San Juan Hills Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Juan Capistrano, California.
- Location
- 31741 Rancho Viejo Road, San Juan Capistrano, California 92675
- CMS Provider Number
- 555763
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at San Juan Hills Healthcare Center during CMS and state inspections, most recent first.
A resident with a physician's order to hold antihypertensive medication for SBP below 110 mmHg experienced multiple low blood pressure readings, including values as low as 83/57 mmHg. Despite these findings, there was no documentation that the physician was notified of the change in condition, as required by facility policy. Staff interviews confirmed the lack of notification and awareness of the policy requirements.
A resident at risk for constipation did not receive timely as-needed bowel management interventions as ordered by the physician, despite ongoing monitoring that showed no bowel movement for several days. Nursing staff delayed administration of prescribed laxatives and other interventions, resulting in the resident developing abdominal distention, nausea, and vomiting, and ultimately requiring transfer to an acute hospital where a small bowel obstruction was diagnosed.
A resident with severe cognitive impairment experienced multiple episodes of nausea, vomiting, diarrhea, and increased weakness, but the facility did not develop or update a care plan to address these changes in condition. Staff confirmed that a care plan should have been created, but none was found in the medical record.
A resident's care plan addressing constipation was not updated despite ongoing symptoms such as no bowel movement, abdominal distention, and nausea. The care plan interventions remained unchanged even after the resident's condition worsened, resulting in the need for hospital transfer. Facility staff confirmed the care plan was not revised as required by policy.
A resident with diabetes experienced a low blood sugar event, but staff failed to document a Change of Condition or notify the resident's representative as required. Additionally, vital signs were recorded as taken after the resident had already been discharged. These actions resulted in incomplete and inaccurate medical records, as confirmed by both the LVN and DON during interviews.
The facility's kitchens were found to have multiple sanitation and food safety deficiencies, including improper food storage, lack of hair restraints, and unsanitary practices. Observations included gnats, rust, and dirty equipment, as well as improper temperature control of food items. These issues indicate a failure to adhere to professional standards and food safety regulations.
The facility failed to ensure safe self-administration of medications for two residents. One resident had supplements and medications at her bedside without an assessment or physician's order, despite cognitive impairment. Another resident had eye drops at her bedside without authorization for self-administration. Staff confirmed the lack of necessary documentation and acknowledged the deficiencies.
The facility did not address concerns from resident council meetings or notify two residents about the outcomes of their grievances. Issues included staff noise, inadequate lighting, meal requests, and call button response times. Interviews confirmed the lack of follow-through and documentation, despite facility policies requiring timely investigation and resolution.
A facility failed to refer a resident with a mental disorder for a PASARR Level II evaluation, as required by their policy. The resident's PASARR Level 1 Screening Form incorrectly indicated no mental disorder, despite diagnoses of major depressive disorder, psychosis, and anxiety, and a prescription for sertraline. Interviews with the MDS Coordinator and DON confirmed the error, posing a risk for inadequate services and assessment.
The facility failed to ensure a safe environment for two residents who smoked. One resident was not assessed for smoking safety, and their smoking materials were found unsupervised. Another resident's smoking paraphernalia was left unsupervised, and they sometimes smoked without staff present. The designated smoking area lacked necessary safety measures, violating the facility's smoking policy.
The facility failed to implement bladder training for a resident and did not develop a toileting care plan for another, risking loss of bladder control. One resident, who was cognitively intact, was not provided with the ordered bladder retraining program, while another, who was continent, was placed in a diaper against her wishes and without a care plan. Staff interviews revealed a lack of awareness and documentation regarding these programs.
The facility failed to ensure clear physician's orders for oxygen administration for two residents, as the orders did not specify whether the oxygen was to be administered continuously or as needed. This lack of clarity was confirmed by the MDS Coordinator and the DON, potentially affecting the residents' respiratory health.
The facility failed to ensure proper pharmaceutical services, including inaccurate accounting of controlled medications for a resident, lack of signatures on pharmacy delivery slips, and improper documentation of medication disposal. These issues posed a risk of drug diversion and highlighted lapses in medication management processes.
A facility failed to accurately perform orthostatic blood pressure monitoring for a resident on antipsychotic medication. The physician's order required monitoring in three positions to check for orthostatic hypotension, but the MAR showed identical readings for all positions, indicating incorrect monitoring. The DON confirmed the inaccuracy, which could lead to adverse complications and incorrect data for medication adjustment.
A facility's medication error rate exceeded the acceptable threshold, with a rate of 7.14%. An LVN failed to administer medications as ordered for two residents. One resident did not receive instructions to chew a calcium carbonate tablet, and another received Effexor XR without food, contrary to physician orders. These errors were confirmed during observations and interviews.
The facility failed to ensure proper medication and supply storage, as expired medications were found in medication carts, and medications were improperly mixed in storage areas. Feeding formulas were stored without temperature monitoring, and over-the-counter medications lacked proper temperature logging. These issues were confirmed by the DON and staff, posing potential risks to residents' well-being.
The facility's dietary staff demonstrated a lack of competency, leading to potential risks in food and nutrition services. Observations revealed incorrect procedures for checking dishwasher temperatures and sanitizing solutions, unsanitary kitchen conditions, and improper handling of food temperatures. These issues highlight deficiencies in the oversight and responsibilities of the food service department.
The facility failed to follow menu and diet orders, leading to deficiencies in food service. Observations showed incorrect serving sizes, unsafe food temperatures, and inaccurate tray tickets. Specific incidents included a resident receiving an altered diet without documentation and another receiving inappropriate food items. These issues posed a risk to residents' nutritional adequacy.
The facility failed to serve prescribed therapeutic diets to two residents. An LVN did not verify meal trays against physician's orders, resulting in a resident receiving an incorrect diet. Additionally, a meal tray included a supplement not listed on the physician's order, confirmed by the Regional RD.
The facility failed to follow infection control practices, including hand hygiene during meal assistance and medication administration, proper storage in the laundry area, and implementing a water management program to prevent Legionella growth. Staff did not wash hands before and after assisting residents or administering medications, and personal clothing was stored with clean pillows. The facility lacked a comprehensive water management program, increasing the risk of pathogen spread.
The facility failed to monitor antibiotic use according to McGeer's criteria for two residents, leading to potential inappropriate antibiotic use. The Antibiotic Stewardship Program requires criteria to be met before prescribing antibiotics, but this was not confirmed for a resident with a cough prescribed azithromycin and another receiving Bactrim DS for pneumonia prophylaxis. Interviews with staff confirmed these findings.
The facility failed to monitor and record the freezer temperature in Medication Room A, leading to ice buildup in the freezer compartment. During an inspection, it was found that the freezer lacked a thermometer and the temperature log showed no documentation of monitoring. The facility's policy required twice-daily temperature checks, which were not followed, as confirmed by the DON.
A facility failed to conduct accurate and complete entrapment assessments for a resident using bed rails, potentially leading to serious injury or death. The Maintenance Director did not measure necessary entrapment zones for the resident's bed, as required by facility policy. This oversight was confirmed through observations, interviews, and document reviews, with the Director of Nursing verifying the findings.
The facility did not follow the puree recipe for seven residents on a puree diet, risking the conservation of nutritive value. Cook 1 added chicken broth instead of the cooking liquid to peas and used excessive thickener, contrary to the recipe. These actions were confirmed by the RD.
A resident with a right humerus fracture had blood pressure readings consistently taken from the affected arm, as documented in their medical records. Despite the resident's refusal and the LVN's acknowledgment that this practice was inappropriate, the facility failed to ensure accurate documentation and adherence to professional standards, potentially impacting the resident's care.
A resident with dementia and chronic kidney disease experienced a delay in receiving her lunch meal, waiting 40 minutes while other residents were served on time. The facility's PCC list of diets did not include her name, and staff, including the DON, could not explain the delay.
The facility did not ensure residents were informed of their rights and how to formally complain to the State Agency. During a resident council meeting, residents stated they were unaware of the contact information for the State Licensing and Certification Office. Interviews with the Activity Director and Admissions Director confirmed that this information was not provided in the admission packet, although it was posted on the consumer board.
A facility failed to follow a physician's order to discontinue a sling for a resident's right shoulder. The resident was seen wearing the sling despite the order, which was noted without a time or signature. Both the DON and DSD confirmed the order was not executed.
Failure to Notify Physician of Resident's Low Blood Pressure Readings
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced multiple episodes of low blood pressure, as required by facility policy. The resident had a physician's order for Benazepril HCL to be held if systolic blood pressure (SBP) was less than 110 mmHg. Medical records showed several instances where the resident's SBP was below this threshold, including readings as low as 100/60 mmHg and, during a physical therapy session, as low as 83/57 mmHg while sitting. Despite these low readings, there was no documentation indicating that the physician was notified of the change in the resident's condition. Interviews with facility staff, including the physical therapist and the Director of Nursing (DON), confirmed awareness of the low blood pressure readings and acknowledged that the physician should have been informed. The DON also verified that facility policy required physician notification when blood pressure medication was held for three consecutive days, but there was no evidence this occurred. The deficiency was identified through interviews, medical record review, and review of facility policies and procedures.
Failure to Provide Timely Bowel Management Interventions
Penalty
Summary
The facility failed to provide necessary care and services for a resident at risk for constipation, as required by their own policies and physician orders. The resident, who had decreased mobility and was at risk for constipation due to possible medication side effects, was to have their bowel movements monitored every shift, with interventions such as prune juice, medications, and physician notification if no bowel movement occurred for more than three days. Despite these orders, the resident did not have a bowel movement from 5/30 to 6/6, and as-needed bowel management medications were not administered as ordered until six days after the last recorded bowel movement. During this period, the resident experienced abdominal distention, nausea, and vomiting. Medical record review showed that the resident was administered some scheduled bowel management medications, but the escalation to as-needed interventions, including Milk of Magnesia, Dulcolax suppository, and Fleet Enema, was delayed. Nursing staff and the DON confirmed that the as-needed medications were not provided in a timely manner according to the physician's orders. The resident's condition worsened, leading to transfer to an acute hospital, where a small bowel obstruction was diagnosed.
Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a care plan that addressed a resident's change in condition, specifically episodes of nausea, vomiting, diarrhea, and increased generalized weakness. Despite documentation in the medical record of multiple episodes of these symptoms and the administration of non-pharmacological interventions and medication as ordered by the physician, there was no evidence that a care plan was created or updated to reflect these changes. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and revised as residents' conditions change, but this was not followed in this case. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan should have been developed in response to the resident's change in condition, and both verified that no such care plan was present in the medical record. The resident involved had severe cognitive impairment and experienced multiple documented episodes of gastrointestinal symptoms and increased weakness, yet the care plan was not updated to address these needs.
Failure to Revise Care Plan for Constipation Management
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was at risk for constipation, despite ongoing changes in the resident's condition. The care plan initially addressed the risk for constipation related to decreased mobility and possible medication side effects, with interventions such as monitoring and recording bowel movements every shift, reporting abnormal stool, and notifying the physician if there was no bowel movement for more than three days. However, when the resident experienced no bowel movement for more than three days, along with symptoms of abdominal distention, nausea, and vomiting, the care plan was not updated to include additional or different interventions. Medical record review showed that the resident continued to have no bowel movement and worsening symptoms, leading to the administration of a fleet enema and eventual transfer to an acute care hospital due to persistent constipation and related symptoms. Interviews with facility staff, including an LVN and the DON, confirmed that the care plan was not revised in response to the resident's ongoing issues. The facility's policy required care plans to be updated when a resident's condition changed or when desired outcomes were not met, but this was not followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Diabetic Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with diabetes, as required by their own policies and professional standards. Specifically, when the resident experienced a low blood sugar level of 58 mg/dL, there was no documentation that a Change of Condition (COC) was initiated, nor was there evidence that the resident's representative was notified of the hypoglycemic event. The facility's policies require that such events be documented, including notification of the physician and the resident's representative, but these steps were not recorded in the medical record. Both the LVN and the DON confirmed during interviews that a COC should have been initiated for blood sugar levels below 70 mg/dL, and acknowledged that the required documentation was missing. Additionally, the resident's medical record contained inaccuracies regarding the timing of vital sign documentation. Vital signs were recorded as being taken after the resident had already been discharged and transferred to an acute care hospital. The DON verified that these entries were made post-discharge, which is inconsistent with accurate and timely recordkeeping practices. The facility's policy mandates that all documentation be objective, complete, and accurate, including the date and time care was provided and the name and title of the individual documenting. These documentation failures were identified through interviews, medical record reviews, and policy reviews. The lack of proper documentation for a significant change in condition and the inaccurate recording of vital signs after discharge had the potential to impact the provision of necessary care and services due to incomplete medical record information.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in both the satellite and main kitchens, posing a risk to food service standards. Observations included improper defrosting of juice in a hand wash sink, presence of gnats, rust on equipment, and dirty drains. Staff were observed without proper hair and beard restraints, and cutting boards were found marred and improperly stored. Food storage practices were inadequate, with items stored too close to the sprinkler system and unlabeled food in the residents' refrigerator. Further inspections revealed ongoing issues, such as staff using inappropriate methods to open equipment, improper storage of personal items near food, and continued presence of gnats. The facility also failed to maintain proper temperature control for food items, as evidenced by the cottage cheese being left unrefrigerated and served at an unsafe temperature. The Cool Down Log was incomplete, missing entries for chicken salad, and there was no documentation for the use of precooked chicken. Additionally, staff were observed engaging in unsanitary practices, such as touching masks and meal carts without hand hygiene, and placing personal items in the ice machine. These deficiencies indicate a lack of adherence to professional standards and food safety regulations, as outlined by the USDA Food Code 2022, potentially compromising resident safety.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for two residents. Resident 132 was observed with several bottles of supplements and medications at her bedside, including Biotin, coconut oil, and a hair growth medication. Despite the resident's fluctuating capacity to understand and make decisions, as indicated by a BIMS score of 9, there was no documented assessment for her ability to self-administer these medications. Additionally, there were no physician's orders authorizing self-administration, and the MDS Coordinator confirmed the absence of such orders in the resident's medical records. Similarly, Resident 14 was found with eye drops at her bedside, which she had been using for six weeks. Although there was a physician's order for the administration of artificial tears, there was no documented evidence of an assessment or physician's order permitting self-administration. LVN 3 verified the lack of documentation and confirmed that the medication should not have been kept at the bedside. The DON was informed of these findings and acknowledged the deficiencies.
Failure to Address Resident Council Concerns and Notify Residents of Outcomes
Penalty
Summary
The facility failed to address concerns raised during resident council meetings and did not notify two residents about the outcomes of their grievances. The facility's policy and procedure (P&P) required the use of a Resident Council Response Form to track issues and their resolution, with the relevant department responsible for addressing the concerns. However, documentation from the Resident Council Meeting Agenda & Notes showed unresolved issues, such as staff being loud in hallways, a resident needing more light in their room, and another resident having issues with meal requests and call button response times. There was no documentation on how these concerns were resolved or if the residents were informed of the outcomes. Interviews with the Activity Director and the Director of Nursing (DON) confirmed the lack of follow-through on the concerns raised. The Activity Director stated that the Administrator was notified of the concerns, and they were discussed in meetings with department heads, but admitted there was no follow-up. The DON verified the absence of documentation on the investigation and resolution of the concerns, as well as the lack of communication with the residents about the outcomes. The facility's P&P required concerns to be investigated within 72 hours, but this was not adhered to.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with a mental disorder was referred to the state PASARR representative for a Level II evaluation and determination screening process. This deficiency was identified during a review of the facility's Preadmission Screening & Resident Review (PASRR) policy and procedure, which mandates that the facility confirm the PASARR process was completed by the hospital before accepting a resident. In the case of Resident 16, the PASARR Level 1 Screening Form incorrectly indicated that the resident did not have a mental disorder or intellectual disability, despite the resident's admission record showing diagnoses of major depressive disorder, psychosis, and anxiety. Additionally, the resident was prescribed sertraline, an antidepressant medication, which further indicated the presence of a mental disorder. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the error in the PASARR assessment for Resident 16. The MDS Coordinator acknowledged that the PASARR Level 1 was not accurately completed and that the resident had been receiving antidepressant medication for depression. The DON was informed of these findings and verified the deficiency. This oversight posed a risk for the resident not receiving the appropriate level of services, comprehensive assessment, intervention, and evaluation for their mental disorder.
Failure to Ensure Safe Smoking Practices for Residents
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for two residents who smoked. Resident 383 was not accurately assessed to determine if supervision or adaptive equipment was needed while smoking, nor was there a determination if they could safely store their own cigarettes or lighters. The resident's smoking materials were found unsupervised on their bedside drawer, and the facility staff were unaware of the resident's smoking habits. The medical records did not show evidence of a smoking assessment, physician's order, or a developed care plan for smoking. Resident 432's smoking paraphernalia was left unsupervised on their overbed table while they were not in the room. The resident, who was assessed as requiring supervision, sometimes smoked without staff present. The facility's care plan for Resident 432 included interventions for observing unsafe smoking practices, but these were not adequately followed. Additionally, the designated smoking area lacked readily available and accessible safety measures such as fire-retardant smoking aprons and portable fire extinguishers, as verified by the Activity Director. The facility's policy and procedure for safe smoking required that residents be evaluated for their ability to smoke safely and that safety measures be in place in designated smoking areas. However, these protocols were not followed, leading to potential fire hazards and risks of serious injuries to residents who smoked and others in the facility. The Director of Nursing verified the findings, confirming the facility's failure to adhere to its smoking policy and procedures.
Failure to Implement Bladder Training and Toileting Programs
Penalty
Summary
The facility failed to provide necessary care and services to maintain or restore bladder functions for two residents. Resident 285, who was cognitively intact, expressed a preference to use the bathroom rather than a disposable brief at night. Despite a physician's order for a bladder retraining program and a care plan intervention to follow a toileting schedule every two hours, there was no documented evidence that this program was implemented. Interviews with facility staff, including a CNA and LVN, revealed a lack of awareness and documentation regarding the bladder training program for Resident 285. Resident 436, who was continent for bladder needs, was placed in a diaper against her wishes and without a care plan addressing her specific toileting needs. Despite being able to verbalize her need to use the toilet, she was wearing a diaper, which she was allergic to. The DON confirmed that a care plan for Resident 436's toileting needs was not developed, and acknowledged that even residents in diapers could be taken to the toilet. These failures posed a risk for the residents to lose their bladder control.
Oxygen Administration Orders Lacked Clarity
Penalty
Summary
The facility failed to ensure that the physician's orders for oxygen administration for two residents were clear regarding whether the oxygen was to be administered continuously or as needed. Resident 132 was observed receiving oxygen at 2 liters per minute via nasal cannula, but the physician's order did not specify if this was to be continuous or PRN. The MDS Coordinator confirmed the lack of clarity in the physician's order during a review of the medical records. Similarly, Resident 282 was observed receiving oxygen at 3 liters per minute via nasal cannula, with the physician's order also lacking specification on whether the administration was continuous. The MDS Coordinator verified the ambiguity in the physician's order, and the DON confirmed these findings. This lack of clarity in the physician's orders had the potential to affect the respiratory health and well-being of the residents.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to ensure proper pharmaceutical services, resulting in several deficiencies. One significant issue was the inaccurate accounting and documentation of controlled medications for a resident. During an inspection, a discrepancy was found in the count of buprenorphine-naloxone tablets for a resident, with the physical count not matching the controlled medication accountability record. The Director of Nursing (DON), who was involved in the count, confirmed the discrepancy but did not initiate an investigation or provide a response when questioned about the facility's protocol for such discrepancies. Additionally, the facility did not follow proper procedures for receiving medications from the pharmacy. Several pharmacy delivery slips for controlled medications lacked signatures from the receiving nurse, indicating a failure to verify and document the receipt of medications. Furthermore, the facility did not properly document the disposal of medications, as observed in the drug disposition records, which lacked dates for when the medications were disposed of. These failures posed a risk of drug diversion and highlighted lapses in the facility's medication management processes.
Inaccurate Orthostatic Blood Pressure Monitoring for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to accurately perform orthostatic blood pressure monitoring as ordered by the physician for a resident receiving antipsychotic medication. The physician had ordered the monitoring of blood pressure in three positions (lying, sitting, and standing) once a week to check for orthostatic hypotension, which is defined as a significant decline in blood pressure upon standing. However, the medical administration record (MAR) for November showed identical blood pressure readings for all three positions on two separate occasions, indicating that the monitoring was not conducted correctly. During an interview and concurrent medical record review, the Director of Nursing (DON) confirmed that the licensed nurses did not accurately monitor the orthostatic hypotension, as evidenced by the same blood pressure readings for all positions. This inaccuracy in monitoring had the potential to result in adverse complications for the resident due to the use of antipsychotic medication and could lead to incorrect data being provided to the prescriber, affecting the adjustment of the medication dose.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 7.14%. This deficiency was identified during a survey where a licensed nurse, LVN 4, did not administer medications as per physician orders for two residents. Resident 134, who had a physician's order for Calcium Carbonate Tablet Chewable 500 mg to be chewed and swallowed for indigestion, was not instructed to chew the tablet before swallowing. This oversight occurred during a medication administration observation, where LVN 4 prepared and administered multiple medications to Resident 134 without providing the necessary instructions for the calcium carbonate tablet. Additionally, Resident 4, who had a physician's order for Effexor XR to be administered with food for depression, received the medication without food. During the medication administration observation, LVN 4 administered several medications to Resident 4, including Effexor XR, before the resident had eaten breakfast. This failure to follow the physician's order for administering the medication with food was confirmed during an interview and record review with LVN 4, who verified the findings.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage, which was identified through observations and interviews. During an inspection of Medication Cart A, expired povidone-iodine prep pads were found, and the Director of Nursing (DON) confirmed these findings. Additionally, Medication Cart B contained a mix of Zofran, acetaminophen suppositories, and bisacodyl suppositories, which was verified by an LVN. Furthermore, in Medication Room B, eye drop medications were stored alongside oral medications, and nasal sprays were stored with oral medications, which was acknowledged by an LVN. The facility also failed to properly store feeding formulas and monitor temperatures. The Central Supply Designee confirmed that enteral feeding formulas and oral supplements were stored in a room with a temperature of 75 degrees Fahrenheit, but the temperature log had not been maintained. Additionally, over-the-counter medications were stored in the Health Equipment room without a thermometer or temperature log. These deficiencies in medication and supply storage practices had the potential to negatively impact residents' well-being and lead to medication errors.
Deficiencies in Dietary Staff Competency and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that dietary staff were competent in performing their duties, which posed a risk to residents receiving appropriate food and nutrition services. During a kitchen inspection, it was observed that the Certified Dietary Manager (CDM) 1 incorrectly checked the dishwasher's temperature during the prewash cycle instead of the wash cycle, as required for proper operation. Additionally, CDM 1 was unable to demonstrate the correct procedure for checking the sanitizing solution's range, using soap and water instead of the appropriate sanitizing solution. The posted instructions indicated that the sanitizer solutions should be maintained at a range of 150-250 ppm, but the logs showed inconsistencies in the recorded ppm levels. Further observations revealed unsanitary conditions in the main kitchen, which had been previously discussed with CDM 2. During a lunch trayline observation, a container of cottage cheese was left unrefrigerated, and its temperature was not checked until prompted, revealing it was at 53 degrees, outside the acceptable range. Despite this, CDM 1 continued to serve the cottage cheese until the Registered Dietitian (RD) confirmed the temperature issue, at which point it was disposed of. These findings indicate a lack of competency and oversight in the food service department, as outlined in the duties and responsibilities of the RD and CDMs.
Deficiencies in Dietary Management and Food Service
Penalty
Summary
The facility failed to ensure that the menu and diet orders were followed, leading to several deficiencies in food service and dietary management. Observations revealed that chicken salad was not documented on the cool down log, and the kitchen staff used incorrect serving sizes, such as using a 3 oz slotted spoon instead of the required #8 scoop for noodles. Additionally, temperatures for milk and cottage cheese were not taken at the tray line, with cottage cheese being stored at an unsafe temperature of 53 degrees Fahrenheit. Plates of dessert were placed near a dirty sink, and tray tickets were inaccurate for some residents, leading to inappropriate food items being served. Specific incidents included a meal tray for a resident on a Consistent Carbohydrate Diet No Added Salt (CCHO NAS) being altered to a regular diet without proper documentation, and another resident on a liberal renal diet receiving inappropriate food items such as gravy and yogurt, which were not listed on their meal ticket. Furthermore, a resident's food tray did not include a bread roll as requested, despite the presence of butter on the tray. These findings indicate a risk of residents not receiving nutritional adequacy due to the facility's failure to adhere to prescribed diet orders and menu plans.
Failure to Serve Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were served as prescribed by the residents' physicians for two residents. During a dining room observation, an LVN was seen checking meal trays against meal tickets but not against the physician's orders. This resulted in a resident being served a no added salt, regular diet instead of the prescribed no added salt, mechanical soft diet. The LVN admitted to having memorized most of the residents' diets and acknowledged the oversight in not verifying the meal served against the physician's orders. In another instance, during a lunch trayline observation in the facility's satellite kitchen, a meal tray for a resident was found to include a Magic cup supplement that was not listed on the physician's order. The resident was supposed to be on a puree nectar thick liquid diet, but the tray ticket incorrectly included a mechanical soft meat. This discrepancy was confirmed by the Regional RD, indicating a failure to adhere to the prescribed dietary orders for the resident.
Infection Control Deficiencies in Hand Hygiene, Laundry, and Water Management
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by several observations and interviews. In one instance, an occupational therapy (OT) staff member did not perform hand hygiene before and after assisting a resident with meals. The OT staff member was observed putting on gloves without washing hands, feeding the resident, and then removing gloves to open a door for another resident. The OT staff member then put on a new pair of gloves and resumed feeding without washing hands. This was confirmed during an interview with the OT staff member, who acknowledged the lapse in hand hygiene. Additionally, the facility did not ensure proper handwashing practices during medication administration for two residents. Licensed Vocational Nurses (LVNs) were observed not performing hand hygiene before and after administering medications. Interviews with the LVNs and the Director of Nursing (DON) confirmed that handwashing should occur between administering medications to different residents, but this was not followed. The facility's policy on administering medication and hand hygiene emphasizes the importance of handwashing to prevent infection spread, yet these practices were not adhered to. The facility also failed to maintain infection control in the laundry area, where personal clothing was stored with clean pillows, as verified by the Maintenance Director. Furthermore, the facility did not have an established and implemented water management program to prevent Legionella growth. The Maintenance Director and other staff were unable to provide documentation of regular testing or specific control measures for Legionella prevention. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Administrator confirmed the lack of a comprehensive water management program, posing a risk for the spread of Legionella and other pathogens.
Failure to Monitor Antibiotic Use According to McGeer's Criteria
Penalty
Summary
The facility failed to monitor and address the use of antibiotics according to McGeer's criteria for two residents, which could lead to inappropriate antibiotic use and the development of antibiotic-resistant bacteria. The facility's Antibiotic Stewardship Program, dated June 2021, requires that antibiotics be prescribed only when clinical definitions of active infection or suspected sepsis are met, and pathogen susceptibility is confirmed. However, the Infection Preventionist (IP) did not track or review whether McGeer's criteria were met before prescribing antibiotics to Resident 7 and Resident 10. Resident 7 was admitted with a cough and was prescribed azithromycin, but the surveillance log did not confirm if McGeer's criteria were met. Similarly, Resident 10 received Bactrim DS for recurrent pneumonia prophylaxis, but the records did not show if the infection met McGeer's criteria. Interviews with the Director of Staff Development/Infection Preventionist (DSD/IP) and the Director of Nursing (DON) confirmed these findings, indicating a lapse in the facility's antibiotic stewardship practices.
Failure to Monitor Freezer Temperature and Address Ice Buildup
Penalty
Summary
The facility failed to ensure the freezer compartment inside the medication refrigerator in Medication Room A was free of ice buildup and did not monitor or record the freezer temperature in the temperature log. During an inspection and interview with the DON, it was observed that the freezer compartment had ice buildup and contained ice packs, but lacked a thermometer. The facility's policy required verification and documentation of refrigerator, freezer, and room temperatures twice daily, with any deviations reported to the Nurse Leader or Health Care Administrator. However, the temperature log for November 2024 showed no documentation of freezer temperature monitoring, with horizontal lines recorded from November 1 through November 14, 2024. The DON confirmed that the freezer temperature should have been monitored and recorded twice daily, and the ice buildup should have been addressed.
Failure to Conduct Accurate Entrapment Assessments for Bed Rails
Penalty
Summary
The facility failed to ensure accurate and complete entrapment assessments for a resident using bed rails, which could lead to potential entrapment, serious injury, or death. The deficiency was identified through observation, interviews, and document reviews, revealing that the entrapment zones for the resident's bed were not properly measured. Specifically, the entrapment zones 1, 2, 3, and 4 for the right side rail, as well as zones 6 and 7 for both side rails, were not assessed. This oversight was confirmed by the Maintenance Director, who admitted to not being aware of the resident's use of bilateral grab rails and failing to measure the necessary zones. The resident involved was observed with elevated bilateral grab rails, and the facility's policy requires that all bed systems leave no gap wide enough to entrap a resident's head or body. The Maintenance Director, responsible for conducting these assessments, acknowledged the failure to measure the entrapment zones as required. The Director of Nursing was informed and verified the findings, highlighting a lapse in the facility's adherence to its own policies and procedures regarding bed safety and entrapment risk assessments.
Failure to Follow Puree Recipe for Residents
Penalty
Summary
The facility failed to adhere to the puree recipe for seven residents on a puree diet, which posed a risk of not conserving the nutritive value of the food. During an observation of puree meal preparation, Cook 1 was seen adding chicken broth to cooked peas instead of using the liquid from the cooked peas as specified in the recipe. Additionally, Cook 1 added multiple tablespoons of thickener to the food items, deviating from the recipe instructions that called for one and one-half tablespoons of thickener. These actions were verified with the Registered Dietitian (RD).
Inaccurate Medical Record Documentation for Resident with Fracture
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record of a resident, identified as Resident 132, which had the potential to impact the resident's care needs. Resident 132 was admitted with a diagnosis of a right humerus fracture and had a fluctuating capacity to understand and make decisions. Despite this, the medical records showed that blood pressure readings were consistently taken from the resident's right arm, which was the site of the fracture. This was observed over a series of dates, with multiple blood pressure readings documented from the right arm. During an observation on November 13, 2024, a Licensed Vocational Nurse (LVN) attempted to take the resident's blood pressure from the right arm, but the resident refused. In a subsequent interview, the LVN confirmed that the blood pressure should not have been taken from the right arm due to the fracture. The Director of Nursing (DON) was informed of the situation and acknowledged that taking blood pressure from the right arm could cause pain and worsen the fracture. This oversight in documentation and practice highlights a deficiency in the facility's adherence to professional standards for safeguarding resident care.
Failure to Provide Equal Access to Nutritional Services
Penalty
Summary
The facility failed to provide equal access to nutritional services for a resident, identified as Resident 25, which posed a risk to the resident's rights. Resident 25, who was admitted with diagnoses including dementia and chronic kidney disease, was observed during a lunch meal waiting 40 minutes for her meal tray while other residents were already eating. The lunch was scheduled to be served at 1215 hours, but Resident 25 did not receive her meal until much later. A review of the facility's PCC list of diets did not include Resident 25's name, and staff, including the Director of Nursing, were unable to explain the delay in serving her meal.
Failure to Inform Residents of Complaint Procedures
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and provided with information on how to formally complain to the State Agency about the care they received. During a resident council meeting, six residents expressed that they were unaware of the contact information for the State Licensing and Certification Office and did not know how to file a formal complaint. Instead, they mentioned that they would typically talk to the nurses if they had grievances or complaints. Interviews with the Activity Director and the Admissions Director confirmed that the residents were not provided with the necessary information on how to contact the State Agency. Although the State Agency's contact information was posted on the facility's consumer board, it was not included in the admission packet. The Admissions Director acknowledged that the information was not mentioned to the residents unless they specifically asked for it, and it was not part of the documents provided during admission.
Failure to Discontinue Sling Use as Ordered
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable physical well-being. Specifically, the facility did not carry out a physician's order to discontinue the use of a sling for the resident's right shoulder. The resident was observed wearing the sling during an initial tour of the facility, despite an order to discontinue its use being written on the same day. The order was noted without a time or signature from the licensed staff, and the Director of Nursing (DON) confirmed that the order was not executed. The Director of Staff Development (DSD) also verified that the order to discontinue the sling was not carried out as it should have been.
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.
