Orchards Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Rancho Mission Viejo, California.
- Location
- 1 Amistad Drive, Rancho Mission Viejo, California 92694
- CMS Provider Number
- 555922
- Inspections on file
- 12
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Orchards Skilled Nursing during CMS and state inspections, most recent first.
Surveyors found that kitchen utensils and cutting boards were in poor condition, including being chipped, cracked, frayed, discolored, and deeply grooved, making them difficult to clean and sanitize. The RD and Chef de Cuisine confirmed these items should have been replaced to meet infection control standards, as most residents consumed food prepared in the kitchen.
A resident's advance directive was not maintained in the medical record as required by facility policy. Although the family indicated an advance directive existed, it was neither present in the paper chart nor uploaded to the EMR. The SSD confirmed the document was missing and acknowledged it should have been obtained and readily available for staff reference.
A resident with heart failure used a personal heart monitor daily without staff assistance or oversight. Facility staff were unaware of the device, and there was no physician's order, care plan, or assessment documented for its use, contrary to facility policy requiring such measures for resident-owned equipment.
A resident with altered respiratory status did not receive oxygen therapy as ordered by the physician. The nasal cannula was not placed on the resident's nares, and the oxygen concentrator was set at 1 liter per minute instead of the ordered 2 liters per minute. Staff confirmed the concentrator was malfunctioning and acknowledged the physician's order was not followed.
Licensed nurses did not follow facility medication administration policies for three residents, including failing to notify a physician when a medication was unavailable, missing documentation for IV antibiotic administration, and not ensuring medication orders accurately reflected the route of administration for a resident with a feeding tube. These actions resulted in missed doses, incomplete records, and discrepancies between prescribed and actual care.
The facility's assessment did not include active participation from direct care staff, their representatives, residents, or family members, and lacked both a plan for recruitment and retention of direct care staff and a contingency plan for staffing needs. The Administrator confirmed these omissions and acknowledged the assessment was not updated per current CMS guidance.
A resident with Alzheimer's disease and no capacity for medical decision-making did not have hospice care properly coordinated, as the hospice calendar lacked complete documentation of skilled nursing and hospice aide visits per physician orders. Staff were unclear about visit frequencies and the identity of the hospice coordinator, leading to uncertainty about whether the resident received all necessary hospice services.
The facility did not ensure its infection surveillance logs and data collection forms were accurate and complete, resulting in mismatched and incomplete reporting of HAIs, CAIs, and infections not meeting McGeer's criteria. Several residents who received antibiotics for infections had incomplete documentation regarding infection classification, and both the IP and DON confirmed these discrepancies during review.
A laptop containing residents' medical information was left open and unattended on a medication cart in a hallway, allowing staff, residents, and visitors to view confidential data. An LVN acknowledged the privacy breach, and the DON confirmed the incident, which was not in accordance with facility policy requiring screens to be secured and logged off when unattended.
A resident's POLST form inaccurately indicated that an Advance Directive was not available, even though the document had been uploaded to the EMR. This discrepancy was confirmed during a review with the SSD, who acknowledged the POLST should have reflected the accurate status of the resident's Advance Directive.
The facility failed to ensure food safety and sanitary requirements in the kitchen, leading to multiple deficiencies. Observations revealed improper meat thawing, expired food not discarded, unmonitored TCS foods, unclean ice machines, lack of hair and beard restraints, poor condition of food preparation equipment, improper storage and labeling of food items, and dirty drying racks.
The facility failed to assess a resident for the capability to self-administer medications. An opened bottle of nasal spray was found on the resident's overbed table, and the resident admitted to using it daily without a physician's order. The resident's assessment indicated no interest in self-administration, and the LVN was unaware of the nasal spray at the bedside.
A facility failed to notify a resident's physician, responsible party, and RD of significant weight loss, as required by their policies and procedures. Despite the resident experiencing notable weight changes, the necessary notifications were not documented, as confirmed by interviews and medical record reviews.
An LVN failed to follow the facility's policy for taking a blood pressure reading by placing the stethoscope diaphragm over a resident's sweater instead of directly on the skin. This was confirmed by both the LVN and the DON.
The facility failed to ensure timely intervention for a resident experiencing significant weight loss. Despite the resident's weight loss being identified by the EHR system, there was no documentation of intervention by the nutritional services or RD. The process for addressing weight changes was disrupted due to the RD's vacation, leading to the resident's weight loss not being addressed in a timely manner.
The facility failed to provide appropriate respiratory care for a resident by not labeling the oxygen tubing and allowing it to touch the floor, contrary to the facility's policy and procedure. The resident had physician's orders for oxygen therapy, which were not fully adhered to, as confirmed by an RN and the DON.
A resident's oxycodone-acetaminophen was not accurately reconciled, as the Controlled Drug Record showed medication removal without corresponding documentation in the electronic MAR. The discrepancy was confirmed by LVN 3 and acknowledged by the DON.
The facility failed to ensure proper disposal and storage of medications, with issues found in a medication cart, a medication room, and a resident's bedside cabinet. An LVN and the DON verified these findings.
The facility failed to ensure that the Food and Nutrition Services Director (FNSD) was competent in managing the day-to-day functions of the food services department. Multiple issues were found in the main kitchen, including improper thawing processes for meats, failure to discard expired food, and lack of monitoring of cooling for TCS foods. Interviews revealed gaps in the oversight and competency assessment of the kitchen staff.
The facility failed to follow the puree procedure for meat and vegetables, resulting in inconsistent products that may not meet the nutritional needs of residents on pureed diets. This was confirmed by the Administrator, FNSD, RD, and Chef.
A resident's food preference was not honored, leading to the continued serving of cranberry juice despite the resident's expressed dislike. The facility's process for updating dietary preferences was not effectively implemented, resulting in a failure to meet the resident's dietary needs.
The facility failed to communicate safe food handling guidelines to residents' family members and visitors who brought food from outside. Staff were trained on these guidelines, but the required 'Safe Food Handling Guide for Visitors and Staff' was not provided to visitors, as confirmed by the DON.
The facility failed to ensure complete and accurate medical records for three residents, as their POLST forms were found to be incomplete. The SSD left sections blank, hoping residents would eventually have capacity or waiting for family submissions, leading to potential risks in emergency situations. The DON confirmed these findings.
The facility failed to implement a water management program to prevent Legionella growth and did not ensure proper hand hygiene practices among staff. An LVN did not change gloves or perform hand hygiene before administering eye drops, and a CNA did not perform hand hygiene after touching a floor mat. The DON confirmed these lapses in infection control.
The facility failed to revise the comprehensive care plan for a resident to include non-pharmacological interventions for pain management as ordered by the physician. The LVN confirmed the omission during a medical record review, and the DON acknowledged the deficiency.
The facility failed to store trash in a sanitary manner, as evidenced by an uncovered green organic trash container and an open dumpster lid. The FNSD noted the trash container cover was broken, and the EVS Manager admitted staff often forget to close dumpster lids, contrary to facility policy and the US Food Code.
The facility failed to ensure the comprehensive care plan reflected the current care needs and interventions for a resident diagnosed with dementia. During a medical record review and interview with an LVN, it was found that the care plan did not address the specific care needs related to dementia, which was confirmed by the LVN.
Unsanitary Kitchen Utensils and Cutting Boards Identified
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by the presence of multiple kitchen utensils and cutting boards that were not in good repair or cleanable condition. During an initial kitchen tour, surveyors observed and verified with the Registered Dietitian (RD) and Chef de Cuisine that several utensils, including basting brushes, spatulas, ice cream scoops, and serving spoons, were discolored, frayed, chipped, cracked, peeling, melted, or otherwise worn out. These items did not meet the facility's own policies or the USDA Food Code requirements for food contact surfaces to be smooth, durable, and easily cleanable. Additionally, the facility's cutting boards were found to be heavily marred, fuzzy, and had deep grooves, making them difficult to clean and sanitize. The RD and Chef de Cuisine acknowledged that these cutting boards should have been replaced according to facility policy and food safety standards. These deficiencies were identified during a review of the kitchen where 38 of 40 residents consumed food prepared on-site, and the findings were confirmed through observation, interview, and review of facility policies and relevant food safety codes.
Failure to Maintain Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one resident reviewed for advance directives. According to the facility's policy and procedure, the Social Service Director (SSD) or designee is responsible for inquiring about the existence of any written advance directives upon admission and ensuring that information about the advance directive is prominently displayed in the medical record. For the resident in question, medical record review showed that although the family member stated an advance directive existed and would provide a copy, no such document was found in the resident's medical record or uploaded in the electronic medical record (EMR). Further review of the resident's records, including the POLST and H&P examination, did not reveal the presence of the advance directive. During an interview, the SSD confirmed that the advance directive was not present in the medical record and acknowledged that it should have been obtained and maintained. The Director of Nursing (DON) was informed and acknowledged these findings.
Failure to Assess and Care Plan for Resident-Owned Heart Monitor
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary services for a resident with a heart condition who brought a personal heart monitoring machine from home. Upon observation, the machine was found on the resident's bed, plugged in, and covered with a pillowcase. The resident reported using the machine daily to monitor her heart, but stated that facility staff did not assist with the care or functionality checks of the device. Review of the resident's medical records revealed no documentation of a physician's order for the heart monitor, no care plan addressing its use, and no assessment or documentation of the machine's presence or maintenance upon admission, despite the resident's diagnosis of heart failure. Interviews with facility staff, including an LVN and the DON, confirmed that they were unaware of the heart monitor at the bedside and acknowledged the absence of required documentation, orders, and care planning for the device. The facility's policy required adherence to manufacturer guidelines for resident-owned equipment, but this was not followed. The DON verified that a physician's order, care plan, and assessment should have been completed for the heart monitor when the resident was admitted.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident by not administering oxygen therapy as ordered by the physician. During an observation, the resident was found lying in bed with oxygen tubing labeled and dated, but the nasal cannula was not placed on the resident's nares. The oxygen concentrator was set at 1 liter per minute, which was inconsistent with the physician's order for 2 liters per minute via nasal cannula every shift to maintain oxygen saturation above 92%. The resident's care plan also specified the need for oxygen at 2 liters per minute due to altered respiratory status. Interviews with facility staff confirmed that the oxygen concentrator had been replaced due to malfunction, and the dial to set the oxygen flow was not working. Staff acknowledged that the physician's order for oxygen administration should have been followed, and the DON confirmed awareness of the findings. The resident was noted to have no capacity to make health care decisions but could express simple needs. The failure to follow the physician's order and ensure proper oxygen administration constituted a deficiency in providing safe and appropriate respiratory care.
Failure to Follow Medication Administration Policies and Procedures
Penalty
Summary
The facility failed to ensure that licensed nurses followed their policies and procedures for medication administration for three residents. For one resident with a history of cancer and dry mouth, the ordered Biotene medication was not available, resulting in missed doses over two days. Documentation showed that the medication was not administered, and there was incomplete progress note documentation explaining the missed doses. Although the facility's policy required notifying the physician when medications were unavailable, this was not consistently done, as confirmed by staff interviews and review of the medical record. Another resident, admitted with a urinary tract infection and ESBL resistance, had a physician's order for intravenous Ertapenem. The medication administration record (MAR) lacked documentation for four specific dates, and staff confirmed there was no evidence the medication was administered as ordered. The DON verified the missing documentation and acknowledged that what was not documented was considered not done, emphasizing the requirement for immediate documentation after medication administration. A third resident with an enteral feeding tube and a diagnosis of dysphagia was observed receiving all medications via gastrostomy tube (GT), despite physician orders specifying oral administration. The MAR reflected that medications were signed as given orally, not via GT, and staff confirmed that the orders should have accurately reflected the actual route of administration. The discrepancies between the physician's orders, the MAR, and the actual administration route were acknowledged by nursing staff and facility leadership.
Facility Assessment Lacks Required Stakeholder Involvement and Staffing Plans
Penalty
Summary
The facility failed to ensure its Facility Assessment was developed with the active involvement of required individuals, including direct care staff, their representatives, residents, residents' representatives, and residents' family members. Review of the assessment and interviews with the Administrator confirmed that these groups were not actively involved in the development process. Additionally, the assessment did not include a plan to maximize recruitment and retention of direct care staff, nor did it contain a contingency plan for staffing needs. These omissions were identified during a review of the facility's assessment and an interview with the Administrator, who verified the lack of involvement from key stakeholders and the absence of required plans. The Administrator also acknowledged that the Facility Assessment had not been updated to reflect the latest CMS guidance, as outlined in QSO-24-13-NH, which requires these elements to be addressed.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to coordinate hospice care for one resident, resulting in incomplete documentation and uncertainty regarding the provision of required hospice services. Specifically, the hospice calendar did not accurately reflect the scheduled and completed skilled nursing (SN) and hospice aide (HA) visits as ordered by the physician. Staff interviews revealed a lack of clarity about the frequency of these visits, with the LVN unable to confirm how often the HA visited the resident and acknowledging that the hospice calendar was not properly marked. This incomplete documentation made it unclear whether the resident received the necessary hospice care as outlined in the care plan. Additionally, there was confusion among staff regarding the identity of the facility's hospice designee or coordinator. The LVN incorrectly identified the DON as the hospice coordinator, while facility documents indicated that the Social Services Director (SSD) held this role. The DON later confirmed that the SSD was the designated hospice coordinator. The resident involved had a primary hospice diagnosis of Alzheimer's disease, lacked capacity to make health care decisions, and required routine hospice care as per physician orders.
Inaccurate Infection Surveillance Documentation and Incomplete Data Collection
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically by not ensuring the accuracy and completeness of its monthly Infection Prevention and Control Surveillance Log and Surveillance Data Collection Forms. For the months of January and February 2025, the numbers recorded on the surveillance logs did not match the infection control monthly summary reports, resulting in inaccurate reporting of healthcare-associated infections (HAIs), community-acquired infections (CAIs), and infections not meeting McGeer's criteria. This discrepancy was confirmed by both the Infection Preventionist (IP) and the Director of Nursing (DON) during interviews and document reviews. Additionally, the Surveillance Data Collection Forms for several residents who received antibiotics for infections were incomplete, as they failed to indicate whether the infections were classified as HAI or CAI, despite documentation of antibiotic administration and McGeer's criteria assessment. The IP acknowledged that these forms were incomplete and that the infection data should have matched across all reports to ensure accurate infection control information. The DON also verified and acknowledged these findings during the review.
Failure to Safeguard Electronic Medical Records
Penalty
Summary
The facility failed to safeguard residents' medical records and protect confidential health information as required by its own policies and procedures. During an initial tour, a laptop containing residents' information was observed left open and unattended on top of a medication cart in a hallway near Nurses' Station A. The cart and laptop were unattended, with no licensed nurse present, while other staff, residents, and visitors passed by, making the information visible and accessible to unauthorized individuals. When questioned, an LVN acknowledged the laptop was left open and confirmed that the computer screen should have been closed to maintain privacy. The Director of Nursing (DON) was also informed of the incident and verified the findings. The facility's policy requires that workstation screens be positioned to limit public view and that staff log off when leaving terminals, but these procedures were not followed in this instance.
Inaccurate POLST Documentation of Advance Directive
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the documentation of the resident's Advance Directive on the POLST form. During a review of the medical record for one resident, it was found that the POLST form indicated the Advance Directive was not available, despite the fact that the document had been uploaded into the electronic medical record several days after the POLST was completed. This discrepancy was confirmed during an interview and concurrent record review with the Social Services Director, who acknowledged that the POLST form should have reflected the presence and review of the Advance Directive in the resident's current medical record. The facility's policy requires that all entries in the medical record be accurate, but this was not followed in the case of the resident's POLST documentation.
Multiple Food Safety and Sanitary Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitary requirements in the kitchen, leading to multiple deficiencies. Observations revealed that the meat thawing process was not followed, with various meat items lacking use-by dates or freezer pull dates. Additionally, expired food was not discarded, and Time/Temperature Control for Safety (TCS) foods were not monitored to ensure proper cooling. These lapses were confirmed by the Food and Nutrition Services Director (FNSD) and the Chef during interviews and inspections of the walk-in refrigerator and cook's preparation refrigerator. The facility also failed to maintain cleanliness and proper hygiene in the kitchen. Two ice machines were found to be unclean, with slimy and crusty residues observed on the ice machine deflector and chute. Dietary personnel did not wear appropriate hair and beard restraints, exposing food to potential contamination. Furthermore, food preparation equipment, including frying pans, muffin pans, and cutting boards, were found to be in poor condition with thick residue buildup and heavy knife marks. These issues were verified by the FNSD and the Plants Operation Manager. Additional deficiencies included improper storage and labeling of food items. A storage container was found with a scoop left inside, and a dry food storage container was not properly sealed. Food preparation equipment was not air-dried before storage, and opened food in the freezer was not properly labeled and dated. The drying rack was also observed to be dirty with yellow and black debris. These findings were confirmed by the FNSD and the Chef during the kitchen tour and interviews.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that Resident 33 was accurately assessed for the capability to self-administer medications. An opened bottle of oxymetazoline hydrochloride nasal spray was found on Resident 33's overbed table, and the resident admitted to using it daily to relieve a stuffy nose. However, there was no physician's order for the nasal spray, and the resident's assessment for self-administration of medications indicated no interest in self-administration. Additionally, the resident had a BIMS score of 9, indicating moderate cognitive impairment. During an interview and concurrent medical record review, LVN 4 confirmed that they were unaware of the nasal spray at the bedside and that Resident 33 had not been assessed for self-administration of the medication. No care plan was developed for the administration of the nasal spray, and there was no physician's order for its use. This oversight had the potential for unsafe medication administration for Resident 33.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the notification of change for a resident reviewed for weight loss. Specifically, the facility did not communicate Resident 14's significant weight loss to the resident's physician, responsible party, and registered dietitian (RD). This failure was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). The resident experienced a weight loss of 5.4% and 7.6 lbs. from 2/28/24 to 3/29/24, and a further weight loss of 6.5% and 9.2 lbs. from 3/7/24 to 4/3/24. Despite these significant changes, there was no documentation showing that the necessary notifications were made. During interviews, both RN 1 and the Director of Nursing (DON) confirmed that the resident's weight loss should have triggered notifications to the physician, RD, and responsible party. The DON stated that the charge nurse or clinical nurse supervisor is responsible for making these notifications once a significant weight change is identified. However, a review of Resident 14's medical record confirmed that these notifications were not made, which is a clear deviation from the facility's P&P and the guidelines outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual.
Improper Blood Pressure Measurement
Penalty
Summary
The facility failed to ensure services provided met professional standards of care when an LVN improperly took a blood pressure reading for a nonsampled resident. The LVN wrapped the blood pressure cuff on the resident's left upper arm and placed the diaphragm of the stethoscope on the left brachial artery over the resident's sweater, contrary to the facility's policy, which requires the diaphragm to be placed directly on the skin. This was confirmed during an interview with the LVN and the Director of Nursing (DON), who both acknowledged that the correct procedure was not followed.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to ensure timely intervention for a resident experiencing significant weight loss. Resident 14, who was readmitted to the facility after a hospital stay, showed a weight loss of 5.4% and 7.6 lbs from 2/28/24 to 3/29/24, and a further weight loss of 6.5% and 9.2 lbs from 3/7/24 to 4/3/24. Despite these significant weight changes, there was no documentation of intervention by the nutritional services or the Registered Dietician (RD). The facility's policy required a referral to dietary services and an assessment by the Nutritional Services Director or RD upon identification of significant weight loss, but this was not followed for Resident 14. Interviews with facility staff revealed that the process for addressing weight changes involved weekly Nutritional At Risk (NAR) meetings, which were disrupted due to the RD's vacation. The resident's weight loss was identified by the electronic health record (EHR) system, but there was no documentation showing that the weight loss was reported or addressed. The Director of Nursing (DON) confirmed that the resident's weight loss should have been addressed within the week, but the covering RD did not review Resident 14 during the RD's absence. This lack of timely intervention had the potential to result in continued nutritional decline for the resident.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that Resident 26 received appropriate respiratory care. Specifically, the oxygen tubing used by Resident 26 was not labeled and was observed touching the floor on multiple occasions. The facility's policy and procedure (P&P) for oxygen management, revised on 5/31/21, requires that nasal cannulas, masks, and tubing be changed every seven days, dated, timed, and initialed. However, during observations on 4/2/24 and 4/3/24, the oxygen tubing for Resident 26 was found to be non-compliant with these guidelines. Resident 26, who was admitted to the facility on an unspecified date, had a physician's order to administer oxygen at one to three liters per minute via nasal cannula to maintain oxygen saturation levels above 92%. Another order required the oxygen nasal cannula to be changed every Sunday night or as needed. During an interview on 4/3/24, RN 1 confirmed that the oxygen tubing was not labeled and was touching the floor, which was against the facility's P&P. The Director of Nursing (DON) was informed of these findings on 4/4/24 and verified the observations.
Failure to Accurately Reconcile Controlled Medication
Penalty
Summary
The facility failed to ensure that Resident 13's oxycodone-acetaminophen, a narcotic pain medication, was accurately reconciled. The Controlled Drug Record indicated that the medication was signed out on two occasions, but the electronic Medication Administration Record (MAR) did not show documented evidence of administration for these instances. This discrepancy was verified by LVN 3 during a controlled medication reconciliation. The facility's policy requires each dose of controlled drugs to be signed, dated, and timed out on the proof of count sheet prior to administration, and the medication nurse must sign out the dose, not just initial it. However, this procedure was not followed in the case of Resident 13's medication administration on the specified dates. Resident 13 was admitted to the facility and had the capacity to understand and make decisions, as noted in the Internal Medicine H&P examination. A physician's order was in place for the administration of oxycodone-acetaminophen for moderate to severe pain. Despite this, the medication bubble pack showed the correct number of remaining tablets, indicating that the medication was removed but not properly documented as administered. The Director of Nursing (DON) acknowledged the findings and confirmed that licensed nurses are required to sign both the Controlled Drug Record and the MAR, which was not done in this case.
Improper Disposal and Storage of Medications
Penalty
Summary
The facility failed to ensure the proper disposal and storage of medications. In Medication Cart A, two open boxes of Restasis eye drops were stored next to three boxes of levalbuterol inhalation solution. This was verified by an LVN during an observation and interview. In Medication Room A, a waste disposal bin with multiple whole tablets inside was observed, and various medications were improperly stored together. An LVN confirmed these findings and stated that the facility did not use any liquid to dissolve the tablets, contrary to the facility's policy. The DON acknowledged that non-narcotic medications should be dissolved using the Drug Disposal System Rx Destroyer solution and disposed of daily or weekly as necessary. During an initial tour, a resident was found with a bottle of Theraworx Muscle Cramps foam on top of their bedside cabinet, which had been brought in by a family member but not used at the facility. The resident was cognitively intact, and an LVN verified the finding, stating it was the first time seeing the medication. The DON was informed and acknowledged this finding as well.
Incompetence in Food and Nutrition Services Management
Penalty
Summary
The facility failed to ensure that the Food and Nutrition Services Director (FNSD) was competent in managing the day-to-day functions of the food services department. The FNSD's personnel file lacked documentation of food service training, such as a certification from the American National Standards Institute-Conference for Food Protection, to show training in food service safety and sanitation guidelines. During the annual recertification survey, multiple issues were found in the main kitchen, including improper thawing processes for meats, failure to discard expired food, lack of monitoring of cooling for TCS foods, inadequate hair and facial hair covering, and improper storage of food and refuse. These deficiencies were observed despite the FNSD's claims of conducting kitchen walk-throughs and in-servicing staff. Interviews with the FNSD and the Administrator revealed gaps in the oversight and competency assessment of the kitchen staff. The FNSD stated that employee competency was evaluated once a year and that the Chef was responsible for overseeing back-of-the-house activities. However, the FNSD could not provide written documentation of kitchen inspections. The Administrator mentioned that department heads' competency was assessed based on their experience, knowledge of policies and procedures, and oversight by a consultant Dietitian. Despite these measures, the facility failed to ensure that the FNSD and kitchen staff were adequately trained and competent, leading to multiple deficiencies in the food services department.
Failure to Follow Puree Procedure for Meat and Vegetables
Penalty
Summary
The facility failed to ensure the resident menu was followed correctly during the preparation of pureed meals, specifically for meat and vegetables. During an observation of lunch meal preparation, Cook 3 did not adhere to the facility's recipe for pureed vegetables and meat. For the pureed green beans, Cook 3 added more thickener than specified in the recipe after initially finding the mixture too runny. Similarly, for the pureed pork, Cook 3 used incorrect measurements and added extra broth and thickener to achieve the desired consistency. These deviations from the recipe resulted in an inconsistent product that may not meet the nutritional needs of the residents on pureed diets. The issue was confirmed during a discussion with the Administrator, Food and Nutrition Services Director (FNSD), Registered Dietitian (RD), and Chef, who acknowledged that the puree procedure was not followed correctly. This failure posed a risk to the nutritional adequacy of the meals provided to the five residents who received pureed diets, as the consistency and nutritional content of the food could be compromised by not following the established recipes and procedures.
Failure to Honor Resident's Food Preference
Penalty
Summary
The facility failed to honor the food preference for one of the sampled residents, Resident 17, which had the potential for inadequate nutrition. The facility's policy and procedure (P&P) required obtaining food preferences, allergies, or intolerances and noting them on the dietary interview/pre-screen form and tray card. Despite Resident 17's expressed dislike for cranberry juice, which she communicated to the staff, she continued to be served cranberry juice for breakfast on multiple occasions. This was observed during concurrent observations and interviews with Resident 17 on two consecutive days. The Licensed Vocational Nurse (LVN) 4 acknowledged the resident's preference and noted it on her diet card, but the diet order was not updated accordingly, resulting in the resident being served cranberry juice again the following day. Further interviews revealed that the facility's process for updating food preferences was not followed correctly. LVN 4 confirmed that despite noting the resident's preference, the diet card still listed cranberry juice as the beverage. The Food and Nutrition Services Director (FNSD) stated that the nurse could communicate changes to the kitchen staff either verbally or through a slip, but this process was not effectively implemented in this case. As a result, Resident 17's food preference was not honored, indicating a failure in the facility's system to ensure residents' dietary needs and preferences are met as per their policy.
Failure to Communicate Safe Food Handling Guidelines to Visitors
Penalty
Summary
The facility failed to ensure the safe food handling guidelines were communicated to the residents' family members and visitors who brought food from outside. The facility's policy and procedure (P&P) titled 'Food from Outside Sources' required the community to help visitors understand safe food handling practices as summarized in the 'Safe Food Handling Guide for Visitors and Staff (DOC 403)'. However, during an interview, an LVN stated that she only educated family members and visitors about the resident's diet and not on safe food handling. Additionally, the Director of Nursing (DON) confirmed that while staff received in-service training on outside food and safe food handling, the facility had not provided the Safe Food Handling Guide to family members and visitors, citing that it was overwhelming for them to read the document.
Incomplete POLST Forms for Three Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for three residents reviewed for advanced directives. Specifically, the POLST forms for Residents 14, 26, and 35 were found to be incomplete. For Resident 14, the POLST form was missing information in Section D regarding the presence and review of an advance directive. The SSD admitted to leaving this section blank, hoping the resident would eventually have capacity to make decisions. Similarly, Resident 35's POLST form also had an incomplete Section D, with the SSD again leaving it blank to avoid having to complete a new POLST if the resident later formulated an advance directive. Resident 26's POLST form was incomplete as well, with the SSD waiting for the resident's family to submit the advance directive, which was pending at the time of the review. Interviews and concurrent medical record reviews with the SSD and DON confirmed these deficiencies. The SSD acknowledged the incomplete sections and provided reasons for leaving them blank, while the DON verified the findings and stated that the expectation was for all resident documents to be completed. These actions and inactions led to the potential risk of the residents' advanced directive statuses not being communicated to healthcare staff in the event of an emergency.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility did not implement a water management program to prevent the growth of Legionella and other opportunistic pathogens. The Plant Operation Manager was unable to provide documentation of control measures, corrective actions, or contingency response plans, and incorrectly believed that ongoing testing and control measures were unnecessary if there was no standing water. The Infection Preventionist was also unaware of the implementation and oversight responsibilities for Legionella monitoring, as outlined in the facility's policy and CDC guidelines. Additionally, the facility failed to ensure proper hand hygiene practices among staff. During a medication pass, an LVN did not change gloves or perform hand hygiene after touching a bedside table before administering eye drops to a resident. The LVN also used the same tissue for both eyes, contrary to the facility's hand hygiene policy. The DON confirmed that the gloves should have been changed and separate tissues should have been used for each eye. Furthermore, a CNA did not perform hand hygiene after touching a floor mat with bare hands before delivering a meal tray to another room. The CNA acknowledged the lapse in hand hygiene and admitted to not knowing if hand hygiene was necessary in that situation, despite having received prior training. The DON was informed and acknowledged these findings, which indicate a failure to adhere to the facility's hand hygiene policy.
Failure to Revise Comprehensive Care Plan for Pain Management
Penalty
Summary
The facility failed to ensure the comprehensive plan of care for Resident 639 was revised to address the resident's specific care needs and interventions. The facility's policy and procedure (P&P) required the Interdisciplinary Team to develop and implement a comprehensive person-centered care plan for each resident within seven days after the completion of the comprehensive assessment and after each Minimum Data Set (MDS) assessment, except the discharge assessment. The care plan should be reviewed and revised as the resident's conditions change. However, the care plan for Resident 639, who was admitted to the facility on an unspecified date, was not updated to include non-pharmacological interventions for pain management as ordered by the physician on 3/17/24. These interventions included repositioning, dim light/quiet environment, hot/cold applications, relaxation, distraction, music, massage, aromatherapy, and other methods documented in progress notes. On 4/3/24, during an interview and concurrent medical record review, LVN 1 confirmed that Resident 639's plan of care did not include the non-pharmacological interventions for pain as ordered by the physician. LVN 1 stated that she documented the non-pharmacological interventions provided on the Medication Administration Record (MAR) under the resident's behavior. On 4/4/24, the Director of Nursing (DON) was informed of the findings and acknowledged the deficiency. This failure posed a risk for Resident 639 to not receive the care and services required to attain or maintain their highest level of physical and mental well-being.
Improper Trash Storage
Penalty
Summary
The facility failed to store trash in a sanitary manner, as evidenced by the improper covering of a green organic trash container and one of three dumpsters. During an initial tour of the kitchen, a green organic trash container with raw vegetables inside was observed without a cover, which the Food and Nutrition Services Director (FNSD) stated was broken. Later, an observation of the trash disposal area revealed that the lid of one of the dumpsters was fully open. The Environmental Services (EVS) Manager acknowledged that staff had forgotten to close the dumpster cover and admitted to having ongoing issues with employees not closing the dumpster lids. The facility's policy and procedure (P&P) on garbage and trashcans, revised on 5/20/20, mandates that all food waste must be placed in covered garbage and trashcans, and that dumpster lids must be closed to prevent pest harboring, in accordance with the US Food Code 2022, Section 5-501.113.
Failure to Address Dementia Care Needs in Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure the comprehensive care plan reflected the current care needs and interventions for one resident diagnosed with dementia. The facility's policy required the Interdisciplinary Team to develop and implement a comprehensive person-centered care plan with measurable objectives and time frames within seven days after the completion of the comprehensive assessments. However, during a medical record review and interview with an LVN, it was found that the care plan for the resident did not address the specific care needs related to dementia. The LVN confirmed the absence of documentation for the resident's care plan problem specific to dementia, verifying the deficiency.
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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