Premier Care Center For Palm Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Palm Springs, California.
- Location
- 2990 East Ramon Road, Palm Springs, California 92264
- CMS Provider Number
- 056328
- Inspections on file
- 42
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Premier Care Center For Palm Springs during CMS and state inspections, most recent first.
A resident with cognitive communication deficit, syncope, collapse, and a history of falls experienced multiple unwitnessed falls over several months while the facility failed to consistently evaluate and modify fall-prevention interventions. IDT notes described the resident as confused, lacking safety awareness, and exhibiting behavior-related falls, yet recommended measures such as bilateral bed bolsters and a psych consult were not clearly implemented, and no new interventions were added after some subsequent falls. Care plan interventions included a low bed, fall mats, non-skid footwear, and neuro checks, but post-fall neurological assessments were repeatedly incomplete or missing required vital signs and neuro parameters over the mandated 72-hour periods. Although orders allowed use of alarms and placement near the nurses’ station, there was no sitter care plan, and the DON confirmed that post-fall neuro assessments were not completed as required, resulting in a deficiency for failing to maintain an accident-hazard-free environment and provide adequate supervision to prevent accidents.
Surveyors found that the facility failed to integrate ventilation and HVAC practices into its infection prevention and control program during a COVID-19 outbreak. COVID-positive residents were cohorted on one wing without consideration of how multiple rooms were connected by shared HVAC units, and the IP reported there was no ventilation mitigation strategy or policy for airborne infections. The DM explained that vents and returns in rooms of COVID-positive residents should be covered and portable AC units used, but there was no evidence this was consistently applied, and the facility used MERV 12 filters despite higher-efficiency recommendations in national guidance. The DM also stated that HVAC filters were last changed several months earlier and could not provide documentation of required 90-day filter changes or maintenance logs, contrary to the facility’s own maintenance and infection control policies and national ventilation guidelines.
Surveyors found that an emergency exit door on one wing and an adjacent maintenance shop door were left open and unattended, despite the DON and DM stating these doors should remain closed, alarmed, and locked unless staff are physically present. The investigation also revealed that required monthly generator tests were not documented for the past year, contrary to facility policy. In addition, the DM could not locate water temperature logs since mid-year, and on-site checks showed hot water temperatures in resident rooms and a conference room sink above the facility’s policy limit of 120°F, indicating that environmental monitoring and controls were not being consistently maintained.
A resident with hemiplegia and intact cognition developed a pruritic rash and was twice evaluated by dermatology, which diagnosed scabies and ordered Permethrin 5% cream treatment with a repeat dose and recommended contact precautions and management of close contacts. Facility staff did not transcribe or carry out the initial Permethrin order, later entered and then discontinued a Permethrin order on the same day without administering any doses, and discontinued an order for a skin scraping for scabies without performing the test or documenting a reason. The resident was not placed on contact isolation, roommates were not prophylactically treated, and no close contact list was initiated, despite facility policy and expectations described by the IP and DON.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and were linked to failures in following established protocols.
A resident with a recent UTI and catheter removal reported significant pain, and while PRN Tylenol was administered, nursing staff failed to document the location of the pain in both progress notes and condition monitoring, contrary to facility policy and care plan requirements. Interviews confirmed that staff were expected to include pain location in documentation, but this was not done, resulting in an incomplete pain assessment.
A resident with a history of stroke and encephalopathy experienced two unwitnessed falls, after which required neurological assessments were not fully completed or documented according to facility policy. Multiple scheduled neuro checks were missed or incomplete, and key assessment forms lacked signatures or were not filled out, as confirmed by interviews with nursing staff and the DON.
Five residents did not receive their scheduled 9 a.m. medications within the required timeframe, with doses administered several hours late due to an LPN becoming busy and not seeking assistance. The medications included treatments for chronic conditions such as hypertension, seizures, and depression. Facility policy requires medications to be given within one hour of the scheduled time, which was not met.
The facility failed to schedule a registered nurse (RN) for eight consecutive hours on multiple dates, relying instead on licensed vocational nurses (LVNs) to manage in the RN's absence. This deficiency was identified during an unannounced visit, with interviews revealing that the Director of Staff Development was unaware of the requirement, and the Director of Nursing acknowledged insufficient RN hours. Documentation confirmed the RN's reduced hours, raising concerns about potential delays in care and risks to resident safety.
A resident with a suprapubic catheter was observed with an uncovered urinary drainage bag, contrary to the facility's policy to maintain dignity. The resident expressed discomfort, and the LVN acknowledged the oversight. The DON confirmed the potential psychosocial impact of this failure.
A facility failed to provide a functional call light system for a resident with quadriplegia, leaving him unable to call for assistance. The resident was given a portable call bell, which he could not use due to his paralysis, and had to resort to yelling for help. The call light system was broken, and the facility's maintenance and accommodation policies were not followed, resulting in this deficiency.
A resident with hemiplegia and hemiparesis experienced verbal abuse from a CNAS who used inappropriate language and gestures during care. The incident was witnessed by a CNA and reported to the LVN, who confirmed the behavior as verbal abuse. The facility's Administrator acknowledged the failure to prevent the altercation, which violated the facility's policy on abuse prevention.
A facility failed to report an allegation of verbal abuse by a CNAS towards a resident to CDPH within the required timeframe. The incident involved a verbal altercation where the CNAS used inappropriate language and gestures, leading the resident to feel disrespected and verbally abused. The incident was reported to an LVN by a CNA, but the DON did not investigate further or report it to CDPH. The facility's policy requires immediate reporting within two hours, which was not followed.
A facility failed to report a verbal abuse allegation by a CNAS towards a resident to CDPH within the required 2-hour timeframe. The resident, who had hemiplegia and hemiparesis, reported feeling disrespected after a verbal altercation with the CNAS. The incident was initially reported by a CNA to an LVN, but the DON did not investigate or report it promptly. The SSD confirmed the delay in reporting, which was against the facility's policy.
A resident experienced significant weight loss due to the facility's failure to follow the Registered Dietitian's recommendations for weekly weight monitoring. Despite being identified as at risk for weight loss, the resident's weight was not consistently recorded, and there was no documentation explaining the oversight. Interviews with facility staff confirmed the lack of adherence to the interdisciplinary team's recommendations.
The facility failed to update care plans for residents experiencing gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. One resident with nutritional deficiency and anemia did not have their care plan updated to include Zofran and IV hydration. Another resident with heart failure and detected Norovirus had no care plan for diarrhea. A third resident with diabetes had a delayed care plan update for diarrhea treatment. Lastly, a resident with spinal stenosis had a care plan that was not updated to include Zofran and lab tests. The DON acknowledged the delay in updating care plans.
The facility failed to implement effective infection control practices during a GI outbreak, leading to the spread of infection among residents and staff. Staff did not perform hand hygiene after contact with high-touch areas, and appropriate PPE was not used while providing care to residents requiring Enhanced Barrier Precautions. Additionally, the facility did not monitor residents with GI symptoms or conduct timely surveillance tracking, resulting in a delayed identification of the outbreak and late notification to health authorities.
Three residents were found with medications on their overbed tables without proper assessments for self-administration. One resident had eye drops, another had a respiratory inhaler, and the third had muscle balm ointment. Despite being mentally capable, there were no documented assessments or physician's orders for self-administration, leading to potential risks of improper medication use.
A facility failed to administer medications according to physician orders for a resident with hypertension, did not monitor or document skin discolorations for another resident, and neglected to notify a physician of a change in condition before transporting a third resident to an appointment. These deficiencies involved improper medication administration, lack of documentation, and failure to follow change of condition protocols.
A LTC facility failed to administer medications as prescribed, including incorrect dosing of fluticasone nasal spray, missed doses of IV antibiotics, improper documentation for withheld blood pressure medication, and incorrect oxycodone dosing for severe pain. These errors were confirmed by the DON.
The facility failed to meet the special dietary needs of three residents during a lunch meal. Two residents on a fortified diet were initially served regular pureed chili instead of fortified chili, which was later corrected. Another resident on a dysphagia mechanical soft diet was served a meal without a starch component, which was acknowledged as an oversight and corrected with mashed potatoes. The facility's policy requires menus to meet residents' nutritional needs.
The facility failed to store residents' food items in accordance with professional standards, as observed during an inspection of the nurses' station refrigerator. Several food items, including yogurt, creamer, apple juice, and leftovers, were found undated or past their storage dates, contrary to the facility's policy requiring labeling and discarding after 72 hours. The DON acknowledged these lapses, which could potentially lead to foodborne illnesses among residents.
The facility failed to maintain infection control practices when a resident was observed with a urinal hanging from their wheelchair, and staff were not wearing fit-tested N95 masks while caring for COVID-19 positive residents. The facility's policies require proper waste containment and fit-tested respirator use to prevent infection spread.
A resident experienced a delay in assistance after activating the call light, waiting 30 minutes for a juice refill. Despite two nurses being present at the station, they did not respond, and a CNA eventually assisted after 15 minutes. Staff interviews confirmed the expectation for prompt response, ideally within five seconds, as per facility policy.
A facility failed to ensure a resident's Advance Directive (AD) was available in their medical record, risking non-compliance with the resident's treatment wishes if they became unable to decide. Despite the resident having an AD and the family member visiting regularly, the AD was not in the record. The Social Service Director acknowledged the oversight, and the facility's policy required ADs to be communicated to the care team and physician.
A resident experienced discomfort and potential risk due to a detached chair rail molding above their bed, which was not reported or repaired by the facility staff. Interviews with staff confirmed the issue, and facility policies indicated the need for routine maintenance to ensure safety and comfort.
A resident with diabetes was observed with long, thick toenails after his requests for nail care were ignored. A CNA responsible for his care did not notice the issue due to being hurried and failed to inform the charge nurse. The facility's policy required licensed nurses to perform nail care for diabetic residents, but this was not followed, leading to a deficiency in maintaining the resident's personal hygiene.
The facility failed to properly store medications, resulting in expired and discontinued medications being found in storage areas. An RN found expired daptomycin IVPB bags in the medication refrigerator, and an LVN discovered a discontinued medication in the medication cart. Additionally, an insulin pen without an open or expiration date was found, contrary to guidelines. These issues could lead to residents receiving ineffective medications.
A resident experienced discomfort due to a persistent water leak from a pipe under the sink in their room, which was not addressed despite being reported to staff. The Maintenance Supervisor was unaware of the issue, and the Administrator acknowledged the need for repair. The facility's policies on equipment maintenance and providing a homelike environment were not followed, leading to an unsafe and uncomfortable living condition for the resident.
Failure to Evaluate and Modify Fall-Prevention Interventions and Complete Post-Fall Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure that fall-prevention interventions for a resident with multiple falls were evaluated for effectiveness and modified appropriately. The resident was admitted with diagnoses including cognitive communication deficit, syncope, and collapse, and had a known history of falls prior to admission. Progress notes document repeated unwitnessed falls beginning in June and July 2025, often with the resident found on the floor next to the bed, sometimes stating he was reaching for something or trying to get up. The resident was described as alert with confusion, lacking safety awareness, and not following fall precautions, and the IDT identified the falls as likely related to behaviors, spontaneous movements, and limited cognitive ability for safety. Across multiple IDT meetings, various fall-related issues were discussed, but interventions were not consistently implemented or updated in response to repeated falls. In July 2025, the IDT discussed several unwitnessed falls and noted the resident’s confusion and behavioral component, planning bilateral fall mats, a psych referral, and encouraging time in a wheelchair at the nurses’ station. In September 2025, after another fall, the IDT noted the resident slid off the bed while trying to get up and documented existing interventions such as a geri chair, fall mats, and possible bed alarm. Later in September, after another fall, the team considered bilateral bolsters in bed to mitigate rolling off the bed, but subsequent progress notes in October 2025 did not indicate that these bolsters were in place, and there were no new interventions implemented after the September 22 fall despite additional falls on October 17 and October 25, 2025. The resident continued to report rolling out of bed or acting on confused perceptions, such as chasing animals he believed were in the room. The facility also failed to complete required post-fall neurological assessments for this resident following unwitnessed falls. Review of Post Fall-Neurological Check documents showed multiple missing entries for vital signs and neurological parameters over several dates. On various dates in July, August, and September 2025, documentation lacked pulse, respirations, assessments of pupils and extremities, and evaluations for seizure, headache, nausea, or vomiting. Several shifts had no entries for respirations, level of consciousness, response, or speech, and some entries lacked times or dates. The DON confirmed that neurological assessments are required for 72 hours after unwitnessed falls or possible head injury and acknowledged that these assessments were not completed as required for this resident. The facility’s fall management policies required individualized care plans with measurable objectives, post-fall risk evaluations, 72-hour follow-up documentation, neurological assessments after unwitnessed falls, investigation of causal factors, and care plan updates, but the documented record for this resident showed repeated falls without consistent modification of interventions and incomplete post-fall neurological monitoring. Additional documentation showed that orders for alarms and supervision were present but not clearly tied to effective modification of the care plan in response to ongoing falls. Physician orders in November 2025 allowed the resident to be up in a geri chair when not in bed and permitted use of tab alarms and alarm pads in bed and chair to remind the resident to call for assistance and alert staff to unsupervised transfers or ambulation. The DON stated that the resident had been moved closer to the nurses’ station for better supervision and that when up in a geri chair he was to be near the nurses’ station, but there was no care plan or order for a sitter. The DON also stated that a psychology consult was ordered in July 2025 but could not find documentation that it was completed. Overall, the record shows that despite multiple falls and identified behavioral and cognitive risk factors, the facility did not consistently evaluate the effectiveness of fall interventions, did not reliably implement or document planned interventions such as bed bolsters and psych evaluation, and did not complete required 72-hour neurological assessments after unwitnessed falls, leading to the cited deficiency. The resident’s care plan documented actual falls on October 17 and October 25, 2025, with interventions including a fall mat, low bed, keeping items within reach, neuro checks, non-skid footwear, and monitoring and documentation for 72 hours. However, the pattern of repeated falls and the gaps in neurological check documentation demonstrate that these interventions and monitoring requirements were not fully carried out or adjusted in response to ongoing incidents. The facility’s own fall management policies required reassessment of fall risk with significant changes in condition and updating of the care plan after each incident, but the clinical record for this resident shows that after certain falls, such as the October 17 event, no new interventions were added beyond those previously considered, and recommended measures like bilateral bolsters were not clearly implemented. These documented inactions and incomplete assessments form the basis of the deficiency related to accident hazards and inadequate supervision to prevent accidents for this resident.
Failure to Implement Ventilation-Based Infection Control and HVAC Filter Maintenance
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control standards related to its HVAC system and ventilation practices. During an unannounced complaint investigation focused on infection control, surveyors learned that the facility had experienced a COVID-19 outbreak in which approximately 20 residents and several staff members tested positive. COVID-positive residents were placed on isolation precautions and transferred to the B wing, but the Infection Preventionist (IP) stated she did not know how the HVAC units connected multiple rooms and that the ventilation system was not considered when placing COVID-positive residents. The IP also reported that the facility did not have a ventilation mitigation strategy or policy for airborne infections to minimize potential contamination between rooms sharing the same HVAC unit. Observations and interviews with the Director of Maintenance (DM) revealed that several HVAC units served multiple resident rooms and other areas, with each room having vents and returns that recirculated air back into the system. The DM stated that when a resident was COVID-positive, the vent and return in that room should be covered and a portable air conditioning unit used with the door closed to prevent recirculation of air to other rooms; however, there was no indication that this was systematically done during the outbreak. The DM also stated that the facility used MERV 12 filters in the ventilation system, and that the last filter changes occurred in September 2025, but he could not locate documentation to verify that the filters had been changed as required. Record review showed that national guidance from CDC/NIOSH, ASHRAE, the Occupational Health Branch, and CDC’s ventilation in healthcare settings emphasized the importance of ventilation, appropriate filtration (including recommendations for MERV 13–14 or higher where possible), and routine HVAC maintenance and documentation to reduce airborne infectious aerosol exposure and COVID-19 transmission risk. The facility’s own maintenance policy required visual inspection and replacement of HVAC filters at least every 90 days, with detailed documentation of all actions taken, and required the maintenance supervisor to participate in infection control education and follow guidelines for heating and ventilation systems. The facility’s infection prevention and control program and transmission-based precautions policies called for comprehensive infection detection, prevention, and control, individualized resident placement decisions, and adherence to national standards, but these policies did not translate into a ventilation-focused strategy or documented HVAC filter maintenance consistent with the facility’s stated requirements and referenced guidelines.
Failure to Secure Exits and Maintenance Area, and to Monitor Generator and Hot Water Temperatures
Penalty
Summary
Surveyors identified multiple failures in maintaining safe and functional environmental conditions for residents and staff. During an unannounced complaint investigation focused on the physical environment, an emergency exit door at the end of B wing was observed propped open with no staff present, and the adjacent maintenance shop door was also open and unattended. The DON confirmed that the emergency exit door, which is equipped with a wander guard and alarm, is required to remain closed with the alarm set unless someone is physically present, and that the maintenance shop door must be closed and locked when maintenance staff are not there. The DM similarly stated that both doors should remain closed and secured for resident safety and that maintenance staff should not leave these doors open when unattended. Surveyors also found that the facility was not following its own policies for generator testing and water temperature monitoring. The DM reported he could not locate documentation verifying that the emergency generator had been tested for the past year, despite a facility policy requiring the generator to be run monthly under load for 30 minutes with documentation of the checks. The DM further stated he could not find any logs confirming that water temperatures had been checked since May 2025, even though facility policy requires weekly checks and documentation. When surveyors measured water temperatures in various locations, they found readings of 124°F at a conference room sink and 120.4°F to 122°F in several resident rooms, exceeding the facility’s stated maximum of 120°F for resident care areas and the policy requirement that hot water in resident rooms and common areas be maintained between 105°F and 120°F.
Failure to Implement Scabies Treatment and Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered and recommended infection control interventions and treatment for a cognitively intact resident with suspected and later diagnosed scabies. The resident, admitted with hemiplegia following a stroke and scoring 13 on the BIMS, was noted on November 17, 2025, to have self-inflicted scratches and a rash on the chest and arms. On the same date, a dermatology visit documented an impression of scabies with linear burrows and a plan to treat with Permethrin 5% cream applied from neck to toes overnight and repeated in one week. The dermatology note also stated that scabies is very contagious and that household contacts should be treated, and contaminated clothing isolated and laundered appropriately. However, after this consultation, no physician order for Permethrin was entered, and the November 2025 TAR showed that Permethrin was not administered. On November 26, 2025, a physician order was written to “scrap” for scabies, but this order was discontinued later the same day without the procedure being completed and without any documentation explaining the discontinuation. The Infection Prevention Nurse (IP) confirmed that there were no skin scraping results for November 2025 and that she did not know why the order was discontinued, as it was not communicated to her and there was no nursing documentation. The DON similarly verified that no skin scraping was performed, that the order was discontinued without explanation, and that there were no results in the record, despite the facility policy stating that a diagnosis is made via physical exam and/or skin scrapings with microscopic exam. On December 1, 2025, the resident had a follow-up dermatology consultation again documenting an impression of scabies with linear burrows and the same plan for Permethrin 5% cream treatment and repeat in one week. A physician order for Permethrin was entered on December 1, 2025, but was discontinued twice on the same date, and the December 2025 MAR showed that the treatment was not administered or repeated one week later. There was no documentation in the progress notes explaining why the Permethrin treatment was discontinued or not given. Although a physician order for contact isolation for a diagnosis of scabies was written on December 17, 2025, the IP and DON confirmed that after both dermatology consultations, the facility did not implement contact isolation precautions, did not perform the ordered skin scraping, did not prophylactically treat the resident’s roommates, and did not initiate a close contact list, contrary to the facility’s communicable disease policy that required immediate containment, treatment, use of contact precautions, simultaneous treatment of roommates, and documentation of treatments and monitoring.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the facility's failure to follow established protocols for continence care, catheter management, and infection prevention.
Incomplete Pain Assessment and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to conduct a complete pain assessment for a resident with a history of urinary tract infection (UTI) and acute pain. The resident, who had recently had a urinary catheter removed, reported ongoing burning sensation during urination and rated her pain as 6 or 7 on a scale of 1-10. Although Tylenol was administered as ordered for severe pain, documentation in the progress notes and condition monitoring failed to include the location of the pain, despite the resident indicating discomfort in the bladder area. The care plan required monitoring and documenting the probable cause of each pain episode, but this was not fully carried out. Interviews with nursing staff and review of facility policy confirmed that the expected process was to document the location of pain when administering PRN pain medications. However, both the progress notes and condition monitoring records lacked this information for the resident on the relevant dates. The Director of Nursing also stated that staff were expected to assess and document the location of pain prior to medication administration, but this was not done in this case, resulting in incomplete pain assessment and documentation.
Failure to Complete Required Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure proper monitoring and completion of neurological assessments for a resident following two unwitnessed falls. The resident, who had a history of cerebral infarction and encephalopathy, experienced a change in condition and was noted to have fallen on two separate occasions. After the first fall, documentation showed that vital signs were taken and the resident was assessed, but the neurological assessment was incomplete, lacking documentation of pupil and extremity checks, and the falls checklist and CNA post-fall assessment were not completed or signed. Following the second fall, facility policy required neurological checks at specific intervals for unwitnessed falls or suspected head trauma. However, the resident's neurological status was not documented as completed at multiple required times over the subsequent days. Several scheduled neurological checks were either missing or incomplete, and there were gaps in documentation across multiple shifts. Interviews with nursing staff and the DON confirmed that the expected protocol was not followed, and that there were numerous blanks and uncompleted neurological monitoring entries for the resident after both unwitnessed falls. The facility's own policy required thorough assessment and documentation after such incidents, but these procedures were not consistently carried out or recorded in the resident's medical record.
Delayed Administration of Scheduled Medications
Penalty
Summary
The facility failed to ensure that five residents received their scheduled 9 a.m. medications within the required timeframe, as observed and confirmed through interviews and record reviews. On the day in question, medications for these residents were administered several hours late, with some not given until after 1 p.m. The medications included treatments for high blood pressure, nerve pain, depression, seizures, anemia, and other chronic conditions. Staff interviews revealed that the nurse responsible for administering the medications became busy and did not seek assistance, resulting in the delay. The Director of Nursing confirmed that the medications should have been administered within one hour of the scheduled time, in accordance with facility policy. Resident interviews indicated awareness of missed or delayed medications, with one resident specifically noting concern about a missed dose of Ritalin. The Medication Administration Records corroborated the late administration times for all five residents. The facility's policy requires accurate and timely preparation, administration, and documentation of oral medications, which was not followed in these instances.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled for eight consecutive hours in a 24-hour period on multiple dates in November and December 2024. This deficiency was identified during an unannounced visit on January 27, 2025, following a complaint about nursing services. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the RN worked only six hours on the specified dates, and the facility relied on licensed vocational nurses (LVNs) to handle issues in the RN's absence. The DSD was unaware of the requirement for an RN to be present for eight consecutive hours, and the DON acknowledged the lack of sufficient RN hours, which could lead to delays in care. The facility's documentation, including the Daily Assignment and Census Sheet, staffing sign-in log sheet, and time card records, confirmed the RN's reduced hours. The DON and LVN both expressed concerns that the absence of an RN for the required hours could delay the identification and treatment of life-threatening conditions, compromising the health and safety of residents. The facility's policy on adequate staffing emphasized the need to meet residents' needs, but the failure to comply with the RN staffing requirement posed a risk to resident care.
Failure to Maintain Resident Dignity by Not Covering Urinary Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not covering the urinary catheter drainage bag with a dignity bag. During an observation and interview, the resident expressed discomfort about the visibility of the urine collection bag. The Licensed Vocational Nurse (LVN) acknowledged that the urinary bag was exposed and should have been covered, indicating a lapse in maintaining the resident's dignity. The resident, who was admitted with neuromuscular dysfunction of the bladder, was cognitively intact and had a care plan that included placing the catheter bag inside a basin. The Director of Nursing (DON) confirmed that the uncovered urinary bag could have a psychosocial impact on the resident. The facility's policies on resident rights and indwelling urinary catheter care emphasized the importance of covering the drainage bag to maintain dignity, which was not adhered to in this instance.
Failure to Provide Functional Call Light System for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a call light system was available and functional for a resident with quadriplegia, which resulted in the resident being unable to call for assistance. During an unannounced visit, it was observed that the resident had a portable call bell placed on his overbed table, but he was unable to use it due to his paralysis. The resident expressed frustration as he had to yell for help, which was not a reliable method for requesting assistance. The Licensed Vocational Nurse confirmed that the call light system was broken and that the resident could not use the bell due to his condition. The Maintenance Assistant acknowledged that the call light system was broken and should have been repaired. The facility's Administrator stated that maintenance issues should be addressed immediately and that the call light system should have been fixed to meet the resident's needs. The facility's policies on equipment maintenance and accommodation of needs emphasize the importance of ensuring equipment is in good working order and that residents' needs are accommodated, including the use of call lights. However, these policies were not followed, leading to the deficiency.
Verbal Abuse Incident Involving CNA Student
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a Certified Nurse Assistant Student (CNAS) used inappropriate language towards a resident. The incident involved a resident who was admitted with hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side. The resident was mentally capable of understanding and had a care plan indicating a potential for psychosocial well-being problems related to verbal altercations with staff. During an interaction, the CNAS told the resident to 'f____ off' and made an inappropriate gesture, which the resident found disrespectful. The incident was reported by a Certified Nursing Assistant (CNA) who witnessed the verbal altercation and was shocked by the CNAS's behavior. The Licensed Vocational Nurse (LVN) confirmed that the CNAS should not have engaged in a verbal altercation with the resident, identifying the behavior as verbal abuse. The facility's Administrator acknowledged that the verbal altercation should have been prevented and emphasized the expectation for all staff to maintain a facility free from any types of abuse. The facility's policy on abuse prevention clearly states that residents have the right to be free from verbal abuse, which includes the use of disparaging and derogatory terms.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) within the required timeframe. The incident involved a verbal altercation between the CNAS and a resident who was mentally capable of understanding and had a history of hemiplegia and hemiparesis following a cerebral infarction. The resident reported feeling disrespected and verbally abused after the CNAS used inappropriate language and gestures during care. The incident was initially reported to a Licensed Vocational Nurse (LVN) by a Certified Nursing Assistant (CNA), who witnessed the altercation, but the Director of Nursing (DON) did not investigate further or report the incident to CDPH. The Social Service Director (SSD) confirmed that the incident was reported to the facility's administrator two days after the allegation was made, which was not in compliance with the facility's policy requiring immediate reporting within two hours. The facility's policy, dated October 2024, mandates that all alleged violations involving abuse be reported immediately to the administrator, the state Survey Agency, and Adult Protective Services. The failure to adhere to this policy had the potential to result in further abuse, affecting the resident's emotional and psychosocial well-being.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse by a Certified Nursing Assistant Student (CNAS) towards a resident to the California Department of Public Health (CDPH) immediately or within 2 hours after the allegation was made. The incident involved a resident who was mentally capable of understanding and had been diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident reported feeling disrespected and verbally abused after a verbal altercation with the CNAS, during which inappropriate words were exchanged, and the CNAS made an offensive gesture. The incident was initially reported by a Certified Nursing Assistant (CNA) to a Licensed Vocational Nurse (LVN), who was expected to escalate the report. However, the Director of Nursing (DON) did not investigate further or report the incident to CDPH, despite being informed by the LVN. The Social Service Director (SSD) confirmed that the incident was reported to CDPH two days after the allegation was made, which was not in compliance with the facility's policy requiring immediate reporting within two hours. The facility's policy clearly outlined the need for prompt reporting of abuse allegations to ensure resident safety.
Failure to Follow Nutritional Recommendations for Resident
Penalty
Summary
The facility failed to provide adequate nutritional care and services for a resident, identified as Resident 7, who experienced significant weight loss. The Registered Dietitian (RD) had recommended weekly weight monitoring for four weeks due to the resident's unexpected weight loss, but these recommendations were not followed. The resident's weight was not recorded on several occasions, and there was no documentation to explain the lack of monitoring. Resident 7 was admitted with a diagnosis of diabetes mellitus and was initially alert and oriented. The resident's weight decreased from 156 pounds at admission to 114 pounds over several months, indicating a significant weight loss. Despite the care plan identifying the resident as at risk for weight loss and dehydration, the facility did not consistently monitor the resident's weight as recommended by the interdisciplinary team (IDT). Interviews with the Director of Nursing (DON), Dietary Supervisor (DS), and RD confirmed the failure to follow the IDT's recommendations. The DON acknowledged the lack of documentation for the missed weigh-ins, and the RD emphasized the importance of following the IDT's recommendations to prevent further weight loss. The facility's policy required accurate and regular weight monitoring, especially for residents with significant weight changes, but this policy was not adhered to in Resident 7's case.
Failure to Update Care Plans for GI Symptoms
Penalty
Summary
The facility failed to update care plans with measurable goals and interventions for residents experiencing gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. This deficiency was identified during an unannounced visit for an infection control investigation. Resident 1, admitted with nutritional deficiency and anemia, experienced vomiting and nausea, leading to new orders for Zofran and IV hydration. However, the care plan did not include these interventions. Resident 2, admitted with heart failure, had diarrhea and was transferred to a hospital where Norovirus was detected. Despite this, there was no care plan addressing the diarrhea episodes. Resident 6, with nutritional deficiency and Type 2 diabetes, experienced diarrhea and was prescribed Immodium and IV hydration, but the care plan was not updated until ten days later. Resident 21, admitted with spinal stenosis and elevated white blood cell count, reported nausea and was given Zofran, but the care plan was not updated to include this medication or the ordered laboratory tests until two days later. The Director of Nursing acknowledged that several care plans were not updated in a timely manner, which was contrary to the facility's policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
Inadequate Infection Control During GI Outbreak
Penalty
Summary
The facility failed to implement effective infection control practices during a gastrointestinal (GI) outbreak, as evidenced by several deficiencies. Staff members did not perform hand hygiene after contact with high-touch areas, such as the electronic time clock, which is considered a high-touch area. This lack of adherence to hand hygiene protocols was observed by surveyors and acknowledged by the Director of Nursing (DON), who confirmed that staff should have used alcohol-based hand rub (ABHR) or washed their hands before and after using the time clock. Additionally, the facility staff did not wear appropriate personal protective equipment (PPE) while providing care to residents requiring Enhanced Barrier Precautions (EBP). A Certified Nursing Assistant (CNA) was observed assisting a resident without wearing gloves or a gown, despite the resident being on EBP due to an indwelling urinary catheter. The CNA admitted to not following proper infection control practices, which exposed both herself and the resident to potential infections. The facility also failed to monitor residents with GI symptoms and conduct surveillance tracking, resulting in a delayed identification of the GI outbreak. The Infection Preventionist (IP) reported that residents with GI symptoms were not placed on isolation precautions in a timely manner, and the outbreak was not reported to the California Department of Public Health (CDPH) promptly. This delay in implementing infection control measures and notifying relevant authorities contributed to the spread of the infection, affecting 30 out of 90 residents and seven staff members, with three residents testing positive for Norovirus.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for safe self-administration of medication for three residents, leading to potential risks of improper medication use. Resident 38 was found with an opened bottle of eye drops on his overbed table, which he used to relieve eye irritation. Despite being mentally capable, there was no documented self-administration assessment or physician's order for the eye drops. A registered nurse confirmed the absence of necessary documentation and orders. Resident 42 had an opened respiratory inhaler on his overbed table, which he used for shortness of breath without knowing the correct frequency of use. Although a physician's order existed for the inhaler, there was no self-administration assessment documented. Both a licensed vocational nurse and a registered nurse acknowledged the lack of assessment and physician's order for self-administration, highlighting potential adverse effects from unsupervised use. Resident 77 was found with an opened container of muscle balm ointment on his overbed table, which he applied for pain relief. Despite being mentally capable, there was no self-administration assessment or physician's order for the ointment. A licensed vocational nurse and the Director of Nursing confirmed the absence of required documentation and orders, emphasizing the risk of residents not receiving medications according to physician's orders and not being monitored for adverse effects.
Medication and Monitoring Deficiencies in Resident Care
Penalty
Summary
The facility failed to administer medications according to physician orders for Resident 28, who was diagnosed with hypertension and hemoptysis. Lisinopril and Metoprolol were given despite the resident's systolic blood pressure (SBP) being below the prescribed threshold on multiple occasions, and Midodrine was not administered when the SBP was below 90. Additionally, there was no documentation of blood pressure readings on several dates, and no follow-up assessments were conducted after the resident's readmissions from the hospital, potentially delaying necessary care and treatment. For Resident 33, the facility did not identify or monitor discolorations on the resident's forearms, despite the resident having a history of traumatic subdural hemorrhage and diabetes mellitus. The discolorations were not documented in the resident's skin evaluations or change of condition forms, and staff members, including an LVN and RN, acknowledged the lack of documentation and assessment regarding these changes in the resident's condition. Resident 88 experienced a change in condition characterized by lethargy, but the primary care physician was not notified before the resident was transported to a medical appointment. The resident's condition was not medically cleared for travel, and the family eventually took the resident to the hospital. The facility's policy required notification and assessment of significant changes in condition, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered as prescribed by the physician, leading to several deficiencies. During a medication pass observation, a Licensed Vocational Nurse (LVN) administered an incorrect dose of fluticasone nasal spray to a resident, giving two sprays in each nostril instead of the prescribed one spray per nostril. This error was acknowledged by the LVN during an interview. Another deficiency involved a resident who did not receive four doses of an intravenous antibiotic medication, cefazolin, as prescribed. The Medication Administration Record (MAR) showed missing documentation for two doses and a lack of nursing notes for the other two doses. The Director of Nursing (DON) confirmed the absence of documentation and acknowledged the error. Additionally, a resident's blood pressure medication, lisinopril, was held without proper documentation of the resident's systolic blood pressure and pulse, which were necessary to determine if the medication should be withheld. Furthermore, another resident received an incorrect dosage of oxycodone for severe pain, as the MAR indicated only one tablet was given when two were prescribed for severe pain levels. The DON confirmed these errors during interviews.
Failure to Provide Special Dietary Needs
Penalty
Summary
The facility failed to provide special dietary needs for three residents during a lunch meal preparation. Resident 46 and Resident 76, who were both on a puree - level 4, fortified diet, were initially served regular pureed chili instead of the fortified version. This discrepancy was identified during the meal preparation, and the dietary staff corrected the error by replacing the regular chili with fortified chili. The Registered Dietitian confirmed that the residents should have received fortified chili to meet their nutritional requirements. Resident 192, who was on a dysphagia mechanical soft diet and had specific dislikes for toast, bread, and rice, was served a meal without a starch component. The Dietary Supervisor initially justified the omission by stating that the resident usually finished the meal without the starch and had other food items like yogurt and milk to supplement intake. However, it was later acknowledged that an alternative starch component should have been provided, and mashed potatoes were prepared for the resident. The facility's policy indicated that menus should meet the nutritional needs of residents using established national guidelines.
Improper Food Storage in Nurses' Station Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by improperly storing residents' food items in the nurses' station refrigerator. During an inspection, several food items were found undated or past their storage dates, which could potentially lead to foodborne illnesses among the medically vulnerable resident population. Specific items included an opened tub of yogurt, a bottle of Coffeemate creamer, a bottle of Mott's apple juice, a takeout box with leftover food, another takeout box containing pancakes, and a half peanut butter and jelly sandwich. All these items were either undated or had exceeded the 72-hour storage guideline set by the facility. The Director of Nursing (DON) acknowledged during interviews that these food items should have been dated upon receipt and discarded after 72 hours if opened. The facility's policy, titled 'Foods Brought by Family or Visitor,' mandates that all resident food must be labeled with a resident identifier and date, and perishable prepared foods should be discarded after 72 hours. The DON confirmed that the nursing staff is responsible for labeling and dating food items upon receipt to ensure proper monitoring. The failure to comply with these guidelines resulted in the presence of outdated and undated food items in the refrigerator.
Infection Control Deficiencies in Waste Management and PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices in two observed instances. First, a resident was seen in the dining room with a urinal hanging from the back of his wheelchair. This was confirmed by both a Licensed Vocational Nurse and the Director of Nursing as an infection control issue, as the facility's policy requires proper containment of waste to minimize infection transmission. The resident had been admitted with a fracture and chronic kidney disease, which necessitates careful handling of waste to prevent infection. Secondly, staff members were observed not wearing the appropriate N95 respirator masks while providing care to COVID-19 positive residents. A Certified Nursing Assistant and a Licensed Vocational Nurse were both using Honeywell N95 masks, which they had not been fit tested for, instead of the BYD N95 masks they were fit tested to use. The Infection Preventionist confirmed that the staff should have followed the policy of wearing fit-tested respirators, as using the wrong mask increases the risk of spreading infection. The facility's policy mandates fit testing for respirators to ensure proper protection against communicable diseases.
Delayed Response to Call Light
Penalty
Summary
The facility failed to ensure that the call light system was answered promptly for one resident, leading to unmet care needs. On November 12, 2024, a resident was observed waiting for assistance for 30 minutes after activating the call light to request a refill of fruit juice. During this time, two licensed nurses were present at the nurse's station but did not respond to the call light. A Certified Nursing Assistant (CNA) eventually attended to the resident after a 15-minute wait, explaining that the delay was due to the assigned CNA being busy and emphasizing that any available staff, including the nurses at the station, should have responded. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the expectation was for call lights to be answered promptly, ideally within five seconds or as soon as possible. The facility's policy indicated that call lights should be answered within a reasonable time and that staff should respond to residents' requests. The resident involved was mentally capable of understanding and had been admitted with diagnoses including muscle weakness and nutritional deficiency.
Failure to Ensure Advance Directive Availability in Resident's Record
Penalty
Summary
The facility failed to ensure that a copy of the Advance Directive (AD) was available in the medical record for a resident, which could potentially result in the resident's medical treatment wishes not being followed if they became unable to make decisions. The resident was admitted with diagnoses including sepsis and diabetes and had the capacity to understand and make decisions. The Social Services Assessment indicated that the resident had an AD, and a copy was requested from the resident and their family member. However, the AD was not found in the resident's record. Interviews with the Social Service Director (SSD) and Social Services Assistant (SSA) revealed that the family member visited the facility regularly, and a follow-up regarding the AD was planned but not executed. The SSD acknowledged that the AD should have been in the resident's chart. The facility's policy stated that a resident's choice about advance directives would be recognized and respected, and once received, the AD should be communicated to the care plan team and the physician. The Administrator expected the AD to be readily available in the chart if a resident had one.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment for a resident when the chair rail molding above the resident's bed was detached and damaged from the wall. This issue was identified during an observation and interview with the resident, who expressed discomfort and concern about the broken piece of wood hanging above his head, which affected his ability to sleep comfortably. The resident was worried about the potential risk of hitting his head on the broken molding. Interviews with facility staff, including a registered nurse and the maintenance supervisor, confirmed that the broken chair rail molding was not properly attached and should have been reported and repaired. The facility's policies on equipment maintenance and providing a homelike environment were reviewed, indicating that routine inspections and maintenance should be conducted to ensure resident safety and comfort. The administrator acknowledged that the maintenance staff should have addressed the issue to prevent accidents and maintain a homelike environment.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 9, who was unable to perform activities of daily living (ADL) independently. On November 12, 2024, Resident 9 was observed with long, yellowish, and thick toenails, which he described as resembling 'hawk nails.' The resident reported that his requests for nail trimming were ignored, and he had not been seen by a nail doctor. Certified Nurse Assistant (CNA) 1, responsible for Resident 9's care, admitted to not noticing the long toenails due to being in a hurry and stated that she would inform the charge nurse if a resident needed toenail trimming. However, she did not take action to address Resident 9's toenail care. Resident 9's medical records indicated he was admitted with a diagnosis of diabetes mellitus, which requires special attention to foot care. The facility's policy stated that only licensed nurses should perform nail care for diabetic residents. Despite this, CNA 1 mentioned that any staff could cut residents' toenails, contradicting the facility's policy. Registered Nurse (RN) 1 confirmed that Resident 9's toenails were excessively long and should have been trimmed to prevent infection and injury. The facility's failure to adhere to its policy and provide necessary nail care resulted in a deficiency in maintaining proper grooming and personal hygiene for Resident 9.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications, leading to the presence of expired and discontinued medications in the medication storage areas. During an inspection, two expired daptomycin IVPB bags were found in the medication refrigerator for a resident, despite being labeled with a discard date that had already passed. The registered nurse acknowledged the expiration and confirmed the medication had been discontinued by the physician, yet it had not been disposed of as per the facility's policy. Additionally, a discontinued medication for another resident was found in the medication cart alongside active medications. The licensed vocational nurse confirmed there was no current order for the medication, which should have been disposed of on the day it was discontinued. Furthermore, an insulin pen without an open or expiration date was found in the medication cart, contrary to guidelines that require such medications to be labeled with an open date and discarded after a specified period. These oversights had the potential to result in residents receiving expired and ineffective medications.
Failure to Address Water Leak in Resident's Room
Penalty
Summary
The facility failed to provide a comfortable environment for a resident due to a water leak from a pipe under the sink in the resident's room. This issue was observed during a visit, where a puddle of water was noted on the floor. The resident expressed discomfort and reported that the leak had been ongoing for some time, despite having informed the staff about it. The resident described the situation as unpleasant, especially when the sink was used, causing water to drip onto the floor. The Maintenance Supervisor was unaware of the leak and acknowledged the potential hazard it posed, such as accidents from stepping on the wet surface. The Administrator was aware of the need for repair but had not ensured the issue was addressed. The facility's policy on equipment maintenance requires routine inspections and prompt attention to maintenance needs, which was not adhered to in this case. Additionally, the facility's policy on providing a homelike environment was not upheld, as the resident's living conditions were disrupted by the unresolved leak.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
