Park View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 3751 Montgomery Dr, Santa Rosa, California 95405
- CMS Provider Number
- 056411
- Inspections on file
- 34
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Park View Post Acute during CMS and state inspections, most recent first.
A resident with Parkinson's disease, dyskinesia, dysphonia, muscle weakness, and intact cognition reported that an unlicensed staff member repeatedly engaged in sexual contact with her during personal care, including digital and penile penetration, despite her saying no. A licensed nurse observed the staff member at the bedside with his pants pulled down, holding his exposed penis, which was pressed against the resident’s buttock while his hand was on her buttock. The business office manager was informed and interviewed the involved staff, and the unlicensed staff member did not deny having his penis exposed. A charge nurse reported the resident said that boundaries were crossed, that the staff member was rough, pushed his fingers on her anus, and lingered too long during care. A police detective later reported that the resident described multiple incidents of sexual contact and that the staff member admitted to inappropriate touching with his penis and fingers on multiple occasions, despite a facility policy of zero tolerance for abuse.
A nurse left a cup with two heart medication pills unattended at the bedside of a resident with multiple cardiac conditions and dementia. The resident was unable to identify the pills, and there was no authorization for self-administration or bedside storage in the medical record or care plan. Facility policy requires medications to be secured and not left at the bedside without a written order. The DON confirmed the incident and acknowledged the safety risk.
A resident with a history of pneumonia, asthma, and COPD was transferred to the hospital, but vital signs were documented in the medical record after the resident had already left the facility. The DON confirmed this was a documentation error, and the facility's policy required timely and accurate recording of vital signs.
Licensed nursing staff did not update a resident's care plan to include BIPAP therapy, despite physician orders and the resident's diagnoses of respiratory failure, sleep apnea, and morbid obesity. As a result, the resident did not receive BIPAP therapy on one occasion due to inoperable equipment, and the care plan did not reflect this essential intervention.
A resident with multiple chronic conditions did not receive ordered BIPAP therapy due to an inoperable machine, and the physician was not notified by nursing staff. Additionally, the same resident missed a scheduled dose of Ozempic® for diabetes management because the medication was unavailable, and again, the physician was not informed. Facility leadership and staff interviews confirmed that required notifications were not made in both cases.
A resident with pulmonary hypertension, end stage kidney disease, and diabetes received incorrect dosages of Uptravi due to staff administering either one or four tablets per dose based on conflicting information between the MAR and the medication bottle label. Nursing staff did not consistently verify the tablet strength, leading to rapid depletion of the medication supply and concerns raised by the family. The DON became aware of the issue after a refill was requested sooner than expected, and facility policy regarding verification of medications brought in by family was not followed.
A resident with Epilepsy and Restless Leg Syndrome did not receive six scheduled medications due to delayed arrival, and the physician was not notified of the missed doses. The DON confirmed the importance of administering medications as ordered and notifying the physician, especially for critical medications like Levetiracetam, which could lead to seizures if missed.
A speech therapist failed to follow contact enteric precautions for a resident with an active Cdiff infection, entering the room without performing hand hygiene, wearing gloves, or donning a gown, and leaving without washing hands with soap and water. The infection preventionist and DON confirmed the importance of these precautions to prevent infection spread.
The facility failed to honor resident rights by not responding promptly to call lights, leading to residents waiting for assistance and experiencing distress. Additionally, the facility did not adhere to its smoking policy, allowing a resident to smoke unsupervised. Staff also used residents' rooms as shortcuts, compromising their privacy.
The facility did not ensure residents knew how to contact the Department to file a complaint. During a Resident Council interview, all 12 residents were unaware of where to find this information. The Activities Director confirmed that the contact details were not discussed in meetings, and the Medical Records Director stated there was no policy on providing this information. The facility's Resident Rights policy mentioned communication with outside agencies but lacked specifics on informing residents.
The facility did not update the survey binder with investigation results since 2021 and failed to inform residents of its location. The Administrator confirmed deficiencies were received after 2021 but not included in the binder. Residents were unaware of the binder's location, and the Activities Director had not discussed it during Resident Council meetings. The facility lacked a policy on informing residents about the binder, despite a policy indicating residents' rights to examine survey results.
The facility failed to maintain a comfortable noise level, disturbing residents' rest and sleep. Multiple residents with intact cognition reported excessive noise, particularly during the night, caused by staff and other residents. Despite being a recurring issue in Resident Council meetings, the noise problem persisted, indicating a failure to adhere to the facility's policy on maintaining a homelike environment.
The facility failed to ensure the Resident Council knew how to file a grievance, as the Social Services Director had not attended meetings due to scheduling conflicts. A review of meeting minutes and interviews revealed that most residents were unaware of the grievance process. The facility's grievance policy did not specify how residents would be informed of their rights or the process.
A facility failed to follow professional standards when an LVN left medications, including potassium chloride, on a resident's bedside without a self-administration order. Additionally, LVNs improperly signed off on IV medications administered by RNs, leading to inaccurate records. The facility's policy requires the administering individual to sign the MAR, which was not adhered to.
Three residents were not provided with activities that matched their interests, leading to potential negative impacts on their well-being. One resident with ALS was not given supplies for her interests, another with heart failure had inaccurate activity evaluations, and a third with pneumonitis was only observed watching TV. The facility's policies on resident-centered activities were not followed.
The facility's QAPI program was ineffective due to inadequate data tracking and reassessment of interventions. The Administrator failed to document call light response times and did not reassess interventions for reducing falls and missing items, despite increases in both areas. The facility's policy emphasized continual assessment, which was not followed.
The facility failed to maintain a safe kitchen environment due to unrepaired cracks and missing tiles on the floor, which were observed during a survey. The Maintenance Supervisor acknowledged the need for repairs and mentioned a proposed grease trap project that included floor replacement, pending approval.
The facility failed to maintain a system for tracking staff compliance with mandatory training, leading to potential inadequacies in staff competency. The DSD could not provide evidence of training participation for all staff, and some mandatory trainings were overdue. This deficiency highlights a gap in the facility's training compliance and tracking system.
A resident with multiple medical conditions was transferred to a hospital due to worsening symptoms, but the facility failed to notify the Long-term Care Ombudsman as required. The Notice of Transfer/Discharge form was incomplete, lacking the resident's name and the date of notification to the Ombudsman. The Social Services Assistant could not find documentation of the notification, and the Social Services Director confirmed the expectation for prompt notification. The facility's policy mandates notifying the Ombudsman simultaneously with the resident or their representatives during emergency transfers.
The facility failed to develop comprehensive care plans for two residents, leading to potential negative outcomes. One resident with ALS and Dysphagia was not engaged in activities reflecting her interests, while another resident with a fractured arm did not have a care plan addressing this condition. The facility's policies on activity assessment and care planning were not followed, impacting the quality of care provided.
A resident with fractures in both arms was inaccurately assessed as medium fall risk upon admission, as the presence of a sling and the fracture diagnosis were not documented. Staff interviews confirmed these omissions, and the DON acknowledged that the fall risk assessment should have included the fracture as a risk factor, which could have led to inadequate precautions.
A facility failed to ensure nursing staff had updated competencies, leading to inadequate care for a resident with complex medical needs. A resident experienced a critical change in condition, but the staff did not notify the physician or document the incident. The Director of Staff Development lacked a system to track mandatory training, resulting in incomplete training records for staff. This deficiency posed a risk to resident safety due to insufficient staff preparedness.
The facility failed to ensure sanitary storage of portable urinals, as observed with two residents in the same room. A strong urine odor was noted, and one resident's urinal was placed on an overbed table next to a drinking mug. A nurse acknowledged the unsanitary condition and moved the urinal. The facility's procedure lacked specific cleaning instructions and did not address handling urinals for residents with UTIs.
Failure to Protect a Resident From Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. The resident, who had Parkinson's disease with dyskinesia, dysphonia, muscle weakness, and intact cognition per a recent MDS (BIMS score 13), was dependent on staff for care and had contracted limbs. On one occasion, a licensed nurse entered the resident's room and observed an unlicensed staff member standing beside the resident, with his pants pulled down in the front, holding his exposed penis in his hand. The nurse saw his penis pressed against the resident’s left buttock at the gluteal fold while his other hand was on the resident’s left buttock. The resident was lying on her bed with her legs contracted, positioned on the right side of the bed, facing the door, with her buttocks on the edge of the left side of the bed where the unlicensed staff member was standing. Following this event, the business office manager was informed and interviewed both the licensed nurse and the unlicensed staff member. The unlicensed staff member did not deny having his penis exposed in the resident’s room and responded, "I don't know" and "whatever she said" when asked about the allegation. The resident later reported that the unlicensed staff member had been inappropriate with her, that he did things she did not want him to do, and confirmed that he had inserted two to three fingers into her vagina when cleaning her and had put his penis in her vagina more than once, despite her saying no. A charge nurse reported that the resident stated "boundaries were crossed" during personal care, that the staff member sometimes pushed his fingers on her anus, was rough, and lingered too long in her room. A police detective stated that the resident reported multiple instances of the staff member touching her with his penis and inserting his penis and fingers into her vagina, and that the staff member admitted to touching the resident inappropriately with his penis and fingers on multiple occasions. This conduct occurred despite a facility policy stating a zero-tolerance stance toward any form of resident abuse.
Unattended Medications Left at Bedside Without Authorization
Penalty
Summary
A licensed nurse left a cup containing two medication pills unattended on the bedside table of a resident who had diagnoses including hypertension, atrial fibrillation, heart failure, and dementia. The resident was unable to identify the pills or state how long they had been there. The nurse confirmed that the medications were heart medications that had been withheld due to the resident's low heart rate and blood pressure, and admitted to accidentally leaving the medication cup at the bedside. The nurse acknowledged that this action created a risk for the resident, as well as the possibility that another resident could have ingested the medications. Review of the resident's medical record and care plan showed there was no authorization for self-administration or bedside storage of medications. Facility policy requires a written order for bedside medication storage and specifies that missed medications should be returned to secured storage. The Director of Nursing confirmed awareness of the incident and agreed that leaving medications unattended at the bedside was unsafe and could have resulted in another resident accessing the medications.
Inaccurate Documentation of Vital Signs After Resident Discharge
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had been transferred out of the facility. Specifically, vital signs were documented in the resident's medical record after the resident had already been discharged to the hospital. The resident, who had a history of pneumonia, asthma, and chronic obstructive pulmonary disease, was admitted in June 2025 and transferred to the hospital on June 28, 2025 at 7:32 p.m. However, the medical record showed that vital signs were recorded for this resident at 12:15 a.m. on June 29, 2025, after the resident was no longer present in the facility. During an interview and record review, the DON confirmed that the transfer form indicated the resident was no longer in the facility at the time the vital signs were documented. The DON acknowledged that this was an error in documentation. The facility's policy required that vital signs be obtained, recorded, and reported in a timely and accurate manner, which was not followed in this instance.
Failure to Develop and Implement Care Plan for BIPAP Therapy
Penalty
Summary
Licensed nursing staff failed to develop and implement a resident-centered care plan for a resident who required Bilevel Positive Airway Pressure (BIPAP) therapy. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypercapnia, sleep apnea, and morbid obesity. Although a physician ordered BIPAP therapy at bedtime for obstructive sleep apnea, the resident's care plan for altered respiratory status was not updated to include this intervention. Review of facility records confirmed that the care plan did not address BIPAP therapy, and the Medication Administration Record showed the resident did not receive the ordered BIPAP therapy on a specific date due to the equipment being inoperable. Interviews with facility staff confirmed that care plans are intended to address the whole person and should be updated to reflect changes in care needs. The facility's policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan based on the resident's needs. However, the lack of a care plan intervention for BIPAP therapy decreased the facility's ability to provide individualized care and ensure the resident's safety, as the therapy was not administered as ordered.
Failure to Notify Physician of Inoperable BIPAP and Missed Diabetes Medication
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician after a resident's BIPAP machine became inoperable, resulting in the resident not receiving the ordered BIPAP therapy. The resident, who had diagnoses including acute and chronic respiratory failure with hypercapnia, type 2 diabetes, sleep apnea, and morbid obesity, was instead provided with oxygen via nasal cannula. There was no documentation that the physician was informed of the BIPAP issue, despite facility leadership and the physician stating that such notification was expected. Additionally, the same resident did not receive a scheduled dose of Ozempic®, a medication prescribed for diabetes management, because the medication was not available. The medication administration record and progress notes confirmed the missed dose, and interviews with staff and the physician indicated that the physician was not notified of the omission. The facility's policies required medication administration in accordance with prescriber orders, but there was no policy specifically addressing physician notification for medication errors or omissions. Interviews with the DON, ADON, and licensed nurse confirmed the missed BIPAP therapy and medication dose, as well as the lack of physician notification in both instances. The DON acknowledged the importance of notifying the physician about missed medications and high-risk medication omissions, but also stated that discretion was left to the licensed nurse. The facility's documentation and staff interviews confirmed that the required notifications did not occur.
Medication Administration Error Due to Dosage Confusion
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident with end stage kidney disease, diabetes, and pulmonary hypertension was not given the correct dosage of Uptravi (selexipag). The resident was admitted with a physician's order for Uptravi 200 mcg tablets, four tablets by mouth twice daily (totaling 800 mcg per dose). However, the medication bottle provided by the family was labeled for 800 mcg tablets, with instructions to give one tablet twice daily. Nursing staff administered the medication based on the Medication Administration Record (MAR), which directed four tablets per dose, without consistently verifying the actual tablet strength on the medication bottle label. This led to confusion and inconsistent administration, with some staff giving one tablet and others giving four, depending on whether they followed the MAR or the bottle label. Interviews revealed that staff did not always read the medication bottle label and relied solely on the MAR, resulting in the medication supply depleting faster than expected. The family raised concerns after noticing the medication was running out quickly and questioned the staff's ability to read the label. The Director of Nursing became aware of the issue when a refill was requested earlier than anticipated and began investigating the discrepancy. Facility policy required that medications brought in by family be properly labeled and verified by a physician or pharmacist prior to use, but there was no documentation that this verification had occurred for this medication.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice. Specifically, the resident did not receive six of her scheduled medications, which included Atorvastatin, Latanoprost, Dorzolomide, Ropinorole, Levetiracetam, and Lubiprostone. These medications were not administered as they were still awaiting arrival. The resident had been admitted with diagnoses of Epilepsy and Restless Leg Syndrome, conditions that require consistent medication management to prevent adverse health outcomes. Additionally, the facility did not notify the physician when the resident missed her scheduled medications. The Director of Nursing confirmed that the resident should have received these medications as ordered and acknowledged the importance of notifying the physician, especially regarding the missed dose of Levetiracetam, which could lead to seizure activity. The facility's policy on medication administration emphasizes the necessity of accurate and timely administration according to the physician's order, highlighting a deviation from established procedures in this case.
Failure to Follow Contact Enteric Precautions for Cdiff
Penalty
Summary
The facility failed to adhere to contact enteric precautions for a resident with an active Clostridium Difficile (Cdiff) infection, which is highly contagious and can be life-threatening. During an observation, a speech therapist entered the resident's room without performing hand hygiene, wearing gloves, or donning a gown, as required by the precautionary measures. Upon leaving the room, the speech therapist also failed to wash her hands with soap and water, which is a critical step in preventing the spread of infection. The infection preventionist and the director of nursing both confirmed the necessity of following these precautions to prevent the spread of Cdiff. The signage posted outside the resident's room clearly indicated the need for hand hygiene, gown, and gloves before entry, and soap and water handwashing upon exit. The speech therapist acknowledged not following these procedures, which constitutes a break in infection control and poses a safety issue for both staff and other residents.
Failure to Honor Resident Rights and Privacy
Penalty
Summary
The facility failed to honor the rights of several residents by not responding promptly to call lights, leading to residents waiting for assistance for 20 minutes or more. This delay resulted in multiple residents experiencing distressing situations, such as urinating or soiling themselves while waiting for help. For instance, Resident 20 urinated in bed and felt terrible about it, while Resident 55 feared for his wife's safety as she attempted to get out of bed after a long wait. Resident 69 expressed feeling bad after soiling his bed, and Resident 76 had to sleep on a wet bed until the morning shift arrived to clean him. Additionally, the facility did not adhere to its smoking policy, as evidenced by Resident 42 wheeling himself across the parking lot to smoke without staff supervision. Despite being informed that the facility was non-smoking, Resident 42 was not provided with a Safe Smoking Evaluation upon admission, and his requests for assistance in obtaining cigarettes were ignored. The facility's failure to assess and accommodate Resident 42's smoking needs, as outlined in their policy, put him at risk of potential harm. Furthermore, the facility staff used residents' rooms as shortcuts to enter and exit the building, compromising the residents' privacy. Residents, including Resident 3, Resident 63, and Resident 51, reported feeling that their privacy was violated when staff used the sliding doors in their rooms to access the back patio. This practice was against the facility's policy, which emphasized respecting residents' privacy and using designated exit doors instead.
Failure to Inform Residents of Complaint Filing Process
Penalty
Summary
The facility failed to ensure that residents were informed about how to contact the Department to file a complaint. During a confidential Resident Council interview, all 12 residents present were unaware of where to find the contact information for the Department. One resident mentioned that while residents' rights were reviewed during meetings, the specific information on how to contact the Department was not discussed. The Minimum Data Set (MDS) assessments indicated that three residents, including the one who spoke, were cognitively intact, while seven had moderate cognitive impairment. The Activities Director, responsible for coordinating the Resident Council meetings, confirmed that the contact information for filing complaints was not discussed during these meetings. Additionally, the Medical Records Director revealed that the facility did not have a policy on providing residents with the necessary contact information. The facility's policy on Resident Rights, last revised in February 2021, stated that residents have the right to communicate with outside agencies, but it did not specify how this information should be provided to the residents.
Failure to Update Survey Binder and Inform Residents
Penalty
Summary
The facility failed to update the survey binder with the results of complaint and facility-reported incident investigations for three years, and did not notify residents of its location. During a record review and interview, it was revealed that the survey binder, located in the hallway outside the Administrator's office, lacked updates since 2021. The Director of Nursing confirmed the absence of investigation results in the binder, attributing it to the lack of deficiencies since the 2021 survey. However, the Administrator later confirmed that the facility had received deficiencies after 2021, which were not included in the binder. During a Resident Council interview, all 12 residents were unaware of the binder's location. The Activities Director, responsible for coordinating Resident Council meetings, admitted that the location of the survey binder was not discussed during meetings. Additionally, the Medical Records Director confirmed the absence of a policy on informing residents about the binder's location. The facility's policy on Resident Rights, last revised in 2021, indicated that residents have the right to examine survey results, yet this was not effectively communicated or facilitated.
Excessive Noise Levels Disturb Residents' Rest
Penalty
Summary
The facility failed to ensure a comfortable noise level for four of the twenty-four sampled residents, which compromised their right to a safe, clean, comfortable, and homelike environment. Residents reported excessive noise levels at various times, particularly during the night, which disturbed their rest and sleep. Resident 3, with an intact cognition score of 15, reported hearing staff talking loudly and laughing as late as 10:30 p.m. Similarly, Resident 63, with a cognition score of 13, and Resident 51, with a cognition score of 15, also complained about the noise caused by staff and other residents during the night. The issue of noise was a recurring topic in Resident Council meetings over the past four months, as documented in the meeting minutes. Complaints included loud staff and students in hallways, particularly during the NOC shift, and bursts of loud noise and laughter at various times. Despite some improvements noted in the minutes, the problem persisted, with residents expressing dissatisfaction with the noise levels and the impact on their sleep. Anonymous residents also reported similar issues, with one stating that the noise and lack of sleep made her feel unwell. The Activities Director acknowledged the ongoing noise issues and stated that they were addressed in Resident Council meetings and followed up with the Interdisciplinary Team (IDT). However, the resolution of these issues was informal, often based on whether the Resident Council president mentioned them again. The facility's policy on maintaining a homelike environment emphasized comfortable sound levels, yet the persistent noise complaints indicated a failure to adhere to this policy.
Failure to Inform Resident Council on Grievance Process
Penalty
Summary
The facility failed to ensure that the Resident Council was informed about how to file a grievance, which could potentially lead to unresolved resident issues. During a review of the Resident Council Meeting Minutes over the past four months, it was noted that the council had requested the Social Services (SS) department to attend a meeting to discuss grievances, theft, and loss, as well as to meet new SS staff. However, the Social Services Director (SSD) had not attended the meetings due to scheduling conflicts, specifically needing to pick up her children from school at the same time as the Resident Council meetings. In a confidential interview, 10 out of 12 residents did not know how to file a grievance. The facility's grievance policy, last revised in January 2022, identified the SSD as the grievance official but did not specify how residents would be informed of their right to file a grievance or the grievance process itself. Among the residents interviewed, three were cognitively intact, while seven had moderate cognitive impairment, indicating a significant portion of the residents might not fully understand the grievance process without proper guidance.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice when a Licensed Vocational Nurse (LVN) left several medications, including a physician-prescribed potassium chloride, on a resident's bedside table without a physician's order for self-administration. The resident, who was diagnosed with alcoholic cirrhosis, had medications left by the LVN for self-administration, despite only having an order to self-administer supplements she purchased herself. The LVN signed off on the medication administration record as if the medications had been administered, without verifying that the resident had taken them. Additionally, the facility did not follow proper procedures for documenting the administration of intravenous (IV) medications. LVNs were signing off on the administration of IV medications and saline flushes that were actually administered by Registered Nurses (RNs). This practice was confirmed through record reviews and interviews, where it was noted that LVNs were not authorized to administer IV medications, and the RNs who administered the medications should have been the ones signing the medication administration records. The facility's policy on administering medications requires that the individual who administers the medication must sign the medication administration record. However, this policy was not followed, leading to inaccurate medical records and potential medication errors. The Director of Nursing acknowledged the issue and confirmed that LVNs were signing off on IV medications administered by RNs, which is outside their scope of practice.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide appropriate activities for three residents, leading to potential negative impacts on their well-being. Resident 78, diagnosed with Amyotrophic Lateral Sclerosis and Dysphagia, was observed not participating in any activities and lacked supplies for her interests such as drawing, painting, and gardening. Her care plan did not reflect her interests, and the Activities Director confirmed that these supplies were not provided. Resident 33, with a diagnosis of Heart Failure, was also not engaged in activities and was often seen in her room or hallways with her eyes closed. Although she expressed an interest in reading and sports, her activity evaluations did not reflect these preferences. The Activities Assistant admitted to copying and pasting previous evaluations without interviewing the resident, which led to inaccurate documentation of her interests. Resident 4, diagnosed with Pneumonitis, was observed only watching TV and not participating in other activities. She expressed a preference for painting, drawing, and socializing, but these were not included in her activity evaluations or care plan. The Activities Assistant confirmed that she did not interview Resident 4 and copied previous evaluations, failing to update the resident's preferences. The facility's policies require that activities be based on comprehensive assessments and resident preferences, which were not adhered to in these cases.
Ineffective QAPI Program and Lack of Data Tracking
Penalty
Summary
The facility failed to establish an effective Quality Assurance Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) program. The Administrator was unable to demonstrate that the interventions in place for various quality improvement projects were reassessed for effectiveness. During an interview and record review, it was revealed that the Administrator had not consistently tracked or documented data related to call light response times, despite having a system capable of doing so. Additionally, the facility's 'angel rounds' lacked documentation to verify that residents were asked about call light response times. The facility also failed to implement effective interventions to reduce resident falls and missing items. Despite a significant increase in falls from February to March 2024, the Administrator believed the interventions were effective, although only one intervention was mentioned. Similarly, the number of missing items increased in April 2024, yet the Administrator maintained that the interventions were effective. The facility's policy on QAPI, last revised in September 2020, emphasized the importance of continual assessment and monitoring, which was not adhered to, as evidenced by the lack of data tracking and ineffective interventions.
Unrepaired Kitchen Floor Tiles Pose Safety Hazard
Penalty
Summary
The facility failed to maintain a safe and functional environment in the kitchen due to unrepaired cracks and missing tiles on the kitchen floor. During an initial observation, a sunken circular cut on the tile with dark matter or accumulated dirt was noted beside the drain on the contaminated side of the dishwashing section. Further observations revealed cracks on the floor tile below the low-temperature dishwasher and on the clean side of the dishwashing section. A follow-up visit also identified a broken tile on the floor by the corner of the kitchen center island near the entrance door. During an interview, the Maintenance Supervisor acknowledged the issues, explaining that the circular cut was a clean-out drain used for unclogging. The Maintenance Supervisor stated that the tiles needed to be changed. A concurrent record review revealed a proposed grease trap project, which included plans to replace the kitchen floor, but it required approval from the Department of Health Care Access and Information. The Food Code 2017 was reviewed, indicating that materials for indoor surfaces should be smooth, durable, and easily cleanable, which the current state of the kitchen floor did not meet.
Deficiency in Staff Training Compliance Tracking
Penalty
Summary
The facility was found to lack a system for tracking staff compliance with mandatory training, which could lead to inadequate staff competency and poor quality of care. During an interview, the Director of Staff Development (DSD) presented a binder of in-person training sessions provided over the last four months, including topics such as bowel & bladder, urinary tract infections, abuse, pressure injuries, and infection control. However, the DSD could not provide a clear method for tracking staff participation in these mandatory trainings, relying instead on staff to attend and follow up if they missed a session. Evidence was requested for five sampled Licensed Nurses, but the DSD could only provide online training records for four of them, with no evidence for the fifth nurse, Licensed Staff H, regarding specific trainings. Further investigation revealed inconsistencies in the training records. The Administrator was asked to provide a list of annual mandatory trainings and evidence of completion by night shift staff. The records showed that some mandatory trainings were overdue by several years, and some staff had not received required refresher courses. The facility's job description for the DSD emphasized the responsibility to ensure all educational programs comply with applicable standards to maintain high-quality resident care, highlighting a significant gap in the facility's training compliance and tracking system.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long-term Care Ombudsman's office regarding the transfer of a resident, identified as Resident 209, to a hospital. Resident 209 had been admitted with multiple medical diagnoses, including fractures in both arms, cognitive communication deficit, and muscle weakness. On a specific date, the resident's condition worsened, prompting a transfer to a local acute care hospital's emergency room. However, the Notice of Proposed Transfer/Discharge form, completed by Licensed Staff G, was missing the resident's name and the date the notice was mailed to the Ombudsman. This oversight was confirmed during interviews with the Medical Records Director and Licensed Staff G. Further investigation revealed that the Social Services Assistant could not find any documentation indicating that the Ombudsman's office was notified of the transfer. The Social Services Assistant explained that the usual process involved the nurse filling out the form and social services notifying the Ombudsman, typically by fax. However, in this case, the form was incomplete, and the notification was not sent. The Social Services Director confirmed that staff were expected to inform the Ombudsman of hospital transfers promptly. The facility's policy, as outlined in All Facilities Letter 17-27, requires notification to the Ombudsman at the same time notice is provided to the resident or their representatives, especially in emergency transfers to a hospital.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to potential negative outcomes. Resident 78, diagnosed with Amyotrophic Lateral Sclerosis and Dysphagia, was admitted with interests in activities such as drawing, painting, music, reading, writing, and gardening. However, her care plan did not reflect these interests, and she was observed not participating in any activities, spending her time staring at the wall. The Activities Director confirmed that the care plan was not based on the initial activity evaluation and that supplies for independent activities were not provided to Resident 78. Resident 209, who had a fractured right arm from a fall prior to admission, did not have a care plan addressing this condition. Despite the presence of a sling on his arm during the admission skin assessment, the care plan was not updated to include the fracture. The Director of Nursing acknowledged that the care plan should have included the right arm fracture but was not opened at the time of the incident, leading to a focus solely on the left humerus fracture. The facility's policies on activity assessment and care planning were not adhered to, resulting in deficiencies in the care plans for both residents. The lack of comprehensive care plans for Resident 78 and Resident 209 had the potential to impact their quality of care, as the facility did not ensure their needs and preferences were adequately addressed.
Inaccurate Fall Risk Assessment for Resident with Arm Fractures
Penalty
Summary
The facility failed to accurately assess the fall risk of a resident, identified as Resident 209, which potentially contributed to a fall incident. Upon review, it was found that Resident 209 had been admitted with multiple medical diagnoses, including fractures in both arms, cognitive communication deficit, and muscle weakness. However, the admission assessment did not document the presence of a sling or mention the arm fracture, and the fall risk assessment inaccurately categorized the resident as medium risk without considering the fracture diagnosis. Interviews with staff revealed that the omission of the sling and fracture in the admission assessment was an oversight. Licensed Staff L acknowledged that the sling should have been documented, and the fall risk assessment should have included the fracture as a risk factor. The Director of Nursing confirmed these omissions and stated that an inaccurate fall risk assessment could lead to inadequate precautions being implemented for the resident. The facility's policy on fall risk assessment emphasizes the importance of identifying residents at risk for falls and implementing preventative care plans, which was not adhered to in this case.
Deficiency in Nursing Staff Competency and Training
Penalty
Summary
The facility failed to ensure that its nursing staff had the appropriate competencies to care for residents, as evidenced by the lack of updated annual competencies for a licensed staff member, and the Director of Staff Development (DSD) not having a system to track staff participation in required training. Specifically, Licensed Staff B did not have updated competencies for assessing and documenting changes in a resident's condition, which led to a failure to provide timely emergency care to a resident with significant medical needs. The resident, who had a complex medical history including a frontal lobe stroke, respiratory failure, and other serious conditions, experienced a critical change in condition that was not properly addressed by the staff. The report details an incident involving a resident who was found with low oxygen saturation and an unstable heart rate. Despite these alarming signs, Licensed Staff B did not notify the physician or document the change in condition, nor did she have the necessary competencies to manage the situation effectively. The resident was on oxygen therapy, and the staff failed to follow the physician's orders for oxygen administration, which required notifying the doctor if the oxygen saturation fell below a certain level. Additionally, the staff did not adhere to infection control protocols, as evidenced by the lack of personal protective equipment use during high-contact care activities. Furthermore, the DSD was unable to provide evidence of mandatory training completion for certain staff members, indicating a lack of oversight and tracking of staff competencies. The DSD's failure to ensure that all staff received necessary training, either in-person or through an online platform, contributed to the overall deficiency in staff preparedness and competency. This lack of training and competency assessment posed a risk to the safety and well-being of residents, as staff were not adequately equipped to handle changes in residents' conditions or adhere to facility policies and procedures.
Inadequate Sanitary Storage of Portable Urinals
Penalty
Summary
The facility failed to ensure the sanitary storage of portable plastic urinals used by residents, which had the potential to increase the risk of infection and disease transmission. During an initial tour and resident interview, a strong smell of urine was noted in a resident's room. Resident 32, occupying Bed C, mentioned that he used a portable urinal to urinate in bed and that his Certified Nursing Assistant (CNA) only rinsed it occasionally. This indicates a lack of consistent cleaning and storage practices for the urinal. A follow-up observation revealed that Resident 71, occupying Bed A in the same room, had a portable urinal placed on top of his overbed table next to his drinking mug, further contributing to unsanitary conditions. Licensed Nurse A (LN A) acknowledged the unsanitary nature of the situation and moved the urinal under the table, suggesting there was a designated place for it. The facility's procedure for handling urinals lacked specific instructions on cleaning materials and did not address the handling of urinals used by residents with urinary tract infections, indicating a gap in the facility's infection prevention and control program.
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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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