Samarkand Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Barbara, California.
- Location
- 2566 Treasure Drive, Santa Barbara, California 93105
- CMS Provider Number
- 555762
- Inspections on file
- 20
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Samarkand Skilled Nursing Facility during CMS and state inspections, most recent first.
The facility did not have a process to check the operational status, battery life, or cleanliness of Wander Guard bracelets for two residents at risk for wandering. Staff were unaware of procedures to verify device functionality, and the DON confirmed the absence of documentation or protocols for maintenance, despite manufacturer guidelines and facility policy referencing the use of these devices.
Two residents' assessments were completed using SBAR forms that were either unsigned or signed only by an LVN, without RN validation or co-signature. The DON and administrator confirmed that these forms are considered assessments and should have been completed or validated by an RN, in accordance with professional standards.
The facility failed to follow food safety standards by not labeling food items with preparation and expiration dates, resulting in expired food in the kitchen. Additionally, the concentration of sanitizing solution in red buckets was below the recommended level, compromising sanitation effectiveness. The Dietary Manager confirmed these issues during interviews.
A facility failed to protect the privacy of two residents' electronic health records when a nurse left a computer screen open on a medication cart, exposing sensitive information to the public. The facility's policies require that such information be kept confidential, in line with HIPAA regulations. The Director of Nursing acknowledged the breach of privacy rights.
The facility failed to transmit MDS records for two residents to CMS iQIES within required timeframes. A resident's discharge assessment was not transmitted within 14 days, and another resident's quarterly assessments were delayed by 28 and 39 days. Additionally, the MDS for a deceased resident was not submitted within 14 days. An LPN could not recall the reasons for these delays.
A facility failed to develop a care plan for a resident with a urinary catheter, despite the resident's history of UTIs and recent hospitalization. The resident was observed with a catheter but no care plan was documented, contrary to the facility's policy requiring comprehensive care plans.
A resident experienced a fall resulting in a hospital stay and was diagnosed with a septic joint, requiring intravenous antibiotics. Upon returning to the facility, the care plan was not updated to reflect these changes, despite facility policy requiring revisions as the resident's condition changes. The DON acknowledged the oversight, which increased the risk of recurring falls due to the lack of an updated plan for staff to follow.
A resident did not receive prescribed eye drop medication for glaucoma for two days due to a supply issue. The facility's policy and the pharmacist's recommendation on the disposal of eye drops conflicted, leading to the medication not being administered. The DON was unaware of the pharmacist's recommendation, contributing to the oversight.
The facility failed to follow physician orders for two residents, leading to unnecessary medication administration. One resident received Acetaminophen instead of Tramadol for severe pain and was given blood pressure medication despite low readings. Another resident was administered Oxycodone without prior pain assessment. The DON acknowledged these oversights, and the facility's policies on medication administration were not followed.
The facility failed to justify the continued use of psychotropic drugs for a resident and did not monitor another resident for side effects and sleep hours when administering trazodone. The lack of physician documentation for extending Ativan and Lorazepam use beyond 14 days and the absence of monitoring for trazodone administration were acknowledged by the DON, contrary to facility policies.
Expired medical supplies and medications were found in the medication storage areas of a facility, including an IV start kit, a filter needle, and anti-diarrheal medication. Interviews with staff confirmed the oversight, and facility policies require expired items to be removed and disposed of, which was not adhered to.
The facility failed to ensure that a resident's post-fall assessment and other assessments were performed by an RN, as required by professional standards. Instead, these assessments were conducted by an LVN without RN validation or co-signature, which is outside the LVN's scope of practice.
Failure to Maintain Wander Guard Bracelets in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that Wander Guard bracelets, which are used to monitor residents at risk for wandering or elopement, were maintained in safe operating condition for two of three sampled residents. Specifically, the facility did not have a process in place to check the operational status or battery life of the Wander Guard bracelets, nor did they have a regimen for cleaning and disinfecting the devices. Interviews with a licensed nurse revealed that while staff were trained to check the placement of the bracelets, they were unaware of any procedures to verify if the devices were functioning or had sufficient battery power. The Director of Nursing confirmed that there was no documentation or process to ensure the Wander Guards were operational, had adequate battery life, or were being cleaned as recommended by the manufacturer. A review of the manufacturer's manual indicated that the bracelets require weekly battery testing and periodic cleaning and disinfection, with specific instructions for how this should be done. The facility's own policy referenced the use of Wander Guards as an intervention for residents at risk of wandering or elopement but did not include procedures for maintaining the devices. As a result, the lack of maintenance and monitoring of the Wander Guard bracelets created a deficiency in ensuring the safety and security of residents identified as at risk for wandering.
Assessments Not Performed or Validated by RN
Penalty
Summary
The facility failed to ensure that assessments for two sampled residents were performed by a registered nurse (RN) as required by professional standards and the facility's comprehensive care plan. Specifically, review of the residents' records revealed that several SBAR Communication Forms, which are used to evaluate residents across ten body systems, were either unsigned or signed only by a licensed vocational nurse (LVN) rather than an RN. In some instances, the signature area was left blank, and in others, the forms were completed and signed solely by an LVN without RN validation or co-signature. The director of nursing (DON) and administrator confirmed that these forms are considered assessments and acknowledged that they were not completed or validated by an RN as required. The report references the Nursing Practice Act and the Scope of Vocational Nursing Practice, which clarify that while LVNs may contribute to data collection, only RNs are qualified to analyze, synthesize, and make clinical judgments necessary for comprehensive assessments. The failure to have RNs complete or validate these assessments means that the facility did not meet the professional standards of quality required for resident care planning and assessment. The DON and administrator acknowledged these findings during the surveyor's review.
Plan Of Correction
What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice On April 8, 2025, DON assessed resident #1 after notification by nurse that the X-ray result showed a closed nondisplaced fracture of the right ilium, unspecified fracture morphology. IDT reviewed the occurrence of injury of unknown source on April 8, 2025. On 2/11/2025, the IDT reviewed the fall occurrence of resident #2 the same day. Both residents did not sustain significant changes after occurrences. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents had the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur On April 17, 2025, DON initiated in-services for licensed nurses for completion and signing of the SBAR and Scope of Practice of LVNs. On May 21, 2025, DON initiated in-service for licensed nurses to write clinical notes or progress notes detailing observations after an incident of fall. The findings will be communicated with the physician. The DON also continued the discussion about the role of LVN and RN that was initiated on the April 17, 2025, in-service. How the corrective action(s) will be monitored to ensure the deficient practice will not recur; i.e., what quality assurance programs will be put into place DON or designee will review the fall incidents, including documentation, care plans, new interventions, and notifications. This review will take place during the daily Interdisciplinary Team (IDT) meetings, held on business days. Findings from weekly audits for 12 weeks will be presented by the DON to the QAPI committee monthly for 3 months. Date by which systemic corrections will be completed: May 31, 2025
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional food safety standards by not labeling food items with preparation and expiration dates, leading to the presence of expired food in the kitchen. During an observation, several food items, including a pack of ground beef, bags of potato wedges, hamburger buns, and dinner rolls, were found to be beyond their expiration dates or unlabeled. Additionally, bags of grapes brought from the independent living kitchen were unlabeled, with one bag showing signs of mold. The Dietary Manager confirmed these findings during interviews. Furthermore, the facility did not maintain the recommended concentration of sanitizing solution in red buckets, which is crucial for effective sanitation. Observations revealed that the concentration of the sanitizing solution in two red buckets was 170 ppm, below the recommended level as per the facility's policies and procedures. The Dietary Aide and Dietary Manager acknowledged the discrepancy, indicating that the solution was not as effective at the observed concentration. The facility's policy requires testing the sanitizer solution when buckets are filled and maintaining a concentration of a specified ppm, which was not met in this instance.
Breach of Resident Privacy Due to Unattended Computer
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of two residents' electronic health records. During an observation, a Registered Nurse left a medication cart unattended with an open computer screen displaying the electronic health records of two residents. This exposure occurred at the Garden Court station, where the records were visible to the public as two individuals passed by the cart. The nurse acknowledged the oversight and confirmed that the electronic medical records should have been closed to protect the residents' privacy. The facility's policies and procedures emphasize the importance of maintaining confidentiality and privacy of residents' health information, in compliance with HIPAA regulations. The policies require that electronic information about residents should not be exposed or posted publicly. The Director of Nursing acknowledged that the residents' rights to privacy and confidentiality were not upheld in this incident, as per the facility's established guidelines.
Failure to Transmit MDS Records Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) records for two unsampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) within the required timeframes. Specifically, the discharge assessment MDS for Resident 31 was not transmitted within 14 days of their discharge date, as required. During an interview, a licensed nurse (LN1) confirmed that the transmission date for Resident 31's discharge assessment was unavailable because it had not been transmitted. For Resident 37, the facility also failed to transmit MDS assessments within the required timeframes. The MDS quarterly assessment for Resident 37 was transmitted 39 days after the assessment reference date (ARD), and another quarterly assessment was transmitted 28 days after the ARD. Additionally, the MDS for Resident 37, who was discharged with a status of deceased, was not submitted within 14 days of the death in the facility. LN1 was unable to recall the reasons for these delays.
Failure to Develop Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident with a urinary catheter, which is a flexible rubberized tube inserted into the urinary tract to drain urine. This deficiency was identified during an observation where the resident was seen in bed with a urinary catheter connected to a urine bag. A subsequent review of the resident's clinical record revealed that there was no care plan in place for the urinary catheter, despite the resident having a history of urinary tract infections (UTI) and being readmitted to the facility after hospitalization for a UTI. The facility's policy and procedure for comprehensive person-centered care plans, dated March 2022, requires the interdisciplinary team to develop and implement a care plan that reflects recognized standards of practice for problem areas and conditions. However, the licensed nurse acknowledged that no care plan was in place for the resident's urinary catheter, which could potentially lead to further complications such as UTIs, dislodgement, and other bladder issues.
Failure to Update Care Plan After Resident's Fall
Penalty
Summary
The facility failed to review and update the care plan for a resident after a fall, which was identified during an interview and record review. The resident, referred to as Resident 18, experienced a fall two weeks prior to the interview, resulting in a week-long hospital stay. During the hospital stay, the resident was diagnosed with a septic joint and began intravenous antibiotic treatment. Upon returning to the facility, the care plan was not updated to reflect these changes, despite the facility's policy requiring care plans to be revised as the resident's condition changes. The Director of Nursing acknowledged that the care plan for falls was not updated when the resident returned from the hospital. The interdisciplinary team notes indicated that the care plan would be updated to include resident teaching on using the call button for assistance, but the last update to the fall care plan was dated prior to the resident's hospital admission. This oversight placed the resident at a higher risk for recurring falls due to the lack of an updated plan for staff to follow and implement for prevention.
Failure to Administer Glaucoma Medication Due to Supply Issues
Penalty
Summary
The facility failed to provide an eye drop medication for glaucoma as ordered by the physician for one of the residents, identified as Resident 12. This failure occurred when the supply of the medication ran out, and the medication was not administered on two consecutive days, 12/17 and 12/18/2024. During a medication pass observation, a registered nurse indicated that the eye drop medication would not be administered as it was being reordered. The physician's order dated 7/10/2024 specified that Resident 12 was to receive Timolol Maleate 0.5% eye drops daily for glaucoma. The facility's policy and procedure on medication administration indicated that multi-use eye drops should be disposed of 28 days after initial use, while the pharmacist's recommendation suggested discarding them after two months from the open date. The Director of Nursing was unaware of the pharmacist's recommendation and acknowledged the conflicting information between the pharmacist's guidance and the facility's policy. This lack of awareness and conflicting information contributed to the non-administration of the medication to Resident 12 for two days.
Failure to Adhere to Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, as evidenced by improper medication administration and lack of adherence to physician orders. Resident 54, an 82-year-old with hypertension, stroke, and fractures, was administered Acetaminophen for severe pain levels instead of the prescribed Tramadol for moderate to severe pain. This occurred on multiple occasions, and the facility's Director of Nursing (DON) acknowledged that the physician's order was not followed, with no documentation to justify the deviation or notification to the physician. Additionally, Resident 54 was given blood pressure medication despite having systolic blood pressure readings below the physician-ordered parameters. The medication was administered on two separate dates when the resident's blood pressure was recorded as 109 and 99, contrary to the order to hold the medication if the systolic blood pressure was less than 110. The DON confirmed the oversight and was unable to provide documentation supporting the decision to administer the medication or any communication with the physician regarding the deviation. Resident 57's medication administration also demonstrated deficiencies, as Oxycodone was given without prior pain assessment, contrary to the physician's order. The facility's policy required pain evaluation before administering medication, but records showed that Oxycodone was administered on several dates without such assessments. The facility's policy emphasized the importance of evaluating the effects of medications and ensuring that drug regimens are free from unnecessary medications, which was not adhered to in this case.
Failure to Justify and Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for two residents. For one resident, there was no justification from the physician for the continued use of Ativan and Lorazepam beyond 14 days. The physician's orders for these medications did not include a stop date, and the Director of Nursing acknowledged the lack of documentation for the continued use of these medications. The facility's policy requires that orders may be extended beyond 14 days only if the attending physician documents the rationale for the extended time period in the medical record. For another resident, the facility failed to monitor for side effects and hours of sleep when administering trazodone, an antidepressant medication. The resident's care plan indicated the need to monitor for side effects such as constipation, dry mouth, anxiety, agitation, headache, and falls. However, there was no documented evidence of monitoring for side effects or hours of sleep when trazodone was administered. The Director of Nursing confirmed that the monitoring was missed, which was contrary to the facility's policy on psychotropic medication use that requires adequate monitoring for efficacy and adverse consequences.
Expired Medications and Supplies Found in Medication Storage
Penalty
Summary
The facility failed to remove expired medical supplies and medications from the medication storage areas, which could potentially lead to residents receiving expired and ineffective treatments. During an observation in the Garden Court station medication room, several expired items were found, including an IV start kit, a filter needle, and an opened box of bio patch discs. Additionally, an unopened box of anti-diarrheal medication was found expired in the medication cart. Interviews with the Registered Nurse and the Director of Nursing confirmed the presence of these expired items. The facility's policy and procedure documents, which were reviewed, indicate that medications should be administered safely and timely, with expiration dates checked prior to administration. The policy also states that outdated or deteriorated medications should be immediately removed from stock and disposed of according to procedures. However, these protocols were not followed, leading to the deficiency.
Failure to Ensure RN Conducted Resident Assessments
Penalty
Summary
The facility failed to ensure that Resident 1's post-fall assessment and other assessments were performed by a registered nurse (RN) as required by professional standards of practice. According to the Nursing Practice Act, an RN is responsible for comprehensive assessments, including data collection, analysis, and making clinical judgments. However, the assessments for Resident 1 were conducted by a licensed vocational nurse (LVN) without RN validation or co-signature. This included an SBAR Communication Form and a Daily Skilled Progress Note, both of which were created by an LVN and included evaluations of the resident's body systems. During interviews, the interim assistant director of nursing (IADON) and the administrator (ADMIN) confirmed that the assessments were performed by an LVN and acknowledged that this practice was not within the LVN's scope. The IADON confirmed that the SBAR Communication Form was the only assessment done before Resident 1 was sent to the hospital emergency department. The ADMIN acknowledged the need to review and change the facility's practice to ensure compliance with professional standards of practice.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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