Peninsula Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlingame, California.
- Location
- 1609 Trousdale Drive, Burlingame, California 94010
- CMS Provider Number
- 555856
- Inspections on file
- 24
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Peninsula Post-acute during CMS and state inspections, most recent first.
A resident with dementia, repeated falls, abnormal gait, and a known subdural hematoma experienced a fall and was later observed by family to become increasingly lethargic, less responsive, more unsteady, and with poor intake. Despite these changes and the resident’s eventual transfer to the hospital, where a left holohemispheric chronic SDH was identified and neurosurgery performed, the DON did not initiate a formal investigation of the incident as an unusual occurrence. The Medical Director agreed that the case should have been formally investigated to assess nursing practices, and the facility’s Unusual Occurrence Reporting policy addressed reporting but not formal investigation of such events.
The facility failed to ensure food safety and sanitation, with fish served at improper temperatures, improper thawing methods, and unlabeled, expired items in a resident's refrigerator. Hand hygiene and glove use were not followed, and kitchen equipment and food carts were inadequately cleaned, risking foodborne illness for 56 residents.
A long-term care facility experienced a 25% medication error rate due to improper administration practices. An LVN left medications at a resident's bedside without observing intake, and an RN administered Repaglinide during a meal instead of before. Additionally, insulin was administered without proper blood sugar checks, and the technique used was inconsistent with professional standards. These actions were contrary to facility policies and prescriber orders.
The facility failed to properly label and store medications, including allowing a resident to keep medication at the bedside without an order, using undated medication bottles, and storing expired biologicals. Controlled drugs and a resident's money were improperly stored in a medication cart, and a cart was left unlocked and unattended. These actions violated the facility's policies and procedures.
The facility failed to serve green beans in accordance with the approved menu, using a 1/3 cup scoop instead of the required 1/2 cup scoop. This error affected 49 residents who were supposed to receive regular textured green beans, potentially impacting their nutritional intake. The issue was confirmed by dietary staff during an interview.
The facility failed to provide palatable food for a lunch meal, affecting 34 residents who received meatballs and pureed green beans. Food temperatures were not measured before service, resulting in meatballs being served below the required temperature. Additionally, pureed green beans were found to be excessively salty compared to their regular counterparts, indicating a failure to adhere to recipe guidelines.
The facility failed to provide completed contracts for dialysis services and transportation, which were being provided by an external agency. An internal agreement request form for dialysis was not a finalized contract, and the transportation contract lacked the facility representative's signature. The Administrator confirmed the absence of a formal dialysis contract.
The facility admitted more residents than its licensed capacity of 62 skilled nursing beds for 13 days in September. Despite the Fire Marshall's temporary approval for 68 beds, the facility's official license only permits 62 beds, leading to non-compliance with state regulations.
A facility failed to obtain a POLST for a resident upon admission, risking non-compliance with the resident's end-of-life wishes. Despite having a DNR order and no cognitive impairment, the POLST form was missing from the resident's records, as confirmed by an LVN. The resident had multiple medical conditions, and the absence of this documentation could lead to their treatment preferences not being honored.
A resident's MDS was inaccurately encoded with a diagnosis of depression, despite no medical history of the condition. The error was identified during a review of the resident's medical records, which showed diagnoses of spinal stenosis and low back pain but not depression. The MDS Director confirmed the inaccuracy, noting the facility's policy requires accurate certification of assessments.
The facility failed to develop accurate care plans for two residents. One resident's care plan incorrectly indicated Duloxetine was for depression, despite no such diagnosis, while another resident lacked a care plan for indefinite Cephalexin use for UTIs. The facility's policy requires care plans to be developed within specific timeframes, which was not followed, leading to deficiencies in meeting residents' needs.
Two residents experienced deficiencies in insulin administration due to an LVN's failure to follow professional standards and facility policies. The LVN did not inject air into the insulin vial or pinch the skin during injection for one resident, and obtained a glucose reading during a meal for another resident, administering insulin without a prescribed pre-meal glucose check. The ADON confirmed these actions were against facility policy.
A resident with Japanese as their primary language was not provided with adequate translation services, as staff were unaware of resources beyond family members or communication boards. The facility does not subscribe to medical translation services, relying instead on family or translation apps like Google Translate.
A facility failed to monitor a resident on psychotropic medication for behavioral symptoms and side effects. The resident, admitted with schizophrenia, was prescribed amisulpride, and informed consent was obtained seven days late. Monitoring of side effects also started seven days after medication administration, contrary to facility policy.
A resident was administered Acetaminophen beyond the prescribed dosage, exceeding the maximum allowed 3000 mg in 24 hours. The resident, with fractures in the left femur and humerus, received 1000 mg three times daily and additional doses, leading to a significant medication error. Both the LVN and IDON confirmed the error, which could affect liver function.
The facility failed to ensure a kitchen staff member's competency in manual warewashing using the three-compartment sink, omitting the sanitizing step. This deficiency was identified during an observation and interview, where the Dietary Aide incorrectly described the procedure, potentially leading to contamination of food and utensils.
The facility's electronic medical record system failed to provide appropriate diet order options for residents with renal insufficiency, offering only a 'Liberal Renal' diet not defined in the facility's diet manual. This affected three residents, including one with end-stage renal disease on dialysis, potentially leading to inappropriate nutrient levels. The Registered Dietitian and Dietary Supervisor confirmed the discrepancy between the electronic system and the approved diet manual.
A facility failed to follow infection control standards for a resident on enhanced barrier precautions (EBP) due to multiple antibiotic resistances and an indwelling urinary catheter. PT and OT staff were observed providing care without the necessary PPE, specifically gowns, during high-contact activities. The Infection Preventionist confirmed the oversight and noted the absence of signage indicating EBP requirements, contrary to the facility's policy on transmission-based precautions.
The facility failed to ensure that RNs completed assessments for four residents who experienced changes in condition, including falls and severe pain. Instead, LVNs performed the assessments, which is not within their job description. This led to inadequate care for residents with significant medical issues.
A resident with severe cognitive impairment was injured during a transfer from a wheelchair to a bed using a hoyer lift. The resident panicked and flipped upside down, hitting her head on the base of the lift, resulting in severe pain and a bump on the head. Facility policies on safe lifting were not adequately followed.
Failure to Investigate Unusual Occurrence After Fall and Worsening Subdural Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to identify and investigate an unusual occurrence related to a resident with a known subdural hematoma and history of repeated falls. The resident was admitted with multiple diagnoses including dementia, glaucoma, repeated falls, abnormal gait and mobility, and a subdural hematoma. On 1/21/26, a Change in Condition Evaluation documented that around 5:00 AM the resident was found sitting on the floor at the foot of her bed, unable to state what happened, denying head injury and pain, with no new skin tears, normal PERRLA, intact upper and lower extremity movement, and refusal of vital signs at that time. The DON later acknowledged awareness of this fall, the resident’s subsequent transfer to the hospital on 1/31/26, and neurosurgery performed that same day, but stated she did not formally investigate the case as an unusual occurrence. In the days following the fall, the resident’s family member reported noticing the resident becoming lethargic, less responsive, more unsteady, and not eating well, and stated she had to beg staff to transfer the resident to the hospital for evaluation. Hospital records from 1/31/26 documented that the daughter had been notified of the 1/21 fall and had observed the resident becoming more unsteady, lethargic, and with decreased intake over several days, and that the resident presented with altered mental status and less mobility over the past weeks, especially in the last couple of days. The hospital identified a left holohemispheric chronic subdural hematoma and recommended burr hole drainage. During interviews, the DON stated she did not formally investigate the case and, in retrospect, believed she should have, and the Medical Director agreed that the facility should have formally investigated the case to determine if nursing practices needed improvement. Review of the facility’s Unusual Occurrence Reporting policy showed it addressed reporting unusual occurrences but did not address formal investigation to identify deficiencies and develop interventions.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment, leading to potential food contamination. During a kitchen observation, the Dietary Supervisor (DS) served fish that was not cooked to the recommended temperature of 145 degrees Fahrenheit, with initial temperatures recorded as low as 109.1 degrees Fahrenheit. Additionally, raw fish fillets were improperly thawed on the countertop, contrary to the facility's policy which requires thawing in a refrigerator, under running water, or in a microwave. The facility also failed to maintain proper labeling and dating of food items in a resident's refrigerator, which contained unlabeled, undated, and expired items such as yogurt, protein drinks, and milk. The DS acknowledged that the refrigerator should be monitored daily to prevent the storage of expired items, but it was only checked weekly. Furthermore, the DS did not follow proper hand hygiene and glove use protocols, as observed when she picked up items from the floor without washing her hands or changing gloves, risking cross-contamination. The kitchen equipment and food carts were not cleaned appropriately, with the microwave and plate warmer found to have visible residue. The cleaning schedule did not include the microwave, and the plate warmer was not cleaned after each use. Food carts were cleaned with an incorrect bleach solution concentration, despite the availability of a quaternary sanitizing solution. These lapses in sanitation practices could lead to foodborne illnesses among the 56 residents receiving food from the kitchen.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 25% error rate during medication administration for four residents. Licensed Vocational Nurse (LVN) 3 left seven medications on Resident 53's bedside table without observing the resident take them, contrary to the facility's policy and procedure. The resident was in a rush and requested the medications be left for later consumption, but there was no order for self-administration, and LVN 3 acknowledged the mistake during an interview. Registered Nurse (RN) 1 administered Repaglinide to Resident 43 during a meal, despite the medication's requirement to be taken 30 minutes before meals as per the prescriber's order and FDA guidelines. This action was inconsistent with the facility's policy that medications should be administered according to prescriber orders and within the specified time frame to ensure optimal therapeutic effect. LVN 3 also failed to follow professional standards for insulin administration for Residents 219 and 24. Insulin was administered without proper blood sugar checks, and the technique used did not align with the facility's policy or the American Diabetes Association's guidelines. For Resident 24, insulin was administered during a meal without a prescribed blood sugar check, and LVN 3 admitted there was no order for pre-meal blood glucose checks, which was confirmed by the Assistant Director of Nursing (ADON).
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during a survey. In one instance, a medicine bottle containing FETILIDE 500 MCG was found in a resident's bedside drawer without an order or assessment allowing the resident to self-administer the medication. The facility's policy requires that residents may only self-administer medications if the attending physician and interdisciplinary planning team have determined it is safe. Additionally, during a medication pass, an LVN prepared Adult Tussin DM for a resident from an opened and undated bottle, contrary to the facility's policy that requires the open date to be marked. Further deficiencies were noted with medication labeling and storage. A registered nurse prepared Sevelamer Carbonate for a resident, but the medication label did not reflect the current order, which had been changed. An inspection of a medication cart revealed an opened and undated multi-dose insulin vial, which should have been discarded 28 days after opening. Controlled drugs of discharged residents and discontinued medications were improperly stored in the medication cart, along with a resident's money, which should have been kept in a safe by social services. The facility also failed to remove expired biologicals from active storage. A bottle of Assure Dose Control Solution was found stored beyond its expiration date. Additionally, a medication cart was left unlocked and unattended in the hallway during a medication pass, violating the facility's policy that requires all medications and biologicals to be stored in locked compartments when not in use. These practices were acknowledged by the staff during interviews, indicating a lack of adherence to the facility's policies and procedures regarding medication management.
Incorrect Scoop Size Used for Serving Green Beans
Penalty
Summary
The facility failed to ensure that meals were plated in accordance with the approved menu, specifically regarding the serving size of green beans. During a kitchen observation, it was noted that an employee used a green scoop, which measures 1/3 cup, instead of the required gray scoop, which measures 1/2 cup, to serve green beans to residents during lunch. This discrepancy was confirmed during an interview with the dietary staff, who acknowledged the incorrect scoop size was used. The facility's menu and tray tickets indicated that 49 residents were to receive regular textured green beans, and the failure to use the correct scoop size had the potential to result in these residents not receiving the prescribed amount of nutrients according to their dietary needs.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food for a lunch meal, specifically meatballs and pureed green beans, which affected 34 residents who received these items according to their diet orders. The facility's policy required that food temperatures be checked before service, with hot entrees needing to be at or over 120 degrees Fahrenheit at delivery. However, during an observation, it was found that the food temperatures were not measured before the trayline started. When temperatures were eventually taken, the meatballs were found to be below the required temperature, with readings as low as 102.2 degrees Fahrenheit. The Registered Dietitian confirmed that the meatballs were cooler than ideal when sampled. Additionally, the pureed green beans were found to be extremely salty and did not taste like green beans, unlike the regular textured green beans which were not overly seasoned. The Registered Dietitian and Dietary Supervisor both confirmed the difference in taste, with the pureed version being notably saltier. This discrepancy in food preparation and taste was not in line with the facility's recipe guidelines, which emphasized preparing tasteful meals and adjusting seasoning as needed.
Incomplete Contracts for Dialysis and Transportation Services
Penalty
Summary
The facility failed to provide a completed written agreement for dialysis services and transportation to dialysis, which were being provided by an external agency. During an interview and record review, it was revealed that the facility had an internal agreement request form for nursing home dialysis transfer, dated May 18, 2021, which was not an actual contract. The Administrator confirmed that this was merely a request for an agreement and not a finalized contract. Additionally, the facility's transportation contract, dated January 1, 2024, was found to be incomplete as it lacked the signature of the facility representative, although it was signed by the Owner/CEO of the transportation agency. The Administrator acknowledged that the contract was not signed by the facility. Furthermore, when the facility's dialysis contract was requested on two separate occasions, the Administrator stated that it was still pending and not available for review, indicating that the facility did not have a formal contract on file for the dialysis services being provided.
Facility Exceeds Licensed Bed Capacity
Penalty
Summary
The facility failed to operate within its licensed capacity by admitting more residents than permitted. The facility is licensed for 62 skilled nursing beds, as per the State of California, Department of Public Health. However, a review of the Detailed Census Report for September 2024 revealed that the facility admitted 63 to 64 residents on multiple days throughout the month, specifically on September 1, 2, 4, 9, 15, 16, 19, 23, 24, 25, 26, 27, and 29. This resulted in the facility exceeding its licensed capacity for a total of 13 days. During an interview on October 18, 2024, the Administrator acknowledged admitting more residents than the licensed capacity, citing approval from the Fire Marshall for a temporary increase to 68 beds, with plans to further increase to 70 beds pending approval of a facility application submitted on August 6, 2023. Despite this, the facility's official license only permits 62 skilled nursing beds, indicating a failure to comply with the licensing requirements and regulations.
Failure to Obtain POLST on Admission
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life-Sustaining Treatment (POLST) was obtained upon admission for a resident, identified as Resident 219. This oversight was discovered during an interview and record review, where it was noted that the POLST form was missing from the resident's clinical record. The absence of this critical document could potentially lead to the resident's end-of-life wishes not being honored in an emergency situation. The resident was admitted with several medical conditions, including a fracture of the left femur, gait and mobility abnormalities, type 2 diabetes, anxiety disorder, and hypertension. Despite the resident having no cognitive impairment, as indicated by the Minimum Data Set (MDS), and a Do Not Resuscitate (DNR) order being placed, the POLST form was not completed. The Licensed Vocational Nurse (LVN) involved in the review confirmed the absence of the advance directive and/or POLST form in the resident's records. According to the California Emergency Medical Services Authority, the POLST form should be completed by a healthcare provider based on the patient's preferences and medical indications, and it does not replace the advance directive. The lack of this documentation highlights a failure in the facility's admission process to ensure that the resident's medical treatment preferences were properly documented and accessible.
Inaccurate MDS Encoding for a Resident
Penalty
Summary
The facility failed to accurately encode the Minimum Data Set (MDS) for one of the residents, identified as Resident 20, by incorrectly documenting a diagnosis of depression. This error was discovered during a review of Resident 20's medical records, which included a face sheet, active diagnoses list, and discharge summary. The face sheet, dated October 18, 2024, listed multiple diagnoses such as spinal stenosis and low back pain but did not include depression. During interviews and record reviews with the MDS Director, it was confirmed that depression was not an active diagnosis for Resident 20, nor was it part of the resident's past medical history as per the discharge summary dated September 9, 2024. The MDS assessment for Resident 20, dated September 11, 2024, inaccurately indicated an active diagnosis of depression. This discrepancy was acknowledged by the MDS Director, who confirmed that the assessment did not reflect the resident's actual medical condition. The facility's policy on certifying the accuracy of resident assessments, last revised in November 2019, requires that any person completing any portion of the MDS assessment must sign it to certify its accuracy. This policy was not adhered to in the case of Resident 20, leading to the inaccurate documentation of the resident's condition.
Deficiencies in Care Plan Development for Two Residents
Penalty
Summary
The facility failed to develop an accurate comprehensive care plan for two residents, Resident 20 and Resident 31, which led to deficiencies in their care. For Resident 20, the care plan inaccurately indicated that Duloxetine was prescribed for depression, despite the absence of a depression diagnosis in the resident's medical records. The Interim Director of Nursing (IDON) confirmed that the care plan was incorrect as the medication was actually prescribed for chronic low back pain, a condition documented in the resident's medical history. For Resident 31, the facility did not develop a care plan for the indefinite use of Cephalexin, an antibiotic prescribed for recurrent urinary tract infections (UTIs). The resident's care plan lacked documentation for monitoring the side effects of the medication and the signs and symptoms of UTIs. The Licensed Vocational Nurse (LVN) acknowledged that the care plan for Cephalexin was only added on the day of the interview, although it should have been completed when the medication was initiated. The facility's policy requires that a comprehensive person-centered care plan be developed within seven days of the completion of the required MDS assessment and completed within 21 days of admission. The failure to adhere to this policy resulted in care plans that were not person-centered or specific enough to meet the residents' medical and physical needs.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice and its own policies and procedures in the administration of insulin for two residents. During a medication pass observation, an LVN prepared and administered insulin to Resident 219 without following the correct procedure. The LVN did not inject air into the insulin vial before drawing the medication, which is necessary to prevent a vacuum. Additionally, the LVN administered the insulin injection at a 90-degree angle without pinching the skin, contrary to the facility's policy that requires pinching the site and holding the syringe for 5 to 10 seconds before removal. For Resident 24, the LVN obtained a glucose reading during a meal, which is against the facility's policy that requires blood glucose checks before meals. The LVN then administered insulin without a prescribed glucose check order for pre-meal administration. The LVN acknowledged the absence of a specific order for pre-meal glucose checks in the resident's electronic health record (EHR) and proceeded with the administration based on a sliding scale order. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires blood glucose checks before meals and that insulin should be administered following specific procedures, including injecting air into the vial and pinching the skin at the injection site. The facility's policy and the American Diabetes Association guidelines emphasize the importance of these steps to ensure proper insulin administration and absorption.
Deficiency in Language Translation Services
Penalty
Summary
The facility failed to provide necessary language translation services for a resident whose primary language is Japanese. Despite the resident's request for a translator, multiple staff members were unaware of how to access translation resources beyond using family members or a communication board. This lack of awareness and resources was evident during interviews with staff, including a registered nurse and a licensed vocational nurse, who admitted to relying on family or non-verbal communication for translation needs. The Director of Social Services confirmed that the facility does not subscribe to any medical translation services and typically relies on family members or communication boards for translation. In cases where more complex communication is required, staff were advised to use translation applications like Google Translate. This deficiency in providing adequate translation services could hinder proper assessment and communication of the resident's needs.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor a resident on psychotropic medication for behavioral symptoms, side effects, and adverse consequences. Resident 220, who was admitted with diagnoses including schizophrenia, was prescribed amisulpride, a psychotropic medication not available in the USA, and was allowed to use their own supply. The informed consent for the use of this medication was obtained seven days after the resident's admission, contrary to the facility's policy that requires informed consent prior to administration. Additionally, the monitoring of the resident's behavior and side effects did not commence until seven days after the medication was first administered. This delay in monitoring was acknowledged by the Assistant Director of Nursing during an interview. The facility's policy mandates that monitoring should begin as soon as the medication is administered, which was not adhered to in this case. This oversight had the potential to place the resident at risk for adverse health consequences, impacting their mental, physical, and psychosocial well-being.
Resident Exceeded Prescribed Acetaminophen Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident was administered Acetaminophen beyond the parameters ordered by the medical provider. The resident, who was admitted in 2024 with multiple diagnoses including fractures of the left femur and left humerus, had two orders for Acetaminophen. The first order was for 500 mg to be given twice daily with a maximum of 3 grams in 24 hours, and the second order was for 325 mg to be given every 4 hours as needed, also not to exceed 3 grams in 24 hours. On specific dates, the resident received 1000 mg of Acetaminophen three times a day, and additional doses of 650 mg were administered, resulting in the resident exceeding the maximum allowed dosage of 3000 mg in 24 hours. Both the LVN and the Interim Director of Nursing acknowledged that the resident was given Acetaminophen over the prescribed limit, which could potentially affect liver function. The facility's policy on administering medications, dated 2001, indicated that medications should be administered in accordance with prescriber orders.
Failure in Kitchen Staff Competency for Manual Warewashing
Penalty
Summary
The facility failed to ensure the competency of one kitchen staff member in manual warewashing using the three-compartment sink, which is essential for cleaning and sanitizing utensils and food-contact surfaces. This deficiency was identified during an observation and interview with the Dietary Aide (DA) and the Dietary Supervisor (DS). The DA incorrectly described the procedure for using the three-compartment sink, omitting the crucial step of sanitizing. According to the facility's policy, the first compartment is for washing with detergent and hot water, the second for rinsing with clean hot water, and the third for sanitizing with a solution. However, the DA stated that the first sink was for scraping food, the second for washing with soap, and the third for rinsing in plain water, without mentioning the sanitizing step. The DS confirmed that the procedure should include scraping, washing, rinsing, and sanitizing, with the first sink for washing, the second for rinsing, and the third for sanitizing. The failure to ensure the DA's competency in this procedure had the potential to result in contamination of food, utensils, and equipment, which could lead to illness caused by pathogens. This deficiency was noted as affecting one of the eight kitchen staff members responsible for manual warewashing when the dish machine is not operational.
Inadequate Diet Order Options for Renal Patients
Penalty
Summary
The facility failed to ensure that its electronic medical record system provided physicians with appropriate diet order selections for residents with renal insufficiency or failure, consistent with current standards of practice and the terminology used by the approved diet manual. This deficiency was identified during a review of the facility's policy and procedure on therapeutic diets, which indicated that the terminology of physician-ordered diets should match that used by the Food and Nutrition Services department. However, the facility's electronic system only offered a 'Liberal Renal' diet option, which was not defined in the facility's diet manual and did not align with the specific dietary needs of residents with renal conditions. The deficiency affected three residents who were prescribed a renal diet. For instance, one resident's physician ordered a 'Liberal Renal' diet, which included an extra bowl of gravy and low potassium, but there was no approved guidance for this term. Another resident with end-stage renal disease on dialysis was prescribed a 'CCHO, Liberal Renal' diet with double protein and no concentrated sweets, which did not conform to the standards of practice. The Registered Dietitian and Dietary Supervisor confirmed that the 'Liberal Renal' diet was not in the diet manual, and the electronic medical record did not provide options consistent with the facility's approved diet manual, potentially leading to inappropriate nutrient levels for the residents involved.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards for Resident 19, who was on enhanced barrier precautions (EBP) due to multiple antibiotic resistances and the presence of an indwelling urinary catheter. During an observation, Physical Therapist (PT) 1 and Occupational Therapist (OT) 1 were seen providing care to Resident 19 without wearing the necessary personal protective equipment (PPE), specifically gowns, which are required for high-contact activities under EBP. This oversight occurred despite the resident's condition, which included quadriplegia and a neurogenic bladder, necessitating the use of a Foley catheter. The Infection Preventionist (IP) confirmed that staff should wear gowns and gloves when performing activities such as dressing, bathing, or transferring residents on EBP. However, during the observed session, PT 1 and OT 1 were only wearing gloves while repositioning and assisting Resident 19 with exercises and transfers. The IP acknowledged the absence of appropriate PPE and noted the lack of signage indicating the EBP requirements for Resident 19. The facility's policy on transmission-based precautions, revised in September 2022, supports the use of additional PPE for residents with risk factors for multi-drug resistant organisms (MDROs), which was not followed in this instance.
Failure to Ensure RN Assessments for Residents with Changes in Condition
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed an assessment for four sampled residents when they experienced a change in condition. Resident 1, who had diagnoses including a left ankle wound, congestive heart failure, and osteopenia, was found hanging upside down from a hoyer lift and later complained of severe head pain. Despite this, an LVN, rather than an RN, assessed the resident, who was later diagnosed with a neck fracture. Similarly, Resident 2, with diagnoses including sepsis, diabetes, and heart failure, had an unwitnessed fall, but no RN assessment was completed. Resident 3, with a fractured femur, hypertension, and osteomyelitis, also experienced a fall without an RN assessment. Resident 4, with osteoarthritis, atrial fibrillation, and fibromyalgia, was found lying on the floor after a fall, again without an RN assessment. During an interview, the Director of Nursing stated that LVNs perform assessments on residents with changes in conditions, which contradicts the facility's job description for LVNs. The job description for LVNs includes tasks such as catheterization, tube feedings, and taking vital signs but does not include performing resident assessments. This practice of allowing LVNs to perform assessments instead of RNs led to a failure in providing appropriate care and assessment for residents experiencing significant changes in their conditions.
Failure to Prevent Injury During Transfer
Penalty
Summary
The facility failed to prevent an injury to a resident during a transfer from a wheelchair to a bed using a hoyer lift. The resident, who had severe cognitive impairment and required extensive assistance for daily activities, was being transferred by two CNAs. During the transfer, the hoyer lift's wheels were obstructed by wound vacuum tubing on the floor. One CNA left the resident's side to move the tubing, causing the resident to panic, scream, and flip upside down, hitting her head on the base of the hoyer lift. The resident experienced severe pain and sustained a bump on the back of her head. The incident was observed by an occupational therapist who responded to the resident's scream and found her hanging upside down from the hoyer lift. A vocational nurse assessed the resident and decided to transfer her to the bed. The resident complained of severe pain and was noted to have a small bump on her head. The facility's policies on safe lifting and movement of residents, as well as the use of mechanical lifting devices, were reviewed and found to include guidelines for assessing the resident's condition and ensuring their comfort during transfers. However, these guidelines were not adequately followed, leading to the resident's injury.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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