Reo Vista Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 6061 Banbury St., San Diego, California 92139
- CMS Provider Number
- 056330
- Inspections on file
- 47
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Reo Vista Healthcare Center during CMS and state inspections, most recent first.
Two residents receiving IV antibiotics for serious infections experienced improper medication administration and documentation by an RN. For one resident on IV Cefepime for osteomyelitis, the RN documented a scheduled morning dose as given based only on another nurse’s verbal report, even though he had not administered it himself. For another resident on IV Vancomycin for MRSA bacteremia and sepsis, the RN administered a scheduled dose four hours late due to the resident being out for a medical appointment, without notifying the physician, obtaining new orders, or documenting a change of condition, despite facility policy requiring timely administration within one hour of the ordered time and accurate documentation by the nurse who actually gives the medication.
Two residents receiving IV antibiotics for serious infections did not receive care in accordance with prescriber orders and facility policy. For one resident with osteomyelitis and a chronic foot ulcer, an RN documented a scheduled IV Cefepime dose as given even though he had not administered it, relying on a verbal report from the night shift and entering the documentation later when he noticed it was missing. For another resident with sepsis and endocarditis on IV Vancomycin for MRSA bacteremia, the same RN administered a scheduled dose four hours late due to the resident being out for a medical appointment, did not notify the physician of the missed scheduled time, did not document a change of condition, and acknowledged he could have administered the dose before the appointment. Interviews with staff and review of the facility’s medication policy confirmed that medications were required to be given within one hour of the scheduled time, that the nurse who actually administers the medication must document it, and that physician notification is expected when doses cannot be given as ordered.
The facility failed to timely report and thoroughly investigate two separate resident-to-resident abuse allegations and did not submit required 5‑day follow‑up reports to the State Survey Agency. In one case, a resident with moderate cognitive impairment told Social Services he kicked his roommate after a verbal threat over TV volume; the original note documenting the kick was struck from the EMR at the DON’s direction, and no abuse investigation, IDT follow‑up, or external reporting occurred, despite the roommate later describing being kicked, falling into his wheelchair, and developing a back bruise consistent with a documented fall note. In the second case, a resident with moderate cognitive impairment and serious medical conditions was found soaked after reporting that a man in a wheelchair threw water on him; CNAs and a CRN recognized this as abuse, documented the event, and reported it to the DON and ADM, and nursing notes reflected the complaint and the suspected roommate’s prior aggressive behavior, yet there was no documented investigation, separation of residents, or reporting to external authorities. The ADM, who served as abuse coordinator, acknowledged he did not complete or document full investigations or 5‑day summaries and did not report either incident to the ombudsman or State Survey Agency, contrary to the facility’s abuse policy requiring immediate reporting and thorough, documented investigations.
The facility failed to follow its abuse reporting and investigation policy after two separate resident-to-resident abuse allegations. In one case, a resident told social services he had kicked his roommate after a verbal threat over TV volume, and the roommate later described being kicked, falling into his wheelchair, and developing a back bruise consistent with a prior documented fall. The original social services note documenting the kick was struck from the EMR at the DON’s direction, no investigation or IDT follow-up was documented, and the ADM, as abuse coordinator, did not report or complete a 5‑day summary. In the second case, a resident with moderate cognitive impairment was found soaked and reported that a man in a wheelchair had thrown water on him; CNAs and the CRN reported this as abuse to the DON and ADM, and nursing notes documented both the complaint and the suspected aggressor’s prior aggressive behavior and staff concern he might throw water or harm his roommate. The ADM stated he spoke with the residents and offered room changes but did not document an investigation, did not complete full investigations or 5‑day summaries, and did not report to outside authorities, while the DON acknowledged the event met the definition of abuse but believed it had not occurred.
A resident with multiple complex diagnoses experienced a significant change in condition, including severe abdominal pain and confusion, which was observed by therapy staff and reported to nursing. However, nursing staff did not document their assessments or timely notifications to the NP in the EMR as required, with the first nursing note entered nearly three hours after the initial observation. The resident was later transferred to the hospital after persistent symptoms and family request.
A resident with incontinence and multiple medical conditions was not provided timely assistance with incontinent care, resulting in prolonged discomfort. Staff delayed changing the resident's brief after requests for help, despite facility policies requiring prompt response and incontinence management. Interviews confirmed that the resident waited up to an hour for care on more than one occasion.
A resident with diabetes was admitted with an order for insulin but without a physician's order for blood sugar fingerstick testing. Staff began checking the resident's blood sugar only after the resident reported her diabetes, and the first result was abnormally high. Review of records and staff interviews confirmed that no order for blood sugar checks was present, despite facility policy and care plan requirements.
Eight residents with various medical conditions had incomplete POLST forms, specifically missing information in the section regarding advance directives. Nursing staff acknowledged that this section was not consistently completed during admission, despite facility policy requiring complete and accurate documentation to support interdisciplinary communication. The omission resulted in a lack of documentation that residents or their responsible parties had been asked about advance directives.
A resident with diabetes and neuropathy was not served a meal tray at the same time as others during lunch, resulting in a 30-minute wait while other residents ate. The resident expressed hunger and discomfort with the delay. Staff interviews confirmed that all residents should be served simultaneously to maintain dignity, in accordance with facility policy.
A resident with a diagnosis of cystitis was incorrectly coded on the MDS as receiving dialysis, despite no physician orders, no physical evidence of dialysis access, and confirmation from both the resident and staff that dialysis was not provided. The MDS nurse and DON confirmed the inaccuracy, which resulted in the submission of incorrect data to the federal database.
The facility did not follow professional standards for two residents: one with a midline catheter did not have required measurements documented during dressing changes, and another with dysphagia and weight loss was not provided with a prescribed nutritional supplement during meals, despite physician orders and facility policy. Staff interviews confirmed these omissions.
A resident with chronic kidney disease developed swelling and pain in the left hand and arm after an IV infiltration, but nursing staff did not monitor, reassess, or document the change in condition as required by facility policy. Interviews confirmed the absence of documentation and monitoring following the incident.
A resident admitted with a femur fracture and no pressure injuries developed a stage four pressure ulcer after not being repositioned as required, including spending over five hours in a wheelchair. Despite being identified as at risk and having a care plan for repositioning, the resident developed multiple pressure injuries, indicating lapses in preventive care and adherence to facility policy.
A resident with dysphagia and recent significant weight loss was not provided with a physician-ordered high-calorie nutritional supplement (Boost VHC) during meals, as observed and confirmed by staff interviews and record review. Despite documented weight loss and orders for nutritional intervention, the supplement was not given, and the dietician was unaware of the omission. Facility policy required monitoring and provision of adequate nutrition, but the supplement was not administered as ordered.
A resident with diabetes did not receive a scheduled dulaglutide injection as ordered by the physician because an LPN overlooked the medication on the administration record and it was not available at the time of administration. The DON confirmed that medications must be available and given as ordered, in accordance with facility policy.
A resident with anxiety and depression was routinely administered alprazolam without a properly documented clinical indication, as staff and care records inaccurately described her symptoms and failed to provide adequate behavior monitoring. This resulted in the continued use of a psychotropic medication without proper justification, contrary to facility policy and regulatory standards.
A licensed nurse opened beverage cartons by touching the spout with her bare finger before feeding a resident, contrary to infection control practices. Both the nurse and a restorative nursing assistant acknowledged this as an infection control issue, and the facility's policy lacked clear guidance on standard precautions.
The facility failed to notify physicians and family members of significant changes in the conditions of four residents. One resident's wound deteriorated to a stage four pressure ulcer without family notification. Two residents experienced significant weight loss, but their physicians were not informed. Another resident developed a stage four pressure ulcer, and the family was not notified. The facility's policy requires prompt notification of such changes.
A resident with dementia and muscle weakness developed a stage four pressure ulcer due to inadequate care and monitoring in an LTC facility. Despite being dependent on staff for mobility and having an air mattress, the resident's condition worsened from initial maceration to multiple stage two ulcers, eventually becoming a stage four ulcer. The facility's policy lacked clear guidance, and staff were unaware of the resident's initial skin condition, leading to a significant lapse in care.
The facility failed to provide necessary PPE for staff entering the room of a resident on enhanced barrier precautions for MRSA, despite clear indications and physician orders. Staff confirmed the absence of PPE and acknowledged the infection control issue, increasing the risk of infection transmission.
The facility failed to notify a resident's responsible party before changing the resident's room, leading to the RP being unaware of the resident's location. The resident, diagnosed with Hemiplegia, had their room changed multiple times without proper notification. The Director of Staff Development admitted to forgetting to notify the RP, contrary to the facility's policy requiring advance notice.
Improper IV Antibiotic Administration and Documentation by Licensed Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse administered and documented IV antibiotics according to professional standards and facility policy for two residents. One resident had been admitted with osteomyelitis and a chronic left foot ulcer and had an order for IV Cefepime 2 grams every eight hours for infection. The IV administration record showed that on a specific date, the scheduled 7 a.m. Cefepime dose was documented by a licensed nurse at 10:34 a.m. During interview and concurrent record review, the nurse acknowledged that he documented the 7 a.m. dose even though he had not administered it, based solely on a verbal report from the night shift RN that the medication had been given. He stated he should not have done this and that it did not follow standards of practice. The second resident had been admitted with sepsis and unspecified valve endocarditis and had an order for IV Vancomycin 900 mg every 12 hours for MRSA bacteremia, with a scheduled administration time of 8 a.m. The IV administration record indicated that on a specific date, the licensed nurse administered and documented the 8 a.m. Vancomycin dose at 12 p.m., four hours after the prescribed time. In interview, the nurse stated the resident had a doctor’s appointment and was not in the facility at the scheduled time, and that the resident left by transportation at 9 a.m. for a noon appointment and returned at noon. The nurse acknowledged he did not notify the physician about the missed 8 a.m. dose, did not document a change of condition related to the missed dose, and recognized he should have obtained further orders to administer the Vancomycin late and could have given the dose earlier before the appointment. Another licensed nurse stated she would never document another nurse’s medication administration and described that as wrong and not following standards of practice. She also stated that staff had access to residents’ appointment information and that she reviewed appointment schedules at the start of her shift and would notify the physician if a medication was missed due to an appointment. The DON stated that medications should be given in a timely manner, including for residents with outside appointments, that nurses were expected to plan ahead, and that the delayed Vancomycin dose could have been given an hour earlier than scheduled. The DON further stated that documenting another nurse’s medication administration was not acceptable and not the facility’s standard of practice. Facility policy on administering medications required medications to be given in accordance with prescriber orders and within one hour of the prescribed time, and required that the individual administering the medication initial the MAR after giving each medication and record their signature and title in the medical record.
Failure to Administer and Document IV Antibiotics per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure IV antibiotics were administered and documented in accordance with physician orders and facility policy for two residents. One resident was admitted with osteomyelitis and a chronic left foot ulcer and had an order for Cefepime 2 grams IV every 8 hours for infection. The IV administration record for this resident showed that on 3/17/26 the scheduled 7 a.m. Cefepime dose was documented as given at 10:34 a.m. by a licensed nurse (LN 1). During interview and record review, LN 1 acknowledged that he documented the 7 a.m. dose even though he had not actually administered the medication, stating he received report from the night shift RN that the medication had been given at 7 a.m. and later entered the documentation when he noticed it was missing. The second resident was admitted with sepsis and unspecified valve endocarditis and had an order for Vancomycin 900 mg IV every 12 hours for MRSA bacteremia. The IV administration record indicated that on 3/11/26 the scheduled 8 a.m. Vancomycin dose was administered and documented by LN 1 at 12 p.m., four hours later than the prescribed time. LN 1 stated that the resident had a doctor’s appointment and was not in the facility at the scheduled administration time, and that the resident left by transportation at 9 a.m. for a noon appointment and returned at noon. LN 1 confirmed he did not notify the physician about the missed 8 a.m. dose, did not document a change of condition related to the missed dose, and acknowledged he should have obtained further orders to administer the Vancomycin late and could have administered the dose before the resident left for the appointment. Additional interviews and policy review further described the expectations that were not followed. LN 1 stated that the medication administration process included verifying the right patient, right medication, and following physician orders, and that medications were to be given within one hour before or after the scheduled time, with physician notification if medications could not be given on time. Another licensed nurse (LN 2) stated she never documented another nurse’s medication administration and described this as wrong and not in line with standard practice, and also stated she reviewed residents’ appointment schedules at the start of her shift and would notify the physician if a medication was missed due to an outside appointment. The DON stated medications should be given in a timely manner, including for residents with outside appointments, and that it was not acceptable for LN 1 to document another nurse’s administration or to delay the Vancomycin dose without physician notification or change-of-condition documentation. The facility’s medication administration policy required medications to be administered in accordance with prescriber orders and within one hour of the prescribed time, and required the individual administering the medication to initial the MAR after giving each medication and record their signature and title in the medical record.
Failure to Report and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to timely report and thoroughly investigate two separate allegations of resident-to-resident abuse, and to submit required 5‑day follow‑up investigation reports to the State Survey Agency, as required by facility policy and regulation. In the first incident, one resident with a history of right tibia fracture, hypertension, and alcohol dependence, and with moderate cognitive impairment but independent functional abilities, reported to Social Services that he had kicked his roommate in the lower torso after the roommate allegedly threatened him over television volume. The Social Services Assistant (SSA) documented that the resident admitted to kicking his roommate and stated he had not reported it earlier because he feared being arrested. The SSA’s original electronic note clearly described the kick and her plan to notify administration and the DON, but this note was later struck out as “incorrect documentation” at the DON’s direction, and a handwritten follow‑up note omitted the physical act of kicking and stated that further investigation did not warrant any change. The roommate, who had intact cognition, epilepsy, and other medical conditions but no behavioral issues, later told surveyors that his former roommate had kicked him, causing him to fall back onto his wheelchair and sustain a bruise on his lower back from the brake lever. His EMR contained a nurse’s note documenting a fall in his room with a large reddish discoloration on his back, consistent with his description, but there was no documentation in the EMR of any abuse investigation, IDT follow‑up, or reporting to the Administrator (who was the abuse coordinator), physician, responsible party, police, ombudsman, or the State Survey Agency. The Quality Nurse, SSA, ADON, and Charge Nurse all described a facility process that required immediate separation of residents, head‑to‑toe assessments, reporting to the Administrator, and documentation of investigation and care plan changes, but they were unable to locate any such follow‑up in the record. The Administrator confirmed he had not been notified of this allegation at the time, did not initiate an investigation, and did not submit a 5‑day investigation summary or required external reports. The DON acknowledged she considered the allegation to be resident‑to‑resident abuse, did not investigate because she believed it was only verbal and that the alleged aggressor had been discharged, and asked the SSA to strike the original note because it appeared to describe unreported abuse. In the second incident, a resident with moderate cognitive impairment, sepsis, UTI, epilepsy, and malignant brain neoplasm reported that someone had thrown water on him while he was resting in bed and complained that the person said he snored too much. Two CNAs, who had earlier showered and dressed him dry, later found him soaking wet; the resident told them that “the man in the wheelchair” had thrown water on him. Both CNAs and the Charge Nurse identified this as resident‑to‑resident abuse, stated that they immediately reported it to the DON and Administrator via verbal report and text message to the IDT, and the EMR contained a nurse’s note documenting that the resident claimed someone threw water on him and that his gown was wet. Another resident reported that the suspected roommate frequently called him derogatory names, and nursing notes documented that this suspected roommate had a history of verbal aggression, threatening behavior, and staff concern that he might throw water or otherwise harm his roommate if disturbed by noise. Despite this, there was no documentation of a completed abuse investigation, separation of residents, or IDT follow‑up in the EMR, and the Administrator acknowledged that he did not complete or document a full investigation, did not submit 5‑day investigation summaries, and did not report either incident to the ombudsman or State Survey Agency. The DON stated that the water‑throwing incident met the definition of resident‑to‑resident abuse and that policy required reporting within two hours, but she and the Administrator did not report it externally because they believed the incident might not have occurred. The facility’s written abuse policy required immediate reporting of suspected abuse to the Administrator and specified agencies, and mandated thorough, documented investigations, which were not carried out or reported as required in either case. The facility’s abuse policy, dated 2001, defined suspected abuse as requiring immediate reporting to the Administrator and to state licensing/certification, ombudsman, resident representative, law enforcement, and the resident’s physician, with “immediately” defined as within two hours for allegations involving abuse or serious bodily injury. The policy also required the Administrator to determine protective actions for residents and to ensure all allegations were thoroughly investigated, including review of documentation and evidence, review of the resident’s medical record and status, observation of the alleged victim, and interviews with the reporter, witnesses, the resident or representative, staff on all shifts, and the roommate, with complete documentation of the investigation. In both the kicking and water‑throwing incidents, staff at the point of care recognized the events as potential resident‑to‑resident abuse and reported them up the chain, but the Administrator and DON did not ensure that the required investigations, documentation, and external reports, including 5‑day summaries to the State Survey Agency, were completed in accordance with facility policy and regulatory expectations.
Failure to Investigate and Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report two separate allegations of resident-to-resident abuse involving four residents. In the first incident, one resident with moderate cognitive impairment and a history of right tibia fracture and alcohol dependence reported to the Social Services Assistant (SSA) that, about a week earlier, his roommate had threatened him over television volume. He stated that the roommate told him that if he did not lower the TV, he would be hit, and that he responded by kicking the roommate in the lower torso. The SSA documented that the resident admitted to kicking his roommate and that she would notify administration and the DON. The SSA later struck this note from the EMR at the DON’s direction and replaced it with a handwritten paper note that removed the admission of kicking and stated only that there were disagreements over the TV and that the resident felt unsafe. No follow-up, investigation, or IDT documentation regarding this alleged abuse was found in the EMR. The roommate, who had intact cognition and used a wheelchair and walker, later reported that a few weeks earlier his former roommate had kicked him, causing him to fall back into his wheelchair and sustain a bruise on his lower back from the wheelchair brake lever. A nurse’s note documented that this resident had reported a fall in his room on a prior date, with a reddish discoloration on his back consistent with his description. Multiple staff, including the Quality Nurse (QN), Charge Nurse (CRN) 2, the ADON, and the Administrator (ADM), confirmed that the facility’s process for alleged resident-to-resident abuse required immediate separation of residents, head-to-toe assessments, notification of the ADM as abuse coordinator, and timely reporting to the MD, responsible party, police, ombudsman, and state agency, along with thorough investigation and documentation. The QN, CRN 2, ADON, and ADM all acknowledged that no investigation, reporting, or 5‑day summary was completed for this incident, and the DON stated she did not investigate because she believed it was only words, thought the incident was old and the alleged aggressor had been discharged, and asked the SSA to strike the original note because it appeared to show abuse that was not reported. In the second incident, a resident with moderate cognitive impairment, sepsis, UTI, epilepsy, and malignant brain neoplasm reported that someone had thrown water on him while he was resting in bed and complained that the person said he snored too much. Two CNAs stated that they had showered and dressed this resident in dry clothing earlier that day and later found him soaked, and the resident told them that “the man in the wheelchair” had thrown water on him. Both CNAs and CRN 1 identified this as resident-to-resident abuse and reported it to the DON and ADM, with CRN 1 also texting the IDT, including the ADM and DON, that the resident had water thrown on him by another resident. A nursing note documented that the resident claimed someone threw water on him but could not recall the face, and another note for the suspected aggressor described prior verbal aggression, threatening behavior, and staff concern that he might throw water or harm his roommate if disturbed by noise. The ADM stated he interviewed both residents, offered room changes (which were refused), did not document his investigation in the EMR, did not complete full investigations or 5‑day summaries, and did not report to the ombudsman or other authorities. The DON acknowledged that having water thrown on a resident by another resident was abuse, that the ADM had spoken with the residents, and that the incident was not reported to authorities because she believed it did not happen, despite facility policy requiring immediate reporting and thorough investigation of all abuse allegations. The facility’s written policy on Abuse, Neglect, Exploitation or Misappropriation–Reporting and Investigating required that any suspicion of resident abuse be reported immediately to the administrator and appropriate authorities, defined “immediately” as within two hours for allegations involving abuse or serious bodily injury, and mandated that all allegations be thoroughly investigated by the administrator. The policy specified that the investigation must include review of documentation and evidence, review of the resident’s medical record, observation of the alleged victim, and interviews with the reporter, witnesses, the resident or representative, staff on all shifts, and the roommate, with complete and thorough documentation. In both incidents—resident kicking a roommate and a resident having water thrown on him—staff recognized the events as resident-to-resident abuse and reported them up the chain, but the ADM, as abuse coordinator, did not complete or document full investigations, did not submit required 5‑day summaries, and did not report the allegations to external authorities as required by policy and state law. The DON acknowledged responsibility as DON, admitted that the incidents were considered resident-to-resident abuse, and confirmed that the facility did not follow its own abuse reporting and investigation procedures for these allegations.
Failure to Timely Report and Document Change of Condition
Penalty
Summary
A deficiency occurred when the facility failed to provide services according to standards of clinical practice by not reporting and documenting a resident's change of condition in a timely manner. The resident, who had a complex medical history including acute embolism and thrombosis of the femoral vein, acute kidney failure, obstructive and reflux uropathy, hydronephrosis, and urinary retention, was observed by physical therapy staff to have increased pallor, lethargy, clammy skin, and severe abdominal pain. The physical therapy note indicated that both the medication nurse and charge nurse were made aware of these symptoms at 12:30 P.M., but there was no corresponding nursing documentation of the change in condition at that time. Interviews with nursing staff revealed that although the charge nurse and medication nurse were notified and assessed the resident, they did not document their assessments or the notifications to the nurse practitioner (NP) in the electronic medical record (EMR) in a timely manner. The first nursing note regarding the change of condition was not entered until 3:12 P.M., nearly three hours after the initial observation. Staff reported that they attempted to contact the NP multiple times via text and phone, but these attempts and the lack of response were not documented as required by facility policy. The medication nurse acknowledged that she should have documented her assessment and communication efforts but did not do so due to being busy. Facility policy required timely notification and documentation of significant changes in a resident's condition, including communication with the attending physician or NP and the resident's family. The lack of timely documentation and notification was confirmed by the Director of Nursing, who stated that if actions are not documented, they cannot be proven to have occurred. The resident was ultimately transferred to the hospital later that evening after persistent symptoms and at the family's request.
Failure to Provide Timely Incontinent Care
Penalty
Summary
A resident with a history of left fibula fracture and type 2 diabetes with hyperglycemia, who was incontinent of bowel and bladder, was not provided timely assistance with incontinent care. During the first week of admission, the resident reported waiting an hour before her brief was changed after a bowel movement, resulting in significant discomfort. On another occasion, after requesting to be changed due to a soaking wet brief when breakfast was served, the resident was told by the CNA that the request would be addressed after meal trays were passed. The resident waited approximately an hour before her brief was changed, causing further discomfort. Interviews with staff confirmed that call lights should be answered within five minutes and that residents should be checked and changed prior to meals, especially those with incontinence. The facility's care plan for the resident indicated the need for check and change incontinence management and clean, dry clothes after incontinent episodes. Facility policy also required immediate response to call lights and emphasized residents' rights to dignity and comfort. Despite these policies, the resident's needs for timely incontinent care were not met.
Failure to Obtain Physician's Order for Blood Sugar Monitoring
Penalty
Summary
The facility failed to obtain a physician's order for blood sugar fingerstick testing for a resident with diabetes, despite the resident being admitted with a diagnosis of diabetes mellitus with hyperglycemia and an order for insulin administration. The resident reported that her blood sugar was not being checked upon admission until she informed staff of her diabetes, after which staff began checking her blood sugar before meals. The first recorded blood sugar result was over 300. A review of the resident's physician's orders confirmed there was no order for blood sugar checks, even though insulin was ordered and administered. Interviews with nursing staff and the nurse practitioner revealed that it was expected practice to have a separate physician's order for blood sugar fingerstick testing, and the facility's policy required such an order before performing the procedure. The care plan for the resident indicated that blood glucose checks should be performed as ordered, but no such order was present in the medical record. Staff acknowledged that a physician's order was necessary for both resident safety and compliance with facility policy.
Incomplete POLST Forms and Missing Advance Directive Documentation
Penalty
Summary
The facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST) forms for eight residents, as required by accepted professional standards. Record reviews and interviews revealed that section D of the POLST, which pertains to information regarding advance directives, was left incomplete for these residents. Licensed nursing staff and the Social Service Director confirmed that nurses were responsible for completing this section during admission, but it was not consistently done. One nurse admitted to not completing or following up with section D during her time as an admission nurse, despite recognizing its importance in determining a resident's ability to make decisions regarding care. The affected residents had various significant medical diagnoses, including hemiplegia, hemiparesis, cerebral infarction, femur fracture, paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, cancer, chronic obstructive pulmonary disease, hypertension, dementia, metabolic encephalopathy, and age-related cognitive decline. For example, one resident with intact cognition had a POLST form with section D left blank, and another with moderately impaired cognition also had this section incomplete, as signed by a family member. In each case, the omission meant there was no documentation that the resident or responsible party had been asked about the existence of an advance directive. Facility policy required that medical records be objective, complete, and accurate to facilitate communication among the interdisciplinary team regarding the resident's condition and response to care. The incomplete POLST forms did not provide an accurate representation of the care provided and had the potential to cause confusion among care providers, as noted in staff interviews and policy reviews.
Resident Not Served Meal Tray Timely, Affecting Dignity
Penalty
Summary
A deficiency occurred when a resident with Type 2 Diabetes Mellitus and diabetic neuropathy was not served a meal tray at the same time as other residents during a lunch observation. The resident was observed looking around the dining room while others were eating and expressed feeling hungry, stating that it was not the first time they had to wait for their tray. The resident ultimately received their lunch tray 30 minutes after all other residents had been served. Interviews with staff, including a restorative nursing assistant, a licensed nurse, and the Director of Nursing, confirmed that all residents should be served their trays simultaneously to maintain dignity and respect. The facility's policy on resident rights also emphasized the importance of treating all residents with kindness, respect, and dignity, including ensuring a dignified existence. The failure to serve the meal tray in a timely manner did not preserve the resident's dignity and respect as required.
Inaccurate MDS Coding for Dialysis Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, resulting in the submission of incorrect information to the federal database. Specifically, the MDS for a resident admitted with cystitis was marked to indicate that the resident was receiving dialysis, despite no physician orders for dialysis, no evidence of a dialysis graft, and direct statements from the resident and assigned nurse confirming that dialysis was not being provided. The MDS nurse acknowledged that the assessment was coded inaccurately and emphasized the importance of MDS accuracy for care planning and facility reimbursement. Interviews with the resident, the assigned licensed nurse, the MDS nurse, and the Director of Nursing all confirmed that the resident was not on dialysis. Review of facility policy and the CMS Resident Assessment Instrument User's Manual further supported the requirement for accurate MDS coding. The deficiency was identified through observation, interview, and record review, and was limited to one of seven sampled residents reviewed for MDS accuracy.
Failure to Follow Professional Standards for IV Care and Nutritional Supplementation
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards for two residents. For one resident with a midline catheter, the facility did not perform or document required measurements of arm circumference and catheter length during dressing changes, as specified in both physician orders and facility policy. Observations and interviews confirmed that these measurements were not completed, and staff acknowledged the importance of these steps for proper catheter management. In a separate incident, another resident with a history of dysphagia and recent weight loss was not provided with a prescribed nutritional supplement (Boost VHC) during multiple observed meals, despite clear physician orders. Staff interviews revealed that the supplement was not consistently given, and the registered dietician was unaware of the omission. Facility policy required that physician orders be followed, but the supplement was not provided as ordered during the survey period.
Failure to Monitor and Reassess Change in Condition After IV Infiltration
Penalty
Summary
A deficiency occurred when the facility failed to monitor and reassess a resident following a significant change in condition. The resident, who had chronic kidney disease stage 3, experienced an elevated potassium level, for which a physician ordered a peripheral IV catheter to be inserted. The IV was placed in the back of the resident's left hand. Subsequently, the IV infiltrated, resulting in swelling and pain in the resident's left hand and arm. Despite the visible swelling and the resident's report of pain, there was no documentation of monitoring or reassessment of the affected area in the medical record. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires monitoring and documentation of changes in condition every shift for 72 hours, but this was not done. The lack of monitoring and reassessment was directly observed and acknowledged by staff, and the facility's policy review supported the expectation for such documentation.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident was admitted to the facility with a left femur fracture and no existing pressure injuries, as documented in the admission assessment. The resident was identified as being at risk for pressure sores, with a Braden Scale score of 15, and a care plan was established to assist with turning and repositioning as indicated. Despite these measures, the resident developed a pressure ulcer on the buttock, which progressed from a popped blister to a deep tissue injury, then to an unstageable wound, and ultimately to a stage four pressure ulcer. Staff interviews revealed that the resident required assistance with repositioning and that the resident had spent more than five hours in a wheelchair, exceeding the recommended maximum sitting time of one to two hours as noted in the physician's progress note. Further review indicated that the resident developed additional skin issues, including a blood blister on the coccyx and another deep tissue injury on the right buttock. Staff acknowledged the need for frequent repositioning and changing to prevent pressure ulcers, but the resident's care did not consistently reflect these practices. The facility's policy required individualized repositioning schedules based on risk factors, but the resident's clinical course and staff statements indicated lapses in implementing these preventive measures, resulting in the development and worsening of pressure injuries.
Failure to Provide Ordered Nutritional Supplement for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of dysphagia following a cerebral infarction was readmitted to the facility and had physician's orders for a very high calorie nutritional supplement (Boost VHC) to be provided with meals, as well as participation in a restorative nursing assistant (RNA) dining program. Multiple observations over several days revealed that the resident was not provided with the ordered Boost supplement during meals, despite significant weight loss documented in the medical record. Staff interviews confirmed that the Boost was not given, and the process for obtaining the supplement involved CNAs retrieving it from the medication cart, which did not occur. The resident's weight dropped from 103 lbs to 91 lbs over approximately one month, and the registered dietician's notes indicated underweight status and weight below goal. The registered dietician and the DON both stated that the Boost supplement was an important intervention for the resident's nutritional needs and that staff were expected to follow physician's orders. Facility policy required the identification and provision of adequate food and fluids to maintain sufficient nutrition and hydration, as well as monitoring and documentation of dietary intake. Despite these policies and the resident's significant weight loss, the ordered nutritional supplement was not provided, and the dietician was unaware of this omission until the time of the survey.
Failure to Administer Prescribed Diabetes Medication as Ordered
Penalty
Summary
A deficiency occurred when a licensed nurse failed to administer a prescribed medication, dulaglutide injection, to a resident with diabetes as ordered by the physician. During a medication pass observation, the nurse provided several medications to the resident but omitted the dulaglutide, which was scheduled to be given every Wednesday. The nurse later stated that she did not notice the medication was due because it was listed at the end of the medication administration record and had not yet been given. Further, the nurse revealed that the dulaglutide was not available at the time it was due and needed to be ordered from the pharmacy. The resident involved had a diagnosis of diabetes and was admitted with multiple other conditions. The Director of Nursing confirmed that medications are required to be available and administered as ordered, especially those given on a weekly schedule. Facility policy also requires medications to be administered within one hour of the prescribed time. The failure to provide the dulaglutide as ordered resulted in the resident's medical needs not being met at the scheduled time.
Failure to Ensure Proper Indication and Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not providing a proper clinical indication for the use of an anti-anxiety medication. The resident, who had diagnoses of Anxiety Disorder and Major Depressive Disorder, was receiving alprazolam (Xanax) on a routine basis for anxiety. The physician's order and care plan both cited 'feeling of impending danger' as the indication for use, but interviews with staff revealed that this was not an accurate description of the resident's symptoms, which included panic attacks and increased heart rate, particularly when discussing family issues. Staff also noted that behavior monitoring for the medication was not accurately capturing the resident's actual symptoms, and that the information provided to the physician regarding the resident's progress was inadequate. The resident was cognitively intact and able to communicate her symptoms, yet the documentation and monitoring did not align with her reported experiences. The facility's policy required adequate monitoring for efficacy and adverse consequences, as well as a documented clinical rationale for psychotropic medication use based on assessment of the resident's condition. However, the lack of accurate behavior monitoring and documentation meant that the continued use of alprazolam was not properly justified according to the facility's own policy and regulatory requirements.
Failure to Follow Infection Control Practices During Meal Service
Penalty
Summary
A deficiency was identified when a licensed nurse opened three small beverage cartons during mealtime by touching the spout with her bare finger and then proceeded to feed a resident. This action was observed in the south dining room, where two residents were waiting to be served. The method used to open the cartons did not follow proper infection control practices, as confirmed by both the restorative nursing assistant and the licensed nurse during subsequent interviews. Both staff members acknowledged that touching the spout is an infection control issue. Further review of the facility's infection prevention and control policy revealed that it lacked specific definitions and instructions regarding standard precautions to prevent the spread of infection during resident care activities. The Director of Nursing also confirmed that staff should not open beverage cartons by touching the spout due to infection control concerns. The deficiency was based on direct observation, staff interviews, and a review of facility policy and CDC recommendations.
Failure to Notify Physicians and Families of Resident Condition Changes
Penalty
Summary
The facility failed to notify the attending physician and resident representatives of significant changes in the condition of four residents. Resident 2's representative was not informed of the deterioration of a wound that progressed to a stage four pressure ulcer. Despite the presence of a care plan indicating the risk for skin breakdown, the family was not notified of the worsening condition, as confirmed by the treatment nurse and assistant director of nursing (ADON). The director of nurses (DON) stated that it was expected for licensed nurses to update the family and physician about any changes in the resident's condition. Resident 3 experienced significant weight loss, dropping from 205 lbs to 187 lbs within a month, but the attending physician was not notified. The ADON confirmed that there was no record of physician notification regarding the weight loss, despite the facility's policy requiring such communication. Similarly, Resident 5 also experienced a ten-pound weight loss over a month, but the attending physician was not informed. The registered dietician stated that a list of residents with undesirable weight changes was provided to nursing staff, who were expected to notify the physician. Resident 7 developed a stage four pressure ulcer, but the family was not informed of the wound's condition. The ADON confirmed that the family was not notified, despite the facility's policy requiring notification of changes in a resident's condition. The DON reiterated the expectation for licensed nurses to update the family and physician about any changes in the resident's condition. The facility's policy and procedure document, dated February 2021, also indicated the requirement for prompt notification of changes in a resident's medical or mental condition.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate care to prevent the worsening of a pressure ulcer for a resident, identified as Resident 2. Upon admission, Resident 2 had a maceration on the buttocks, which later developed into multiple stage two pressure ulcers on the medial buttocks. Despite the presence of an air mattress and the resident's dependency on staff for mobility, the pressure ulcers progressed to a stage four ulcer on the sacro-coccyx area, indicating a lack of effective intervention and monitoring. Observations and interviews revealed that the treatment nurse was unaware of the resident's initial skin condition upon admission, and there was no initial skin assessment found in the electronic medical record. The facility's policy required repositioning every two hours to prevent pressure ulcers, but it was unclear if this was consistently implemented. The resident's condition deteriorated, with the pressure ulcer becoming unstageable and eventually classified as stage four, with significant necrotic tissue and drainage. The Quality Assurance nurse and the Director of Nursing acknowledged the deterioration of the resident's skin condition while in the facility. The facility's policy on pressure injuries did not provide adequate guidance for prevention and maintenance, contributing to the deficiency. The lack of a comprehensive and effective care plan for pressure ulcer prevention and treatment led to the resident's condition worsening, highlighting a significant lapse in care and oversight.
Failure to Implement Transmission-Based Infection Control Measures
Penalty
Summary
The facility failed to implement transmission-based infection control measures when personal protective equipment (PPE) was not readily available for staff entering the room of a resident on enhanced barrier precautions (EBP) for a history of Methicillin-resistant Staphylococcus aureus (MRSA). Despite the presence of an orange dot and a sign indicating the need for gloves and a gown, no PPE was available outside or inside the resident's room. This deficiency was observed during a survey on 4/18/24, where multiple staff members, including a licensed nurse, a medical doctor, and a certified nursing assistant, confirmed the absence of necessary PPE and acknowledged the infection control problem it posed. The resident in question was admitted with a diagnosis of a sacral pressure ulcer and had physician orders for EBP due to a history of MRSA. During the survey, it was noted that staff had physical contact with the resident without wearing the required PPE, increasing the risk of infection transmission. The facility's infection prevention nurse confirmed that PPE should be available at the door of any resident on EBP, and the lack of it was a significant oversight. The facility's policy and procedure document, revised in 9/2022, did not specify the protocol for enhanced barrier precautions, contributing to the deficiency.
Failure to Notify Responsible Party of Room Change
Penalty
Summary
The facility failed to notify the responsible party (RP) before changing a resident's room for one of two sampled residents. This failure created the risk of the RP being unaware of the resident's location while attempting to visit. The resident was admitted with diagnoses including Hemiplegia. The RP stated that the facility had changed the resident's room multiple times without always notifying them. Specifically, the facility did not notify the RP of the latest room change until the following day. The Director of Staff Development admitted to coordinating the room change but forgetting to notify the RP. According to the facility's policy, all parties involved in a room change should be given advance notice, which was not followed in this instance.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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