San Luis Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newman, California.
- Location
- 709 N Street, Newman, California 95360
- CMS Provider Number
- 055839
- Inspections on file
- 26
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at San Luis Care Center during CMS and state inspections, most recent first.
A resident who was fully dependent for all care, including toileting and repositioning, suffered a serious fall and multiple injuries when a CNA failed to use a draw sheet or proper technique during pericare and did not request assistance from another staff member. The CNA turned the resident on her side, allowed her feet to dangle off the bed, and turned away to dispose of a soiled brief, resulting in the resident falling to the floor. The resident sustained a scalp laceration, traumatic brain injury, rib and manubrial fractures, and a pneumothorax, requiring ICU admission. Facility records and interviews confirmed that established protocols and training for safe repositioning were not followed.
The facility failed to provide written notification of the bed hold policy to two residents or their representatives upon hospital transfer, as required by their policy. The EMR lacked documentation of this information for both residents, and the Business Office Manager confirmed that bed hold consents were typically handled over the phone without written confirmation.
The facility failed to notify the ombudsman of hospital transfers for three residents, as required by policy. The Social Services staff mistakenly sent notifications to an incorrect fax number, resulting in the ombudsman not receiving the necessary transfer information. This oversight risked residents and their representatives having incomplete information about the transfers.
A facility failed to update a resident's care plan to include refusals for weekly weights. The resident, with medical conditions such as Hydronephrosis and Dysphagia, was assessed as cognitively alert and at risk for weight fluctuations. Despite recommendations for weekly weights, the care plan did not document the resident's refusals, as confirmed by interviews with an LVN and the DON.
A resident with Parkinson's and muscle contracture did not receive the planned range of motion care to prevent further contractures of her right hand. The care plan required placing a rolled washcloth in her hand, but observations showed this was not done. A CNA acknowledged the intervention but did not follow through, failing to notify the charge nurse of the resident's refusal, contrary to facility policy. The facility's lack of adherence to procedures led to this deficiency.
A resident experienced significant weight loss, and the facility failed to ensure weekly weight monitoring as recommended by the Registered Dietician. Despite the resident's medical conditions and dietary recommendations, there were no recorded weights for two months, and only one instance of refusal was documented. The LVN responsible did not implement the necessary interventions, as confirmed by the DON.
A resident on Enhanced Barrier Precautions did not receive proper wound care as staff failed to wear the required PPE and did not use a clean barrier for supplies. The LVN and CNA involved admitted to not following infection control protocols, which was confirmed by the Infection Preventionist and Director of Nursing.
The facility failed to ensure residents were treated with respect and dignity, as evidenced by CNA 1's rude and dismissive behavior towards four residents. The residents reported feeling disrespected by being called 'girlie' or 'girl' and being told that other 'premium people' were prioritized. The facility's policy on resident rights was reviewed, and the residents were found to be cognitively intact.
A resident with severe cognitive impairment and multiple diagnoses had a fractured finger that was not splinted until the day after the injury was identified. The delay occurred because the LVN lacked experience in applying a splint and did not question the NP's order to continue monitoring without immediate splint placement, risking further injury.
The facility failed to implement a resident-centered comprehensive care plan for a resident with severe cognitive impairment and a history of aggression, resulting in an unsupervised altercation where the resident punched another resident. Staff acknowledged the need for constant supervision but cited difficulties due to other care responsibilities.
Failure to Provide Adequate Supervision and Safe Repositioning During Pericare
Penalty
Summary
Facility nursing staff failed to provide adequate supervision and utilize proper turning techniques during pericare for a fully dependent, bedridden resident with severe cognitive impairment and multiple comorbidities, including Parkinson's disease, hypothyroidism, hyperlipidemia, depression, dysphagia, coronary artery disease, and a pacemaker. The resident required total assistance for all activities of daily living, including toileting and repositioning, and was assessed as dependent, meaning all effort for these activities was to be provided by staff. Despite this, a certified nursing assistant (CNA) attempted to change the resident's brief without using a draw sheet or proper positioning technique, and did not request assistance from another staff member, even though staffing levels were sufficient to allow for a second helper. During the incident, the CNA turned the resident on her side, allowing her feet to dangle off the bed, and then turned away to dispose of a soiled brief. At this point, the resident fell from the bed to the floor, sustaining a scalp laceration, traumatic brain injury with intracranial hemorrhage, left rib fracture, left pneumothorax, and a manubrial fracture, requiring urgent transfer to an acute care hospital and admission to the ICU. The CNA did not pull the resident close or use a draw sheet as required by facility competency and training, and instead relied on verbal instructions to the resident, who was unable to assist or follow commands due to her cognitive and physical limitations. Interviews and record reviews confirmed that the CNA did not follow established protocols for safe repositioning, and that the resident's care plan and assessments clearly indicated the need for full assistance. The facility's own policies and competency checklists required the use of draw sheets or proper manual techniques for moving dependent residents, and staff were trained to seek assistance when needed. The failure to implement these interventions and provide adequate supervision directly resulted in the resident's avoidable fall and serious injuries.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents or their representatives upon transfer to the hospital, as required by their policy. The policy, revised in November 2018, mandates that residents or their representatives receive written information about the duration of the state bed-hold policy before or upon transfer for hospitalization or therapeutic leave. However, for two residents, identified as R47 and R62, there was no evidence in the electronic medical records (EMR) that such information was provided during their transfers to the hospital. Resident R47 was transferred to the hospital on two occasions, and in both instances, the EMR lacked documentation of the bed hold policy being provided. Similarly, for Resident R62, the EMR did not show evidence of the bed hold policy being communicated upon their transfer to the hospital. An interview with the Business Office Manager revealed that the facility typically handled bed hold consents over the phone and did not document or confirm the provision of written bed hold information upon transfer, which was confirmed for Resident R62.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the ombudsman for three residents who were transferred to the hospital. The facility's policy requires notifications to the Office of the State LTC Ombudsman to occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. However, the facility did not adhere to this policy for three residents, identified as R41, R47, and R62, who were transferred to the hospital on various dates. The lack of notification placed the residents and their representatives at risk of having incomplete information and misunderstanding the reason for transfer or discharge, as well as the discharge appeal process. During an interview, the Social Services (SS) staff confirmed that the facility failed to provide the written notice of transfer or discharge to the ombudsman for the three residents after their hospital transfers. The SS staff had been sending notifications to a fax number they believed belonged to the local ombudsman, but the ombudsman confirmed they had not received any transfer notifications. The SS staff acknowledged that they thought the ombudsman was receiving the notifications through fax but confirmed they never received any confirmation forms.
Failure to Update Care Plan for Weight Refusal
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R41, to include refusals for weekly weights. R41 was admitted with medical diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia, and Muscle Weakness. The resident's quarterly Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, showing cognitive alertness. Despite being at risk for altered nutrition/hydration status and weight fluctuations, the care plan, last revised on 08/01/24, did not document any refusals of weekly weights by the resident. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the LVN was responsible for updating the care plan with all dietician recommendations, including weekly weights. The LVN acknowledged that R41 sometimes refused weights, but only one refusal was documented from May 2024 through July 2024. The DON stated that if a resident refuses interventions and is still at risk for weight loss, staff should inform the Registered Dietician and Physician to discuss the risks and benefits with the resident. However, this process was not reflected in R41's care plan, leading to the deficiency.
Failure to Provide Range of Motion Care for Resident
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) care and treatment for a resident, identified as R25, who was part of a sample of 30 residents. R25 was admitted with diagnoses including Parkinson's, weakness, and contracture of muscle, among others. The care plan for R25 included a specific intervention to prevent further contractures of her right hand, which involved placing a rolled washcloth in her hand five times a week. However, observations revealed that this intervention was not consistently implemented, as R25's right hand was observed tightly closed in a fist without the washcloth in place. Interviews with facility staff, including a CNA and the Infection Preventionist, revealed that the responsibility for restorative aide care had transitioned to CNAs after the facility no longer maintained a dedicated restorative aide department. The CNA acknowledged awareness of the intervention but admitted to not placing the towel in R25's hand as per the care plan. The CNA documented the resident's refusal in the electronic medical record (EMR) but failed to notify the charge nurse, which was against facility policy. Further interviews with the Administrator and the Director of Nursing (DON) highlighted the importance of notifying nursing staff of any care refusals to ensure proper monitoring and adherence to care plans. The DON confirmed that CNAs are required to document refusals in the EMR and inform nursing staff, who would then document the refusal and reassess the care plan if necessary. The failure to follow these procedures contributed to the deficiency in providing the necessary ROM care for R25.
Failure to Monitor Resident's Weight After Significant Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R41, had weekly weights obtained after experiencing significant weight loss. R41 was admitted with medical diagnoses including hydronephrosis with renal and ureteral calculous obstruction, dysphagia, anemia, and muscle weakness. A review of R41's medical records indicated a significant weight loss over a month, with a decrease from 148 lbs to 136 lbs, and further to 131 lbs by the end of May. The Registered Dietician recommended health shakes, multivitamins, and weekly weight monitoring. However, there were no recorded weights for June or July, and only one documented instance of R41 refusing to be weighed. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) responsible for R41's care did not ensure the resident was placed on weekly weights, despite the recommendation. The Director of Nursing confirmed that LVN 2 was responsible for initiating weekly weights and implementing other nutrition interventions. The failure to monitor R41's weight as recommended had the potential for the resident to lose a significant amount of weight without appropriate interventions, which could have adverse health effects.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions and standard nursing precautions while providing wound care to a resident, identified as R19. The resident had a history of type 2 diabetes, contracture of muscle, venous insufficiency, and anemia, and was on Enhanced Barrier Precautions (EBP) as per physician's orders. During an observation, a Licensed Vocational Nurse (LVN) was seen providing wound care without wearing the required yellow gown and using a clean barrier for wound care supplies. The supplies were placed directly on the resident's breakfast tray, which was not a clean surface, and the HELIX stick used for measuring wounds was placed on an uncleaned surface before use. Interviews with the Infection Preventionist, CNA, LVN, and the Director of Nursing confirmed the breach in infection control protocols. The Infection Preventionist stated that a clean barrier should always be used, and staff must wear masks, gloves, and gowns for residents on EBP. The CNA and LVN admitted to not wearing the yellow gown and not using a clean barrier. The Director of Nursing expressed that nursing competencies are reviewed annually and expected all staff to follow standard precautions to prevent infection control breaches.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by the actions of Certified Nursing Assistant (CNA) 1 towards four residents. Resident 1 reported that CNA 1 was rude, called her 'girlie,' and dismissed her request to go to bed after dinner by stating she had to care for other people. Resident 2 reported that CNA 1 made a comment about needing to hurry to care for 'premium people,' implying that other residents who paid more were prioritized. Resident 3, who has contractures, stated that CNA 1 did not know how to position her properly and suggested that her daughter should change her instead. Resident 5 also reported being disrespected by CNA 1, who called her 'girl' instead of using her name or addressing her respectfully as 'ma'am.' All four residents felt disrespected by these interactions. The grievances were documented and reviewed by the Social Services (SS) and the Administrator (ADM). The facility's policy on resident rights, which emphasizes treating residents with respect and dignity, was reviewed during the investigation. The Minimum Data Set (MDS) assessments for Residents 1, 2, 3, and 5 indicated that they were cognitively intact, with Brief Interview for Mental Status (BIMS) scores of 15 out of 15. Despite this, the residents experienced disrespectful treatment from CNA 1, which was corroborated by their consistent accounts during interviews and observations. The facility acknowledged the issue and stated that CNA 1 had been re-educated on customer service.
Delay in Splint Placement for Fractured Finger
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 4, who had a fractured left fifth finger on 5/19/24. Despite the fracture being identified and an X-ray confirming the injury, a splint was not placed until 5/20/24. The delay occurred because the Licensed Vocational Nurse (LVN) did not have experience applying a splint and did not question the Nurse Practitioner's (NP) order to continue monitoring the resident without immediate splint placement. This inaction placed Resident 4 at risk for further damage to the fractured finger. Resident 4, who has severe cognitive impairment and diagnoses including muscle wasting, muscle weakness, and seizures, was found with a swollen and discolored left fifth finger during routine nail care. The facility's Director of Nurses (DON) confirmed that it is a professional standard of practice to place a splint when a fracture is identified to immobilize and prevent further injury. The facility's policy also mandates consulting with the resident's physician for significant changes in health status, which was not adequately followed in this case.
Failure to Implement Resident-Centered Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a resident-centered comprehensive care plan for Resident 1, who had a known history of physical aggression and severe cognitive impairment. On 4/23/24, Resident 1, who was diagnosed with Alzheimer's, major depression, and anxiety, was left unsupervised, resulting in an altercation where Resident 1 punched Resident 2. The incident occurred while the assigned Certified Nursing Assistant (CNA) was busy performing care for another resident, and the altercation could have been avoided if Resident 1 had been supervised as per his care plan. The care plan specifically required visual supervision at all times, especially when Resident 1 was in his wheelchair to prevent such incidents. During interviews, both the CNA and the Licensed Vocational Nurse (LVN) acknowledged that Resident 1 required constant supervision to ensure safety, but they also noted the difficulty in providing one-on-one observation due to the need to care for other residents. The Director of Nursing (DON) confirmed that the care plan interventions, which included maintaining visual supervision and keeping Resident 1's path clear, were not implemented. The facility's policy on comprehensive care plans emphasized the need for measurable objectives and timeframes to meet residents' needs, but these were not adhered to in this case, leading to the altercation between the two residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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