA1c monitoring every 6 months or capillary blood glucose checks at least twice weekly, as required by the facility’s diabetes protocol. The DON confirmed that no blood glucose monitoring orders were in place, and record review showed no blood sugar assessments for over a year after admission. The attending MD reported that an order set for HbA1c monitoring should have been automatically placed for residents on oral diabetic medications but was not entered for this resident. The resident was later transferred to a hospital with altered mental status and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
A resident with severe cognitive impairment, malnutrition, and type 2 DM was admitted on oral sitagliptin, but the MD did not provide ongoing lab orders or independently review abnormal glucose-related labs. A hemoglobin A1C of 10.8% and later a CMP glucose of 273 mg/dL were documented in the EHR and described by the DON and MD as very high and warranting additional orders, yet the MD relied solely on nursing staff to notify him of abnormal results and did not follow up on ordered labs. Facility policies required the provider to order individualized glucose monitoring and necessary diagnostic testing, but no additional routine monitoring orders were documented, and the resident was later hospitalized with altered mental status and a blood glucose level over 800 mg/dL.
A resident with severe cognitive impairment and type 2 DM had repeatedly elevated blood glucose levels documented in lab reports, including a markedly high HbA1c and elevated CMP glucose. Nursing staff filed the labs in the EHR and documented that the MD was notified, including sending photos of the results by text, but the MD did not review or sign the lab reports or issue new orders. The resident was later hospitalized with altered mental status, weakness, and a blood glucose level over 800 mg/dL, while facility policies required timely MD response and documentation for abnormal lab and diagnostic results.
A resident with intact cognition and a care plan for altered cardiovascular status was receiving Metoprolol with an order to hold the dose if SBP was below 100 or HR below 60, and facility policies required reporting hypotension and SBP below 90 to a physician. Over multiple days, the resident had at least ten SBP readings under 100 mmHg that were not reported, and on one evening was documented with hypotension and altered mental status after routine night medications, with repeated BP readings in the 70s–80s systolic and 30s–40s diastolic before being sent to a hospital for low BP and confusion. In interviews, an LVN, ADON, and DON acknowledged that several of these low readings met criteria for physician notification and that there was no documentation that the physician had been notified, demonstrating a failure to follow physician parameters and facility guidelines for reporting hypotension.
An LVN was found to be working without current Basic Life Support (BLS) certification, despite facility policy requiring all clinical staff, including non-licensed personnel, to obtain and maintain BLS/CPR credentials consistent with American Heart Association guidelines. Review of the LVN’s competency file showed the BLS card listed a renewal due date that had passed, and the DSD confirmed that LVNs are required to have BLS and CPR training to ensure competency in life-saving measures during critical situations.
A resident with moderately impaired cognition who required assistance with toileting was assisted to the floor after being unable to ambulate from a bedside commode. The resident reported mild pain and later showed non-verbal pain cues and increasing right ankle swelling, for which Tylenol was administered. An LVN notified the physician, who ordered a STAT X-ray of both knees and the right ankle, but the imaging was not completed within the expected STAT timeframe and was still outstanding at the end of the evening shift. The night-shift LVN observed swelling, pain, and purple discoloration of the right ankle and found the STAT X-ray had still not been done; the resident was later transferred to the hospital, where a tibia/fibula fracture related to the fall was diagnosed. The DON reported that STAT orders were to be completed within four hours and that unmet timelines required physician notification per facility policy.
A resident with depression and limited English proficiency experienced anxiety after their cell phone went missing. Despite the caregiver notifying staff, no Theft and Loss Report was completed, and the Social Services Director was not informed, resulting in a lack of investigation and delayed resolution.
The facility failed to store food safely and sanitarily, with expired prune juice, improperly stored rice and flour, and unsealed, unlabeled, or expired items in freezers. The Dietary Manager was unaware of storage requirements, while the Registered Dietician highlighted the importance of sealing and proper labeling to prevent contamination.
Failure to Obtain Diabetic Monitoring Orders for a Resident on Oral Hypoglycemics
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain and implement physician orders for hemoglobin A1C monitoring every 6 months and blood glucose capillary/fingerstick assessments at least twice weekly for one resident with type 2 diabetes. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and malnutrition and was prescribed oral sitagliptin. The resident’s MDS dated 2/14/25 documented severe cognitive impairment with a BIMS score of 6/15. Review of the admission record and the Order Listing Report showed no physician orders for A1C monitoring or blood glucose testing at admission or thereafter, despite the facility’s Diabetes Clinical Protocol requiring the provider to order glucose targets and monitoring regimens, including A1C on admission and every 6 months and at least twice-weekly blood glucose monitoring for residents on oral diabetic medications who are well controlled. The DON confirmed during interview that a physician’s order is required to perform blood glucose capillary/fingerstick testing and acknowledged that the resident had no such orders, even though it was important to assess blood glucose to determine blood sugar status and monitor the treatment plan. The attending MD stated that residents with stable type 2 diabetes on oral medications should have an order set in the EHR for A1C monitoring every 6 months and that this was a standard order set automatically placed on admission, but the resident did not receive it for reasons the MD could not explain. Medical Records and the Administrator reported that the MD had access to the facility EHR but used a personal EHR system, with relevant documents uploaded monthly by Medical Records. Review of the resident’s Weights and Vitals Summary showed no blood sugar assessments between admission on 3/11/24 and 3/18/25. The resident was later admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
Failure to Monitor and Follow Up Abnormal Glucose Labs for Diabetic Resident
Penalty
Summary
The deficiency involves the failure of the attending physician to provide appropriate laboratory orders and follow-up for a resident with type 2 diabetes who was receiving oral sitagliptin. The resident, who had severe cognitive impairment (BIMS score 6/15), malnutrition, and type 2 diabetes, was admitted in March 2024 with an order for sitagliptin. A lab report dated 3/16/2024 showed a hemoglobin A1C of 10.8% and an estimated average glucose of 263 mg/dL, which the DON and MD both described as elevated and very high, warranting additional orders. The lab results were reviewed in the EHR by the ADON, and the facility’s process was that abnormal labs should be communicated to the MD via fax, phone, or text. However, the MD stated that the 3/16/2024 lab report was not reviewed by him and that he relied on nursing staff to notify him of abnormal results, and he did not follow up on ordered lab results independently. A subsequent Comprehensive Metabolic Panel collected on 2/21/2025 showed a glucose level of 273 mg/dL, which the MD also stated was high and warranted MD notification for additional orders. Medical Records and the Administrator reported that although the MD had access to the facility’s EHR, he used a personal EHR system, and MR uploaded SOAP notes, history and physicals, lab results, past medical history, and current medications into that system monthly per the MD’s request. The facility’s diabetes clinical protocol required the provider to order desired glucose targets and monitoring regimes and to assess glycemic status by A1C and blood glucose monitoring, and the lab/diagnostic testing policy required the physician to identify and order diagnostic and lab testing based on residents’ needs. Despite these policies and the abnormal lab findings, there were no documented additional lab orders for routine monitoring, and the resident was later admitted to a general acute care hospital with altered mental status, lethargy, confusion, partial responsiveness, and weakness, where a lab result showed blood glucose greater than 800 mg/dL.
Failure to Act on Abnormal Blood Glucose Labs for Diabetic Resident
Penalty
Summary
Facility staff notified the attending physician on two occasions about a resident’s elevated blood glucose levels but the physician did not review the laboratory results, discuss the resident’s status with nursing staff, or change the treatment regimen. The resident, who had severe cognitive impairment with a BIMS score of 6/15 and a diagnosis of type 2 diabetes, had an admission record and MDS documenting these conditions. The DON stated that lab results were filed in the EHR after being received and reviewed by nurses, that physicians had access to the EHR, and that nurses were responsible for placing lab results in the paper chart and documenting physician notification with date, time, and signature on the lab results after communication. The physician reported relying on nursing staff to communicate abnormal lab results by phone or text and stated that abnormal results warranted additional orders. A lab report dated 3/16/2024 showed a hemoglobin A1C of 10.8% and an estimated average glucose of 263 mg/dL, which the physician described as very high and warranting additional orders, but this report was not sent or reviewed by the physician. A CMP dated 2/21/2025 showed a glucose level of 273 mg/dL, which the physician also stated was high and required notification for additional orders. The physician indicated that all orders and new orders were based on communication from nurses during resident assessments and emphasized the importance of abnormal lab results being communicated for proper interventions. Record review showed that the physician did not sign the 3/16/2024 lab results to indicate review or initiate new orders, despite facility text message records showing that the physician was notified of the lab results with three photos and did not respond. Similarly, the CMP from 2/21/2025 had a notation that the physician was notified by an LVN, but the physician did not sign the lab results or initiate new orders. Subsequently, the resident was admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, and hospital labs documented a blood glucose greater than 800 mg/dL. Facility policies on physician notification and lab/diagnostic test results required timely physician response and documentation of when, how, and to whom information was provided, as well as the physician’s response, but the physician did not document review or respond with new orders for the abnormal lab results.
Failure to Report Repeated Hypotension to Physician
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of repeated episodes of hypotension for one resident with known cardiovascular issues and an order for antihypertensive medication. The resident had an MDS BIMS score of 15/15, indicating intact cognition, and a care plan identifying altered cardiovascular status related to persistent hypotension with a goal to remain free from complications of cardiac problems. The physician’s order for Metoprolol Tartrate 100 mg (two tablets at bedtime) included parameters to hold the medication if systolic blood pressure (SBP) was less than 100 or heart rate less than 60. The facility’s own Blood Pressure Measuring policy defined hypotension as BP less than 100/60 mmHg and required that hypotension be reported to the physician, and its Guidelines for Notifying Physicians of Clinical Problems directed staff to report SBP less than 90 mmHg. Despite these parameters and policies, the resident’s Weights and Vitals Summary from 12/1/25 to 12/9/25 showed ten separate instances of SBP less than 100 mmHg that were not reported to the physician. On 12/9/25, documentation of a change of condition noted the resident with hypotension and altered mental status after routine night medications around 2030, with a blood pressure of 75/44 and pulse 76 at 11:30 p.m., and repeat readings mostly in the range of 73–85 systolic and 37–46 diastolic. The resident was subsequently sent to a general acute care hospital that night for low blood pressure and confusion, where a physical exam documented a blood pressure of 87/39 mmHg. During interviews, an LVN stated that SBP less than 90 mmHg should be rechecked and reported to the physician, and the ADON acknowledged that specific low readings (90/56, 86/56, and 86/56) should have been reported and that there was no documentation of physician notification for two hypotensive episodes on 12/8/25. The DON stated that reportable blood pressure was defined in physician orders and that nurses should follow ordered parameters, while also recognizing the importance of reporting hypotension so physicians are aware of resident blood pressure assessments. These observations, interviews, and record reviews show that the facility did not follow its policies or physician parameters to report hypotension to the physician for this resident.
Failure to Ensure LVN Maintained Required BLS Certification
Penalty
Summary
Surveyors identified that an LVN did not hold current Basic Life Support (BLS) certification as required by facility policy. Review of the LVN’s competency and skills folder showed documentation indicating the BLS certification was due for renewal by 07/2024, with no evidence presented that renewal had occurred. In a concurrent interview and record review, the Director of Staff Development stated that LVNs are required to have BLS and CPR training and emphasized the importance of BLS to ensure staff competency in life-saving measures during critical situations. Review of the facility’s policy and procedure titled “Emergency Procedures–Cardiopulmonary Resuscitation” showed that all clinical staff members, including non-licensed personnel, are required to obtain and/or maintain BLS/CPR certification in accordance with American Heart Association guidelines. The report states that this failure to ensure the LVN maintained current BLS certification had the potential to result in residents’ increased risk of adverse events during life-threatening cardiac or respiratory emergencies.
Failure to Complete STAT X-Ray Order After Resident Fall
Penalty
Summary
The facility failed to follow a physician’s STAT order for diagnostic imaging after a resident fall, resulting in a delay of more than 10 hours before appropriate evaluation occurred. The resident, who had moderately impaired cognition per a BIMS score of 9 and required supervision or touching assistance with toileting transfers, was assisted to a bedside commode by a CNA. After toileting, the resident was unable to turn or walk back to bed and was assisted to the floor. The assigned nurse assessed the resident at that time, documented pain rated three out of ten, and administered Tylenol. Later in the afternoon, the evening-shift LVN observed non-verbal pain cues and increased swelling of the resident’s right ankle, administered additional Tylenol, and notified the physician. At approximately 4:00 p.m., the physician ordered a STAT X-ray of both knees and the right ankle related to the fall and swelling, but the imaging was not completed during the LVN’s shift despite the nurse’s understanding that STAT orders should be completed within four hours. The night-shift LVN subsequently noted swelling, pain, and purple discoloration of the right ankle and found that the STAT X-ray still had not been performed. The resident continued to receive Tylenol for pain throughout the evening and night. The resident was ultimately sent to the emergency department after midnight, where hospital records later documented a fracture of the right tibia and fibula related to the fall. The DON stated that STAT orders were expected to be completed within four hours and that if this could not be achieved, the physician should be notified to determine if there was a significant change or need for hospital transfer, consistent with the facility’s policy on acute condition changes.
Failure to Protect Resident Property and Promptly Investigate Loss
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's property from loss, specifically the resident's cell phone. The resident, who was admitted with a diagnosis of depression and primarily spoke Chinese, was assessed as usually able to understand and communicate with some difficulty. The resident's cell phone went missing, and their caregiver reported the loss to staff. However, staff did not take further action or communicate back to the caregiver. The missing cell phone was not reported in the facility's Theft and Loss Binder, and the Social Services Director, who was responsible for investigating such incidents, was not notified. The resident experienced anxiety due to being unable to contact family members because of the missing phone. Interviews with staff revealed that although the caregiver informed an LVN about the missing phone, the LVN did not complete a Theft and Loss Report or notify the Social Services Director. The Director of Nursing acknowledged the importance of resolving the issue promptly, especially given the resident's language barrier and need for communication. A review of the resident's inventory confirmed the cell phone was listed as a personal effect, and facility policy required prompt investigation of all theft or misappropriation reports, which was not followed in this case.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that resident food was stored in a safe and sanitary manner, as observed during a survey. In the dry food storage and freezer room, several items were found to be improperly stored. Sixteen prune juice cups with expired use-by dates were found on a shelf. Additionally, an open box of bananas, and containers of brown rice, white rice, and flour were stored only 3.5 inches above the floor, which is below the required minimum height. In the freezers, various food items such as frozen dinner rolls, strawberry ice cream, fish fillets, chicken, bacon, and meat were found unsealed, unlabeled, or undated, with some items also having expired use-by dates. Interviews with the Dietary Manager (DM) and Registered Dietician (RD) revealed a lack of adherence to the facility's policies and procedures. The DM was unaware of the minimum storage height for food and incorrectly believed that unsealed frozen food was acceptable. The RD emphasized the importance of sealing frozen food to prevent freezer burn and contamination, and stated that food should be stored at least 6 inches above the floor. The facility's policies required all food to be labeled with received, opened, and use-by dates, and to be stored in a manner that protects it from contamination. The failure to follow these procedures had the potential to cause infection and foodborne illness among residents receiving food from the kitchen.
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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