Ridgeway Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Petaluma, California.
- Location
- 523 Hayes Lane, Petaluma, California 94952
- CMS Provider Number
- 555703
- Inspections on file
- 31
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ridgeway Post Acute during CMS and state inspections, most recent first.
Two residents with cognitive impairments were involved in a physical altercation, and the facility did not report the abuse allegation to the state agency within the required 2-hour timeframe. Staff and policy confirmed the reporting requirement, and the delay was acknowledged by the DON.
A resident was transferred to the hospital on two occasions without the required notification to the LTC Ombudsman. Staff interviews and record reviews confirmed that facility policy mandates Ombudsman notification for such transfers, but no documentation was found to show this occurred.
A resident with respiratory conditions repeatedly complained of headaches and throat irritation from a strong floral-scented air freshener used near their bedroom. Despite these complaints and the resident's request, the facility continued to use both spray and mechanical air fresheners in the hallway, and staff were unaware of the specific chemicals involved. The care plan acknowledged the resident's sensitivity but did not list it as an allergy, and the facility's policy on providing a homelike environment was not followed.
A nurse publicly told a resident that medication would be withheld until the resident took a shower, making the statement in front of other residents and staff. This action caused the resident to feel embarrassed and humiliated. Staff interviews confirmed the incident was inappropriate and not in line with facility policies requiring respect and privacy for all residents.
A resident with organ-limited amyloidosis was housed in a room with a damaged window sill, broken blinds, and peeling paint, conditions confirmed by both a CNA and the administrator. The resident reported discomfort and dissatisfaction with the environment, which did not meet the facility's policy for a safe, clean, and homelike setting.
A resident with a history of stroke and muscle weakness experienced pain and infection after staff failed to provide regular toenail care or arrange timely podiatry services, despite repeated complaints. The lack of documented foot care led to the development of cellulitis and ingrown toenails on all toes, ultimately requiring surgical removal of all toenails.
Two residents did not receive regular nail care, with long and dirty fingernails observed and no set schedule or documentation for nail trimming. Another resident did not receive scheduled showers or daily bed baths, with incomplete documentation of refusals and reasons. Staff interviews confirmed a lack of adherence to facility policies for personal hygiene and grooming.
A resident with a history of stroke and muscle weakness experienced significant pain from ingrown toenails and after a matrixectomy on all toes. Despite frequent reports of high pain levels and observable discomfort, staff did not develop or implement a pain management plan or use non-pharmacological interventions such as a bed cradle, resulting in ongoing pain and reduced mobility.
The facility failed to ensure residents wore their own clothing, affecting their dignity and well-being. A resident with dementia attended a family event in women's clothing, unaware due to his condition. Another resident felt disrespected seeing others in his clothes, which were gifts from his sister. Staff admitted to not checking clothing labels, violating the facility's dignity policy.
A facility failed to locate, replace, or reimburse personal items lost by three residents, including dentures and clothing. Despite notifying staff, the items were not recovered, and grievance reports were not updated. The facility did not adhere to its policies on safeguarding personal property and handling grievances, leading to unresolved issues for the residents.
A resident with multiple health conditions, including diabetes and peripheral vascular disease, did not receive proper wound care due to a failure in communication between the Wound Care PA and the Attending Physician. The PA's orders for bacitracin and a wound culture for a heel wound were not entered into the electronic medical system, and the Attending Physician did not review the wound care notes. This oversight was confirmed through interviews with the DON and licensed nurses, highlighting a deviation from the facility's standard procedure for handling verbal orders.
The facility failed to follow food safety and sanitation guidelines, with improper handwashing, inadequate temperature control, and cross-contamination risks observed. Staff did not use hair restraints, and food storage guidelines were not followed, with expired and undated items found. Equipment was unclean, and the kitchen environment was poorly maintained, increasing the risk of foodborne illness for residents.
The facility failed to ensure residents were treated with dignity and respect. A staff member was observed standing while assisting a resident with meals, contrary to the facility's expectation for a dignified dining experience. Additionally, three staff members were observed speaking Spanish in a resident care area, against the policy that staff should only speak a language other than English when communicating with residents in their native language. These actions were noted despite previous resident complaints about feeling ignored and uncomfortable.
The facility did not promptly address or resolve issues raised during resident council meetings, affecting 13 residents. Concerns about staff communication and delayed call light responses were documented without resolution. The Director of Staff Development failed to document training sessions adequately, excluding night shift staff. The facility's policy to track and address resident council issues was not followed.
The facility did not post the location of the survey results in an easily noticeable manner, affecting 76 residents' rights to examine them. The survey binder was found unlabeled and dusty in the entrance lobby, with no indication of its presence. It also lacked updates on complaints or incidents after January 2023. The Administrator confirmed the binder had not been updated since then and was in the process of labeling it. The facility's policy guarantees residents the right to examine survey results, which was not being honored.
The facility failed to maintain a homelike environment by using two shower rooms as storage, making them unusable for residents, and by allowing the smoking area to become dirty and unkempt. Residents reported issues with water temperature in the shower rooms and expressed dissatisfaction with the condition of the smoking area, which was cluttered with medical equipment and trash.
The facility failed to maintain safe water temperatures, with readings exceeding 120 degrees Fahrenheit in two showers and seven restroom faucets, posing a risk of scalds or burns. Despite repeated complaints from residents and staff, the issue persisted, with temperatures recorded as high as 136 degrees Fahrenheit. The facility's policy to keep water temperatures below 120 degrees was not followed.
A facility failed to provide proper pharmaceutical services, resulting in medication errors for three residents. An LPN did not verify a resident's identity before applying a Lidocaine Patch, which was not used according to instructions. Another LPN administered Metformin to the wrong resident and failed to document Tylenol administration. The facility's policies on medication verification and documentation were not followed.
The facility failed to manage and store medications properly, resulting in medication mix-ups among residents and non-compliance with temperature control standards. Medications for a discharged resident were not removed, and medications for four residents were stored incorrectly. Additionally, the medication room temperature exceeded the acceptable range, potentially affecting medication stability.
The facility failed to ensure adequate oversight in kitchen operations, resulting in deficiencies in food safety and sanitation. The CDM did not implement job-specific competency evaluations for new staff, leading to non-adherence to essential food safety practices. The RD's sanitation audits were incomplete, failing to address critical areas such as proper handwashing, monitoring of TCS foods, and cleanliness of equipment.
The facility did not adhere to standardized recipes, leading to unpalatable meals for residents. The preparation of Pacific Rim Pork Roast and Carrots with Parsley deviated from recipes, resulting in watery and improperly textured food. Residents reported the meals as tough, bland, and unappetizing. A test tray audit confirmed these issues, highlighting the facility's failure to ensure proper food preparation.
The facility failed to educate staff and visitors on safe food handling practices for food brought in from outside, as revealed through interviews with a Licensed Nurse, the DON, and the DSD. The facility's policy stated that outside food would not be reheated or stored, but there was no evidence of training on safe food handling. An in-service record lacked details on the material covered or competency assessment, and a document on food safety did not include safe handling information. These deficiencies could lead to unsafe food handling and foodborne illnesses for the 76 residents.
The facility failed to maintain a sanitary storage area for garbage and refuse, with an overflowing dumpster and littered surroundings, including dirty resident equipment. The Maintenance Supervisor confirmed the area was unclean, and the Administrator acknowledged the issue, suggesting a need for more frequent cleaning.
The facility failed to maintain the ice machine in proper working order, as observed during an inspection where black residue was found on its internal components. The Maintenance Supervisor admitted to not following the manufacturer's cleaning guidelines due to not knowing the model number. Additionally, the Registered Dietitian was unaware of how to inspect the internal components, only testing the ice bin's cleanliness. The facility's policy required monthly cleaning per the manufacturer's recommendations, which were not followed.
A resident was served pasta despite their known dislike for it, indicating a failure in honoring food preferences. The meal was initially delivered by unlicensed staff, and the CDM had to intervene to correct the meal. The CDM stated that both the diet aide and nurses are responsible for ensuring meal accuracy.
A resident in a long-term care facility was administered a new pain medication, MS Contin, without informing or obtaining consent from their medical decision-maker. This led to the resident becoming over-sedated and requiring naloxone to reverse the effects. The facility staff, including the DON, acknowledged the oversight, and the Medical Director confirmed the necessity of involving the resident's decision-maker in such decisions.
A resident with multiple medical conditions experienced increased confusion and blood in his urine, prompting a stat urinalysis and culture order. The specimen was rejected due to mislabeling, but the facility failed to collect a new sample or follow up, delaying diagnosis and treatment. The resident's condition worsened, resulting in hospitalization for septic shock and acute cystitis.
The facility failed to ensure an unlicensed staff member wore an N95 respirator while caring for COVID-19 positive residents. The staff member was observed wearing a surgical mask improperly, exposing her nose, despite the facility's policy and training requiring full PPE, including an N95 mask, for such situations. The Infection Preventionist confirmed the residents' COVID-19 status and the expectations for PPE use.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an abuse allegation involving two residents was reported to the state licensing/certification agency within the required 2-hour timeframe. The incident involved two residents, both with moderately impaired thinking and memory as indicated by their BIMS scores of 10, and diagnoses including schizophrenia, major depressive disorder, and dementia. According to the SOC 341 form, one resident reported being punched in the face by their roommate, after which the resident retaliated by hitting the roommate on the right temple, and the roommate then hit back on the nose. The facility became aware of the incident at 5:10 a.m., but the SOC 341 form was not faxed to the state agency until 8:50 a.m., exceeding the 2-hour reporting requirement. Interviews with facility staff, including the MDS coordinator, Director of Staff Development, and Director of Nursing, confirmed that abuse allegations should be reported to the state within 2 hours of discovery, as outlined in the facility's policy and procedure. The Director of Nursing verified that the facility was aware of the abuse allegation at 5:10 a.m. and acknowledged that the report to the state was made late. The facility's policy defines "immediately" as within 2 hours for allegations involving abuse or resulting in serious bodily injury.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman when a resident was discharged and admitted to the hospital on two separate occasions. Interviews with facility staff, including the Minimum Data Set coordinator, Director of Staff Development, Director of Nursing, and Social Services Director, confirmed that notification of the Ombudsman is required by facility policy and is considered essential for resident safety. Record reviews verified that the resident was transferred to the hospital on two specific dates, but there was no documentation indicating that the Ombudsman had been notified of these transfers. The facility's policy and procedure on transfer and discharge notices, as well as state guidance, require that notice of transfer or discharge be provided to the Ombudsman. Despite this, the Social Services Director acknowledged that no documentation existed to show that the Ombudsman was notified for the resident's hospital transfers. This omission was confirmed through interviews and record reviews, establishing that the required notifications were not made as per policy.
Failure to Provide Homelike Environment Due to Air Freshener Use
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for a resident with significant respiratory diagnoses, including respiratory failure, acute bronchitis, and pulmonary hypertension. Despite repeated complaints from the resident about headaches and throat irritation caused by a strong floral-scented air freshener near his bedroom, the facility continued to use both spray and mechanical air fresheners in the hallway adjacent to his room. The resident had previously requested the removal of air fresheners, and while staff refrained from using spray air freshener in his bedroom, mechanical devices remained in use nearby. Staff interviewed were unaware of the specific chemicals in the air fresheners, and the maintenance assistant was not familiar with the devices or their contents. Observations confirmed a noticeable floral fragrance in the hallway outside the resident's room, and a mechanical air freshener device was found mounted on the wall near the ceiling, approximately six feet from the room. The care plan noted the resident's claim of being allergic to air fresheners, but this was not listed among his documented allergies, and no recent change in condition was recorded. The facility's policy emphasized providing a homelike environment with pleasant, neutral scents and minimizing institutional odors, but the continued use of air fresheners despite the resident's complaints and medical history constituted a failure to honor the resident's right to a safe and comfortable environment.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency occurred when a licensed nurse made a humiliating comment to a resident in a public area of the facility, stating, "I am not going to give you your medication until you take a shower!" This statement was made in the presence of other residents and staff, resulting in the resident feeling embarrassed and humiliated. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic pain syndrome, osteoarthritis, hoarding disorder, and major depressive disorder, reported feeling disrespected and stated that the incident was deeply embarrassing. Multiple staff interviews confirmed that the nurse's actions were inappropriate and did not align with the facility's expectations for maintaining resident dignity and privacy. The Assistant Activities Director reported that the nurse had also expressed to her that the resident should not participate in activities until she showered, and confirmed hearing the nurse make the comment out loud in a public area. The Director of Nursing and the Administrator both stated that such matters should be addressed privately and that denying participation in activities or medication based on hygiene in a public setting is not acceptable. A review of the facility's policies and procedures on Resident Rights and Dignity indicated that all residents are to be treated with kindness, respect, and dignity, and that staff are expected to promote, maintain, and protect resident privacy. The policies specifically prohibit demeaning practices and require that residents be encouraged to attend activities of their choice. The nurse's public comment and actions were in direct violation of these established policies, resulting in a failure to honor the resident's right to dignity and respect.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident when the window sill and blinds in the resident's room were found to be damaged, and there was peeling paint on the wall. Specifically, the window sill had two areas of missing or damaged wood, each about six inches in length, reportedly caused by staff moving beds in and out of the room. The horizontal blinds were missing approximately four inches from each strip along the right side, affecting two-thirds of the blind, which allowed more sunlight into the room and made it warmer. Additionally, there was a 12 x 12 inch area above the television with peeling paint, some of which had been painted over. The resident, who had organ-limited amyloidosis and no memory impairment, expressed dissatisfaction with the room's condition, stating it made him feel like he was "living in a dump." Both a CNA and the facility administrator confirmed the presence of the damage and agreed that the room was not homelike and required repair. The facility's policy required that residents be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance.
Failure to Provide Timely Foot Care Resulting in Pain and Surgical Intervention
Penalty
Summary
The facility failed to provide appropriate foot care, including timely toenail trimming, for one resident who was admitted with a history of intracerebral hemorrhagic stroke and muscle weakness. The resident repeatedly communicated to staff about discomfort and pain caused by long and ingrown toenails, which interfered with his ability to walk and wear shoes or socks. Despite these complaints, staff did not provide toenail care or arrange for timely podiatry services, and there was no documentation of nail care or cleaning being provided. The resident was not included in the list of those seen by the podiatrist during a facility visit, and staff interviews confirmed that daily nail care and regular trimming were not performed as required. The resident ultimately developed cellulitis and ingrown toenails on all toes, leading to a surgical procedure (matrixectomy) to remove all toenails. Interviews with staff, including the DON and Infection Preventionist, revealed that the facility did not attempt to arrange an earlier podiatry appointment or send the resident to an outside provider, and no documentation was provided to show such attempts were made. Facility policy required daily cleaning and regular trimming of nails, as well as documentation of care provided, but the facility was unable to produce records showing compliance with these requirements. The lack of timely and appropriate foot care resulted in the resident experiencing pain, infection, and the need for surgical intervention.
Failure to Provide Regular Nail Care and Scheduled Bathing
Penalty
Summary
The facility failed to provide adequate personal hygiene and grooming services to two out of three sampled residents. One resident, who had multiple sclerosis and muscle weakness and required assistance with activities of daily living, reported that staff did not trim her fingernails regularly despite repeated requests. Observations confirmed her fingernails were long, and she expressed discomfort and concern about accidental scratches. Staff interviews revealed there was no set schedule or reminder system for nail care, and documentation of nail care was lacking. Another resident was observed with long fingernails containing blackish material, which he identified as dirt. He stated that staff did not regularly offer to clean his hands or trim his nails, and he would have appreciated more frequent care. Staff and the Director of Staff Development acknowledged that long and dirty fingernails were unacceptable and could harbor bacteria, but were unaware of the facility's policy on nail care frequency and could not provide documentation of recent nail care for these residents. Additionally, the facility did not ensure that one resident received showers or bed baths as scheduled. Review of shower flow sheets showed that the resident received only a few showers and bed baths over a four-week period, with some refusals noted but without documentation of the reasons for refusal. The resident was observed to be unkempt and to have a urine odor, and he reported not receiving daily bed baths or regular showers. He also stated that staff had stopped asking if he needed assistance with bathing, and he did not complain because he assumed staff were too busy. Interviews with staff, including unlicensed staff, the DSD, and the DON, confirmed that residents were expected to receive showers several times a week and daily bed baths if showers were refused. Staff acknowledged that refusals and reasons should be documented, but this was not consistently done. Facility policies required daily cleaning and regular trimming of nails, as well as documentation of nail care and bathing, but these practices were not followed for the residents involved.
Failure to Develop and Implement Pain Management Plan for Post-Matrixectomy Resident
Penalty
Summary
The facility failed to develop and implement a pain management plan for a resident who was at high risk of experiencing pain due to ingrown toenails and following a matrixectomy procedure on all ten toes. The resident, who had a history of intracerebral hemorrhagic stroke and muscle weakness, was admitted in November 2024 and was previously able to ambulate with a walker. Documentation showed that the resident experienced significant pain, with reported pain levels ranging from 6 to 8 out of 10 on multiple occasions after the matrixectomy. Observations and interviews revealed that the resident experienced ongoing pain when blankets touched his bare nail beds, leading to grimacing, frustration, and feelings of depression. The resident reported that the pain from both the ingrown toenails and the post-surgical condition made it difficult to walk, resulting in a transition from using a walker to a wheelchair. Staff interviews confirmed awareness of the resident's pain and the potential for increased discomfort due to the lack of protective interventions, such as a bed cradle to prevent blankets from contacting the sensitive areas. A review of the resident's care plans indicated that no pain management strategies were documented for either the ingrown toenails or the post-matrixectomy period. The facility's own policy required assessment, recognition, and management of pain, including the use of non-pharmacological interventions when appropriate. Despite this, staff acknowledged that no such interventions were implemented, and the resident's pain was not adequately addressed through individualized care planning.
Failure to Ensure Residents Wear Their Own Clothing
Penalty
Summary
The facility failed to ensure that residents wore their own clothing, which compromised their dignity and sense of well-being. Resident 1, who has severe memory impairment due to dementia, was taken to a family Christmas party wearing women's clothing, which he was unaware of due to his condition. This incident was reported by a family member who had observed similar occurrences in the past. Upon inspection, it was found that Resident 1's closet contained clothing labeled with another resident's name, indicating a mix-up in the handling of personal items. Resident 6, who also has severe memory impairment, expressed feelings of disrespect and sadness when he saw other residents wearing his clothing. His clothing held sentimental value as they were gifts from his sister. During an observation, Resident 5 was seen wearing a shirt labeled with Resident 6's name, which he claimed to have bought from a thrift store. This was confirmed by a CNA who admitted to not checking the labels before dressing the residents. The facility's policy on dignity, which emphasizes the importance of respecting residents' private space and property, was not adhered to. The Director of Nursing acknowledged that CNAs are responsible for ensuring residents wear their own clothing, but this protocol was not followed, leading to the reported incidents. The failure to verify clothing ownership resulted in emotional distress for the residents involved.
Failure to Address Missing Personal Items
Penalty
Summary
The facility failed to ensure that three residents who lost personal items had their belongings located, replaced, or reimbursed. Resident 1, who had severe memory impairment due to dementia, lost his dentures approximately a year and a half ago. Despite notifying the Social Services Director (SSD) about the loss, the dentures were neither found nor replaced. Additionally, the inventory sheet for Resident 1 was not updated to reflect additional clothing brought by the responsible party, and it lacked the responsible party's signature. Resident 2, who had no memory impairment, lost all the clothing he was admitted with because he was not informed that his clothes needed to be labeled for identification. His clothes were never returned after being taken to the laundry, and he was unable to communicate effectively with housekeeping staff due to a language barrier. Despite notifying staff, his clothes were not located, reimbursed, or replaced. Resident 2 expressed that the loss of a blue jacket, a gift from his mother, was particularly significant. Resident 4, who also had no memory impairment, reported the loss of three dresses, two of which were reported missing six months prior. Despite filing a theft/loss report with the SSD, the dresses were not located, replaced, or reimbursed. The facility's grievance and missing items reports were not updated since April 2024, and there was no documented evidence of efforts to resolve these grievances. The facility's policies on safeguarding personal property and handling grievances were not followed, leading to unresolved issues and potential distress for the residents involved.
Failure to Communicate Wound Care Orders
Penalty
Summary
The facility failed to follow physician's orders for a resident when licensed nurses did not communicate the treatment orders written by a Wound Care Physician Assistant (PA) for a wound on the resident's left heel to the Attending Physician for approval and signature. This oversight was identified through interviews and record reviews, which revealed that the resident, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus, Diabetic Polyneuropathy, and Peripheral Vascular Disease, had a stage 3 pressure wound on the coccyx and a suspected deep tissue injury on the left heel. The Wound Care PA had ordered bacitracin for the left heel wound and a wound culture, but these orders were not included in the Order Summary Report or the Treatment Administration Record (TAR) for the relevant period. Interviews with the Director of Nursing and licensed nurses confirmed that the orders from the Wound Care PA were not communicated to the Attending Physician, which was a deviation from the facility's standard procedure. The usual process involved the Wound Care PA communicating new orders to the treatment nurse, who would then relay them to the Attending Physician. However, in this case, the orders were not entered into the electronic medical system, and the Attending Physician did not review the wound care notes as part of his standard practice. The facility's policy on verbal orders required that such orders be documented and countersigned by the practitioner, but this process was not followed, leading to the deficiency in care for the resident's wound treatment.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple observations and interviews. Staff members did not follow proper handwashing protocols, with one employee observed touching the trash can and wiping sweat from her face without washing her hands before continuing food preparation. Additionally, the cool down process for leftover foods was not documented, and the temperature control for safety (TCS) was not monitored, with cooked foods stored at improper temperatures. The facility's thawing process was also not followed, as meats were not labeled with pull and use-by dates. Cross-contamination risks were present, with personal items such as a glass of water and a pen found in food preparation areas, and incorrect cutting boards used for different types of food. Cleaning cloths were not stored in sanitizing solutions between uses, and hair restraints were not utilized by staff, increasing the risk of contamination. Food storage guidelines were not followed, with expired and undated items found in the refrigerator and dry storage areas. Equipment and utensils were not clean or in good working order, with dirty and worn items observed, and kitchen cleaning equipment was improperly stored. The kitchen environment was not maintained, with unclean walls, peeling paint, and dirty ceiling vents. Ice packs intended for personal use were stored with food, and the temperature log used was inappropriate for food storage. The manual dishwashing process was inconsistent with the facility's policy, as the immersion time for sanitizing dishes did not match the manufacturer's instructions. These deficiencies increased the risk of foodborne illness for the 76 residents consuming food prepared in the facility's kitchen.
Failure to Ensure Dignity and Respect for Residents
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect in two observed instances. In the first instance, a staff member was observed standing while assisting a resident with meals, which is against the facility's expectation that staff should be seated to provide a dignified dining experience. The staff member admitted to standing while assisting the resident and stated that they had not asked residents if they were comfortable with this practice. The Director of Staff Development confirmed that staff were expected to sit while assisting residents with meals and that in-services had been conducted on this expectation. In the second instance, three staff members were observed speaking Spanish in a resident care area, which was against the facility's policy that staff should only speak a language other than English when communicating with residents in their native language. This behavior was noted despite previous complaints from residents about staff speaking in languages other than English, which made them feel ignored and uncomfortable. The Director of Staff Development confirmed that staff were not allowed to speak a language other than English in resident care areas unless speaking to a resident in their native language, and that the Administrator had recently in-serviced staff on this requirement.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly respond to and resolve concerns raised during resident council meetings, affecting a sample of 13 residents. During a meeting, a resident expressed that issues discussed were not addressed in a timely manner, often resolved only the day before the next meeting. The July 2024 resident council minutes documented complaints about staff speaking in their native language, which upset some residents. However, the facility's response form was left blank, indicating no action was taken. Similarly, the August 2024 minutes recorded concerns about the alarm system and delayed call light responses, with no documented resolutions. Interviews with the Activities Director and the Director of Staff Development (DSD) revealed that concerns were directed to appropriate departments, but responses were not documented. The DSD, new to her position, acknowledged the lack of documentation for staff training sessions intended to address these concerns. Training records showed incomplete information, with only a few staff members attending, and night shift staff largely excluded. The facility's policy required tracking and addressing issues raised by the resident council, but this was not adhered to, leading to unresolved resident care concerns.
Failure to Post Survey Results Noticeably
Penalty
Summary
The facility failed to post the location of the survey results in an easily noticeable manner, which affected the rights of 76 residents to examine the facility's survey results. During an interview and record review, the Activities Director admitted that she did not discuss the location of the survey binder during regular resident council meetings. The survey binder was found on a shelf in the entrance lobby, covered with dust and unlabeled, with no postings indicating its presence. Additionally, the Director of Nursing confirmed that the survey binder did not include results of complaints or facility-reported incidents investigated after January 2023. The Administrator acknowledged that the survey binder had not been updated since January 2023 and was in the process of labeling it for easy identification. The facility's policy on Residents' Rights, last revised in February 2021, guarantees residents the right to examine survey results, which was not being honored due to these oversights.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for its residents by using two of the three shower rooms as storage spaces, which compromised their intended use. Residents reported issues with water temperature in the shower rooms, with one room having scalding hot water and another having cold water. The Chablis Hall shower room was cluttered with lifts and shower chairs, making it impossible to maneuver a resident in a shower chair for bathing. The Merlot Hall shower room was similarly crowded with equipment, leaving little room for residents. These conditions were confirmed by an unlicensed staff member who noted the difficulty in using the shower rooms due to the stored equipment. Additionally, the facility's smoking area was found to be dirty and unkempt, detracting from a homelike environment. Residents and staff observed that the smoking area, located in a wooden shed at the back of a patio, was filled with medical equipment, tarps, and dirty laundry. The area was covered with dust, spider webs, and trash, and the fire blanket was soiled and rusted. Residents expressed dissatisfaction with the condition of the smoking area, stating it did not feel like home. The facility's policy on providing a homelike environment was not upheld, as the smoking area and shower rooms were not maintained in a clean, sanitary, and orderly manner.
Unsafe Water Temperatures in Facility Showers and Faucets
Penalty
Summary
The facility failed to maintain a safe environment for its residents by allowing water temperatures in two showers and seven restroom faucets to exceed 120 degrees Fahrenheit, posing a risk of scalds or burns. This issue was highlighted during a Resident Council meeting where residents expressed concerns about the excessively hot water in the Merlot Hall shower. Despite repeated complaints from residents and staff over several months, the problem persisted, with water temperatures recorded as high as 136 degrees Fahrenheit in some areas. Observations and interviews conducted on 9/27/24 confirmed the ongoing issue, with multiple residents and staff members reporting dangerously high water temperatures in the Merlot Hall shower and other areas. The facility's policy, which mandates water temperatures not exceed 120 degrees Fahrenheit, was not adhered to, as evidenced by the recorded temperatures. The Maintenance Supervisor acknowledged the problem, and staff reported having to use alternative showers due to the unsafe conditions in Merlot Hall.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to medication administration errors. Licensed Nurse A did not verify the identity of a resident before administering a Lidocaine Patch, which was not applied according to the package instructions. The patch was left on for more than the recommended 12 hours, as the nurse was unaware of the correct application instructions. This oversight was confirmed by the Director of Nursing, who noted that the physician's order was unclear and needed revision. Additionally, Licensed Nurse B administered Metformin, a diabetes medication, to a resident for whom it was not prescribed, and failed to document the administration of Tylenol to the same resident. The facility's policy requires verification of resident identity and proper documentation of medication administration, which was not followed in these instances. The Director of Nursing confirmed the lack of documentation for the Tylenol administration, highlighting a breach in the facility's medication administration procedures.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications, leading to significant deficiencies. During an inspection of the medication cart, it was observed that medications belonging to a discharged resident were not removed and were stored among another resident's medications. Additionally, medications for four residents were found in incorrect compartments, which included Gabapentin, Tamsulosin hydrochloride, Metformin, and Pantoprazole being mixed up among different residents' medications. Licensed Nurse B confirmed these discrepancies but could not provide an explanation, suggesting that the evening nurse might have returned the medications to the wrong places. The facility's policy on discontinued medications was not followed, as medications were not removed from the cart in a timely manner after a resident's discharge. Furthermore, the facility failed to maintain the medication room temperature within the required range of 68 to 77 degrees Fahrenheit. During an observation, two thermometers in the medication storage room both read 81 degrees Fahrenheit, exceeding the acceptable temperature range. Licensed Nurse E and the Regional Nurse Resource confirmed the elevated temperature, which was not in compliance with the facility's policy and the United States Pharmacopeia standards. This failure to control the room temperature could potentially affect the stability and efficacy of the stored medications.
Inadequate Oversight in Kitchen Operations Leads to Food Safety Deficiencies
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM) and the Registered Dietitian (RD) adequately oversaw kitchen operations, leading to deficiencies in food safety and sanitation. The CDM did not implement job-specific competency evaluations for new kitchen staff, relying instead on general orientation and shadowing without documented competency assessments. This lack of oversight resulted in staff not adhering to essential food safety practices, such as proper hand hygiene, monitoring the cool down process for time-temperature control for safety (TCS) foods, following thawing guidelines, preventing cross-contamination, and using hair restraints. Additionally, cleaning cloths were not stored in sanitizing solutions between uses, and facility recipes were not consistently followed. The RD's oversight was also insufficient, as the sanitation audits conducted did not comprehensively address critical areas of concern. The audits failed to evaluate proper handwashing, monitoring of TCS foods, adherence to thawing processes, prevention of cross-contamination, and cleanliness of food preparation equipment. Furthermore, the audits did not ensure proper storage of kitchen cleaning equipment, accurate temperature monitoring of the resident nourishment refrigerator, or correct manual dishwashing procedures. The RD acknowledged that the sanitation audit was incomplete and required a more thorough approach to ensure food safety and sanitation standards were met.
Failure to Follow Recipes Results in Unpalatable Meals
Penalty
Summary
The facility failed to ensure that meals were prepared according to standardized recipes, resulting in unpalatable and improperly textured food for residents. Specifically, the preparation of Pacific Rim Pork Roast and Carrots with Parsley did not follow the prescribed recipes. The cook added an excessive amount of water to the pork roast, resulting in a watery mixture, and did not measure the instant mashed potatoes, leading to a chunky texture that was not suitable for a pureed diet. Additionally, the carrots were prepared without salt, contrary to the recipe instructions, which contributed to the lack of flavor. These deviations from the recipes were confirmed by the Registered Dietician (RD) and observed during meal preparation. Residents expressed dissatisfaction with the meals, describing the meat as tough and lacking flavor, and the food as bland and unappetizing. During a test tray audit, the Certified Dietary Manager (CDM) and RD confirmed that the carrots tasted watery and the pork roast was difficult to cut and chew. Residents also reported that the eggs were rubbery and the meat was undercooked. These findings indicate that the facility's failure to adhere to standardized recipes and ensure proper food preparation negatively impacted the quality and palatability of meals served to residents.
Lack of Safe Food Handling Education for Staff and Visitors
Penalty
Summary
The facility failed to ensure that both staff and resident visitors were educated on safe food handling practices, particularly concerning food brought in from outside for resident consumption. Interviews with facility staff, including a Licensed Nurse (LN L), the Director of Nursing (DON), and the Director of Staff Development (DSD), revealed that there was no training provided on safe food handling. LN L confirmed that outside food was never heated and had to be discarded if removed from the refrigerator. The DON was unable to confirm whether staff and visitors were educated on safe food handling practices. The DSD, who had been with the facility for two months, stated she had not conducted any in-service training on safe food handling and was unsure if the previous DSD had done so. The facility's policy on personal food storage indicated that individuals would be educated on safe food handling and storage techniques as needed, but there was no evidence of such training being conducted. The policy also stated that the facility would not store or reheat any outside food. A review of the in-service attendance record for a session titled "Storing Food in the Refrigerator" showed no instructor details, summary of material covered, or any method to assess employee competency. Additionally, a document titled "Food Safety for Your Loved One" lacked information on safe food handling practices. These deficiencies had the potential to lead to unsafe food handling and foodborne illnesses, affecting the 76 residents in the facility.
Improper Garbage and Refuse Storage
Penalty
Summary
The facility failed to maintain a sanitary storage area for garbage and refuse, as observed during a survey. One dumpster was overflowing with trash, preventing the lid from closing, and the surrounding area was littered with various items, including empty cardboard boxes, dirty mops, and resident equipment such as bedframes and wheelchairs. The Maintenance Supervisor confirmed that the trash area was not clean and that the resident equipment was stored outside waiting to be cleaned, which was scheduled to occur every Thursday. Additionally, the kitchen was found to have used soda cans stored in an open container under a counter. The Administrator acknowledged that the dirty resident equipment had been kept outside and suggested that the cleaning schedule might need to be more frequent. The report references the USDA Food Code 2022, which requires refuse to be stored in a manner that is inaccessible to pests and covered with tight-fitting lids. The facility's failure to adhere to these standards increased the potential for harboring pathogens and attracting pests.
Failure to Maintain Ice Machine Cleanliness
Penalty
Summary
The facility failed to maintain essential equipment in proper working order, specifically the ice machine located in the kitchen dry storeroom. During an observation and interview with the Maintenance Supervisor (MS), it was revealed that the ice machine had not been cleaned according to the manufacturer's guidelines. The MS stated that he cleaned the ice machine monthly, with the last cleaning occurring on 8/13/24. However, upon inspection, black residue was found on the internal components of the ice machine, including the ice harvester curtain and ice sensor. The MS confirmed these findings and admitted to skipping a crucial step in the cleaning process because he did not know the model number of the ice machine. Further interviews with the Registered Dietitian (RD) revealed a lack of awareness regarding the inspection of the internal components of the ice machine. The RD stated that she only wiped the inside of the ice bin to test for cleanliness and was not aware of how to inspect the internal components. The facility's policy and procedure for ice machine cleaning, dated 2023, indicated that the ice machine should be cleaned and sanitized monthly per the manufacturer's recommendations. However, the manufacturer's cleaning instructions were not followed, as the MS used an incorrect cleaning solution ratio and skipped steps in the sanitizing procedure.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, leading to a deficiency in dietary services. During a lunch meal observation, a resident who disliked pasta was served spaghetti with meat sauce, despite their known preference against it. The meal was delivered by an unlicensed staff member, who confirmed the resident's dislike for pasta. Upon notification, the Certified Dietary Manager (CDM) intervened and replaced the meal with an alternative that included rice instead of pasta. An interview with the CDM revealed that the diet aide was responsible for ensuring meal accuracy according to the meal ticket, and nurses were also expected to check meal trays for diet accuracy.
Failure to Inform Resident's Decision-Maker of Medication Change
Penalty
Summary
The facility failed to honor the rights of a resident, identified as Resident 5, by not informing or obtaining consent from the resident's medical decision-maker, Family Member 2 (FM2), before administering a new pain medication, MS Contin (morphine sulphate). This oversight led to Resident 5 becoming over-sedated, necessitating the administration of naloxone to reverse the effects of opiate toxicity. The incident occurred after Resident 5, who suffered from arthritis and other medical conditions, was prescribed morphine by a new physician, Physician J, without FM2's knowledge or consent. Interviews and record reviews revealed that Resident 5 had been previously prescribed Norco for pain management, which was changed to oxycodone as needed. However, due to inadequate pain control, the facility's staff contacted Physician J, who ordered MS Contin without consulting FM2. The medication administration record showed that Resident 5 received multiple doses of MS Contin and oxycodone, leading to an opioid overdose and altered mental status. Despite the critical change in medication, there was no documentation of any discussion with FM2 regarding the risks and benefits of the new pain management regimen. Interviews with facility staff, including Licensed Nurses F and G, and the Director of Nursing (DON), confirmed that FM2 was not informed of the medication changes. The DON acknowledged that it was the responsibility of the nurse who took the medication order to notify the resident's responsible party. The Medical Director also verified that the resident or their decision-maker should be involved in decisions regarding changes to pain medication regimens. The facility's policy on resident rights emphasized the importance of involving residents and their families in care planning and treatment decisions, which was not adhered to in this case.
Failure to Follow Up on Stat Lab Order Leads to Resident Hospitalization
Penalty
Summary
The facility failed to follow up on a stat laboratory order for a resident, resulting in a delay in diagnosis and treatment. The resident, who had multiple medical diagnoses including schizoaffective disorder and cognitive communication disorder, exhibited increased confusion and blood in his urine. A stat urinalysis and culture and sensitivity test were ordered, but the specimen was rejected by the lab due to being mislabeled. Despite this, the facility did not collect a new specimen or follow up with the lab, leading to a delay in addressing the resident's condition. Interviews with staff revealed a lack of communication and follow-up regarding the lab results. The Infection Preventionist was preoccupied with COVID response testing and did not track the urine sample. Licensed nurses involved in the resident's care acknowledged the responsibility to follow up on lab results but failed to do so. The Director of Nursing was absent during the critical period, and the clinical interdisciplinary team did not adequately address the resident's change in condition or the missing lab results. The resident's condition worsened, leading to hospitalization where he was diagnosed with septic shock and acute cystitis. The facility's policy required prompt execution of diagnostic orders, but this was not adhered to, resulting in a significant health decline for the resident. The deficiency highlights a breakdown in the facility's processes for handling urgent medical orders and ensuring timely follow-up on critical lab results.
Failure to Use Proper PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that an unlicensed staff member, referred to as Unlicensed Staff B, wore an N95 respirator while caring for COVID-19 positive residents. During an observation, Unlicensed Staff B was seen wearing a gown, gloves, and a surgical mask that was pulled low on her face, exposing her nose, while attending to residents who were confirmed to be COVID-19 positive. This was confirmed by Licensed Staff C, who also observed the improper use of a surgical mask by Unlicensed Staff B. The Infection Preventionist (IP) confirmed that the residents in the room were COVID-19 positive and stated that staff are expected to wear full Personal Protective Equipment (PPE), including an N95 mask, goggles, gloves, and a gown, when entering rooms with COVID-19 positive patients. The facility's policy, revised in September 2022, also mandates the use of an N95 mask in such situations. Despite in-service training provided to all staff on the proper use of PPE, the IP noted that some staff do not adhere to the training, which was evident in this incident.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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