San Francisco Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 1477 Grove Street, San Francisco, California 94117
- CMS Provider Number
- 056272
- Inspections on file
- 25
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at San Francisco Health Care during CMS and state inspections, most recent first.
Two residents in a facility suffered injuries due to inadequate safety measures and supervision. One resident tripped over a fall mat placed between beds, resulting in a hip fracture, while another resident was injured due to a missing armrest padding on her wheelchair, leading to a head injury. The facility failed to document and address these hazards, as well as update care plans and communicate maintenance needs, highlighting deficiencies in safety protocols.
A resident experienced a 24.4% weight loss over six months due to inadequate nutritional support and monitoring. The facility failed to provide 1:1 meal assistance as ordered, did not offer alternatives during poor intake, and had an inadequate meal monitoring system. The resident's food preferences were not assessed, and there was no documentation of supplement intake, hindering effective nutritional intervention evaluation.
The facility failed to maintain sanitary conditions in the kitchen, with issues including a dripping icemaker spout, an unreplaced water filter, and a greasy kitchen hood. The Maintenance Manager's claim of filter replacement lacked documentation, and the facility had no policies for icemaker maintenance. These deficiencies risked foodborne illnesses.
The facility failed to properly dispose of kitchen refuse as two garbage containers in the kitchen were found without lids. This was confirmed by a Dietary Aide and acknowledged by the Registered Dietitian, who agreed that all garbage containers should have lids. The facility's policy requires food waste to be placed in sealed, leak-proof, non-absorbent, and tightly closed containers. The absence of lids could lead to contamination by flying insects.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, leading to potential cross-contamination risks. A resident with a feeding tube had an unlabeled syringe, another with a urinary catheter had an uncovered drainage bag, and a third with a central venous catheter had no special precautions. Additionally, a resident with a gastrostomy tube was observed disconnecting his feeding tube without proper precautions, and there was no signage for EBP in his room.
The facility failed to maintain an effective pest control program, as flying insects were observed in a resident's room and during an interview with another resident. Despite having a subcontracted pest control company, the presence of insects indicated a lapse in the program's effectiveness. The facility's policy required the building to be free of insects, which was not achieved.
A facility was found to have a medication error rate of 25.9% due to several issues, including a nurse administering eye drops without consulting the MAR, a resident not receiving a critical cardiac medication due to unavailability, and inadequate documentation of medication issues. These errors involved multiple residents and contributed to the high error rate observed.
A facility failed to cover a resident's urinary catheter drainage bag with a privacy bag, compromising the resident's dignity and privacy. The bag was observed hanging exposed, with a reddish-brown discoloration and was unlabeled and undated. A CNA confirmed the absence of a dignity bag, and an RN acknowledged the need for privacy coverage.
A facility failed to develop a baseline care plan within 48 hours for a resident with heart failure, kidney disease, and dependence on dialysis. The resident missed a dialysis session due to unarranged transportation, and no care plan addressed his dialysis needs or CVC care. Staff interviews revealed the baseline care plan was incomplete, with no specific deadline for completion, potentially leading to inadequate care.
A facility failed to develop a comprehensive care plan for a resident who fell and fractured his hip, leading to the resident not receiving necessary physical and occupational therapy. The resident, who was on non-weight bearing status, was not evaluated by therapists upon readmission, and the facility's records lacked orders for weight-bearing as tolerated and therapy referrals. Miscommunication and lack of documentation resulted in inadequate care and treatment.
A facility failed to develop a coordinated care plan with a Hospice agency for a resident with end-stage dementia. The resident's care plan did not specify Hospice services or communication protocols, leading to potential gaps in care. Interviews revealed that while Hospice plans were in binders, the facility's care plan lacked documentation of Hospice's role. Staff described communication processes, but the facility's policy on collaboration with Hospice was not fully implemented.
A resident who underwent hip surgery was not provided with necessary physical and occupational therapy upon readmission to the facility. Despite hospital discharge instructions for rehabilitation, there were no therapy orders or interdisciplinary team meetings to address the resident's fall and care plan. The facility's failure to adhere to its fall management protocol and lack of communication led to this deficiency.
A resident was discharged from the facility without a documented discharge basis or summary, despite having multiple health issues. The Director of Social Worker confirmed the absence of necessary documentation, which is required by facility policy and the State Operations Manual.
A facility failed to prevent a resident from having unsupervised access to smoking materials, leading to multiple incidents of the resident smoking inside the facility and in non-designated areas. Despite multiple educations and reminders, the resident continued to violate the smoking policy, and staff were inconsistent in monitoring and enforcing the policy.
The facility failed to maintain clean and homelike shower rooms, with observations revealing peeling paint, rust, water damage, and visible stains. A resident expressed dissatisfaction with the cleanliness, and staff confirmed the deteriorating conditions. Despite attempts to address the issues, the shower rooms remained in poor condition.
The facility failed to complete a facility-specific risk assessment to identify areas where Legionella and other waterborne pathogens could grow and spread. Despite having policies for Legionella surveillance, no risk assessment or water-flow diagram was completed. Multiple staff members, including the ADON, Maintenance Manager, previous DON, and CEO, confirmed the lack of a risk assessment and water testing.
The facility failed to ensure comprehensive care plans reflected all care needs for several residents, including accurate hospice provider information, clothing preferences, documented behaviors, and the use of an indwelling urinary catheter. Staff acknowledged these deficiencies during interviews.
The facility failed to ensure that residents' EHRs and physical medical charts accurately reflected their treatment wishes, including CPR decisions. This deficiency was identified for three residents, with discrepancies between POLST forms, EHRs, and physical charts, leading to potential confusion about the residents' code status and treatment preferences.
The facility failed to ensure personal privacy for two residents during showers. One resident was left fully unclothed with the privacy curtain and door open, while another resident's backside was exposed during transport to and from the shower room. Staff interviews confirmed that privacy protocols were not followed.
The facility failed to include a diagnosis of schizophrenia on the PASRR Level I screening for a resident admitted with schizophrenia, epilepsy, and Parkinson's disease. The omission was identified during a review of the resident's records, and staff interviews confirmed the oversight.
A facility failed to meet professional standards when an RN reused a needle to administer an intramuscular injection to a resident, contrary to facility policy and CDC guidelines. The resident had a history of acute pyelonephritis and other medical conditions.
A resident with a feeding tube did not receive appropriate treatment as staff failed to check tube placement before administering water flushes and medications, and used a syringe plunger instead of gravity flow, contrary to facility policy and physician's orders.
The facility failed to maintain a medication error rate below 5%, resulting in a 5.8% error rate. A resident with a history of diabetes, heart failure, and dysphagia received incorrect medications due to RN misreading orders and failing to locate the correct medication. The DON confirmed the expectation for correct medication administration.
A facility failed to ensure all drugs and biologicals were secured and accessible only by licensed personnel. An RN left a medication cart unlocked and out of sight with medications on top, violating facility policy. Interviews with the ADON and DON confirmed the expectation for nurses to lock the cart and keep keys with them at all times.
The facility failed to maintain an effective pest control program, resulting in a cockroach infestation in a resident's room. Despite efforts to address the issue, including deep cleaning and sealing entry points, the presence of food in the room exacerbated the problem, leading to ongoing pest sightings and resident complaints.
Failure to Prevent Accidents and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for two residents. Resident 25 experienced a fall due to a fall mat placed between his bed and his roommate's bed, obstructing safe passage. This resulted in Resident 25 tripping, falling, and sustaining a right hip fracture that required surgical repair. Despite being at high risk for falls, as indicated by his care plan and assessments, there was no documentation of an interdisciplinary team meeting to assess the cause of the fall or update his care plan. Additionally, there was no order for weight-bearing as tolerated or a physical therapy referral upon his readmission to the facility. Resident 73 suffered an injury due to a missing armrest padding on her wheelchair, which was not reported or replaced. This led to her sliding her right arm on the metal part of the wheelchair, hitting her head on the window, and sustaining a large hematoma on her forehead. Despite the incident, there was no documentation of a fall in her clinical record, and the missing padding was not reported to maintenance for repair or replacement. The facility's maintenance log did not contain any reports regarding the broken wheelchair, indicating a lack of communication and follow-up on safety hazards. The facility's policies and procedures for fall prevention and maintenance were not adequately followed. The interdisciplinary team and staff failed to identify and address environmental hazards and did not document or communicate necessary interventions to prevent further accidents. The lack of proper assessment, documentation, and maintenance contributed to the injuries sustained by both residents, highlighting deficiencies in the facility's safety protocols and supervision.
Inadequate Nutritional Support and Monitoring for Resident
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for Resident 3, who experienced a significant weight loss of 24.4% over six months. The resident, who had memory problems and sometimes understood others, was not provided with the 1:1 assistance during meals as ordered by the physician. Observations revealed that staff only set up the meal tray and did not assist the resident with eating, despite the resident's poor appetite and usual intake of only 20% of meals. Additionally, the facility did not offer alternatives or other interventions during poor meal intake, as required by their policy. The facility's meal monitoring system was inadequate, as it could not distinguish between 0-25% intake, which is critical for determining when to intervene. The Director of Nursing acknowledged this shortcoming and the importance of intervening even if a resident was on comfort measures. Furthermore, the facility did not document the percentage of nutritional supplements consumed by the resident, making it difficult to evaluate the effectiveness of nutritional interventions. Despite requests for this information, it was not provided by the time of the survey exit. The facility also failed to assess Resident 3's food preferences, which could have informed better meal planning and interventions. There was no evidence that the facility reached out to the resident's responsible parties or family members to assist with this assessment. The resident's records showed that she ate 51-100% of her food for only 24% of meals, with no analysis of whether higher intakes were related to specific food preferences. For 47.1% of meals, the resident ate between 0-25%, with no assessment of whether these low intakes were related to controllable factors such as menu items or meal timing.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during an inspection. Specifically, one of the icemaker's dispensing spouts was dripping water, and the icemaker had two water filters, one of which was not replaced. The Maintenance Manager claimed both filters were changed in December 2024, but there was no documentation to support this, as only one filter was purchased according to facility records. Additionally, the bottom of the kitchen hood was covered in a greasy film, with at least 30 spots where the substance was lumped into droplets, indicating a lack of regular cleaning. During interviews, it was revealed that the facility did not have policies regarding the replacement of icemaker water filters or maintenance to address drips. The facility's existing policy on hoods, filters, and vents required cleaning every two weeks to be free of dust and grease, which was not adhered to. These deficiencies in food storage, preparation, and service practices had the potential to put residents at risk for foodborne illnesses.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of kitchen refuse, as observed during an inspection. Two garbage containers in the kitchen were found without lids, which was confirmed by a Dietary Aide during the initial observation. This deficiency was further corroborated during an interview with the Registered Dietitian, who acknowledged that all garbage containers in the kitchen should have lids. The facility's policy, dated 2023, requires that all food waste be placed in sealed, leak-proof, non-absorbent, and tightly closed containers. The absence of lids on the garbage containers had the potential to result in flying insects contaminating food items, food preparation areas, and utensils.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement its infection control program by not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident 62, who was admitted with multiple diagnoses including stroke and diabetes, was observed with an unlabeled and undated irrigation syringe hanging on the feeding pump pole. The registered nurse confirmed that the syringe should have been labeled and dated, and acknowledged that Resident 62 was not on any precautions. The care plan for Resident 62 did not address infection control precautions. Resident 25, who was readmitted with a fracture and neuromuscular dysfunction of the bladder, was observed with an uncovered and unlabeled urinary catheter drainage bag. The certified nursing assistant acknowledged the lack of labeling and covering, and the registered nurse stated that contact precautions were followed during dressing changes. However, the care plan did not address infection control precautions for the suprapubic catheter. Resident 204, admitted with heart failure and kidney disease, had a central venous catheter for dialysis. The registered nurse supervisor stated that no special precautions were followed for this resident, and the care plan did not address infection control precautions. Additionally, Resident 256, who had a gastrostomy tube, was observed disconnecting his feeding tube without proper precautions, and there was no signage for EBP in his room. The infection preventionist acknowledged the lack of signage and PPE setup for residents with catheters and tube feedings.
Failure in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flying insects within the premises. During an observation and interview in a resident's room, a family member pointed out a flying insect resting on the wall. Additionally, another flying insect was observed in the presence of the Kitchen Supervisor during an interview with another resident. The Maintenance Manager confirmed that the facility had subcontracted a pest control company as part of their pest management program. However, the presence of insects indicated a lapse in the effectiveness of this program. The facility's pest control policy, last revised in May 2008, stated that the building should be kept free of insects and rodents, which was not upheld in this instance.
High Medication Error Rate Due to Documentation and Availability Issues
Penalty
Summary
The facility was found to have a medication error rate of 25.9%, with seven medication errors occurring out of 27 opportunities during medication administration for four residents. One incident involved Resident 17, where a registered nurse (RN) crushed and mixed four oral medications with applesauce for administration, which was in accordance with the pharmacy protocol. However, the report does not specify if the medications were meant to be administered together or if there was an error in the dosage or timing. Another incident involved Resident 256, who has a gastrostomy tube and requires medications to be crushed and administered via the tube. The RN prepared six tablets, crushed them, and mixed them with water for administration through the gastrostomy tube. The RN noted that it takes time to dilute the tablets and sometimes requires additional effort, but the report does not indicate any specific error in this process. For Resident 63, the RN administered eye drops without consulting the medication administration record (MAR) due to a system outage, resulting in a deviation from the prescribed order of two drops in the left eye every four hours. Additionally, Resident 72 did not receive a critical cardiac medication, Vyndaquel, due to unavailability, and there was a lack of documentation regarding the medication's absence and the physician's notification. This oversight in documentation and medication availability contributed to the high medication error rate observed during the survey.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure the urinary catheter drainage bag of Resident 25 was covered with a privacy bag, which is necessary to maintain the resident's dignity and privacy. During an initial tour, the drainage bag was observed hanging on the side rail of the bed, partially filled and exposed, with a reddish-brown discoloration on the front of the bag and in the attached tube. The bag was also unlabeled and undated. A Certified Nursing Assistant (CNA) confirmed the absence of a dignity bag and acknowledged the lack of labeling and dating. A Registered Nurse (RN) later stated that the drainage bag should have been covered for privacy, indicating a lapse in maintaining the resident's right to a dignified existence and self-determination.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as Resident 204, who was admitted with multiple diagnoses including heart failure, acquired absence of the left leg below the knee, kidney disease, and dependence on renal dialysis. Upon review, it was found that Resident 204's care plan did not address his dialysis needs or the care of his central venous catheter (CVC), which is crucial for his dialysis treatment. Interviews with the resident and staff revealed that the resident missed a dialysis session due to a lack of arranged transportation, and no special precautions were being followed for his CVC care. Further investigation showed that the baseline care plan for Resident 204 had not been completed, contrary to the facility's practice of completing it within three days of admission. The Registered Nurse Supervisor confirmed that there was no dialysis care plan in place and that the nursing section of the care plan was incomplete. The supervisor also mentioned that there was no specific deadline for completing the baseline care plan, indicating a lack of urgency in addressing the resident's immediate care needs. This oversight had the potential to result in inadequate care and services for the resident.
Failure to Develop Comprehensive Care Plan for Resident with Hip Fracture
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who fell and fractured his hip, resulting in the resident not receiving necessary care and treatment such as physical and occupational therapy. The resident, who had a history of falls and was readmitted to the facility after hip surgery, was not evaluated by a physical therapist or occupational therapist upon his return. The resident reported being on non-weight bearing status and had not been out of bed since readmission. The facility's records did not include an order for weight-bearing as tolerated (WBAT) or a referral for physical therapy, and there was no documentation of an interdisciplinary team meeting to discuss the fall and update the care plan. The resident's care plan was outdated and did not reflect the recent fall and fracture. The facility's staff, including the Registered Nurse Supervisor and the Physical Therapist, were unaware of the resident's recent fall and fracture until several days after the incident. The lack of communication and documentation led to miscommunication between the staff and the resident regarding aftercare and weight-bearing activities. The resident's post-fall assessment and hospital discharge summary indicated the need for skilled nursing facility rehabilitation, but these were not incorporated into the resident's care plan, resulting in inadequate care and treatment.
Lack of Coordinated Care Plan with Hospice Agency
Penalty
Summary
The facility failed to develop a coordinated plan of care and communication process with the Hospice agency for a resident admitted under Hospice Services. The resident, who was admitted with an end-stage diagnosis of dementia, did not have a care plan that addressed the specific services Hospice would provide or when the facility should notify Hospice. This lack of coordination and documentation was identified during a review of the resident's records and interviews with facility staff, including the MDS Coordinator and the Director of Social Services. Interviews with facility staff revealed that while Hospice residents have binders containing the Hospice agency's plan of care, there was no mention of Hospice in the facility's care plan for the resident. The Director of Social Services acknowledged the absence of documentation regarding Hospice's role and the coordination process between the facility and Hospice. Additionally, the Director of Nursing and a Registered Nurse described the communication process with Hospice, but the facility's policy on collaboration with Hospice providers was not being fully implemented, as evidenced by the lack of documented collaboration efforts and care plan updates.
Failure to Provide Rehabilitative Services Post-Surgery
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident who required physical and occupational therapy following a right hip hemiarthroplasty. The resident, who had been readmitted to the facility after a fall that resulted in a hip fracture, was not evaluated by a physical therapist or occupational therapist upon return. Despite the resident's discharge summary from the hospital indicating the need for rehabilitation services, there was no documentation of orders for weight-bearing as tolerated or a referral for physical therapy. The resident, who had a history of falls, reported not being out of bed since readmission and stated that the therapy team was unaware of his recent fall and subsequent surgery. The facility's registered nurse supervisor confirmed the absence of documentation for therapy orders and noted that no interdisciplinary team meeting had occurred to address the resident's fall and update his care plan. The facility's policy on falls required assessment and intervention within 24 to 48 hours of a fall, which was not adhered to in this case. The physical therapist confirmed being unaware of the resident's recent fall and fracture until several days after the readmission. The facility's failure to follow its protocol for fall assessment and management, as well as the lack of communication and documentation regarding the resident's need for rehabilitative services, contributed to the deficiency in care provided to the resident.
Inadequate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure an appropriate discharge for a resident, identified as Resident 1, due to the absence of a documented discharge basis and discharge summary. Resident 1 was admitted with multiple health issues, including cachexia, severe protein-calorie malnutrition, iron deficiency, and unsteadiness on feet. Despite a doctor's order indicating a discharge to home with home health services, there was no evidence in the medical record of the basis for the discharge or a discharge summary from the doctor. Interviews with the Director of Social Worker (DoSW) confirmed the lack of documentation regarding the discharge. The DoSW acknowledged that there should have been a discharge note and a documented reason for the discharge, but these were missing from Resident 1's medical record. The facility's policy on discharging residents, as well as the State Operations Manual, require that the basis for discharge be documented, which was not adhered to in this case.
Failure to Prevent Unsupervised Access to Smoking Materials
Penalty
Summary
The facility failed to implement measures to prevent a resident from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This deficiency was observed when the resident was found in possession of smoking materials in the hallway and later smoking outside without supervision. Despite multiple educations and reminders to both the resident and a visitor, the non-compliance continued, leading to the resident smoking inside the facility and in non-designated areas, posing a significant safety risk. The resident had a history of tobacco use, senile degeneration of the brain, delirium, and muscle wasting. The resident's care plan required supervision while smoking and mandated that smoking materials be stored by the facility. However, the resident repeatedly violated the smoking policy, and the facility failed to enforce the necessary supervision and storage of smoking materials. The resident's smoking assessments were not updated regularly, and staff were inconsistent in monitoring and enforcing the smoking policy. Interviews with staff revealed a lack of clarity and consistency in the enforcement of the smoking policy. Some staff members were unaware of the resident's smoking restrictions, and others admitted to leaving the resident unsupervised while smoking. The facility's failure to reassess the resident's smoking safety and enforce the smoking policy led to multiple incidents of the resident smoking inside the facility and possessing smoking materials, creating a hazardous environment for all residents and staff.
Facility Fails to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain 4 of 4 resident shower rooms in a clean and homelike condition. Observations revealed that the shower rooms had peeling paint, rust, water damage, and visible stains. The third-floor shower room had worn tiles, rust stains, and a musty smell. The second-floor women's shower room had a hole in the wall, peeling paint, rusted fixtures, and visible water damage. The second-floor men's shower room had peeling paint, dirty tiles, and water stains. These conditions were confirmed by multiple staff members, including CNAs and the Maintenance Manager, who acknowledged the deteriorating state of the shower rooms and the challenges in maintaining them. Resident #79, who was cognitively intact and required moderate assistance with showering, expressed dissatisfaction with the cleanliness of the shower rooms, describing them as filthy and unclean. The resident mentioned that the shower rooms had feces in one of the stalls and appeared run down. Despite the resident's concerns, they had not complained to the facility, believing that the staff should be aware of the conditions without being told. Interviews with facility staff, including CNAs, the Maintenance Manager, the VP, the ADON/Infection Preventionist, and the DON, revealed that the shower rooms had been in poor condition for an extended period. The Maintenance Manager had attempted various methods to address the peeling paint and rust issues, but these efforts were unsuccessful. The VP and CEO acknowledged the repeated attempts to repaint the shower rooms, which only provided temporary improvements. Housekeeping staff confirmed that the shower rooms were cleaned daily, but the persistent issues with peeling paint and rust made it difficult to maintain a clean and homelike environment.
Failure to Conduct Legionella Risk Assessment
Penalty
Summary
The facility failed to complete a facility-specific risk assessment to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Despite having policies in place for Legionella surveillance and a water management program, the facility did not have a completed risk assessment or a water-flow diagram indicating areas at risk. This oversight was confirmed through multiple interviews with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Maintenance Manager, the previous Director of Nursing (DON), and the Chief Operating Officer (CEO), all of whom acknowledged that no risk assessment had been conducted. Additionally, the facility had not conducted any testing of standing water for Legionella detection, relying only on annual pH testing. The Maintenance Manager admitted to not knowing the layout of the water flow in the facility. The lack of a risk assessment and water testing was further corroborated by the ADON, the previous DON, and the CEO, who all stated that the facility staff were unaware of the requirement to complete a risk assessment of the water system. No previous positive cases of Legionella were reported, but the absence of a risk assessment and water testing posed a potential risk to all residents in the facility.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans reflected all care needs for several residents. Resident #400's care plan did not accurately reflect the current hospice provider and contact information, despite the resident receiving hospice services from a different provider than listed. This discrepancy was confirmed through observations and interviews with facility staff, including the RN/MDS coordinator, the Administrator, and the DON, all of whom acknowledged the care plan should have been updated to reflect the correct hospice provider information. Resident #15's care plan did not reflect the resident's preference to wear a hospital gown instead of personal clothing. Despite multiple observations of the resident in a hospital gown and interviews with CNAs and RNs who confirmed the resident's consistent refusal to wear personal clothing, the care plan was not updated to reflect this preference. The DON and other staff members acknowledged that the care plan should have included the resident's clothing preference and refusals. Resident #86's care plan failed to identify and address the resident's documented behaviors, such as flooding the bathroom, taking excessively long showers, and being combative with staff. Despite multiple progress notes documenting these behaviors and interviews with various staff members who were aware of these issues, the care plan did not include specific interventions to manage these behaviors. The Administrator, ADON, and other staff members confirmed that these behaviors should have been included in the care plan. Resident #49's care plan did not address the use of an indwelling urinary catheter or the specific care needs associated with it. Despite the resident having an active order for an indwelling urinary catheter and observations confirming its use, the care plan only mentioned a toileting deficit and incontinence. Interviews with the ADON, DON, and CEO confirmed that the care plan should have included details on the care of the indwelling urinary catheter.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that each resident's electronic health record (EHR) and physical medical chart accurately and consistently reflected their treatment wishes, including their decision regarding cardiopulmonary resuscitation (CPR). This deficiency was identified for three residents out of thirteen sampled. The discrepancies involved mismatched information between the residents' Physician Orders for Life-Sustaining Treatment (POLST) forms, EHRs, and physical charts, leading to potential confusion about the residents' code status and treatment preferences. For Resident #39, the facility's records showed conflicting information regarding the resident's code status. The resident's POLST form dated a specific date indicated a Do Not Attempt Resuscitation (DNR) order, while another POLST form dated earlier indicated a full code status. The resident's EHR and physical chart contained inconsistent information, and staff interviews revealed that the discrepancies could result in mistakes, potentially leading to the resident's wishes not being followed. Resident #12's records also showed inconsistencies. The resident's POLST form prepared on one date indicated a DNR order with comfort-focused treatment, while another POLST form prepared later indicated selective treatment with a trial period of artificial nutrition. The EHR and physical chart did not consistently reflect these orders, and the responsible party confirmed that the resident should be listed as DNR. Similarly, Resident #92's records contained conflicting information, with the POLST form indicating an attempt resuscitation order, while the EHR and physical chart listed a DNR order. Staff interviews confirmed that these discrepancies were not always identified and corrected promptly, leading to potential risks of not following the residents' treatment wishes.
Failure to Ensure Resident Privacy During Showers
Penalty
Summary
The facility failed to ensure personal privacy for two residents during the provision of showers. Resident #301, who was admitted with diagnoses including cerebral infarction and essential hypertension, was observed sitting fully unclothed in a shower chair with the privacy curtain and door open. This allowed several people to see the resident as they passed by the shower room. The CNA attending to Resident #301 acknowledged the oversight but failed to completely close the privacy curtain, leaving the resident exposed to passers-by in the hallway. Resident #11, who had diagnoses including senile degeneration of the brain and peripheral vascular disease, was transported to and from the shower room in a shower chair with their backside exposed. Despite being covered with a sheet and bath blanket, gaps in the coverage left the resident's buttocks visible during transport. The CNA responsible for Resident #11 speculated that the resident's movements might have caused the blanket to shift, exposing the resident's backside. Interviews with the facility's staff, including the ADON and DON, confirmed that the expectation was for CNAs to ensure residents' privacy by closing the privacy curtain and door during showers and ensuring residents were fully covered during transport. The observations and interviews revealed that these protocols were not followed, resulting in a failure to maintain the residents' privacy during personal care activities.
Failure to Include Schizophrenia Diagnosis on PASRR Level I Screening
Penalty
Summary
The facility failed to include a diagnosis of schizophrenia on the Preadmission Screening and Resident Review (PASRR) Level I for Resident #26. The resident was admitted to the facility with a diagnosis of schizophrenia, epilepsy, and Parkinson's disease. However, the PASRR Level I screening document dated 07/03/2018 did not indicate the diagnosis of schizophrenia, and Section V-Mental Illness was left blank. This omission was identified during a review of the resident's records, including the Minimum Data Set (MDS) and care plan, which clearly documented the diagnosis of schizophrenia. Interviews with facility staff revealed that the PASRR Level I screenings were completed by the facility staff in 2018, and the Assistant Director of Nursing (ADON) or Registered Nurse (RN)-MDS was responsible for completing these screenings. The Administrator and ADON confirmed that the diagnosis of schizophrenia was not indicated on the PASRR Level I screening for Resident #26. The Director of Nursing (DON) and Chief Executive Officer (CEO) emphasized the importance of accurate and thorough PASRR Level I evaluations, noting that the facility's nurses used to complete these screenings, but now they are completed by hospital staff. The failure to include the diagnosis of schizophrenia on the PASRR Level I screening led to the deficiency identified by the surveyors.
Improper Injection Technique
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for a resident who required an intramuscular injection. Specifically, a Registered Nurse (RN) prepared the injection by reconstituting the medication and then used the same needle to administer the medication to the resident. The RN also stuck the resident with the needle, removed it prior to administering the medication, and then re-stuck the resident with the same needle to administer the medication. This action was against the facility's policy and CDC guidelines, which state that a needle should never be reused either from one patient to another or to withdraw medication from a vial. The resident involved had a medical history that included acute pyelonephritis, diabetes mellitus, atherosclerotic heart disease, chronic systolic heart failure, and benign prostatic hyperplasia. The resident was cognitively intact and had an active diagnosis of a urinary tract infection. The incident was observed during the administration of an antibiotic injection. Both the Assistant Director of Nursing and the Director of Nursing confirmed that the needle should not have been reused, as it could be unclean and dull, increasing the risk of infection and causing pain during the injection.
Failure to Follow Feeding Tube Protocols
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate treatment and services to prevent potential complications. Specifically, the staff did not check the placement of the resident's feeding tube before administering water flushes and medications, as required by the physician's order and the facility's policy. Additionally, the staff administered the water flushes and medications by using the plunger of a syringe to push them into the feeding tube, instead of administering them by gravity flow as directed by the facility's policy. The resident involved had a medical history that included dysphagia following a nontraumatic intracranial hemorrhage and required attention to a gastrostomy. The resident's comprehensive care plan indicated the need for tube feedings due to dysphagia, and the physician's orders specified checking the feeding tube placement before each use and flushing the tube with water before and after medication administration. However, during an observation, a registered nurse failed to check the tube placement and used a syringe with a plunger to push water flushes and medications into the feeding tube. Interviews with the registered nurse, the Director of Nursing, and the Assistant Director of Nursing confirmed that the proper procedure was not followed. The registered nurse admitted to not checking the tube placement and using the syringe plunger to ensure the medications entered the tube. Both the Director of Nursing and the Assistant Director of Nursing stated that the correct procedure involved auscultating the feeding tube before administration and using gravity flow to administer water and medications. The failure to follow these procedures could result in complications such as gastroesophageal reflux disease, ulcers, or pressure in the stomach.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than 5 percent, resulting in a medication error rate of 5.8%. This deficiency affected one resident who was observed during medication administration. The resident, who had a medical history including type two diabetes mellitus, congestive heart failure, and dysphagia, was admitted to the facility on 11/08/2023. The resident had active orders for aspirin 81 mg chewable tablet and oyster shell calcium with vitamin D 250 mg-3.125 mcg, both to be administered once daily at 9:00 AM. During an observation, RN #3 administered an 81 mg enteric coated aspirin instead of the prescribed chewable aspirin and gave oyster shell calcium 500 mg instead of the prescribed oyster shell calcium with vitamin D 250 mg-3.125 mcg. RN #3 acknowledged the errors during an interview, stating she misread the order and failed to locate the correct medication. The Director of Nursing confirmed that nursing staff are expected to administer medications correctly using the five rights of administration.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure all drugs and biologicals were secured and accessible only by licensed personnel. Specifically, a Registered Nurse (RN) left the medication cart unlocked and not within their line of sight, with medications lying on top of the cart unsecured. The incident occurred when the RN parked the medication cart outside a resident's room to administer medications, prepared an intramuscular injection, and entered the room without locking the cart. The RN left a vial of antibiotic medication and a bottle of lidocaine on top of the cart and stepped behind the privacy curtain, leaving the cart unattended and out of sight. The RN then walked to the medication room to retrieve insulin, leaving the cart unlocked and unattended for an extended period. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the facility's policy required nurses to lock the medication cart and keep the keys with them at all times. The policy also stated that no medications should be left on top of the cart if the nurse could not see the cart. Both the ADON and DON reiterated that the expectation was for nurses to lock the medication cart when walking away and to ensure no medications or sharp items were left unsecured on top of the cart. The RN admitted to forgetting to lock the cart and leaving the medications on top of it, which was a clear violation of the facility's policy and professional principles for medication storage and security.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in Resident #76's room. The resident, who was cognitively intact with a BIMS score of 14, reported seeing bugs in their room frequently. Observations confirmed the presence of multiple cockroaches on the walls, floor, and furniture in the resident's room, including near food items left out in the open. The facility's pest control policy, revised in May 2008, mandates an ongoing pest control program, but the implementation was found lacking as evidenced by the recurring pest issue in the resident's room. Interviews with staff, including a CNA, RN, Director of Maintenance, ADON, and DON, revealed that the facility was aware of the cockroach problem. The CNA mentioned seeing cockroaches frequently, especially at night, and the RN had reported seeing a cockroach at the nurses' station months ago. The Director of Maintenance acknowledged the issue and described efforts to move residents, seal entry points, and conduct deep cleaning, but these measures were not consistently effective. The ADON and DON both expressed concerns about the pest problem and the need for regular pest control services and thorough cleaning to prevent recurrence. A review of the pest control vendor's monthly report from December 2023 indicated pest activity but did not specify the rooms treated. The facility's staff admitted that the presence of food in residents' rooms, like in Resident #76's case, exacerbated the problem. Despite efforts to address the issue, including deep cleaning and sealing entry points, the facility's pest control measures were insufficient to eliminate the cockroach infestation, leading to ongoing pest sightings and resident complaints.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
