Northgate Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 40 Professional Center Parkway, San Rafael, California 94903
- CMS Provider Number
- 056430
- Inspections on file
- 26
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Northgate Postacute Care during CMS and state inspections, most recent first.
A resident with major depressive disorder, mild neurocognitive disorder with behavioral disturbance, anxiety disorder, severe memory impairment, and need for assistance with personal care was not protected from misappropriation of property when a staff member allegedly used the resident’s bank card without authorization. An Ombudsman reported that the resident’s bank had linked the card to a staff member’s phone number and identified thousands of dollars in charges. A bank employee stated that a joint account holder raised concerns about money being taken and that an internal investigation showed fraudulent withdrawals over about a year, totaling more than $4,000. Law enforcement and facility leadership confirmed that the staff member’s phone number was connected to the resident’s card transactions and that approximately $27,571.49 was missing from the resident’s account.
Surveyors found that the facility failed to complete a required criminal background check for an employee with direct access to residents. The personnel file showed that the 7-year county review portion of the background screening was closed as incomplete after the screening agency did not receive needed information from the applicant, and there was no documentation that this issue was ever resolved. In interview, the Administrator acknowledged there was no evidence the background check had been completed, despite facility policies requiring thorough background screening and prohibiting employment of individuals with histories of abuse, neglect, mistreatment, or misappropriation of property.
The facility did not ensure an RN was present for at least eight hours on four days, with some days having no RN coverage at all. This lapse was confirmed by the DON and Administrator, and was not in accordance with facility policy for staffing to meet the needs of a medically fragile population.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within regulatory limits.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Three resident bathrooms were found in disrepair, including a scratched toilet seat, a corroded door frame with exposed debris, and a separated baseboard with rust and wall discoloration. The DON acknowledged these issues during surveyor observations, confirming they did not meet facility standards for cleanliness and maintenance.
A LVN provided wound care to a resident with a skin tear, including the application of calcium alginate and A&D ointment, without obtaining a physician's order as required by facility policy. The absence of an active wound care order was confirmed through record review, and staff interviews indicated that the expected protocol was not followed.
A resident receiving hospice care for a dislocated hip prosthesis and Huntington's disease did not have updated wound care orders or care plans in the hospice binder. The hospice RN and DON confirmed the oversight, resulting in a lack of coordinated care and incomplete documentation as required by facility policy and hospice contract.
The facility did not complete required annual performance evaluations for two CNAs, as confirmed by record review and staff interviews. The Director of Staff Development and DON both acknowledged that these evaluations were missing, despite facility policy mandating annual reviews for all employees.
Surveyors found that used fentanyl patches were improperly stored in a medication cart by an LVN instead of being immediately disposed of according to facility policy. The DON confirmed that the patches should have been brought directly for proper disposal, and the pharmacist stated that patches must be rendered non-retrievable to prevent misuse.
A medication cart was left unlocked and unattended by an LVN, and an open bottle of Senna syrup without an expiration date or original packaging was found in a medication cart. Both issues were confirmed by the DON and pharmacist as not meeting facility policy, which requires medication carts to be locked when not in use and medications to be stored in their original packaging with expiration dates.
Garbage and refuse were not properly disposed of, with overflowing dumpsters left open and trash bags and boxes observed on the ground. The Certified Dietary Manager confirmed that this practice was unacceptable and contrary to facility policy, which requires sealed containers and closed lids to prevent pest attraction.
A hospice RN left a resident exposed from the waist down and visible to the public for over 20 minutes while delaying a wound change, and also exhibited unprofessional behavior by crying and yelling in the resident's presence, causing distress. The DON confirmed these actions did not meet professional standards or facility policy for maintaining resident dignity.
A resident with multiple open wounds, including a traumatic amputation and a sacral wound, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. PPE and EBP signage were not present outside the room, and both the IP and DON confirmed the oversight during interviews.
A broken, rust-covered laundry machine and a resident's bed with non-functioning locks were not promptly repaired or maintained, resulting in delays in laundry services and potential safety concerns. Staff and department heads confirmed the lack of regular maintenance and the importance of keeping equipment, such as laundry machines and bed locks, in safe working order, especially for residents with significant medical histories.
A handrail in the east wing hallway was observed to have a crack and was not firmly secured to the wall. Upon inspection by the MDR, the handrail separated from the wall, confirming it was unstable. Facility policy requires the maintenance department to keep equipment safe and operable at all times.
A resident was not given advanced written notice of two daily rate increases or a required security deposit, as required by facility policy. The resident and her representative did not receive an admission agreement or documentation of these financial changes, and billing statements lacked itemization for the security deposit. Staff interviews confirmed that notifications were not provided in writing and that required documentation was missing, resulting in financial hardship for the resident.
The facility did not maintain signed admission agreements for three residents and failed to provide a copy of the agreement to a resident who was cognitively intact and experiencing billing confusion. Admission agreements for two residents were signed long after admission, and one resident's agreement was missing entirely, contrary to facility policy requiring signed agreements and copies for all residents.
The facility failed to properly investigate and address allegations of misappropriation of property involving two residents, who reported missing debit cards and unauthorized transactions. The investigation was incomplete, lacking interviews with key staff, and the facility did not implement protective measures for other residents. Additionally, the facility failed to maintain a theft and loss log and did not incorporate these incidents into their QAPI program.
A resident with hemiplegia and hemiparesis following a cerebral infarction did not receive timely physician visits as required by the facility's policy. Despite the resident's MDS score indicating no cognitive impairment, there was no documented evidence of physician or nurse practitioner visits for several months. The resident reported not having a physician for a period, and the facility's Administrator confirmed the lack of documentation, potentially delaying necessary care.
The facility failed to maintain documentation and present evidence of its ongoing QAPI program. Unlicensed staff were unaware of the Quality Committee or QAPI projects. The Administrator could not initially find the QAPI binder, which later revealed only outdated documentation. The Director of Nursing mentioned a pest control project, but documentation was incomplete. The facility did not provide requested QAPI policies, attendance sheets, minutes, or agendas.
The facility failed to control a cockroach infestation in the kitchen and resident rooms, with live and dead roaches observed in food preparation areas and around residents' beds. Despite pest control measures, recommendations were not followed, and gaps in infrastructure allowed pest entry. Two residents were directly affected, with one refusing facility food after finding a roach on her meal plate and in her CPAP machine. The issue had been ongoing for about a year, with inadequate responses to pest control recommendations.
A resident with generalized anxiety disorder was not invited to participate in quarterly care conferences for 12 months. Despite the DON's recollection of the resident attending a meeting, there was no evidence in the clinical records to confirm the resident's participation or invitation to the conferences.
A facility failed to ensure a resident with generalized anxiety disorder was seen by a physician every 60 days. The resident's clinical record showed only two physician progress notes in the past year, and the DON could not provide evidence of regular visits or documented refusals. The resident confirmed not receiving regular physician visits.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a staff member made unauthorized charges to the resident’s bank card. The resident was admitted with major depressive disorder, mild neurocognitive disorder with behavioral disturbance, anxiety disorder, and a need for assistance with personal care. An MDS assessment indicated the resident had severe memory impairment and was only oriented to self. An Ombudsman reported to the DON that the resident’s bank had identified the resident’s bank card as being connected to a phone number belonging to a facility employee (Staff 1), with charges greater than $4,000. The facility’s abuse and neglect prohibition policy stated that misappropriation of property for all residents is prohibited. A police report documented that between mid-January and early November, the resident’s debit card had been fraudulently used by an employee of the facility, and the bank had accounted for approximately $27,571.49 missing from the resident’s account. In interviews, the Administrator and DON confirmed that Staff 1’s phone number was connected to the charges on the resident’s credit card, and the Administrator acknowledged that Staff 1’s employment had been separated based on this incident. A bank employee reported that a joint account holder had contacted the bank about money being taken from the resident’s account and that the bank’s investigation showed the fraud had been occurring for about a year and exceeded $4,000. A police officer stated that Staff 1 was definitely involved in the misappropriation of the resident’s property and confirmed the amount of the charges as $27,571.49, with the investigation ongoing.
Incomplete Criminal Background Screening for Direct-Care Employee
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough criminal background screening for an employee, identified as Staff 1, prior to or during employment. Record review showed that Staff 1’s criminal background check results indicated the 7-year county review “need attention” and that the service was closed as incomplete because the screening agency attempted to obtain information from the applicant/client but did not receive the needed information. Despite this notation, there was no further documentation in Staff 1’s personnel file showing that the incomplete background check was ever resolved or completed. During an interview, the Administrator stated that he would not have moved an applicant forward until the background check matter had been satisfied, yet he confirmed there was no documentation in Staff 1’s file indicating completion of the background check. The facility’s Abuse and Neglect Prohibition Policy requires screening of potential hires for a history of abuse, neglect, mistreatment, or misappropriation of property and prohibits employment of individuals found guilty by a court of law of such conduct. The facility’s Background Screening Investigations policy further requires employment background screening, reference checks, and criminal investigation checks on all applicants with direct access to residents, and states that applicants with convictions for abuse, neglect, mistreatment, or misappropriation of property are not to be employed. The incomplete and unresolved background check for Staff 1 was inconsistent with these written policies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for at least eight hours a day on four separate days in July 2025, as confirmed by review of the RN time sheet and interviews with the Director of Nursing (DON) and the Administrator. Specifically, on July 6 and July 20, the RN coverage was less than eight hours, and on July 12 and July 13, there was no RN present at all. The DON confirmed that neither she nor the MDS RN worked on those weekends and was unaware of the missed coverage. The facility's policy requires adequate RN staffing to meet residents' needs, but this was not met for a medically fragile population of 48 residents during the identified days.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct observation and review of medication administration practices, which revealed that the error rate exceeded the regulatory threshold.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling protocols. The report does not provide specific details about the individuals involved or the exact nature of the food procurement or handling issues observed.
Failure to Maintain Resident Bathrooms in Safe and Homelike Condition
Penalty
Summary
Surveyors observed that three out of thirteen resident bathrooms were not properly maintained, resulting in conditions that did not meet standards for a safe, clean, and homelike environment. During observations with the DON, one shared bathroom had a toilet seat with numerous scratches, which the DON acknowledged was abnormal and required replacement. Another shared bathroom had a door frame that was corroded at the baseboard, exposing a large black hole filled with debris, which the DON stated needed immediate repair. In a third shared bathroom, the baseboard was separated from the wall, exposing rust on the toilet plumbing and discoloration on the wall, with the DON noting the baseboard needed to be reattached. Review of facility policies confirmed requirements for maintaining cleanliness and repair of interior areas, which were not met in these instances.
Wound Care Provided Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) provided wound care to a resident without a physician's order. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and sepsis, was observed with a skin tear on her left hand. The LVN removed the resident's bandage, cleansed the wound, applied A&D ointment, placed a calcium alginate dressing, and covered it with an island dressing. Review of the Treatment Administration Record (TAR) confirmed there was no active wound care order for this resident at the time of the treatment. During interviews, the LVN acknowledged that a physician should have been contacted to obtain a new wound care order before providing treatment. The Director of Nursing (DON) confirmed that staff are expected to update the physician and obtain appropriate orders for wound care. The facility's wound care policy also requires verification of a physician's order prior to performing wound care procedures. The pharmacist noted that improper use of calcium alginate could delay wound healing.
Failure to Ensure Collaborative Hospice Care and Updated Care Plans
Penalty
Summary
The facility failed to ensure collaborative care with the contracted hospice agency for a resident who was admitted with a dislocated internal left hip prosthesis and Huntington's disease. During an observation and interview, the hospice registered nurse case manager was found without the necessary wound care orders and had not updated the hospice binder with the resident's wound care plans. The director of nursing confirmed that there were no wound orders or care plans for the resident in the hospice binder, which was an oversight and impacted the resident's comfort of care. Further review of facility policies and the hospice contract revealed that hospice providers are required to maintain updated and coordinated care plans, including the most recent hospice plan of care and all relevant physician orders. The facility is responsible for ensuring collaboration and that the hospice agency's nursing care plan is included in the resident's record. In this case, the lack of updated documentation and care plans in the hospice binder led to a breakdown in communication and coordination of care for the resident.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two certified nursing assistants (CNAs), as required by its policy. During interviews and record reviews with the Director of Staff Development, it was found that neither CNA had a documented annual performance evaluation for the 2024/2025 period. The Director of Staff Development confirmed that these evaluations should have been completed. Additionally, the Director of Nursing was unaware that multiple staff members were missing evaluations and acknowledged that annual evaluations were necessary. The facility's policy, dated January 2018, specifies that performance evaluations must be conducted at the end of the 90-day probationary period and at least annually thereafter, with completed evaluations to be filed in the employee's personnel record.
Improper Disposal of Used Fentanyl Patches
Penalty
Summary
The facility failed to properly dispose of used fentanyl patches, a potent opioid medication, as observed during a survey. Nine opened and used fentanyl patches were found stored in a plastic cup inside a medication cart by an LVN, who stated that the patches were awaiting disposal by the DON. The DON confirmed that used fentanyl patches should not have been stored in the medication cart and should have been brought directly to the DON for proper disposal. The facility pharmacist explained that used fentanyl patches should be cut up and placed into a disposal bin containing liquid to ensure they cannot be reused, noting that residual medication on the patches could be dangerous if touched. Review of the facility's policy indicated that destruction of controlled substances must render them non-retrievable, permanently altering their properties so they cannot be used or diverted.
Unattended Unlocked Medication Cart and Improper Medication Labeling
Penalty
Summary
A medication cart was observed left unlocked and unattended in the hallway by an LVN, who walked away into a resident's room, leaving the cart accessible. The LVN later confirmed that the cart was left unlocked and unattended, acknowledging this was a mistake. The facility's policy and procedure require that medication carts be locked when not in use to prevent unauthorized access, and the DON confirmed that carts should always be locked when unattended. Additionally, an open bottle of Senna syrup was found in a medication cart without an expiration date and not in its original packaging. The LVN present stated that the Senna syrup needed to be discarded due to the missing expiration date and lack of original packaging. The DON and the facility's pharmacist both confirmed that medications should be kept in their original packaging with the expiration date visible, and the facility's policy supports this requirement.
Improper Disposal and Storage of Garbage
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations in the garbage storage area where a trash dumpster was found with both lids unsecured and open due to overflowing garbage. Multiple bags and boxes of trash were also seen on the ground in the same area. During an interview, the Certified Dietary Manager acknowledged that leaving trash unsecured and on the ground was unacceptable because it attracts pests and rodents. A review of the facility's policy and procedure on garbage and trash indicated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers and disposed of as necessary to prevent nuisance or unsightliness, with no debris on the ground and lids closed. These requirements were not met during the observation.
Failure to Ensure Resident Dignity and Professional Conduct During Hospice Care
Penalty
Summary
A deficiency occurred when a hospice registered nurse (HRN) failed to maintain a resident's dignity and privacy during care. The resident, who had a dislocated internal left hip prosthesis and Huntington's disease, was left exposed from the waist down and visible to the public for approximately 22 minutes while waiting for a wound change. The HRN was present in the room but did not begin the procedure, and the Director of Nursing (DON) confirmed the resident remained unclothed during this period, which was not in accordance with the facility's policy on accommodating resident needs and maintaining dignity. Additionally, the HRN displayed unprofessional conduct by crying and yelling unprovoked in the resident's room, causing the resident to appear confused and scared. The DON intervened and asked the HRN to leave the room, later confirming that the HRN's behavior was unprofessional and made the resident feel scared. The facility's policies and hospice contract require contracted hospice providers to meet professional standards and ensure resident dignity, which was not upheld in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when the facility failed to identify the need to place a resident with multiple open wounds on Enhanced Barrier Precautions (EBP), an infection control strategy designed to prevent the spread of multidrug-resistant organisms (MDROs). The resident, who was admitted with a complete traumatic amputation of the left midfoot, had an open wound on the left foot with moderate serosanguineous drainage and a sacral wound with light serosanguineous drainage. During observation, there was no personal protective equipment (PPE) or EBP signage posted outside the resident's room, despite the resident receiving wound care for both the left foot and buttocks. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the resident was not on EBP, even though facility policy required EBP for residents with wounds. The DON stated she was unaware that the resident was not on EBP and acknowledged that the resident should have been placed on these precautions due to the presence of wounds. Review of the facility's policy indicated that PPE should be available outside the resident's room and clear signage should be posted, neither of which was observed during the survey.
Failure to Maintain Safe and Operable Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition, as evidenced by two specific deficiencies. In the laundry room, one of the laundry machines was observed to be broken and covered in rust. The Maintenance Director (MDR) confirmed the machine was not functioning and acknowledged that maintenance was only performed when equipment was already malfunctioning, rather than on a regular schedule. The Housekeeping Staff stated that the broken machine had been out of service for an extended period, causing delays in the laundry process for residents. Additionally, the MDR was unable to locate the laundry machine manual, which was noted as important for troubleshooting. In a resident's room, Certified Nursing Assistants (CNAs) were unable to lock the bed due to malfunctioning bed locks. The MDR and the Director of Nursing (DON) both confirmed that the bed locks were not working and emphasized the importance of functioning bed locks to prevent falls and injuries. The resident involved had a history of left hip prosthesis dislocation, Huntington's disease, and a previous fall from a chair. Review of the facility's maintenance policy indicated that the maintenance department was responsible for ensuring all equipment was kept in a safe and operable manner at all times, including providing regularly scheduled maintenance.
Unsecured Handrail in Hallway
Penalty
Summary
During an observation in the east wing hallway, a handrail located between two rooms was found to have a crack along its seam and was not firmly secured to the wall. When the Maintenance Director inspected the handrail, it separated from the wall upon being tugged, confirming it was not properly attached. The Maintenance Director acknowledged that the handrail should have been secured and required reinforcement. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring that buildings, grounds, and equipment are maintained in a safe and operable manner at all times.
Failure to Provide Written Notice of Rate Increases and Security Deposit
Penalty
Summary
The facility failed to provide a resident with advanced written notice of increases in the daily room and board rate on two separate occasions, as well as failed to provide written notice or documentation regarding a required security deposit. The resident, who was cognitively intact as indicated by a BIMS score of 13, experienced two rate increases—first from $412 to $525 per day, and then from $525 to $680 per day—without receiving the required 30-day written notice. The increases were communicated verbally, if at all, and there was no documentation to support that proper notification was given. Additionally, the resident was required to pay a security deposit without prior written notice or agreement, and the amount was not itemized or documented in billing statements or the admission agreement. The admission agreement for the resident was not completed at the time of admission and was only signed much later, with key financial sections such as the daily room rate and security deposit left blank or marked as not applicable. The resident and her power of attorney both confirmed that they did not receive an admission agreement or written notification of rate changes or deposit requirements. Billing records showed retroactive charges for the increased rates and a lack of itemization for the security deposit, further indicating a lack of transparency and proper communication regarding the resident's financial responsibilities. Interviews with facility staff, including the Medical Records Director, Accounts Receivable Director, Admissions Coordinator, and Administrator, revealed a lack of awareness and documentation regarding the notification process for rate increases and security deposits. Staff confirmed that written notice was not provided, and there was no documentation to show that the resident agreed to the new rates or the security deposit. Facility policies required written notification and itemized billing, but these procedures were not followed in this case, resulting in financial hardship for the resident.
Failure to Maintain and Provide Signed Admission Agreements
Penalty
Summary
The facility failed to maintain signed admission agreements for three out of five sampled residents and did not provide a copy of the admission agreement to one resident. Specifically, one resident, who was cognitively intact with a BIMS score of 13, reported not receiving information about a required security deposit and was unable to reference the terms of her admission, including the daily room rate and security deposit amount. The resident experienced confusion and difficulty regarding billing, as she was asked to pay a security deposit after being in the facility for over a year and did not receive clear answers from staff. Record reviews and staff interviews confirmed that admission agreements for two residents were signed years after their initial admissions, only after an audit was prompted by a surveyor's request. Additionally, the facility could not produce an admission agreement for a third resident, and the Admissions Coordinator acknowledged that copies of agreements were not consistently provided or documented as offered. Facility policy required a signed admission and financial agreement for every resident, with a copy to be given to the resident and another kept in permanent records, but this procedure was not followed.
Failure to Investigate and Prevent Misappropriation of Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of property involving two residents who reported missing debit cards and unauthorized transactions. The investigation conducted by the Administrator was incomplete, as it lacked interviews with key staff members, including the alleged perpetrator, the Social Services Director. The facility's policy required comprehensive interviews with all relevant staff, but this was not adhered to, resulting in an inadequate investigation process. Additionally, the facility did not implement measures to protect other residents from potential theft. The inventory of personal effects for the residents was not properly itemized, which is crucial for tracking and safeguarding residents' belongings. Despite an in-service training conducted to address this issue, the inventory process remained insufficient, as evidenced by another resident's inventory lacking detailed documentation of wallet contents. The facility also failed to maintain a theft and loss log for the past 12 months, which is a requirement according to their policy. This log is essential for tracking incidents and ensuring accountability. Furthermore, the incidents of misappropriation were not incorporated into the facility's Quality Assurance and Performance Improvement (QAPI) program, as they were not discussed in recent QAPI committee meetings. This omission indicates a lack of systematic review and improvement efforts regarding theft and loss prevention within the facility.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure timely physician visits for a resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was admitted to the facility with these conditions, had a Minimum Data Set (MDS) score indicating no cognitive impairment. Despite the facility's policy requiring physician visits upon admission and every 30 days for the first 90 days, followed by at least once every 60 days thereafter, there was no documented evidence of physician or nurse practitioner visits for the resident during the months of August, September, October, and November of 2024. During interviews, the resident expressed that there was a period when she did not have a physician and had gone a long time without seeing one. The facility's Administrator confirmed the expectation for physician visits but acknowledged the lack of documentation for the specified months. This oversight had the potential to delay the detection of declining health and the provision of necessary care for the resident.
Failure to Maintain QAPI Documentation and Awareness
Penalty
Summary
The facility failed to maintain documentation and present evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program implementation and activities. During interviews, multiple unlicensed staff members were unaware of the Quality Committee or QAPI, and they did not know of any current quality improvement projects. The Administrator was unable to locate the QAPI binder initially and later provided one that only contained documentation from December 2024. She admitted to not knowing the current QAPI status or any performance improvement projects the facility was working on. The Director of Nursing stated that the QAPI Committee met monthly and at least quarterly, mentioning a project related to pests in the kitchen. However, a review of the facility's Quality Assessment and Assurance Committee Quality Assurance Performance Improvement Plan indicated incomplete documentation for a pest control plan dated December 3, 2024, with no data collection or results. The facility failed to provide requested policy and procedures for QAPI, attendance sheets, minutes, and agendas by the end of the survey.
Cockroach Infestation in Facility Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of cockroaches in both the kitchen and resident areas. Observations revealed live and dead cockroaches in the pantry and food preparation areas, with gaps and damages in the kitchen infrastructure that allowed pest entry. Food particles and uncovered garbage were also noted, contributing to the pest problem. Despite the presence of insect bait traps, the pest control measures were inadequate, and recommendations from pest service reports were not followed. Two residents were directly affected by the infestation, with cockroaches observed in and around their beds. One resident reported finding a cockroach on her meal plate, leading her to refuse facility-prepared food. The resident also discovered roaches inside her CPAP machine, which was confirmed by staff observations. The facility's administrator was unaware of the pest issues until a grievance was filed, and a log for pest sightings was initiated but remained blank. Interviews with staff and the pest control technician revealed that the roach infestation had been ongoing for about a year. The technician noted that the facility had not implemented his recommendations for repairs and cleaning. The Environmental Health Services conducted an inspection in response to the complaint, and the facility's policy on pest control was found to be ineffective in preventing the infestation.
Resident Not Invited to Care Conferences
Penalty
Summary
The facility failed to ensure that Resident 1 was invited to participate in quarterly care conferences, which are interdisciplinary meetings to review and revise residents' care plans. Resident 1, who was admitted with a primary diagnosis of generalized anxiety disorder, was not invited to participate in these meetings for the past 12 months. This was confirmed through a review of Resident 1's clinical records and interviews with both Resident 1 and the Director of Nursing (DON). Despite the DON's claim of having seen Resident 1 in one of the care conferences, there was no documentary evidence to support that Resident 1 was invited or attended any of the care conferences held on 3/14/23, 6/15/23, 9/14/23, 12/14/23, and 3/6/24.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least every 60 days, as required. The resident, who was admitted with a primary diagnosis of generalized anxiety disorder, had only two physician progress notes documented in the past 12 months. During a review of the resident's clinical record, the Director of Nursing (DON) was unable to provide evidence of regular physician visits, offering only three additional progress notes over the same period. The DON claimed that the resident refused physician visits but could not provide documentation to support this claim. In an interview, the resident confirmed not receiving regular physician visits and could not recall the last time they were seen by a physician at the facility.
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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