Palomar Vista Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Escondido, California.
- Location
- 201 N Fig Street, Escondido, California 92025
- CMS Provider Number
- 055067
- Inspections on file
- 30
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Palomar Vista Healthcare Center during CMS and state inspections, most recent first.
The facility failed to confirm HH services and accurately document post-discharge arrangements before discharging three residents who required ongoing skilled care at home. One resident with a peritoneal abscess and a wound VAC was discharged with orders for RN, wound care, and PT visits, and the discharge paperwork named a specific HHA, but the referral was not sent until after discharge and was then declined, with no discharge-planning notes until days later. Another resident with impaired mobility and pneumocystosis was discharged with orders for RN and PT visits; the discharge summary listed an HHA as arranged even though acceptance was still pending, and only hours after discharge was it documented that the agency had declined, with a different HHA accepting the referral the following day. A third resident with acute cholecystitis and digestive tract ostomies had a discharge summary stating HH services were arranged, while documentation showed the referral was still pending and staff later acknowledged they never confirmed acceptance or followed up before or after discharge. Interviews with leadership and existing policy confirmed that HH referrals should have been initiated early and agencies confirmed prior to discharge, which did not occur in these cases.
Two residents in a facility were using a bathroom without safety rails, which are crucial for safe toilet transfers. One resident required substantial assistance due to conditions like malignant neoplasm and chronic respiratory failure, while the other needed supervision due to gait abnormalities and a history of falls. The absence of safety rails was confirmed by staff and the facility's administrator, who stated they were removed for wall repairs and not replaced, despite the facility's policy requiring them.
A resident with hemiplegia and hemiparesis experienced ongoing diarrhea and developed purple, swollen feet, but the facility failed to create a care plan addressing these issues. Despite documentation of the resident's symptoms, no care plan was developed, leading to delayed care and decreased physical well-being. The facility's policy required comprehensive care plans, which were not implemented in this case.
A resident with hemiplegia and hemiparesis experienced continued diarrhea and skin breakdown due to the facility's failure to administer prescribed diarrhea medication. Despite having an order for Loperamide HCL, it was only given once, and the stool softener was not consistently held. The facility's policy required adherence to physician orders, which was not followed, putting the resident at risk for fluid deficit and dehydration.
A resident with hemiplegia and hemiparesis developed a deep tissue injury due to inadequate care and monitoring of a rash and diarrhea episodes. The facility failed to reposition the resident every two hours and did not document or follow up on the resident's skin condition, leading to the development of a pressure ulcer.
The facility failed to provide RN coverage for eight consecutive hours daily, leading to inconsistent care oversight. Payroll data showed low weekend staffing and a 1-star quality rating. Interviews revealed challenges in maintaining RN staffing, with the DON occasionally assisting on the floor. The facility lacked a staffing policy, contributing to the deficiency.
The facility failed to ensure a sanitary kitchen environment, with unlabeled food items and staff personal items improperly stored in the refrigerator. Additionally, a coil above the food shelf was covered in debris, posing a contamination risk. These issues violated FDA Food Code requirements and increased the risk of foodborne illness.
A resident with neuromuscular dysfunction of the bladder experienced delays in incontinent care, leading to feelings of upset and neglect. The resident reported waiting for hours to be changed, as CNAs were occupied with other tasks. The DON acknowledged the discomfort and potential skin issues resulting from such neglect.
A facility failed to complete the PASRR II evaluation for a resident with schizoaffective disorder, despite a positive Level I screening. The resident, who had been in and out of the facility since 2021, was observed experiencing visual hallucinations. Interviews with staff revealed confusion and lack of responsibility regarding the PASRR process, with no assigned personnel to review and follow up on screenings. The facility's policy required proper PASRR screening, but it was not followed, risking the resident's access to necessary mental health care.
Two residents in the facility did not have appropriate care plans developed to address their specific medical needs. One resident, with obstructive sleep apnea, lacked a care plan for CPAP use, while another, receiving IV antibiotics through a PICC line, had no care plan for its management. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to meet the residents' care requirements.
A resident with obstructive sleep apnea reported that their CPAP machine was not working well and had requested a replacement since admission. Observations revealed the CPAP mask and tubing were held together with tape, indicating a need for replacement. A licensed nurse confirmed the machine needed replacement, and the Director of Nursing expected checks before use. However, the facility's policy lacked guidance on checking the machine's function.
A resident with end-stage renal disease did not receive consistent dialysis access site care as required. The resident, who had mild cognitive impairment, was observed with an intact dressing on the dialysis site, which he often removed himself. Facility staff interviews revealed that the dressing should be removed three hours post-dialysis to prevent infection and allow for assessment, as per physician's orders. The facility's policy required licensed nurses to provide vascular access site care, but this was not consistently followed.
The facility failed to follow infection control practices for three residents, leading to potential contamination of medical equipment. A resident's CPAP mask was left exposed, another's IV tubing and PICC line dressing were undated, and a third resident's CPAP mask was improperly stored. The facility's policies lacked guidance on proper storage and labeling, contributing to these deficiencies.
The facility failed to assess a resident's ability to self-administer medications, leading to a potential risk of over or under medication. The resident, with hemiplegia and hemiparesis, self-administered antibiotics and an ointment without any assessment or supervision from the nursing staff. The facility's policy for self-administration of medications was not followed.
Failure to Confirm Home Health Services Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that home health (HH) services were confirmed and accurately reflected in discharge documentation prior to residents’ discharge. For Resident 1, who was admitted with a peritoneal abscess and required surgical wound dressing changes, there was an order for discharge with HH services for RN visits, wound care, and PT. The discharge summary and post-discharge plan of care identified a specific home health agency as arranged, and the resident was discharged with a wound VAC in place. However, the referral to that agency was not faxed until approximately 29 minutes after the resident had already left the facility, and the agency did not accept the referral. There were no progress notes documenting discharge planning prior to the social services assistant’s (SSA) notes four days after discharge. The resident later reported to a GACH that no nurse had come to his home and that he did not know how to care for his wound VAC. For Resident 2, admitted with difficulty walking and pneumocystosis, an order was written for discharge to home with HH services for RN and PT visits. A discharge progress note documented that a referral had been sent to a home health agency and was pending review and acceptance, yet the discharge summary and post-discharge plan of care stated that this same agency had been arranged to provide services. The resident was discharged home, and more than three hours after discharge, a discharge planning note documented that the agency did not accept the referral. Over 24 hours after discharge, the SSA documented that a different home health agency confirmed acceptance of the referral. The SSA later stated that the day she documented the acceptance was the day the second agency confirmed, which was the day after the resident’s discharge. For Resident 3, admitted with acute cholecystitis and artificial openings of the digestive tract, the discharge summary stated that HH services had been arranged with a specific home health agency. A discharge planning note documented that a referral had been made to that agency and was pending review and acceptance. The social services staff stated she sent the referral but did not hear back from the agency regarding acceptance and did not have a chance to follow up on the referral before or after the resident’s discharge. In interviews, the administrator stated that referrals to HH agencies should have been initiated as soon as the facility became aware of a resident’s discharge date, and the DON in training stated that HH agencies should have been confirmed prior to residents’ discharges. The facility’s own policy required that discharge needs be identified on admission and that a discharge plan be developed and implemented in a timely manner to effectively transition residents to post-discharge care.
Absence of Safety Rails in Resident Bathroom
Penalty
Summary
The facility failed to provide safety rails in a bathroom used by two residents, which had the potential to lead to accidents related to toilet use. Resident 7, admitted for respite care, required substantial or maximal assistance for toilet transfers due to conditions such as malignant neoplasm of the bladder, surgery of the genitourinary system, and chronic respiratory failure. Resident 11, who had abnormalities of gait, muscle weakness, cerebral infarction, and a history of falls, required supervision or touching assistance for toilet transfers. Both residents had access to a bathroom that lacked safety rails, which are essential for maintaining balance and ensuring safe transfers. Observations and interviews conducted on the same day revealed that the bathroom connecting two rooms did not have safety rails by the toilet or anywhere else in the bathroom. Complainant 1, the spouse of Resident 7, confirmed the absence of safety rails. Resident 11, observed using a walker with an irregular gait, also confirmed the lack of safety rails and expressed that using the toilet would be easier with them. Both a CNA and a licensed nurse confirmed the absence of safety rails and emphasized their importance for resident safety during toilet use. The facility's administrator explained that the safety rails had been removed due to wall repairs following a flood, and they had not been replaced. The facility's policy, dated November 2007, mandates that bathrooms must be equipped with safety rails. The failure to replace the safety rails after the repairs created a potential hazard for residents who required assistance with toilet transfers, as confirmed by multiple staff members and the facility's policy.
Failure to Develop Care Plan for Resident's Diarrhea and Swollen Feet
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced diarrhea and purple feet with swelling. The resident, admitted with hemiplegia and hemiparesis following cerebrovascular disease, had loose bowel movements documented over several days and a change in condition noted with swelling and discoloration of the feet. Despite these ongoing issues, the facility did not create a care plan to address these specific health concerns. Interviews and record reviews revealed that the Director of Nurses acknowledged the absence of care plans for the resident's diarrhea and foot condition. The facility's policy required the interdisciplinary team to develop person-centered care plans with measurable objectives and timeframes to meet residents' needs. The lack of a care plan resulted in delayed care and decreased physical well-being for the resident, as staff were not guided or alerted to the necessary interventions for the resident's conditions.
Failure to Administer Diarrhea Medication
Penalty
Summary
The facility failed to administer a medication for diarrhea to a resident, leading to continued diarrhea and skin breakdown on the sacro-coccyx area. The resident, who was admitted with hemiplegia and hemiparesis following cerebrovascular disease, had an intact cognitive score. Despite having an order for Loperamide HCL for diarrhea, the medication was only administered once, and the resident experienced loose bowel movements over a period of 12 days. Additionally, a stool softener was ordered but not consistently held despite the presence of diarrhea, and the resident refused the stool softener on several occasions. Interviews with the licensed nurse and the Director of Nurses revealed that the medication for diarrhea was not administered as needed, and the stool softener was not appropriately held. The facility's policy required medications to be administered according to the physician's written orders, which was not followed in this case. This oversight resulted in the resident being at risk for fluid deficit and dehydration due to the ongoing diarrhea.
Failure to Prevent Pressure Ulcer Formation
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcer formation for a resident with hemiplegia and hemiparesis following cerebrovascular disease. The resident was admitted with a low air loss mattress to prevent skin breakdown, but the facility did not ensure proper repositioning every two hours or timely changing of briefs after episodes of diarrhea. This lack of care led to the resident developing a deep tissue injury on the sacro-coccyx, which was identified upon transfer to the hospital. Interviews with licensed nurses and the treatment nurse revealed that the resident had a rash in the perianal area, which was not adequately documented or monitored. The nursing progress notes lacked detailed descriptions of the rash and its progression, and there was no follow-up documentation regarding the moisture-associated dermatitis. The Director of Nursing confirmed the absence of necessary documentation and stated that licensed nurses were expected to document skin evaluations every shift, which was not done in this case.
Inadequate RN Coverage and Oversight
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, resulting in inconsistent oversight for the coordination, management, and overall delivery of care to residents. The facility's payroll-based journal data indicated low weekend staffing and a 1-star rating for quality of healthcare service in 2024. A review of the facility's daily census for April, May, and June 2024 revealed multiple instances where there was less than eight hours of RN coverage or no RN present for the required duration on specific dates. Interviews with the Staffing Coordinator and the Director of Nursing (DON) highlighted challenges in maintaining adequate RN staffing, particularly on weekends. The Staffing Coordinator mentioned that the DON would sometimes act as a charge nurse and assist on the floor. The DON admitted to not knowing the required RN hours due to the facility's census being below 74 and acknowledged the importance of RN oversight for assessments. It was also noted that the facility lacked a staffing policy, contributing to the deficiency in RN coverage.
Deficiencies in Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen, which increased the risk of foodborne illness and cross-contamination. During an observation, it was noted that the kitchen walk-in refrigerator contained items such as ketchup, soy sauce, and Italian dressing without a use-by date. Additionally, a staff member's plastic water bottle and beverage were improperly stored in the refrigerator. Other food items, including shredded carrots, hot dogs, tortillas, and onions, were not labeled or identified, violating the 2022 US FDA Food Code requirements for food labeling. Further inspection revealed a coil above the food shelf in the refrigerator covered with gray debris, which could potentially contaminate food. The registered dietician acknowledged the issue and indicated that maintenance would be notified. The facility's policies and procedures lacked specific guidance on maintaining the kitchen refrigerator, contributing to these deficiencies. The failure to properly label food and maintain equipment as per the FDA Food Code posed a risk to resident health by potentially exposing them to contaminated food.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to Resident 59, who was admitted with neuromuscular dysfunction of the bladder and muscle weakness. The resident, who was cognitively intact and dependent on assistance for toileting hygiene, reported feeling upset due to delays in receiving care. On one occasion, the resident waited from 6:30 AM to be changed, as the CNA was occupied with passing breakfast trays. This delay in care led to the resident feeling upset and neglected. Further observations revealed that Resident 59 experienced another incident where he was left wet and smelling of urine after a condom catheter came off during the night. The resident called for assistance at 4 AM, but the night shift CNA did not attend to him until 5:25 AM, and even then, deferred the task to the morning CNA. The morning CNA confirmed that the resident's brief was wet at the start of her shift. The Director of Nurses acknowledged that such neglect could cause discomfort and potential skin problems for residents.
Failure to Complete PASRR II Evaluation for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review Level II (PASRR II) for a resident with a mental disorder, specifically schizoaffective disorder. The resident, who had been in and out of the facility since 2021, was readmitted with a diagnosis of schizoaffective disorder. Despite a positive Level I screening indicating the need for a Level II mental health evaluation, the evaluation was not completed due to inaccurate information provided to the State of California-Health and Human Services. The facility's staff, including the Director of Nurses (DON), admitted that there was no assigned personnel to review and follow up on PASRR Level I screenings. Interviews with various staff members, including the certified nurse assistant (CNA), licensed nurse (LN), minimum data set nurse (MDSN), and admissions director (AD), revealed a lack of clarity and responsibility regarding the PASRR process. The CNA noted the resident's refusal of certain care activities, while the LN observed the resident experiencing visual hallucinations. The MDSN and AD both indicated that PASRRs were received from the hospital, but there was confusion about who was responsible for their review and follow-up. The facility's policy stated the requirement for proper PASRR screening, yet it was not adhered to, leading to the potential for the resident not receiving necessary mental health care services in an appropriate setting.
Failure to Develop Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to develop patient-centered care plans for two residents, which could potentially lead to unmet care needs. Resident 169, who was admitted with obstructive sleep apnea and chronic hypoxia, was observed using a CPAP machine at night. However, there was no care plan in place to guide staff on monitoring the resident's breathing, cleaning the CPAP machine, or adding water to it. This oversight was confirmed during a record review and interview with a licensed nurse, who acknowledged the absence of a care plan for the CPAP use. Similarly, Resident 170, admitted with sepsis and receiving IV antibiotics through a PICC line, also lacked a care plan addressing the management of the PICC line. The physician's orders required daily site checks and flushing of the PICC line, but no care plan was developed to ensure these tasks were performed. The Director of Nurses confirmed that care plans should be completed within 14 days, yet this was not done for Resident 170, as revealed during an interview and record review.
Failure to Ensure Functioning CPAP Machine for Resident
Penalty
Summary
The facility failed to ensure that a CPAP machine was functioning properly for a resident diagnosed with obstructive sleep apnea. The resident, who was cognitively intact, reported that the CPAP machine was not working well and had requested a replacement since admission. During an observation, it was noted that the CPAP mask and tubing were held together with gray tape, indicating a need for replacement. A licensed nurse confirmed that the CPAP machine needed to be replaced and acknowledged that it should be functional for the resident to receive its intended benefits. The Director of Nursing stated that licensed nurses were expected to check the CPAP machine before each use to ensure it was functioning properly. However, the facility's policy and procedure for CPAP/BiPAP monitoring and management did not provide guidance for staff to check the machine's function. This oversight had the potential to adversely affect the health and well-being of the resident, as the CPAP machine was essential for managing the resident's obstructive sleep apnea.
Failure to Provide Proper Dialysis Access Site Care
Penalty
Summary
The facility failed to consistently provide appropriate dialysis access site care and assessment for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, who had mild cognitive impairment, was observed to have a dialysis access site on the right upper arm with a dressing intact. The resident reported that he often removed the dialysis dressing himself, which was contrary to the physician's orders that specified the dressing should be removed three hours after dialysis treatment. The resident's dialysis treatments were scheduled for Tuesdays, Thursdays, and Saturdays, and the last recorded dialysis appointment was on a Saturday. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that the dressing should be removed to allow for proper assessment and to prevent infection and bleeding. The facility's policy indicated that vascular access site care should be provided by a licensed nurse according to physician's orders. However, the failure to remove the dressing as required meant that the site could not be assessed, potentially leading to complications. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Infection Control Deficiencies in CPAP and IV Management
Penalty
Summary
The facility failed to adhere to current infection control practices for three residents, leading to potential contamination of medical equipment. Resident 169's CPAP mask was observed left on top of the CPAP machine, exposed to air, rather than being stored in a plastic bag as required for infection control. This was confirmed by a licensed nurse who acknowledged the improper storage of the CPAP mask. Resident 170's IV tubing and PICC line dressing were not properly labeled with dates, which is a critical step in preventing infections. The IV bag and tubing were observed without a date, and the PICC line dressing was undated and worn out. The Director of Nurses confirmed that the lack of labeling and proper dressing changes could be a route for infection, and the facility's policy did not provide adequate guidance on labeling PICC line dressings. Resident 126's CPAP mask was also found uncovered on the bed, contrary to infection control protocols that require it to be stored in a plastic bag. The resident admitted to not cleaning the CPAP machine regularly, and the Infection Preventionist Nurse emphasized the importance of storing the mask properly to prevent exposure to microorganisms. The facility's policy lacked guidance on CPAP mask storage, contributing to the deficiency.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, which led to a potential risk of over or under medication. Resident 3, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, reported having a red rash on his right leg and had been prescribed antibiotics and an ointment by a dermatologist. Resident 3 picked up the medications from the pharmacy and self-administered them without any assessment or supervision from the nursing staff. The resident stated that the nursing staff did not check if he was able to self-administer medications. During interviews, the assigned medication nurse and the Director of Nurses (DON) confirmed that they were aware Resident 3 brought in medications from an outside pharmacy but had not conducted an assessment for self-administration. The facility's policy required a physician's order, an assessment, a care plan, and a lock box for self-administration of medications, none of which were followed. The DON acknowledged the importance of knowing if a resident kept medications at bedside to prevent potential drug interactions and overdoses. The facility's policy and procedure for self-administration of medications were not adhered to in this case.
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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