Pilgrim Place Health Services Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremont, California.
- Location
- 721 Harrison Ave, Claremont, California 91711
- CMS Provider Number
- 055261
- Inspections on file
- 30
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Pilgrim Place Health Services Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and chronic skin issues did not receive prescribed diphenhydramine for itching, and hydrocortisone treatment was not continued as ordered. Nursing staff failed to perform required weekly skin assessments or notify the physician when the resident's condition did not improve, resulting in ongoing scratching and multiple open wounds. The facility did not follow its own protocols for wound care, assessment, and physician communication.
Licensed nurses did not complete or document required weekly skin assessments for a resident with multiple open skin scratches from persistent itching. Despite ongoing visible skin issues and physician orders for treatment, there was a lack of documentation and communication regarding the resident's skin condition over several weeks, contrary to facility policy and professional standards.
A resident with diabetes and hypertension was given blister packs containing other residents' medications at discharge, resulting in the ingestion of an unprescribed drug and subsequent hospitalization for adverse symptoms. The error was attributed to a failure in medication reconciliation by the discharge nurse, as confirmed by the DON.
A resident with diabetes and hypertension did not have follow-up pain assessments, change of condition notes, or physician communication documented after receiving pain medication. Both an LVN and the DON confirmed that required documentation was missing from the medical record, despite facility policy mandating complete and timely charting of care and communications.
A resident with moderate cognitive impairment and pathologic fractures in both arms made an accusation of abuse that was not reported to the administrator or authorities as required by the facility's policy. The resident mentioned brittle bones and could not recall reporting staff involvement. The facility's policy mandates immediate reporting of such allegations, but this was not adhered to, as confirmed by the administrator.
A resident developed a stage 3 pressure ulcer due to the facility's failure to update the care plan upon readmission, conduct a pressure injury risk assessment, and properly set a low air loss mattress. The resident's mobility was impaired by bilateral arm fractures, leading to pain and refusal to reposition, which increased the risk of pressure injuries. The lack of coordination among staff and unclear care interventions contributed to the deficiency.
The facility failed to inform two residents or their legal representatives about Advance Directives, violating their rights to formulate an AD. One resident had severe cognitive impairment and lacked decision-making capacity, while the other was moderately impaired but oriented. The Social Services Coordinator did not have the necessary documentation on file, despite facility policies requiring it within 72 hours of admission.
Two residents at high risk for falls did not have their care plans updated after incidents, contrary to facility policy. One resident's care plan was blank despite multiple fall risk assessments, while another resident's care plan lacked necessary safety measures after a fall. The facility's policy requires care plan revisions upon status changes, but this was not followed, leading to deficiencies.
The facility failed to follow safe food storage and handling practices, with unlabeled and undated food items found in the kitchen and resident areas. A resident's cookies were past their sell-by date, and the snack/nourishment refrigerator was at an incorrect temperature. Additionally, the chemical sanitizing solution in the kitchen was below the required concentration for effective sanitization.
The facility failed to maintain its infection prevention and control program, with deficiencies including improper disinfection of a blood pressure monitor, inadequate labeling of urinals, and improper storage of personal care items and staff belongings. These actions posed risks of cross-contamination and infection spread among residents.
A facility failed to accurately complete the MDS for a resident, who was incorrectly documented as taking anticoagulant medication. The ADON admitted the error, emphasizing the importance of MDS accuracy for resident care. The facility's policy requires comprehensive assessments to develop care plans, but this inaccuracy could lead to inappropriate care.
The facility failed to complete and transmit MDS assessments within the required timeframe for two residents, as per CMS guidelines. One resident's discharge MDS was not sent within 14 days, and another resident's admission and discharge MDS were also delayed. The Acting Director of Nursing acknowledged the oversight and the absence of a facility policy for MDS submission, relying on CMS guidelines instead.
A resident admitted with a suprapubic catheter did not have a baseline care plan developed within 48 hours, as required by facility policy. The resident, with multiple diagnoses and dependent on staff for toileting, had no care plans in their medical records. The Acting DON and Infection Preventionist confirmed the oversight, highlighting the importance of such plans for guiding staff care, especially for catheterized residents.
A facility failed to develop a care plan for a resident at risk of elopement, despite the resident's history and physician's order for a wander guard. The resident, with cognitive impairment and mobility issues, had attempted to leave the facility. A nurse confirmed the absence of a care plan, contrary to facility policy.
A resident at high risk for skin breakdown developed a stage 2 pressure ulcer due to inadequate care. Despite a care plan requiring regular repositioning and skin care, the resident was not encouraged to reposition, and wet diapers were not changed promptly. The facility's policy on pressure injury prevention was not followed, leading to the development of the ulcer.
A resident receiving oxygen therapy for COPD did not have the required oxygen use signage on their door, as per facility policy. This oversight was confirmed during an observation and interview with an LVN, highlighting a lapse in safety protocols.
The facility lacked a full-time Director of Nursing (DON) for about eight months, leading to the Assistant Director of Nursing (ADON) taking on multiple roles, including acting DON and Director of Staff Development (DSD). This situation resulted in a backlog of tasks and impacted the quality of care, as the ADON struggled to manage responsibilities effectively.
A resident in an LTC facility experienced a medication error rate of 11.54% due to improper administration of Eliquis and a multiple vitamin, and incorrect technique for Brimonidine Tartrate eye drops. The resident, with a history of anticoagulant use and a hip fracture, refused some medications, which were not administered or reported as required by facility policy.
A resident in an LTC facility did not receive their prescribed Eliquis, a blood thinner, due to a medication error. The resident spat out all medications except Colace, and the LVN failed to re-administer Eliquis or inform the NP about the refusal. The resident's care plan required Eliquis due to their risk for blood clots, but the facility's policy on medication refusal was not followed, potentially increasing the resident's risk of complications.
A facility failed to ensure a call light was within reach for a resident with muscle weakness and a history of falls, as required by care plans and facility policy. The resident, who needed substantial assistance and was wheelchair-bound, had the call light out of reach, confirmed by staff. This oversight was contrary to the facility's policy, which mandates call lights be accessible to residents.
The facility failed to ensure that the DON and RNS, acting as Infection Control Preventionists, had the necessary IP certificates and training. This was discovered during an investigation of a Covid-19 outbreak. The DON and ADM acknowledged the importance of proper training, but neither could provide proof of completed training. Regulatory documents emphasized the need for a full-time IP with adequate training.
The facility failed to provide a homelike environment for all residents by using meal trays that were cracked and peeling. During an observation, the DON and KS found ten trays in poor condition, acknowledging they were unsafe for serving meals. The facility's policy required maintaining a safe and homelike environment, which was not met, potentially affecting residents' quality of life.
Failure to Provide Ordered Itch Relief and Skin Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for a resident experiencing persistent itching and multiple open skin scratches, as required by its own policies and procedures. The resident, who had a history of psychosis, mobility issues, and muscle wasting, was admitted with skin integrity problems, including open tears and excoriations related to dry skin and scratching. Despite physician orders for hydrocortisone cream and diphenhydramine to address the itching, the resident did not receive diphenhydramine, and hydrocortisone treatment was not continued after the order ended. Observations revealed the resident continued to scratch, resulting in numerous open wounds across the body, with both healed and new excoriations visible. Nursing staff interviews and record reviews indicated that weekly skin assessments were not performed as required, with the last documented assessment being incomplete and not reflecting the resident's current condition. Licensed nurses and the DON confirmed that there was a lack of ongoing monitoring and documentation of the resident's skin status, and that the physician was not notified when the resident's condition failed to improve. The resident's care plan included interventions for skin integrity, but these were not effectively implemented or followed up, as evidenced by the continued presence of open wounds and persistent itching. Further, there was no evidence of communication with the physician regarding the resident's ongoing symptoms until prompted by the surveyor. The wound consultant had never assessed the resident, and there were no wound consultant notes in the medical record. The facility's policies required daily observation for skin changes and weekly documented assessments, as well as prompt notification of the physician for any lack of improvement, but these protocols were not followed. As a result, the resident remained at risk for infection due to the ongoing skin breakdown and lack of effective intervention.
Failure to Document and Assess Resident's Skin Condition Weekly
Penalty
Summary
Licensed nurses failed to accurately assess and document a resident's skin condition weekly, as required by facility policy and professional standards. The resident, who had a history of unspecified psychosis, mobility issues, and muscle wasting, was admitted with multiple open skin scratches caused by persistent itching. Physician orders were in place for topical treatment of the skin issues, but documentation of ongoing skin assessments was missing from the medical record for a period of over six weeks. Record review revealed that after an initial skin assessment on 8/29/2025, there were no further Licensed Nurse Skin Assessment Forms or other documented skin assessments from 8/30/2025 to 10/15/2025. During this time, the resident continued to experience widespread open skin scratches and excoriations, as observed by nursing staff and confirmed during interviews. Staff noted that the resident's skin condition remained unchanged, with numerous new and healed scratch marks visible on various parts of the body, but there was no documentation of these findings in the medical record. Interviews with nursing staff and the Director of Nursing confirmed that required weekly skin assessments were not completed or documented, and that changes in the resident's skin condition were not communicated to the physician as expected. Facility policies required timely and detailed documentation of skin assessments, including any changes or treatments, but these procedures were not followed for the resident during the identified period.
Resident Provided Incorrect Medications at Discharge
Penalty
Summary
A deficiency occurred when a nurse at discharge provided a resident with blister packs containing medications that belonged to two other residents, rather than the resident's own prescribed medications. The resident, who had a history of diabetes mellitus and hypertension and was determined to have the mental capacity to make medical decisions, ingested pantoprazole (Protonix) before realizing the error. The medication was not prescribed to her, and the error was confirmed by the Director of Nursing as a mistake that should not have happened. Following ingestion of the incorrect medication, the resident experienced adverse symptoms including body aches, vomiting, hives, and elevated blood pressure, which required hospital evaluation and monitoring. The facility's policy required the discharge nurse to ensure medication reconciliation at discharge, but this process was not followed, resulting in the resident receiving and ingesting another resident's medication.
Failure to Document Physician Communication and Change of Condition
Penalty
Summary
The facility failed to adhere to its own documentation policy by not recording key clinical information for a resident with diabetes mellitus and hypertension. Specifically, there was no documentation of a follow-up pain score after the administration of a second dose of pain medication, no record of a change of condition (COC), and no documentation of communication with the physician regarding the resident's status. These omissions were confirmed during interviews and record reviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the absence of required documentation in the resident's chart and Medication Administration Record (MAR). The facility's policy, dated August 2024, requires that all care, observations, and communications, including those with physicians, be documented completely, accurately, and in a timely manner. Despite this, the resident's chart lacked progress notes, COC documentation, and a physician's order for hospital transfer, as well as a follow-up pain assessment after pain medication was administered. These failures were identified during a review of the resident's records and confirmed by facility staff.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, which violated the resident's rights and potentially delayed an abuse investigation. The resident, who was admitted with diagnoses including myocardial infarction and hemiplegia, had moderate cognitive impairment and required maximal assistance with mobility. The resident's care plan noted an accusation that someone had hurt and broken the resident's arm, but this allegation was not reported to the administrator or the appropriate authorities as required by the facility's policy. The resident had pathologic fractures in both arms, as indicated by radiology and oncology consultations. During interviews, the resident mentioned that a water bottle fell on their arm and acknowledged having brittle bones, but could not recall reporting that a staff member broke their arm. The facility's policy mandates that any suspected or alleged abuse be reported within two hours to the administrator and relevant agencies, but this protocol was not followed in this case, as confirmed by the administrator during the review.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident, identified as Resident 1, who was readmitted to the facility. Upon readmission, the facility did not develop a comprehensive care plan to address the resident's risk for pressure injuries, despite the presence of redness on the sacrococcyx area. The care plans in the resident's medical record were outdated and not revised to reflect the resident's current condition. Additionally, there was a lack of coordination among the care team to address the resident's needs, particularly in light of the physician's order for minimal turning due to further fractures. The facility also failed to conduct a pressure injury wound risk assessment upon the resident's readmission. This assessment was crucial as it could have triggered the development of a specific care plan and the implementation of preventive measures, such as the use of an alternating pressure pad. The resident's bilateral arm fractures impaired mobility, leading to pain and refusal to reposition, which further increased the risk of pressure injuries. The lack of a clear plan and communication among staff regarding the resident's care needs contributed to the development of a stage 3 pressure injury. Furthermore, the facility did not ensure the proper use of a low air loss mattress, which was set on static mode instead of alternating mode. This setting was not appropriate for pressure relief and circulation, which are essential for preventing pressure injuries. The staff, including the treatment nurse and director of staff development, were unaware of the correct mattress setting needed for the resident's condition. This oversight, combined with the lack of a comprehensive care plan and risk assessment, resulted in the development of a significant pressure injury on the resident's sacrococcyx area.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to ensure that two residents, Resident 9 and Resident 47, or their legal representatives were informed and provided with written information about Advance Directives (AD). This failure violated the residents' rights to formulate an AD, which specifies health-related actions according to the resident's wishes when they are no longer able to make decisions due to illness or incapacity. Resident 9 was admitted with multiple diagnoses, including hemiplegia and dementia, and was assessed as having severely impaired cognitive status and lacking decision-making capacity. Resident 47, with diagnoses including COPD and sepsis, was moderately impaired cognitively but oriented to person, place, and time. During a review of the residents' medical records, it was found that the Social Services Coordinator (SSC) did not have a copy of the AD or the Acknowledgment Form (AF) for either resident. The SSC stated that the AF, which is provided to residents or their representatives to formulate an AD, must be given within 72 hours of admission. The facility's policies indicated that residents have the right to formulate an AD, and it is the SSC's responsibility to review and follow up on the completion of ADs. However, this process was not completed for Resident 9 and Resident 47, leading to the deficiency.
Failure to Update Care Plans for Fall-Risk Residents
Penalty
Summary
The facility failed to revise and update the care plans for two residents who were assessed as being at risk for falls. Resident 2 was admitted with diagnoses including mild cognitive impairment, metabolic encephalopathy, and abnormal gait and mobility. Despite being identified as high risk for falls in multiple assessments, Resident 2's care plan was not updated to reflect necessary interventions to prevent further falls. The registered nurse acknowledged that the care plan was blank and not updated, which was contrary to the facility's policy requiring care plan revisions upon a resident's status change. Resident 39, who was admitted with repeated falls and other medical conditions, was also identified as being at high risk for falls. Despite this, the care plan was not updated after a fall incident, and necessary safety measures such as safety floor mats were not implemented. The resident experienced a fall while trying to reach for clothing, and the interdisciplinary team noted periods of confusion and forgetfulness due to dementia. The Director of Nursing confirmed that the care plan should have been updated to address the fall and implement more effective strategies. The facility's policy mandates that care plans be reviewed and revised when a resident experiences a status change. This includes notifying relevant staff, discussing intervention options, documenting discussions, and updating care plans with new interventions. However, these procedures were not followed for Residents 2 and 39, leading to deficiencies in their care plans and potentially placing them at risk for further falls.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to safe food storage and handling practices in both the kitchen and the snack/nourishment refrigerator, as observed by surveyors. In the kitchen, multiple food items, including spices and vegetables, were found without proper labeling or dating, which is essential for maintaining food quality and preventing foodborne illnesses. Additionally, peeled boiled eggs were found in the walk-in refrigerator without labels, and pork butt meat was improperly stored on the floor of the walk-in freezer. The Executive Chef acknowledged that food items should be labeled with open and use-by dates and stored at least four inches above the floor. In the resident areas, a resident's bedside table contained cookies brought from home that were past their sell-by date, posing a risk of gastrointestinal issues. The Certified Nursing Assistant and Acting Director of Nursing both noted that food brought from home should be labeled and not kept for extended periods to prevent spoilage and potential illness. Furthermore, the snack/nourishment refrigerator was found to have an internal temperature of 31 degrees Fahrenheit, which is below the recommended range, risking the freezing of food items. A pot pie in the refrigerator was also undated, and the Licensed Vocational Nurse confirmed that the refrigerator temperature should be between 36 and 40 degrees Fahrenheit. The facility's policies and procedures were reviewed, revealing that they require proper labeling, dating, and storage of food items to prevent contamination and ensure safety. The chemical sanitizing solution used in the kitchen was also found to be at an incorrect concentration of 50 ppm, below the required 200-300 ppm, which is necessary for effective sanitization. The Executive Chef confirmed that the concentration was insufficient to kill bacteria, further highlighting the facility's failure to maintain professional standards for food service safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved the improper cleaning and disinfection of a blood pressure monitor. A Licensed Vocational Nurse (LVN) used the same wrist blood pressure monitor on two residents without disinfecting it between uses. This oversight was acknowledged by the LVN, the Acting Director of Nursing, and the Infection Preventionist, all of whom confirmed that the equipment should have been disinfected to prevent cross-contamination and the spread of infection. Another deficiency was noted in the labeling of urinals for residents. Resident 208's urinal was not properly labeled, leading to a potential mix-up with another resident's urinal. This was identified as an infection control issue by a Certified Nursing Assistant (CNA) and the Infection Preventionist, who emphasized the importance of proper labeling to prevent cross-contamination of infectious diseases. The facility's policy on infection prevention and control supports the need for individual labeling to avoid such risks. Additional issues included the improper storage of personal care items and staff belongings. A used perineal and skin cleanser was found on top of a toilet tank cover in a shared restroom, which posed a risk of cross-contamination. The Infection Preventionist confirmed that personal items should be stored at the bedside to avoid contamination. Furthermore, food and personal belongings of staff were found in the linen closet, which could lead to contamination of clean linens. The Housekeeping Supervisor and the Infection Preventionist both stated that such items should not be stored in the linen closet to maintain a clean and safe environment.
Inaccurate MDS Completion for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for a resident was completed accurately, as required by the facility's policy and procedure. This deficiency was identified during an interview and record review involving the Acting Director of Nursing (ADON) and the resident's records. The resident, who had multiple diagnoses including dysphagia, oropharyngeal phase issues, and essential hypertension, was inaccurately documented in the MDS as taking anticoagulant medication, which was not prescribed. The ADON acknowledged the error, stating it was important for the MDS to be accurate as it affects the resident's care. The facility's policy, titled MDS 3.0 Completion, Assessment and Care Planning Policy, mandates a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan. According to federal regulations, the facility is required to conduct a comprehensive, accurate, and standardized assessment of each resident's functional capacity. The failure to accurately complete the MDS for the resident had the potential to result in inappropriate care and services based on the resident's preferences, goals of care, functional and health status, strengths, and needs.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the quarterly Minimum Data Set (MDS) assessments in a timely manner for two residents, as required by the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual. For one resident, the MDS was not transmitted within 14 days after discharge from the facility. For another resident, the MDS was not transmitted within 14 days after both admission and discharge. These deficiencies were identified during interviews and record reviews with the Acting Director of Nursing (ADON), who acknowledged the oversight and the lack of a facility policy for MDS submission, relying instead on CMS guidelines. The report highlights that the late completion and transmission of MDS assessments to the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system could potentially affect the facility's quality monitoring data. The ADON admitted to forgetting to complete and send the discharge MDS for one resident and failing to submit the admission and discharge MDS for another resident. The facility was unable to provide a copy of the MDS 3.0 Submission Report for the relevant months to confirm the submission of the assessments.
Failure to Implement Baseline Care Plan for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident who was admitted with a suprapubic catheter within 48 hours of admission, as required by the facility's policy and procedure. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, acute kidney failure, and required a urinary device, was dependent on staff for toileting hygiene. Despite these needs, the resident's medical records did not contain any care plans, which was confirmed during a review with the Acting Director of Nursing. The absence of a baseline care plan was also noted by the Infection Preventionist, who emphasized the importance of having such a plan to guide staff in providing appropriate care, especially for residents with catheters. The facility's policy, revised in September 2022, mandates that a baseline care plan be developed within 48 hours of admission to ensure effective and person-centered care. However, this requirement was not met for the resident, potentially compromising the continuity of care and communication among staff.
Failure to Implement Elopement Care Plan
Penalty
Summary
The facility failed to develop or implement an individualized person-centered care plan for a resident who was at risk for elopement and had a history of elopement. The resident was admitted with diagnoses including mild cognitive impairment, metabolic encephalopathy, and abnormal gait and mobility. Despite being identified as at risk for elopement in assessments conducted on multiple occasions, and having a physician's order for a wander guard due to exit-seeking behavior, the resident did not have a care plan addressing the risk of elopement. During an interview, a family member confirmed that the resident had previously attempted to leave the facility to return home, and a wander guard was ordered to prevent elopement. However, during an observation, the wander guard was found hanging on the resident's walker rather than being worn. A registered nurse confirmed that the resident was high risk for elopement and acknowledged the absence of a care plan to address this risk, which was necessary for the resident's safety. The facility's policy required the development and implementation of a baseline care plan for each resident, which was not followed in this case.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of a pressure ulcer in a resident identified as high risk. Resident 48, who was admitted without pressure ulcers, developed a stage 2 pressure injury on the left buttock. The resident had multiple diagnoses, including end-stage renal disease, endocarditis, and bacteremia, and was assessed as high risk for skin breakdown due to reduced mobility, incontinence, diabetes, coronary artery disease, and aging. The care plan included interventions such as regular repositioning and maintaining skin cleanliness, but these were not adequately implemented. Observations and interviews revealed that Resident 48 was not encouraged or assisted to reposition while in a wheelchair or bed, which contributed to the development of the pressure ulcer. The resident reported that staff did not frequently encourage repositioning and that wet diapers were not changed promptly, leading to prolonged exposure to moisture. The resident was mostly bed-bound and required substantial assistance with activities of daily living, further emphasizing the need for diligent care to prevent skin breakdown. The facility's policy on pressure injury prevention outlined the importance of repositioning every two hours and keeping the skin clean and dry, especially for residents at risk. However, these guidelines were not followed, as evidenced by the resident's statements and the observations made during the survey. The lack of adherence to the facility's policy and the care plan interventions resulted in the development of a pressure ulcer in Resident 48.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to ensure proper respiratory care and safety for a resident receiving oxygen therapy, as per the facility's policy and professional standards. The resident, who was admitted with chronic obstructive pulmonary disease and a history of repeated falls, required oxygen administration at 2 to 4 liters per minute via nasal cannula for shortness of breath. Despite this requirement, there was no sign posted on the resident's door to indicate that oxygen was in use, which is a necessary precaution to inform staff and visitors and prevent potential fire hazards. During an observation, it was noted that the resident was asleep with the nasal cannula connected to an oxygen machine, yet the required signage was absent. This was confirmed during an interview with an LVN, who acknowledged the importance of the sign for safety reasons. The facility's policy on oxygen administration, revised in March 2022, mandates that oxygen warning signs must be placed on the doors of rooms where oxygen is in use, which was not adhered to in this case.
Absence of Full-Time DON for Eight Months
Penalty
Summary
The facility failed to maintain a full-time Director of Nursing (DON) for a period of approximately eight months, starting from early March 2024. This deficiency was identified during an entrance conference where the Administrator acknowledged the absence of a full-time DON and the ongoing search to fill the position. The previous DON went on medical leave in early March 2024 and subsequently resigned in August 2024. During this period, the Assistant Director of Nursing (ADON) assumed multiple roles, including acting as the DON, Director of Staff Development (DSD), and continuing her official duties as the Minimum Data Set Nurse (MDS). The ADON reported being overwhelmed by these responsibilities, which included conducting applicant interviews, being on-call for nursing duties, and managing new hire orientations and performance evaluations. The ADON's additional responsibilities led to a backlog in tasks such as performance evaluations and hindered her ability to effectively oversee the unit and communicate with residents. The ADON expressed that the overwhelming workload negatively impacted the quality of care and potentially affected both residents and staff. The facility's Quality Assurance Committee records confirmed the DON position remained open, and the job description for the DON highlighted the importance of compliance with regulations and quality clinical care, which was compromised due to the absence of a full-time DON.
Medication Administration Errors and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54% during a medication pass for a resident. The errors involved the improper administration of medications, including Eliquis, a blood thinner, and a multiple vitamin, which were not given as per the physician's orders. Additionally, the proper technique for administering Brimonidine Tartrate Ophthalmic Solution was not followed, as the tear duct was not held with gentle pressure after administration. The resident involved had a medical history that included long-term use of an anticoagulant, repeated falls, and a displaced intertrochanteric fracture of the right femur. The resident's care plan specifically indicated the need for administering medications as ordered, particularly Eliquis, due to the risk of poor circulation and blood clotting issues. During the medication pass, the resident refused to take certain medications, and the nurse failed to administer Eliquis and the multiple vitamin, disposing of them instead. Interviews with the nursing staff revealed that the nurse did not inform the nurse practitioner about the refusal of Eliquis and the multiple vitamin, although the refusal of other medications was communicated. The facility's policy on medication refusal requires immediate contact with the prescribing doctor, which was not fully adhered to in this case. The failure to apply pressure to the tear duct after administering eye drops was also acknowledged by the staff as a deviation from the correct procedure.
Failure to Administer Critical Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 109, was free from significant medication errors. During a medication pass observation, it was noted that Resident 109 did not receive their prescribed dose of Eliquis, a blood thinner, as ordered by the physician. The resident spat out all medications except for Colace, and the Licensed Vocational Nurse (LVN 5) did not re-administer the Eliquis or inform the Nurse Practitioner about the refusal of this critical medication. The resident's care plan indicated the necessity of administering Eliquis due to their risk for blood clots, given their medical history of long-term anticoagulant use, repeated falls, and a displaced intertrochanteric fracture of the right femur. The LVN acknowledged the failure to administer Eliquis and did not report the refusal of this medication to the Nurse Practitioner, which was contrary to the facility's policy on medication refusal. The policy required immediate contact with the prescribing doctor in cases of medication refusal, especially for medications critical to the resident's health. The Registered Nurse (RN 1) confirmed that Eliquis should have been administered due to the resident's recent fracture and the need to prevent complications. This oversight had the potential to increase the risk of blood clots for the resident, which could lead to serious medical complications.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light system was within reach for Resident 25, as required by the resident's care plans and the facility's policy and procedure. Resident 25, who was admitted with multiple diagnoses including muscle weakness, difficulty in walking, and a history of falling, had care plans that specified the call light should be kept within reach at all times. During an observation, it was noted that the call light was looped around the left bed grab bar and was out of reach for Resident 25, who was sitting in a wheelchair on the right side of the bed. This was confirmed by Licensed Vocational Nurse 1, who acknowledged that the call light should always be within reach for the resident's safety. Interviews with staff further highlighted the deficiency. Certified Nursing Assistant 1 stated that the call light should always be within reach and not on the opposite side of the bed, as it could increase the risk of falls. The facility's policy, revised in April 2023, also indicated that staff should ensure the call light is within reach and secured as needed. Despite these guidelines, the call light was not accessible to Resident 25, who required substantial to maximal assistance for activities of daily living and was wheelchair-bound, oriented to time, place, and person.
Inadequate Infection Prevention Training for Acting ICPs
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) and the Registered Nurse Supervisor (RNS), who were covering the role of Infection Control Preventionist (ICP), had the necessary Infection Prevention (IP) certificates and completed specialized training in infection prevention and control. This deficiency was identified during a visit to investigate a reported Covid-19 outbreak at the facility. The Administrator (ADM) confirmed that the ICP was on medical leave, and the role was shared between the DON and the part-time RNS. However, neither the DON nor the RNS could provide certificates to verify their completion of the required training. Interviews with the DON and ADM revealed that the DON had been acting as the ICP for several months but could not recall the exact start date. The DON acknowledged the importance of having a properly trained ICP to manage infection control and prevent the spread of diseases like Covid-19. The ADM also emphasized the necessity of a trained ICP to monitor outbreaks and protect residents and staff. A review of regulatory documents from the California Department of Public Health (CDPH) highlighted the requirement for a full-time IP with a minimum of 14 hours of training and ongoing education to stay updated on best practices.
Facility Fails to Provide Homelike Environment Due to Damaged Meal Trays
Penalty
Summary
The facility failed to provide a homelike environment for all 53 residents by not ensuring that meal trays were in good condition. During an observation and interview with the Director of Nursing (DON) and Kitchen Supervisor (KS) in the kitchen area, ten trays were found to have cracks and peeling materials. Both the DON and KS acknowledged that these trays were not appropriate or safe for serving meals to residents. The KS further stated that the facility should not be using broken, cracked, and/or peeling trays and that these trays needed to be disposed of. The facility's policy and procedure titled 'Safe and Homelike Environment,' revised in April 2024, indicated that the facility was responsible for providing a safe, clean, comfortable, and homelike environment in accordance with residents' rights. This included ensuring that resident care equipment, such as meal trays, was kept clean and properly stored. The failure to adhere to this policy resulted in a non-homelike environment, potentially affecting the residents' quality of life.
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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