Park Vista At Morningside
Inspection history, citations, penalties and survey trends for this long-term care facility in Fullerton, California.
- Location
- 2525 Brea Blvd., Fullerton, California 92835
- CMS Provider Number
- 555515
- Inspections on file
- 16
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Park Vista At Morningside during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments was not evaluated for hot beverage safety, resulting in a hot tea spill that caused burns. Staff failed to promptly notify licensed nursing personnel or provide immediate and appropriate interventions, leading to delayed assessment, documentation, and treatment of the burn injury. Two other residents were also not assessed for hot beverage safety as required by facility policy.
A resident with respiratory failure and dependence on supplemental oxygen was not consistently provided with continuous oxygen therapy as ordered by the physician. Oxygen saturation levels were not maintained above the prescribed threshold, and the resident experienced a significant drop in oxygen saturation, resulting in transfer to an acute care facility. Nursing staff confirmed the resident should have been on continuous oxygen, in accordance with facility policy and physician orders.
A resident with a full thickness skin tear did not receive wound care as ordered by the physician, with staff applying foam dressings instead of Steri-Strips and not consistently assessing the wound. Documentation and monitoring were incomplete, and the wound later developed cellulitis, indicating a failure to follow prescribed wound care protocols.
Staff failed to follow infection control protocols, including hand hygiene and proper use of gloves, during wound care and while delivering meals to residents in contact isolation. A nurse used expired hand sanitizer and reused supplies that should have been discarded, while a CNA did not wear gloves or perform hand hygiene after contact with contaminated items, then provided care and delivered meals to other residents. These actions were not in accordance with facility policies and were acknowledged by staff and the DON.
Surveyors found that two residents' medical records were incomplete and inaccurate, with missing or incorrect documentation of intake, output, and eating percentages for one resident, and a lack of documentation regarding a hot tea spill incident for another. Facility staff confirmed missed charting and failure to initiate required change of condition documentation, contrary to facility policy.
The facility failed to meet sanitary requirements in the kitchen, with issues such as improper labeling and dating of food items, expired items, and inadequate cleanliness of equipment. Food brought in by visitors was also not properly labeled or dated. Additionally, food storage practices were not followed, with items stored on the floor and cross-contamination risks present.
The facility failed to maintain accurate medical records for a resident, with missing documentation for behavior monitoring related to psychotropic medications. This included medications for poor meal intake, anxiety, and hyperventilation. The MDS Coordinator confirmed the nursing staff's responsibility to complete this documentation.
The facility failed to ensure proper infection control practices, as LVNs did not don appropriate PPE when administering medications to residents on enhanced barrier precautions. Additionally, improper storage of incontinence briefs and isolation carts touching trash bins were observed, posing a risk of infection spread.
The facility failed to educate and offer influenza and pneumococcal vaccinations to five residents, as required by its policies. Educational materials detailing the risks and benefits were not provided, nor was the type of pneumococcal vaccine specified. This was confirmed by the IP during a review.
The facility failed to maintain two ice machines in safe operating condition by not following the manufacturer's cleaning and sanitizing guidelines. The Maintenance Director admitted that the machines were not cleaned as required, and an orange residue was observed on one machine's spout, indicating improper cleaning.
The facility failed to conduct complete entrapment risk assessments for residents using bed side rails, assessing only some of the necessary zones. This oversight involved three residents, including one who used side rails for repositioning and another who lacked decision-making capacity. The Maintenance Director confirmed the incomplete assessments, which could lead to potential entrapment risks.
A resident experienced significant weight loss over seven weeks, with inadequate nutritional intake and insufficient follow-up on RD recommendations. Despite the facility's P&P for weight management, timely interventions were not implemented, and there was no documented communication with the physician regarding the exhausted nutritional interventions. Interviews with staff confirmed the lack of follow-up and communication, contributing to the deficiency.
The facility failed to provide proper respiratory care for four residents, with issues including incorrect oxygen administration, improper storage, and outdated equipment. A resident received oxygen at a higher rate than ordered, and nasal cannulas were not stored or changed as required. An LPN confirmed these findings, and the DON and Administrator were informed.
The facility failed to provide adequate pharmaceutical services, resulting in medication discrepancies and unavailability of necessary medications for residents. Medications were left at a resident's bedside, and another resident's routine medications were unavailable, potentially leading to poor health outcomes. Discrepancies in the Omnicell system and a breakdown in communication with the pharmacy contributed to these deficiencies.
A resident did not receive a scheduled dose of the antibiotic piperacillin sodium tazobactam as ordered by the physician. The medication was to be administered every six hours for a UTI, but the 0600 hours dose was missed. This was confirmed by the resident and verified by RN 2 during a medical record review.
The facility failed to properly store and label medications in a medication room and two medication carts. An opened tuberculin vial lacked an open date, expired food thickener packets were found, and a bag of home medications was unlabeled. Temperature logs were incomplete. Expired Non-Adhesive Pads were in one cart, and two residents' topical medications lacked open dates.
The facility failed to follow the planned menu for three residents, as they did not receive the garlic breadstick included in their meal tickets. This oversight was due to a kitchen staff error, which was not caught by the checking process involving a third server and nursing staff. The issue was confirmed by the CDM and Chef de Cuisine.
A facility failed to assess a resident for the safety of self-administering eye drops and did not obtain a physician's order or develop a care plan for this practice. The resident was observed with the medication on their bedside table and stated they used it as needed, but there was no documentation supporting this self-administration in their medical record.
A facility failed to ensure a call light was within reach for a resident, posing a risk of delayed care. The resident, who required assistance due to immobility and cognitive impairment, was observed in a wheelchair with the call light on the floor. The MDS Coordinator confirmed the call light was out of reach, although the resident could press it when accessible.
A facility failed to provide and document information on formulating an advance directive for a resident, as required by policy. The resident, who did not have an advance directive, had a legally recognized decision-maker. However, the medical record lacked documentation showing that the resident or their responsible party was informed of their rights. The SSD confirmed this oversight during an interview.
A facility failed to provide the SNF ABN Form CMS-10055 to a resident's responsible party when the resident's Medicare Part A skilled services benefits were exhausted. The facility's guidelines require this notice to be given when a resident no longer needs daily skilled services but remains in the facility. The Social Services Director confirmed the oversight during an interview.
The facility failed to complete and transmit the MDS for discharge for two residents, as required by the CMS RAI Manual. The MDS Coordinator confirmed that the assessments for these residents, who were discharged, were not completed and transmitted within the specified timeframe.
The facility failed to properly store garbage in three of five dumpsters, which were overfilled and unable to close completely. This was observed during an inspection with the Maintenance Director. The FDA Food Code requires that outdoor refuse receptacles be covered with tight-fitting lids. The facility's policy also mandates covered trash bins for infection control. The EVS Director and other staff acknowledged the issue.
Failure to Assess Hot Beverage Safety and Provide Timely Burn Care
Penalty
Summary
The facility failed to ensure that residents were evaluated for their ability to safely handle and consume hot beverages, as required by its own policies and procedures. Specifically, three residents were not assessed for hot liquid safety, including a resident with significant physical and cognitive impairments such as hemiplegia, hemiparesis, aphasia, and lack of capacity to make medical decisions. Despite the facility's policy mandating hot liquid safety evaluations upon admission, readmission, and change of condition, no such assessments were documented for these residents. An incident occurred in which the resident spilled hot tea onto her lap during lunch. Staff present at the time, including two restorative nursing assistants, did not immediately notify a licensed nurse or supervisor as required by facility policy. Instead, they patted the resident dry and allowed her to finish her dessert before informing a CNA, who later reported the incident to licensed nursing staff. The delay in notification resulted in a lack of prompt assessment and intervention for the burn injury. Following the incident, the resident developed blisters on her left upper thigh, which were not discovered until the following day during routine care. Documentation of the injury, physician notification, and appropriate treatment were not initiated until approximately 30 hours after the incident. The initial intervention included the application of ice to the burn, which is not recommended and can be harmful. There was no evidence that the resident's condition was promptly assessed, that a physician's order for burn treatment was obtained, or that the resident was properly monitored in the immediate aftermath of the incident.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care services for one resident who had diagnoses including lung cancer, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The physician's order required continuous oxygen administration via nasal cannula, with oxygen saturation to be maintained above 92%. Medical record review showed that the resident's oxygen saturation was recorded at 92% on room air and with nasal cannula on multiple occasions, and at 93% on room air. Despite the order for continuous oxygen, the resident was not consistently maintained on supplemental oxygen as prescribed. On one occasion, the resident's oxygen saturation dropped significantly from 93% to 51% within less than an hour, leading to the resident being transferred to an acute care facility. Interviews with nursing staff confirmed that the resident should have been on continuous oxygen and that the oxygen should have been titrated to maintain the ordered saturation level. The facility's policy required that all physician orders be specific and complete, and that treatments be administered as ordered, but these requirements were not met in this case.
Failure to Provide Wound Care as Ordered and Inadequate Monitoring
Penalty
Summary
The facility failed to provide necessary wound care services to a resident with a full thickness skin tear on the right lower leg. The physician's order specified the application of Steri-Strips every shift for 21 days, monitoring for infection or drainage, and specific actions if drainage or infection was noted. Medical record review showed that the treatment administration record was marked as completed, but interviews with nursing staff revealed inconsistencies in the actual care provided. Staff reported using a foam dressing instead of Steri-Strips and did not consistently open the dressing to assess the wound, relying instead on monitoring for pain and discharge around the dressing. The treatment nurse admitted to cleansing the wound without a physician's order and acknowledged that the wound care orders were incomplete and should have been clarified. Documentation in the resident's progress notes indicated the presence of a full thickness skin tear with visible adipose tissue and serosanguinous drainage, and later development of cellulitis requiring antibiotic therapy. The care plan included providing treatment as ordered, but staff interviews and record reviews indicated that the wound was not always treated according to the physician's instructions, and wound monitoring and documentation were not accurately performed. These actions and inactions led to a failure in providing the necessary wound care services as ordered.
Infection Control Lapses in Wound Care and Contact Isolation
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three of nine sampled residents, resulting in multiple breaches of protocol. During wound care for one resident, a treatment nurse did not perform hand hygiene or change gloves after removing a soiled dressing, and used the same gloves to handle clean supplies and enter the restroom. The nurse also used an expired alcohol-based hand sanitizer and returned unused gauze, which had been brought into the resident's room, back to the treatment cart for use with other residents. The nurse acknowledged that hand hygiene should have been performed and that unused, potentially contaminated supplies should have been discarded. A certified nursing assistant (CNA) was observed delivering meal trays and providing care in contact isolation rooms without wearing gloves or performing hand hygiene after touching contaminated items. The CNA handled residents' bedside tables, adjusted bedding, and fed a resident without gloves or hand hygiene, and then proceeded to deliver another meal tray to a different resident without sanitizing hands. The CNA admitted to not following proper personal protective equipment (PPE) and hand hygiene protocols when entering contact isolation rooms. Facility policy reviews confirmed that staff are required to perform hand hygiene after removing soiled dressings, dispose of unused disposable supplies brought into resident rooms, and wear gloves and gowns when entering contact isolation rooms. Staff interviews, including with the Director of Nursing (DON), confirmed awareness of these policies and acknowledged the observed failures to adhere to them.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical information for two of nine sampled residents. For one resident, there were multiple instances where intake, output, and eating percentage documentation were either missing or incorrectly recorded. Physician orders required monitoring and documenting intake and output every shift, but several entries were left blank or marked as 'not applicable' without justification. Similarly, eating percentages were either not documented or recorded inaccurately. The Director of Nursing confirmed that these omissions and incorrect entries were due to missed charting and acknowledged that the documentation was not accurate. For another resident, the facility did not document an incident in which the resident spilled hot tea on her left thigh. Although the event was verbally reported to nursing staff and the resident was evaluated and treated for redness and later blisters, there was no corresponding documentation in the medical record regarding the incident on the day it occurred. Staff interviews confirmed that the incident was not documented, and the required change of condition process was not initiated at the time of the event. Facility policies required that all services, changes in condition, and incidents be documented objectively, completely, and accurately in the medical record to facilitate communication among the interdisciplinary team. The lack of documentation for both the intake/output monitoring and the incident involving the hot tea spill resulted in incomplete clinical records for the affected residents.
Sanitary Violations in Kitchen and Improper Food Labeling
Penalty
Summary
The facility failed to adhere to sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items. During an inspection, it was observed that several food items in Refrigerator 1, such as tilapia filets, cleaned chicken, mushrooms, egg salad, chopped onions, and tomato wedges, were not labeled according to the facility's policy. Additionally, expired items like pork chops, mushrooms, marinated vegetables, chopped tomatoes, and Tuscan Caesar dressing were found. Similar issues were noted in Freezer 1, the pantry area, Refrigerator 2, and Freezer 2, where various food items were not labeled as required. The facility also failed to ensure that food brought in by visitors for residents was properly labeled and dated. In Refrigerator 3, several items, including whipped cream cheese spread, veggie spread, ranch dressing, a croissant sandwich, and a bagel with spread, were found unlabeled and undated. Some items were labeled with the resident's name but lacked a date, and expired items like a Silk soy milk carton were also present. The facility's policy required these items to be dated and discarded after three days, but this was not consistently followed. Furthermore, the facility did not maintain cleanliness and proper storage practices in the kitchen. Food items were stored on the floor in Freezer 1, contrary to USDA Food Code requirements. Equipment such as the can opener, blender, microwave, oven, and plate lowerator were found with residues and substances indicating inadequate cleaning. Additionally, there was a failure to prevent cross-contamination, as egg salad was stored on a shelf designated for raw meats, posing a risk of foodborne illnesses to residents.
Incomplete Medical Records and Behavior Monitoring Deficiency
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of the sampled residents, identified as Resident 30. The medical record review revealed multiple instances of missing documentation related to behavior monitoring for various psychotropic medications prescribed to Resident 30. These medications included Remeron for poor meal intake, buspirone for verbalization of feeling anxious, Ativan for anxiety manifested by biting nails and scratching, and lorazepam for hyperventilation. The missing documentation spanned several dates and shifts, indicating a pattern of incomplete record-keeping. Additionally, the facility did not ensure the monitoring of behavior for psychotropic medication on another resident's Medication Administration Record (MAR), identified as Resident 2. This oversight had the potential to impact the resident's care needs due to the incomplete and inaccurate medical record. During an interview and concurrent medical record review, the MDS Coordinator confirmed that the nursing staff should have completed the documentation for Resident 30's behavior monitoring and noted that any inability to do so should have been documented in the progress notes.
Infection Control Lapses in PPE Usage and Storage Practices
Penalty
Summary
The facility failed to implement a safe and sanitary environment to prevent the transmission of infections for three residents. Specifically, the facility did not ensure that Licensed Vocational Nurses (LVNs) donned appropriate personal protective equipment (PPE) when administering medications to residents on enhanced barrier precautions (EBP). For Resident 26, who was on EBP due to a gastrostomy tube, LVN 3 was observed multiple times administering medications and performing medical procedures without wearing an isolation gown. Additionally, the isolation cart for Resident 26 was improperly placed, touching the trash bin inside the room. Similarly, LVN 2 did not wear an isolation gown while administering medication to a nonsampled resident, Resident 2, who required EBP due to a wound. The isolation cart for Resident 2 was also inside the room, indicating a lack of adherence to infection control protocols. Both LVNs were unaware of the residents' EBP status, which contributed to the oversight in PPE usage. Further observations revealed improper storage of incontinence briefs and isolation carts touching trash bins in residents' rooms. In Room A, a stack of incontinence briefs was stored on top of the isolation cart, and in Room B, Resident 31's incontinence briefs were stored on the floor. These practices posed a risk of spreading infection, as acknowledged by LVN 1 during interviews. The facility's failure to maintain proper infection control measures for these residents highlights significant lapses in adherence to established protocols.
Failure to Educate and Offer Vaccinations
Penalty
Summary
The facility failed to ensure that five residents, including four from the final sample and one non-sampled, were educated and offered influenza and pneumococcal vaccinations. Specifically, the facility did not provide educational materials detailing the risks and benefits of these vaccines to Residents 12, 21, 24, 25, and 507. Additionally, the facility did not specify which type of pneumococcal vaccine was offered to these residents, as required by the facility's policies and procedures. The medical records for each of these residents lacked documentation showing that the educational materials were provided or that the type of pneumococcal vaccine was specified. This oversight was confirmed during an interview and concurrent medical record review with the Infection Preventionist (IP), who acknowledged the findings. These failures put the residents at risk for infection and transmission of pneumococcal and influenza infections.
Improper Maintenance of Ice Machines
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically two of the three ice machines, in safe operating condition. The ice machines were not cleaned and sanitized according to the manufacturer's guidelines, as required by the facility's policy and procedure. The policy stated that internal components of the ice machines must be cleaned and sanitized at least twice a year per manufacturer guidelines. However, the Maintenance Director confirmed that the ice machines were not cleaned per these guidelines. Instead, the facility cleaned the filters weekly and the inside every three months, without using any chemicals, which deviated from the manufacturer's instructions. During an observation, an orange residue was noted on the spout of Ice Machine 2, indicating a lack of proper cleaning. The Maintenance Director acknowledged this finding and admitted that the icemaker and ice storage bin had not been cleaned as required. The failure to follow the manufacturer's cleaning and sanitizing instructions had the potential to affect the health status of the residents, as the equipment might not function as intended.
Incomplete Entrapment Risk Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for residents using bed side rails, which could lead to potential entrapment, serious injury, or death. The report highlights that the facility did not assess all necessary zones for entrapment risk as per the Hospital Bed System Dimensional and Assessment Guidance. Specifically, the Maintenance Director only assessed Zones 2, 3, and 4, neglecting Zones 1, 5, 6, and 7, which are critical areas where entrapment could occur. Resident 507, who had the capacity to understand and make decisions, used the side rails to reposition herself in bed. Her entrapment risk evaluation indicated the use of side rails as an enabler for independence and safety, but the assessment did not cover all potential entrapment zones. Similarly, Resident 30, who lacked the capacity to understand and make decisions, also had side rails as enablers, but the assessment was incomplete, missing several zones. The Maintenance Director confirmed the oversight during an interview. Resident 38, who could understand and make decisions, used the side rails for support while turning in bed. Her entrapment risk evaluation also failed to assess all necessary zones, with only Zones 2 and 3 being checked. The Maintenance Director acknowledged the incomplete assessments during a review of the documentation. Interviews with staff, including a CNA and the DON, confirmed the findings, indicating a systemic issue with the facility's assessment process for bed safety.
Failure to Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely Registered Dietitian (RD) evaluations and interventions for a resident experiencing significant weight loss. The facility's policy and procedure (P&P) for weight management required identification and intervention for significant weight variance, but these were not implemented in a timely manner for the resident. The resident experienced a weight loss of 23.4 lbs over seven weeks, with multiple instances of significant weekly and monthly weight loss percentages. Despite the resident's oral intake being consistently below the assessed needs, there was no documented evidence of timely RD or physician intervention to address the ongoing weight loss. The resident's medical records indicated a pattern of inadequate nutritional intake, with a high percentage of meals consumed at 50% or less. The RD made several recommendations, including dietary changes and the use of nutritional supplements, but these were not effectively communicated or followed up with the physician. The RD's recommendations on 7/25/24 to notify the physician about the exhausted nutritional interventions were not documented as communicated, and there was no evidence of further evaluation or recommendations from the physician or RD from 7/25/24 to 8/15/24. Interviews with facility staff, including the RN, DON, and RD, confirmed the lack of documented follow-up on the RD's recommendations and the failure to notify the physician. The RD acknowledged the absence of follow-up documentation regarding the resident's weight loss during the critical period. The DON confirmed that the nursing staff should have carried out the RD's recommendations promptly, ideally the next day, but this did not occur, contributing to the deficiency in addressing the resident's nutritional needs.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by several deficiencies in the administration and management of oxygen therapy. Resident 36 was observed receiving oxygen at four liters per minute, contrary to the physician's order of two to three liters per minute. Additionally, the humidifier was empty, and the oxygen nasal cannula and storage bag were not changed timely, being dated 11/20/24. LVN 1 confirmed these observations and was unaware of the correct physician's order. The MDS Coordinator also verified the discrepancy in the oxygen administration. For Resident 32, the nasal cannula was improperly stored on top of the oxygen concentrator instead of inside the storage bag when not in use, and both the nasal cannula and storage bag were undated or outdated. Similar issues were observed with Resident 31, whose nasal cannula was not stored properly and was undated, with the storage bag dated 11/20/24. Resident 18's nasal cannula was found on the floor, unlabeled, and not stored in a sanitary manner. LVN 1 confirmed these findings and acknowledged the improper storage and labeling of the equipment. The DON and Administrator were made aware of these deficiencies.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in medication discrepancies and unavailability of necessary medications for residents. One resident had medications left at their bedside, and another resident did not have their routine medication available, which could potentially lead to poor health outcomes. The facility's failure to ensure accurate reconciliation and disposal of medications was evident in the discrepancies found in the Omnicell automatic drug delivery system. The facility's policies and procedures for the Automated Drug Delivery System (ADDS) were not followed, leading to several discrepancies in medication counts. For instance, there were unexplained changes in the bin quantities of medications such as zolpidem, hydralazine, tramadol, and levofloxacin. The Director of Nursing (DON) and pharmacy staff were unable to provide explanations for these discrepancies, indicating a lack of proper oversight and accountability in medication management. Additionally, a resident's routine medications, Eliquis and zinc sulfate, were not available due to a failure in the reordering process. Despite multiple attempts by a Licensed Vocational Nurse (LVN) to contact the pharmacy, the medications were not delivered in a timely manner. This highlights a breakdown in communication and coordination between the facility and the pharmacy, further contributing to the deficiency in pharmaceutical services.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident 25 was not administered the piperacillin sodium tazobactam antibiotic as ordered by the physician. The physician's order, dated 11/29/24, required the medication to be administered intravenously every six hours for seven days to treat a urinary tract infection. On 12/2/24, Resident 25 reported not receiving the 0600 hours dose during the previous night shift. A review of the resident's Infusion Medication Administration Record confirmed the omission of the dose. RN 2 acknowledged and verified these findings during an interview and concurrent medical record review.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in one of its medication storage rooms and two medication carts. In the medication room, an opened tuberculin vial was found in the refrigerator without an open date, and an opened box of instant food thickener contained multiple expired packets. Additionally, a bag of home medications without a resident's name was stored on the counter. The temperature log for the medication room had multiple missing entries, which were verified by the Director of Nursing (DON). In Medication Cart A, three packets of Non-Adhesive Pad were found to be expired. In Medication Cart C, topical medications for two residents were not labeled with an open date, as per the facility's policy. The medical records for these residents showed physician orders for the use of diclofenac sodium topical gel for pain management, but the medications were not properly labeled with open dates, which was confirmed by the staff.
Menu Adherence Failure for Three Residents
Penalty
Summary
The facility failed to adhere to the planned menu for three residents, resulting in a deficiency related to nutritional needs. On the specified date, three residents did not receive the garlic breadstick as indicated on their meal tickets. Resident 43, who was supposed to receive a pureed garlic breadstick and butter, did not have it on her meal tray. Similarly, Resident 40's meal tray was missing the soft and buttered garlic breadstick, and Resident 22 also did not receive the pureed garlic breadstick and butter as per his meal ticket. These discrepancies were verified by the Certified Dietary Manager (CDM) and other staff members. The issue arose due to an oversight by the kitchen staff responsible for serving the pureed bread, who missed including the garlic breadstick on the first few trays. Despite having a third server on the line to check the trays and nursing staff performing a final check before meals were served, the error was not caught in time. The CDM and Chef de Cuisine acknowledged the mistake during an interview, indicating that the process for checking meal trays was not effectively implemented in this instance.
Failure to Assess and Document Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safety and clinical appropriateness of self-administering medications. Specifically, Resident 507 was observed to have a bottle of carboxymethylcellulose sodium ophthalmic solution 0.5% eye drops on their bedside table and stated that they self-administered the drops when experiencing dry eyes. However, there was no documentation in the resident's medical record indicating that a physician's order was obtained or that a care plan was developed to address the self-administration of this medication. The facility's policy on self-administration of medications requires an assessment by the interdisciplinary team (IDT) to determine if self-administration is safe and appropriate for each resident. Additionally, the policy mandates that specific medications for self-administration be listed in the physician's orders and documented in the resident's care plan. In this case, the facility did not comply with its policy, as there was no evidence of an assessment, physician's order, or care plan for Resident 507's self-administration of eye drops. This oversight had the potential to lead to unsafe medication administration and negatively impact the resident's physiological well-being.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a nonsampled resident, identified as Resident 307. During an observation on November 18, 2024, at 0900 hours, Resident 307 was seen awake and sitting in a wheelchair with the call light on the floor, out of reach. A review of the facility's policy and procedure from October 2010 indicated that call lights should be within easy reach when a resident is in bed or confined to a chair. Resident 307's medical records showed a care plan addressing risks related to bowel incontinence and deficits in daily living self-care performance, requiring staff assistance for toileting and repositioning. At 1005 hours, the MDS Coordinator confirmed the call light was out of reach and verified that Resident 307 could press the call light when it was accessible.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to provide and document information on how to formulate an advance directive for Resident 508, as required by their policy. The policy, revised on 6/24/15, mandates that written information regarding the rights to formulate an advance directive be provided to residents and their responsible parties. Resident 508, who was admitted to the facility on an unspecified date, did not have an advance directive according to the Social Services Evaluation dated 11/21/24. The POLST dated 11/19/24 indicated that the resident had a legally recognized decision-maker. However, the medical record lacked documentation showing that Resident 508 or their responsible party was informed of their rights to formulate an advance directive. During an interview on 12/3/24, the SSD confirmed that neither Resident 508 nor the responsible party had been informed of these rights.
Failure to Provide SNF ABN Form CMS-10055
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 to a resident's responsible party, which is required when a resident no longer requires daily skilled services but remains in the facility. This deficiency was identified during a review of the facility's Beneficiary Notice Guidelines, which indicated that the SNF ABN should be provided regardless of payer type. The medical record review for the resident, who was admitted and readmitted to the facility, showed that their Medicare Part A skilled services benefits were exhausted on May 17, 2024. An interview with the Social Services Director (SSD) confirmed that the responsible party was not given the SNF ABN Form CMS-10055, despite the exhaustion of benefits, which should have been done to allow informed decision-making regarding Medicare services.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for discharge was completed and transmitted to the Centers for Medicare & Medicaid Services (CMS) for two nonsampled residents, identified as Residents 42 and 46, who were reviewed for resident assessments. According to the facility's guidelines, as outlined in the CMS RAI Manual Version 3.0 Chapter 2, Discharge Assessments for Return Not Anticipated must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date. However, a closed medical record review initiated on December 5, 2024, revealed that Resident 42, who was discharged on July 3, 2024, and Resident 46, who was discharged on July 5, 2024, did not have their discharge MDS assessments completed and transmitted. During an interview and concurrent medical record review, the MDS Coordinator confirmed these findings, acknowledging the failure to complete and transmit the required assessments.
Improper Garbage Storage in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in three out of five dumpsters, which were observed to be overfilled, preventing the lids from closing completely. This observation was made during an inspection conducted with the Maintenance Director. The FDA Food Code 2022 requires that receptacles for refuse be kept covered with tight-fitting lids if stored outside. The facility's policy, dated January 2015, also mandates that trash be moved in covered bins for infection control purposes. The Environmental Services (EVS) Director acknowledged that the dumpster lids should always be covered. The findings were also acknowledged by the CDM, Food and Nutrition Manager, and Chef de Cuisine.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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