San Bruno Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in San Bruno, California.
- Location
- 890 El Camino Real, San Bruno, California 94066
- CMS Provider Number
- 555276
- Inspections on file
- 19
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at San Bruno Skilled Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was discharged to an emergency department solely after Medicare benefits were exhausted, despite no documented change in condition and no medical necessity for an ED transfer. The discharge care plan lacked specific problems, goals, interventions, and a documented destination preference, and it was not updated with the resident’s or representative’s wishes. Provider documentation conflicted, with orders for discharge home with home health services while social services arranged transport to a VA ED to check benefits and assign a social worker. The resident’s representative reported not being informed about applying for Medi-Cal or paying privately, and VA staff confirmed there was no scheduled benefits appointment, that the resident was brought directly to the ED without medical need, and that no Medicaid application had been filed. Facility records showed poor care coordination, conflicting discharge documentation, and failure to follow internal policies requiring appropriate notice, documentation, and financial assistance counseling at discharge.
A resident did not receive consistent range of motion (ROM) exercises to the left lower extremity, leading to the development of contractures. Initial therapy assessments showed normal ROM, but subsequent documentation revealed a decline in knee extension and mobility that was not properly addressed or reflected in the care plan. Upon hospital transfer, the resident had contractures, multiple wounds, and poor circulation in the affected leg.
The facility failed to provide sufficient space for group activities and communal dining, conducting activities in the hallway and serving meals in residents' rooms. This arrangement disturbed residents near the activity area and limited communal dining options. The Activities Director and Administrator confirmed the lack of designated spaces, with activities held in hallways and meals served in rooms since the pandemic.
A facility failed to maintain the privacy of a resident's care instructions, which were posted on the resident's bedroom wall, exposing their medical condition to others. The resident, with cognitive impairment and multiple diagnoses, had their care instructions posted by a family member. The DON acknowledged the issue but noted the family's involvement. This action violated the facility's policy on treating residents with dignity and respect.
A facility failed to assess and educate a resident on the self-administration of doxycycline, an antibiotic, as required by policy. The resident was observed with doxycycline on their bedside table and stated they were taking it for a bacterial infection. The RN and ADON were unaware of a care plan for the medication, and the resident's care plan only included five other medications for self-administration. The care plan was updated after the issue was identified, but the medication orders did not reflect the resident's use of doxycycline.
A resident's POLST form was found incomplete, lacking clear signatures and the identity of the individual with whom it was discussed. The DON confirmed the absence of necessary information, which could impact honoring the resident's end-of-life choices.
A facility failed to provide a resident with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) while receiving Medicare Part A services. The resident, who had multiple diagnoses and was responsible for his own decisions, did not receive the SNF ABN due to being out for dialysis on the day it was supposed to be issued. Although a Notification of Medicare Non-Coverage (NOMNC) was provided, the absence of the SNF ABN meant the resident was not informed about potential financial liability and the right to appeal.
A resident with multiple health issues, including moderate cognitive impairment, reported hip pain later diagnosed as a pathological fracture. Despite no falls or activities explaining the pain, the facility failed to report the injury of unknown origin to the California Department of Public Health, as confirmed by the DON and Director of Staff Development. Facility policies require such injuries to be reported and investigated, but this was not done.
The facility failed to complete MDS assessments for four residents within the required timeframe. Admission and annual assessments were not completed within 14 days of admission or the ARD, as required by the RAI User Manual. The MDS Coordinator confirmed the delays, which could result in delayed identification of residents' needs.
A resident admitted to hospice care with serious health conditions did not have a Significant Change in Status Assessment (SCSA) completed within the required 14-day period. The assessment was completed 16 days after hospice admission, potentially delaying appropriate treatment and services.
The facility failed to complete MDS quarterly assessments within the required timeframe for three residents. The assessments were not completed within 92 days following the previous OBRA assessment, as required. The MDS Coordinator acknowledged the delay, which could result in delayed identification of residents' needs.
The facility failed to implement person-centered care plans for three residents, leading to deficiencies in care. A resident with respiratory issues received incorrect oxygen levels, another resident with COPD was given more oxygen than prescribed, and a resident requiring a two-person assist for transfers was handled by one staff member, contrary to their care plan.
A facility failed to update a resident's care plan after an IDT assessment found their weight loss acceptable due to CHF. The care plan aimed to maintain the resident's weight within 5% of 195 lbs, but the resident's weight dropped to 182.8 lbs. The RD acknowledged the need to update the care plan to align with the IDT's findings, suggesting a BMI-based goal.
The facility did not follow physician's orders for oxygen administration for two residents. One resident with respiratory failure was observed with an incorrect oxygen delivery setup, while another resident with COPD received a higher oxygen flow than prescribed. These actions were inconsistent with the facility's policy and the residents' care plans.
A resident with hemiplegia and other conditions was transferred by a single RNA using a sit-to-stand lift, despite the care plan requiring two-person assistance. The sling used was frayed and missing a buckle. Staff interviews revealed a lack of recent training and inconsistencies in understanding transfer requirements.
A medication error rate of 11% was observed in an LTC facility due to improper administration practices. A nurse failed to verify a resident's identity and did not ensure full consumption of MiraLAX, while another nurse improperly administered Flonase by not following recommended guidelines.
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation. The Certified Dietary Manager (CDM) and another staff member were seen preparing food while wearing the bracelets, which they later removed. The facility's policy specifies minimal jewelry and requires hand jewelry to be covered with gloves.
The facility's QAPI program failed to prevent medication errors, resulting in an 11% error rate during a medication pass. Errors included improper resident identification and incorrect administration of medications. The Quality Committee had only met once in the past year and lacked a project to address these errors.
The facility failed to maintain its infection control program for two residents on transmission-based precautions. A resident with MRSA had no PPE available outside their room, contrary to facility policy. Another resident on enhanced barrier precautions had their PPE cart misplaced, and an LVN handled their Foley bag without PPE. These actions were against CDC guidelines and facility policies, potentially increasing infection spread risk.
Improper Discharge to Emergency Department After Medicare Exhaustion Without Adequate Planning or Counseling
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an effective discharge planning process and to ensure an orderly, appropriate discharge for one of three sampled residents. The resident was admitted with multiple chronic conditions, including COPD with acute exacerbation, centrilobular emphysema, gait and mobility abnormalities, unsteadiness, dysphagia, CKD, and urinary retention. A discharge care plan was initiated but left the discharge destination preference blank and did not identify specific discharge problems, goals, or interventions. The care plan was not revised or updated to reflect any discharge preferences of the resident or the resident’s representative. As the resident’s Medicare Part A coverage approached exhaustion, the facility issued a Notice of Medicare Non-Coverage indicating the end date of coverage. Provider documentation around this time was inconsistent: a practitioner note stated the resident was medically stabilized but not strong enough to return home and that discharge planning was pending therapy progress, while a physician discharge summary documented a planned discharge home with home health services and a stable condition. A physician order later specified discharge home with RN, PT, OT, HHA, and SW services. However, the Notice of Proposed Transfer/Discharge and the facility’s Discharge Summary and Post-Care Instructions instead identified a plan to send the resident to a VA location to check benefits eligibility and assign a social worker for placement under a VA program, with transportation by a friend. On the actual day of discharge, the social worker documented that the resident would be brought to the VA emergency room so that a social worker, VA PCP, and benefits eligibility could be arranged, citing exhaustion of Medicare days at the current and previous SNFs. Nursing documentation recorded that the resident left via a transportation company but did not document the discharge destination or home health information as ordered by the physician. Interviews with the DON and ADON confirmed there was no significant change in the resident’s condition and that the resident was stable on the day of discharge, indicating no medical necessity for an emergency transfer. The social worker and VA staff confirmed that the resident was taken directly to the VA emergency department without an appointment and without an apparent medical reason, and VA staff reported telling the social worker that the resident could not be brought in “for no reason.” The resident’s representative reported not being informed about the option to apply for Medi-Cal or to pay privately to remain at the facility and described the discharge as rushed, with nothing prepared in advance, despite the social worker’s knowledge that the resident had no place to stay because his prior apartment had been demolished. VA staff further stated that no Medi-Cal application had been filed for the resident and characterized the discharge as occurring after the resident ran out of 100 Medicare days. Review of the clinical record showed a lack of documented care coordination and discharge planning discussions with the interdisciplinary team, the resident, and the representative, and the discharge documentation from medical provider, social services, and nursing contained conflicting information. These actions and omissions were inconsistent with the facility’s own transfer/discharge policies, which require that residents not be transferred unless necessary for their welfare, that appropriate notice and documentation be provided, that residents receive assistance with third-party payment applications, and that residents who continue to need LTC services be offered the option to remain privately or with Medicaid assistance.
Failure to Provide Consistent ROM Interventions Resulting in Contractures
Penalty
Summary
A facility failed to provide consistent range of motion (ROM) exercises to a resident's left lower extremity (LLE) from admission until hospital transfer, resulting in the development of contractures. Initial assessments and therapy evaluations indicated that the resident had normal ROM in both lower extremities, with no contractures present. However, subsequent therapy notes and evaluations documented a progressive decline in the resident's left knee extension, with increasing difficulty in straightening the knee and performing transfers. Despite these changes, there was no documented change-of-condition evaluation or timely revision of the resident's care plan to address the decline in mobility. Therapy documentation showed that while some improvement in left knee extension was recorded over a short period, there were also periods with no improvement or worsening of the condition. The care plan addressing physical therapy and restorative nursing ROM was not updated to reflect the resident's declining ROM in the LLE, and there was a lack of documentation indicating that lower extremity ROM exercises were consistently provided. Interviews with facility staff confirmed that changes in the resident's mobility were not properly assessed or documented, and that contractures were not initially recognized or addressed in a timely manner. Upon hospital admission, the resident was found to have contractures in the LLE, along with multiple serious wounds, poor blood flow, and signs of infection and tissue death in the affected leg. The hospital team noted that the resident's poor nutrition, tight leg muscles, and compromised circulation would make wound healing difficult. The failure to provide consistent ROM interventions and to update care plans in response to the resident's declining mobility directly contributed to the development of contractures and associated complications.
Inadequate Space for Activities and Dining
Penalty
Summary
The facility failed to provide adequate space for group activities and communal dining for its 43 residents, as observed during a survey. The facility, licensed for 45 beds, conducted activities in the hallway due to the absence of a designated activity or dining room. This arrangement caused inconvenience to residents whose rooms were near the activity area, as they were disturbed by the noise. Resident 32 expressed discomfort with the noise from activities such as music and karaoke held in the hallway outside his room. The Activities Director confirmed that activities were held in the hallway, and residents in nearby rooms often closed their doors to minimize the noise. Additionally, the facility did not have a designated dining room, resulting in residents eating meals in their rooms. The Certified Dietary Manager stated that all meals were served in residents' rooms since the pandemic, and the previous dining room was repurposed as a rehab room. Resident 20 mentioned a preference for eating in a dining room rather than in his room, highlighting the lack of communal dining space. The Administrator acknowledged that activities and dining were conducted in the therapy room, hallway, or patio, depending on the weather, but noted that residents preferred eating in their rooms or the hallway.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the privacy of a resident's unique care instructions, which were posted in two places on the resident's bedroom wall. This action exposed the resident's medical condition to other residents and visitors. The resident, admitted to the skilled nursing facility with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Major Depressive Disorder, was found to have a cognitive impairment with a BIMS score of 8. During interviews, a CNA mentioned that the resident's daughter posted the care instructions, and the DON acknowledged the posting but suggested that the resident's name should not be included. The facility's policy on Resident's Rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this instance.
Failure to Assess and Educate Resident on Self-Administration of Doxycycline
Penalty
Summary
The facility failed to ensure that a resident could safely self-administer doxycycline, an antibiotic, as there was no assessment or education provided to the resident regarding its self-administration. The facility's policy requires the interdisciplinary team to assess a resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. However, this was not done for the resident in question, who was observed with a bottle of doxycycline on their bedside table and stated they were taking it for a bacterial infection. The registered nurse was unaware of a care plan for the doxycycline, and the case manager confirmed that a self-medication assessment and care plan should be in place for residents self-administering medications. Further investigation revealed that the resident's care plan, dated several months prior, only included five other medications for self-administration, none of which were doxycycline. The assistant director of nursing was also unaware of the resident taking doxycycline and expressed concern about the risk of overdose. The care plan was updated to include doxycycline only after the issue was identified, but the medication orders still did not reflect that the resident was taking doxycycline. This oversight could lead to potential risks such as overdose, drug interactions, or unrecognized side effects.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to maintain a valid Physician Orders for Life-Sustaining Treatment (POLST) for one of the residents, identified as Resident 47. The POLST, which is a critical document for guiding medical treatment decisions during end-of-life care, was found to be incomplete. Specifically, the POLST lacked a clear signature or identity of the individual with whom the POLST was discussed, which is a requirement for its validity. This deficiency was identified during a review of Resident 47's records, which showed that the POLST form did not have the necessary signatures or printed names of either the patient or a legally recognized decision maker. During an interview and record review with the Director of Nursing (DON), it was confirmed that the section of the POLST indicating whether the information was discussed with the patient or a legally recognized decision maker was left blank. The DON acknowledged the absence of a clear signature and printed name, stating that the form was incomplete. Resident 47, who was admitted in April 2024, had a cognitive status indicating intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. The lack of a valid POLST form has the potential to result in the resident's end-of-life choices not being honored.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN, Form CMS-10055) to a resident receiving Medicare Part A services. This notice is essential to inform residents of potential financial liability for non-covered stays and their right to appeal. The deficiency was identified for a resident who was admitted with multiple diagnoses, including orthopedic aftercare following surgical amputation, a non-pressure wound, type 2 diabetes mellitus, and end-stage kidney disease. The resident was responsible for his own decisions and was receiving Medicare Part A skilled services, which started on May 12, 2024, and the last covered day was May 31, 2024. The case manager stated that the resident had reached his maximum potential and was saving the remaining Part A days for an upcoming surgery. Although a Notification of Medicare Non-Coverage (NOMNC) was provided to the resident before the last covered day, the SNF ABN was not issued because the resident was out for dialysis on the day it was supposed to be given. The previous Social Services Director confirmed that the SNF ABN was not issued due to the resident's absence for dialysis. The facility's failure to provide the SNF ABN meant the resident was not informed about the potential financial liability and the right to appeal the termination of Medicare Part A services.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframes for a resident who reported hip pain, which was later diagnosed as a pathological fracture. The resident, who had multiple diagnoses including end-stage renal disease, anemia, and muscle wasting and atrophy, was admitted in January 2024. The resident had a Brief Interview for Mental Status score indicating moderate cognitive impairment. On a specific date, the Director of Nursing (DON) noted the resident's complaint of right hip pain and an X-ray revealed a right distal femoral fracture. Despite the absence of any reported falls or activities that could explain the pain, the incident was not reported to the California Department of Public Health as required. Interviews with the DON and the Director of Staff Development confirmed that the injury should have been reported as an injury of unknown origin. The facility's policies on investigating resident injuries and recognizing signs of abuse/neglect indicate that such injuries should be reported and investigated according to established guidelines. However, the interdisciplinary team deemed the injury as likely a spontaneous pathological fracture, and no report was made to the authorities. This oversight in reporting the injury of unknown origin could lead to delayed identification and investigation of possible harm from abuse.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) assessments for four residents within the required timeframe, as mandated by the Resident Assessment Instrument (RAI) User Manual. Specifically, the admission and annual MDS assessments for Residents 29, 16, 17, and 8 were not completed within 14 days of admission or the Assessment Reference Date (ARD). For Resident 29, the admission MDS assessment was completed 16 days after admission. Resident 16's annual MDS assessment was completed 16 days after the ARD, while Resident 17's annual MDS assessment was completed 17 days after the ARD. Resident 8's admission MDS assessment was completed 29 days after admission. The MDS Coordinator confirmed during interviews that the assessments were completed late and acknowledged the requirement for the admission MDS assessment to be completed by the 14th day of admission and the annual MDS assessment to be completed 14 days after the ARD. The facility's policy and procedure on comprehensive assessments, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, were reviewed and indicated the necessity for timely completion of these assessments to assist in developing person-centered care plans. The failure to adhere to these timelines could result in delayed identification of residents' needs and significant issues affecting their well-being.
Failure to Timely Complete SCSA for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care. The resident, who had diagnoses including stroke, respiratory failure, pulmonary fibrosis, and lung involvement in systemic lupus erythematosus, was admitted to hospice on November 11, 2023. According to the facility's records, the SCSA was completed on November 26, 2023, which was 16 days after the resident's admission to hospice care, exceeding the required 14-day timeframe. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) and the MDS Coordinator were aware of the resident's hospice admission. The MDS Coordinator confirmed that the SCSA should have been completed within 14 days of the hospice admission. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that an SCSA is required when a terminally ill resident enrolls in a hospice program, and the assessment must be completed within the specified timeframe. The delay in completing the SCSA could potentially delay the provision of appropriate treatment and services for the resident.
Failure to Complete MDS Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessments were completed within the required timeframe for three residents. Specifically, the assessments were not completed within 92 days following the previous OBRA assessment, as mandated by regulations. For Resident 20, the quarterly MDS with an Assessment Reference Date (ARD) of May 9, 2024, was completed 26 days after the ARD, instead of the required 14 days. Similarly, Resident 3's quarterly MDS with an ARD of May 14, 2024, was completed 21 days after the ARD, and Resident 17's quarterly MDS with an ARD of May 16, 2024, was completed 17 days after the ARD. The MDS Coordinator acknowledged during interviews that the assessments were not completed within the required timeframe. The facility's policy and procedure, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, require that the MDS completion date must be no later than 14 days after the ARD. The failure to adhere to these timelines could result in delayed identification of needs and significant issues affecting the residents' well-being.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement a person-centered care plan for three residents, leading to deficiencies in their care. Resident 3, who was readmitted with diagnoses including stroke and respiratory failure, was observed with an ill-fitting non-rebreather mask on top of a nasal cannula. The Licensed Vocational Nurse (LVN) noted that Resident 3 was receiving oxygen at 2 liters per minute (LPM) via nasal cannula, contrary to the active order which required 5 LPM. This discrepancy in oxygen administration was not aligned with the resident's care plan, which specified the need for continuous oxygen at 3-5 LPM. Resident 29, admitted with conditions such as heart failure and chronic obstructive pulmonary disease (COPD), was found to be receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The LVN confirmed the error upon reviewing the active orders and adjusted the oxygen flow accordingly. The care plan for Resident 29 indicated the necessity for continuous oxygen at 2 LPM, highlighting a failure to adhere to the prescribed oxygen settings. Resident 16, who has hemiplegia and vascular dementia, required a two-person assist for transfers using a standing lift. However, during an observation, a Restorative Nursing Assistant (RNA) attempted to transfer the resident alone, stating familiarity with the resident's needs. This was contrary to the care plan, which mandated a two-person assist to ensure safety during transfers. The discrepancy between the care plan and the actual practice posed a risk of falls or injury to the resident.
Failure to Update Care Plan After IDT Assessment
Penalty
Summary
The facility failed to update a care plan following an interdisciplinary team (IDT) assessment for a resident whose body weight was beyond the recommended range specified in their care plan. The care plan, initiated on May 14, 2024, aimed to maintain the resident's body weight within 5% of 195 pounds. However, a review on June 4, 2024, showed the resident's weight had dropped to 182.8 pounds, which was below the 5% threshold. Despite this significant weight loss, the care plan was not updated to reflect the IDT's assessment, which considered the weight loss acceptable due to the resident's diagnosis of congestive heart failure (CHF). During interviews and record reviews, both the Director of Nursing (DON) and the Consultant Registered Dietician (RD) acknowledged the discrepancy between the care plan's weight goals and the IDT's assessment. The RD noted that the care plan should have been updated to align with the IDT's findings, suggesting that a goal based on body mass index (BMI) might be more appropriate for the resident. This oversight in updating the care plan could lead to clinical staff not recognizing significant changes in the resident's weight, potentially impacting their care.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of care by not following the physician's orders for oxygen administration for two residents. Resident 3, who was readmitted with conditions including stroke, respiratory failure, and pulmonary fibrosis, was observed wearing an ill-fitting non-rebreather mask over a nasal cannula, contrary to the physician's order of 5 LPM via nasal cannula. The care plan indicated the need for continuous oxygen due to acute respiratory failure, but the observed practice did not align with the prescribed treatment. Similarly, Resident 29, admitted with diagnoses such as heart failure and COPD, was found receiving oxygen at 3 LPM instead of the ordered 2 LPM via nasal cannula. The active orders specified continuous oxygen at 2 LPM, with adjustments only if oxygen saturation fell below 92% or if there was shortness of breath. The facility's policy on oxygen administration emphasized verifying physician orders and ensuring the correct flow of oxygen, which was not followed in these instances.
Inadequate Supervision and Unsafe Transfer Technique
Penalty
Summary
The facility failed to provide adequate supervision and safe transfer techniques for a resident, identified as Resident 16, who required assistance due to medical conditions including hemiplegia, hemiparesis, aphasia, and vascular dementia. The resident's care plan specified the need for two-person assistance during transfers using a sit-to-stand lift. However, a Restorative Nursing Assistant (RNA) conducted the transfer alone, contrary to the care plan instructions. The RNA justified her actions by stating familiarity with the resident, despite acknowledging the requirement for two-person assistance. Additionally, the equipment used for the transfer was found to be in poor condition. The sling used was frayed, torn, and had a missing buckle, which the RNA admitted needed replacement. Interviews with other staff, including a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing (ADON), revealed inconsistencies in understanding the transfer requirements and a lack of recent training on the use of mechanical lifts. The facility's policy and user manuals clearly stated the need for two-person assistance and the importance of using equipment in good condition, which was not adhered to in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 11% during a medication pass. This was due to three medication errors out of twenty-six opportunities involving two residents. One incident involved a registered nurse who administered medication to a resident without verifying their identity, as the resident did not speak English and no photo identification was available. Additionally, the nurse did not ensure the resident consumed the entire dose of MiraLAX, leaving half of the mixture at the bedside, contrary to the manufacturer's instructions. Another error involved a licensed vocational nurse who improperly administered Flonase to a resident. The resident did not blow their nose before administration, and both nostrils were sprayed simultaneously without closing one nostril as recommended. The nurse did not instruct the resident to exhale through their mouth after administration, failing to adhere to the proper technique for optimal delivery and absorption of the medication.
Unsafe Food Handling Practices Due to Jewelry
Penalty
Summary
The facility failed to ensure safe food handling practices when two kitchen staff members were observed wearing yellow bracelets on both arms during food preparation and handling. This was noted during an initial tour of the kitchen, where the Certified Dietary Manager (CDM) and another kitchen staff member were seen preparing food for lunch while wearing the bracelets. During an interview, the CDM acknowledged the oversight and mentioned that the bracelets had been removed. The staff explained that wearing bracelets is a cultural practice for Indians, signifying marriage. The facility's policy on food preparation and service, dated November 2022, specifies that jewelry should be worn minimally, and hand jewelry should be covered with gloves.
Ineffective QAPI Program Leads to High Medication Error Rate
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) program was found to be ineffective in preventing medication administration errors, as evidenced by a medication pass observation revealing an 11% error rate, which exceeds the acceptable threshold of 5%. During the observation, three errors were identified out of twenty-six medication administration opportunities involving two residents. The first error involved a failure to properly identify a resident before administering medication, as the nurse did not verify the resident's identity due to a language barrier and did not follow the facility's policy for identification. The second error occurred when the same nurse administered MiraLAX to the same resident, who did not consume the entire dose, leaving the medication to settle on the bedside table. The third error involved the improper administration of Flonase to another resident, where the nurse did not follow the correct procedure, resulting in the resident inhaling the medication incorrectly. An interview with the Quality Committee members revealed that they had only attended one meeting in the past year and could not recall any discussions on medication errors. They also lacked an ongoing performance improvement project specifically aimed at reducing medication errors, acknowledging the need for improvements in the medication administration process.
Inadequate Implementation of Infection Control Protocols
Penalty
Summary
The facility failed to implement and maintain its infection control program for two residents on transmission-based precautions. Resident 32, who was admitted with multiple diagnoses including an infection of an amputation stump and MRSA, was supposed to be under contact single room isolation precautions. However, during multiple observations, there was no personal protective equipment (PPE) available outside of Resident 32's room, which was necessary for staff and visitors to wear before entering. Licensed Vocational Nurses (LVNs) confirmed the absence of PPE and expressed uncertainty about its removal, which was against the facility's policy requiring PPE to be available directly outside the room. For Resident 34, who was on enhanced barrier precautions due to a Foley catheter, the facility also failed to adhere to infection control protocols. The PPE cart intended for Resident 34 was incorrectly placed next to his roommate's area instead of his care area. Additionally, during an observation, LVN 1 handled Resident 34's Foley bag without wearing the required PPE, which included a gown, gloves, and mask. The Infection Preventionist confirmed that these precautions were necessary during direct contact with the resident, including touching the Foley bag. The facility's policy and procedure, as well as guidelines from the Centers for Disease Control and Prevention (CDC), emphasize the importance of using PPE during high-contact resident care activities to prevent the spread of multidrug-resistant organisms. Despite these guidelines, the facility did not ensure the proper placement and use of PPE for residents on transmission-based and enhanced barrier precautions, potentially increasing the risk of infection spread among staff and residents.
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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