San Mateo Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in San Mateo, California.
- Location
- 222 West 39th Avenue, San Mateo, California 94403
- CMS Provider Number
- 555034
- Inspections on file
- 34
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 46 (1 serious)
Citation history
Health deficiencies cited at San Mateo Medical Center D/p Snf during CMS and state inspections, most recent first.
A resident with recurrent acute diverticulitis reported being in severe pain for several hours, repeatedly using the call light and calling out without staff response, later discovering the call bell was unplugged and independently contacting the hospital for assistance. An LVN stated the resident never activated the call light and was found asleep during rounds, and the Unit Supervisor acknowledged conducting an investigation but failed to document interviews or details and did not interview other residents, roommates, or family members as required by policy. Subsequent testing showed the resident’s call light cord-out feature did not trigger an alarm, additional rooms had non-functioning cord-out features, and the Maintenance Director was unaware of and did not maintain this safety feature.
A resident with recurrent acute diverticulitis reported being very sick and in pain, repeatedly using the call light without staff response for several hours, with the room door closed and the call bell later found to be disconnected. The resident ultimately called the hospital emergency room and, when ambulance staff arrived, told an LVN she had been calling for hours without help. The LVN, Unit Supervisor, and DON were aware of the resident’s allegation that staff did not respond to her calls for assistance, but the Unit Supervisor considered the complaint as the resident “venting” rather than an allegation of neglect, and it was not reported or investigated as required by the facility’s abuse and neglect reporting policy.
The facility did not maintain safe water temperatures in resident bathrooms, allowed multiple residents to keep smoking materials in their possession—including in rooms where oxygen was in use—and failed to provide adequate supervision to prevent two residents from eloping, including one with severe memory impairment. Staff and resident interviews confirmed that facility policies on water temperature, smoking, and elopement prevention were not consistently implemented.
The facility did not conduct a thorough investigation after an allegation of sexual abuse between two residents. Although both residents and a staff witness were interviewed, there was no evidence that other residents in the area were assessed or interviewed, and investigation documentation was incomplete. The facility's policy required thorough investigations but lacked guidance for cases involving non-interviewable residents without family.
A resident developed a Stage III pressure ulcer due to the facility's failure to perform accurate body checks and report earlier stages of skin impairments. The resident, at moderate risk for pressure ulcers, had multiple skin impairments that were not properly documented or reported, leading to the development of in-house acquired Stage III pressure ulcers on the left heel and buttock.
The facility failed to serve food according to residents' preferences, such as Jook and various soups. Despite documented preferences, meals served did not align with these preferences, affecting residents' quality of life and nutritional satisfaction.
The facility failed to provide meals according to scheduled serving hours, with consistent delays in breakfast and lunch service. Staff confirmed the delays, and residents reported receiving cold or frozen food. The facility's policy requires specific meal times, but these were not adhered to, affecting residents' dining experience and well-being.
The facility failed to ensure food safety by not properly drying utensils, cleaning plate warmers, and storing serving trays in a sanitary manner. Additionally, undated food items and overripe grapes were found in the refrigerator, and a hand sanitizer dispenser was improperly used in the kitchen.
The facility failed to ensure dignity and respect for three residents by not adhering to proper feeding and communication protocols. Staff were observed standing over two residents while assisting them with meals, and the facility did not provide adequate communication support for a resident whose preferred language is Cantonese, relying instead on makeshift methods and family members for translation.
The facility failed to ensure proper coordination and communication with the hospice agency for three residents, leading to significant deficiencies in care. For one resident, there was no coordination for communication regarding changes in condition and death, and the family was not notified. Another resident's care plan did not include specific hospice interventions, and a third resident's care plan lacked documentation of hospice care interventions. Facility policies on end-of-life care and hospice care were not followed.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications due to the lack of proper consent and adherence to medication protocols. Consents were not obtained for various medications, and PRN orders were not properly managed, leading to potential adverse health consequences.
The facility failed to ensure medications were not expired and stored properly. One medication cart contained expired or unlabeled eye drops, and multiple medications were stored in the garage without temperature control. Staff acknowledged these issues, and the Pharmacist confirmed the need for controlled storage temperatures and daily temperature logs.
The facility failed to develop comprehensive care plans for two residents, one with pressure ulcers and another using Lorazepam for anxiety, leading to deficiencies in addressing their specific medical needs.
The facility failed to post complete nurse staffing data daily, missing the total number and actual hours worked by each category of nursing staff from 3/11/24 to 3/15/24. Interviews revealed that the correct data was not posted as required by the facility's policy.
The facility failed to maintain accurate reconciliation for Hydromorphone for a resident. The LVN did not document the administration of the medication immediately as required, leading to a discrepancy between the documented and actual number of tablets. This was confirmed by the DON during the survey.
The facility failed to act on the pharmacy consultant's recommendation for a resident's psychotropic medication. The resident, diagnosed with dementia and anxiety, had an order for Lorazepam that was not reviewed or discontinued as recommended, leading to potential unnecessary medication use and adverse health consequences.
A facility failed to follow a physician's order for administering Hydromorphone to a resident, resulting in an excessive dose being given for moderate pain. The LVN administered two tablets instead of one, despite the resident's pain level being documented as a 7, which is considered moderate pain. The DON confirmed the medication was given outside the prescribed parameters.
The facility failed to ensure proper disposal of refuse in the kitchen, as a half-open recycle container near the food preparation area was observed. The Clinical Services Manager and Director of Food and Nutrition Services had differing opinions on when to close the lid, leading to potential contamination risks. Infection Preventionists confirmed that the facility's policy requiring close-fitting covers on waste containers was not followed.
The facility failed to maintain an effective infection control program, evidenced by an expired Biohazard Spill Kit and improper cleaning of a glucometer. The Infection Preventionist acknowledged the expired kit, and a Licensed Vocational Nurse used non-approved wipes for cleaning the glucometer, contrary to the manufacturer's instructions and facility policy.
The facility failed to ensure staff were trained on infection control practices for oral suctioning, with nurses unaware of protocols for changing tubes and cleaning canisters. Interviews revealed no specific policies or procedures for suctioning, and staff were unsure about proper maintenance of the equipment.
Failure to Thoroughly Investigate Allegation of Neglect and Call Light Malfunction
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving Resident 1, one of three sample residents. Resident 1, who had a diagnosis of recurrent acute diverticulitis and reported being very sick and in pain, stated that sometime in January she repeatedly used her call light and called out in pain for approximately four hours without staff responding. She reported that someone closed her room door and that she later discovered her call bell was not connected, although she had not initially realized it was unplugged. She stated that, after no one responded, she called the hospital emergency room herself, and when the ambulance arrived and transported her out of the room, she saw an LVN at the desk and told the LVN she had been calling for hours for help. A hospital discharge summary dated 1/15/2026 documented her diagnosis of recurrent acute diverticulitis. During interviews, LVN 1 characterized the resident as having a history of false accusations and stated that the resident never turned on the call light or called for help, and that staff found her asleep during rounds. The Unit Supervisor reported that he conducted an investigation based on the resident’s complaint that she had been in pain for four hours, had used her call light, and had been unaware that her call light was unplugged from the wall. However, the Unit Supervisor did not document any part of his investigation, including interviews with nurses or the resident, and could not provide specific dates, times, or content of those interviews. He also did not interview other residents, roommates, family members, or responsible parties as required by facility policy. When the resident’s call light was later tested, the cord-out feature did not trigger an alarm at the nursing station, and additional rooms were found with non-functioning cord-out features. The Maintenance Director stated he was unaware the call light system had a cord-out feature and did not include it in his routine maintenance checks. The facility’s Abuse-Reporting & Investigations policy required interviewing individuals who may have information relevant to the allegation, such as the resident, witnesses, other residents, roommates, family, and visitors, which was not done in this case.
Failure to Recognize and Report Resident Allegation of Neglect
Penalty
Summary
Facility staff failed to recognize and report an allegation of neglect when a resident stated she had been in pain and that staff did not respond to her calls for assistance over several hours. The resident reported that sometime in January she was very sick and in pain, repeatedly rang for the nurse, and no one came to her room. She stated that someone had closed her room door and that her call bell was not connected, which she did not initially realize. She continued to ring without response, became worried, and ultimately called the hospital emergency room herself. When ambulance staff arrived and wheeled her out of the room, she observed a LVN sitting at the desk and told the LVN she had been calling for hours for help, describing the experience as very scary. Record review showed that the resident’s hospital discharge summary dated 1/15/2026 documented a diagnosis of recurrent acute diverticulitis, a sudden onset inflammation/infection of a portion of the colon that may cause sudden intense abdominal pain. During interviews, the LVN and the Unit Supervisor both acknowledged they were aware that the resident had alleged she was in pain and that staff did not respond to her calls for assistance. The DON stated that when the Unit Supervisor spoke with the resident by phone regarding her hospitalization on 1/21/2026, the Unit Supervisor did not identify the resident’s statements as an incident of neglect, instead characterizing them as the resident “just venting.” This response was inconsistent with the facility’s Abuse-Reporting & Investigations policy, which requires the facility to promptly report and thoroughly investigate all allegations of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, injuries of unknown source, and suspicions of crimes.
Failure to Prevent Accident Hazards, Unsafe Smoking Practices, and Inadequate Elopement Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for its residents. Specifically, hot water temperatures in six out of eight resident bathroom sinks were found to be excessively high, ranging from 121.6°F to 136.7°F, which exceeded the facility's policy limit of 120°F. Residents affected included individuals with severe cognitive and visual impairments, such as schizoaffective disorder, dementia, and Alzheimer's disease, who were able to access the bathrooms independently. Staff confirmed that daily random water temperature checks were performed, but the temperatures remained above the safe threshold, and the facility's policy on water temperature was not effectively implemented. The facility also failed to ensure safe smoking practices and did not enforce its smoking policy. Multiple residents were allowed to keep lighters and cigarettes in their possession within the resident care areas, despite facility policy requiring all smoking materials to be stored at the nursing stations. One resident was observed igniting a lighter in her room while her roommate was actively receiving continuous supplemental oxygen, directly violating the facility's oxygen therapy and smoking policies. Interviews with residents and staff confirmed that several residents routinely kept smoking materials in their rooms or on their person, and staff were aware of this practice. Additionally, the facility did not provide adequate supervision to prevent elopement for two residents identified as high risk. One resident with a history of wandering and severe memory impairment eloped from the facility and was found over a mile away after more than two hours. Documentation and investigation of the incident were lacking, and the resident's care plan was not updated with effective interventions. Another resident also eloped, and staff interviews revealed that supervision and documentation were insufficient to prevent or address the incident. The facility's policy on wandering and elopement was not consistently followed, as required assessments, notifications, and care plan updates were not completed.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving two residents. According to the documentation, one resident reported to the receptionist that another resident exposed himself and requested inappropriate contact. The facility's investigation included interviews and assessments of both residents and a statement from an activity staff member who witnessed part of the incident. The staff member reported seeing one resident attempting to pull his zipper down but did not observe any exposure of genitals. The investigation documents were not titled or dated, and there was no evidence that the facility assessed or interviewed other residents in the area who may have been affected or had information about the incident. During interviews, the Administrator and DON described their general process for investigating abuse allegations, including interviewing staff, residents, and family, as well as checking the environment and conducting body checks for non-interviewable residents. However, in this case, there was no documentation that these steps were followed for other potentially affected residents. The facility's abuse policy required prompt and thorough investigations, including interviewing witnesses and other residents under the care of the staff member involved, but did not provide specific guidance for situations where a resident was not interviewable and had no family. This lack of thorough investigation did not ensure that other residents were protected from abuse.
Failure to Prevent Development of Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a preventable pressure ulcer for a resident when staff did not perform an accurate body check that reflected and identified the resident's skin condition. The resident, who was readmitted with diagnoses including diabetes, congestive heart failure, and malnutrition, was assessed as moderate risk for developing pressure ulcers. Despite this, the resident developed a Stage III pressure ulcer on the left heel and left buttock, which were in-house acquired and not reported in earlier stages by the staff. The facility's records indicated that the resident had no pressure injuries on readmission, but subsequent assessments revealed multiple skin impairments, including a Stage III pressure ulcer on the sacrum and upper back, which were present on admission, and a new Stage III pressure ulcer on the left heel and left buttock that developed in-house. The facility's documentation and staff interviews revealed that the pressure ulcers were not reported in their earlier stages, and the physician was not notified of the identified skin impairments. The facility's policies on skin integrity management and pressure injury prevention did not provide clear procedures for risk assessment, skin inspection, interventions, and documentation, contributing to the deficiency.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to serve food and substitutes according to residents' preferences, specifically for those who preferred Jook (rice soup) and various types of soups. During an observation and interview with a cook, it was noted that the meal being prepared was meatballs, pasta, and spinach, with no Jook or soup available. Several residents' meal tickets indicated preferences for Jook or soup, but these preferences were not honored. For example, Resident 90's meal ticket indicated a preference for hamburgers and a dislike for pasta, yet no hamburger was served when the menu included meatballs. This discrepancy was confirmed by the kitchen aide and the cook, who acknowledged that Jook was not available on the tray line that day. The Dietary Manager (DM) and the Consultant Registered Dietician (CRD) were also interviewed and confirmed the absence of Jook and soup on the menu. A review of the facility's policy and procedure for dietary profiles and resident preferences revealed that the DM is responsible for meeting with residents within 72 hours of admission to capture and update their nutritional needs and preferences. Despite this policy, the facility failed to provide meals that aligned with the documented preferences of several residents, affecting their quality of life and nutritional satisfaction.
Failure to Adhere to Scheduled Meal Times
Penalty
Summary
The facility failed to provide meals according to the scheduled serving hours, particularly for breakfast and lunch. Observations and interviews revealed that the meal cart consistently arrived late on the second floor, with breakfast being served as late as 10:15 AM. Staff, including a certified nursing assistant and the Dietary Manager, confirmed the delays. The Registered Dietitian Consultant and the facility's Consultant were informed of the issue but did not provide immediate solutions. On one occasion, the last meal cart left the kitchen at 2:30 PM, well past the scheduled lunch hours. Residents reported receiving cold or frozen food, and some were observed waiting for their meals in the hallways or by their doors, indicating a significant delay in meal service. The facility's policy requires that meals be served within specific time frames, with breakfast scheduled between 7:00 AM and 9:00 AM, lunch between 11:30 AM and 1:30 PM, and dinner between 5:00 PM and 7:00 PM. The failure to adhere to these schedules, especially the 14-hour rule between dinner and breakfast, was evident. Residents expressed dissatisfaction with the meal service, citing issues such as cold eggs and frozen foods. The Dietary Manager, who had recently started the job, acknowledged the problems but did not provide immediate corrective actions. The Dietary Supervisor also mentioned managing the employees to ensure efficiency, but the delays persisted, affecting the residents' overall dining experience and well-being.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure food safety requirements in accordance with professional standards for food service. During an observation, multiple stacks of small plastic bowls, large plastic food containers, and baking pans were found to be moist and wet, indicating they were not dried appropriately before storage. This was confirmed by the facility's Consultant and the Regional Registered Dietician (RD). Additionally, three plate warmers were found to be dirty with dust, pebbles, straws, stained papers, and other dried substances, despite the RD stating they were cleaned. The facility lacked a specific policy and procedure for the maintenance of plate warmers, further contributing to the deficiency. Serving trays were observed stacked and stored on a dusty cart outside the kitchen door, surrounded by opened packets of salt and pepper, and a box of hair caps. The Regional RD acknowledged the trays were clean but the surrounding environment was not sanitary. Furthermore, a hand sanitizer dispenser was found in the kitchen, which is not a replacement for proper handwashing. Despite the RD's claim that the dispenser was not in use, it was found to be functional and was later removed after being pointed out. In the refrigerator, 63 bowls of cream of rice and 40 bowls of oatmeal were found undated, which the Director of Food and Nutrition Services (DoFNS) acknowledged should have been labeled with preparation and use-by dates. Additionally, two packs of grapes were found to be overripe and mushy, with received dates indicating they were 13 and 16 days old. The Clinical Services Manager (CSM) confirmed the grapes were overripe and should have been discarded. The facility's Standard Operating Procedures and Shelf Life Chart for Produce were not followed, leading to the deficiency in food safety and storage practices.
Failure to Maintain Resident Dignity and Provide Adequate Communication Support
Penalty
Summary
The facility failed to ensure dignity and respect for three residents by not adhering to proper feeding and communication protocols. Staff were observed standing over two residents while assisting them with meals, which is against the recommended practice of sitting at eye level to make residents feel more comfortable. Both Certified Nursing Assistants (CNAs) involved admitted to standing because it was easier for them, and Licensed Vocational Nurses (LVNs) acknowledged that this practice was incorrect and not in line with facility guidelines. Additionally, the facility did not provide adequate communication support for a resident whose preferred language is Cantonese. The resident's care plan indicated a need for an interpreter, but staff were observed using makeshift methods such as hand gestures, picture boards, and Google Translate to communicate. Interviews with various staff members revealed that the facility lacked a reliable interpreter service, and staff often had to rely on other bilingual staff members or family members to translate, which is against the facility's policy. The facility's policy on translation and interpretation services was not followed, as it mandates the provision of competent oral translation services free of charge and discourages reliance on family members for interpretation. The Social Services Director and other staff confirmed that while some resources like picture boards and Google Translate were available, there was no formal interpreter service in place, leading to potential communication barriers for residents with limited English proficiency.
Lack of Coordination and Communication with Hospice Agency
Penalty
Summary
The facility failed to ensure proper coordination and communication with the hospice agency for three residents, leading to significant deficiencies in care. For Resident A, there was no coordination for communication between the facility and the hospice agency regarding changes in the resident's condition and death. The staff were not trained on the protocol for notifying the family, MD, and hospice. This resulted in the family not being notified of the resident's change in condition and death. Additionally, there were no progress notes or notifications made by the facility staff on the day of the resident's death. For Resident 155, the care plan did not include specific interventions for coordination of care between the facility and the hospice agency. The facility's care plan only mentioned the name of the hospice agency and contact number, without detailing the hospice services or interventions. Interviews with staff revealed that the hospice nurse visits and charts in a separate binder, but this information was not integrated into the facility's care plan. Resident B's care plan also lacked documentation of hospice care interventions. The facility's policies on end-of-life care and hospice care were not followed, as the care plans did not reflect hospice interventions, and there was no collaboration between the facility and hospice staff. This lack of coordination and communication had the potential to result in inadequate treatment and care for the residents involved.
Failure to Obtain Consent and Adhere to Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications due to the lack of proper consent and adherence to medication protocols. For Resident 66, the facility did not obtain consent for the use of Mirtazapine at the increased dosage of 15 mg, despite the medication being administered regularly. The Licensed Vocational Nurse (LVN) confirmed that the consent was not updated to reflect the current order, and the Pharmacist stated that a new consent is required when the dosage is increased. For Resident 118, the facility did not obtain consents for the use of Aripiprazole, Buspirone, and Haloperidol. The LVN and Resident Care Coordinator (RCC) both confirmed that there were no consents on file for these medications. The LVN acknowledged the responsibility of obtaining these consents but failed to do so. Resident 255 was administered Lorazepam and Trazodone without the necessary consents. Additionally, the PRN order for Lorazepam did not have a stop date and was administered beyond the recommended 14-day period. The LVN confirmed the absence of consents and the Pharmacist highlighted the requirement for PRN psychotropic medications to be limited to 14 days unless renewed. The facility's policy also mandates that PRN orders should not exceed 14 days without proper documentation and renewal, which was not followed in this case.
Expired and Improperly Stored Medications
Penalty
Summary
The facility failed to ensure medications were not expired and stored properly. One out of six sampled medication carts contained two prescription eye drops that were either expired or not labeled after opening. During an observation and interview, an opened Latanoprost Ophthalmic solution was found in the medication cart drawer with an expiration date that had passed. Another Latanoprost Ophthalmic solution was found without an open date or expiration date after opening. The Licensed Vocational Nurse acknowledged that these medications should have been discarded. Additionally, multiple medications were found to be stored in the garage without temperature control. Bottles of Hydrogen Peroxide 3%, Milk of Magnesia, ClearLax, and Stomach Relief were observed on the shelves in the garage storage. The Infection Preventionist and Central Supply Coordinator acknowledged that these over-the-counter drugs should not be stored in the garage and should be kept in the medication room in the nursing station. There was no thermometer or temperature log in the garage storage to ensure that medications were stored at room temperature. The Pharmacist confirmed that over-the-counter drugs should be stored at controlled temperatures and that temperature logs should be maintained daily.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident 111, who was readmitted with diagnoses including diabetes, congestive heart failure, and malnutrition, had two Stage 3 pressure ulcers. Despite the presence of these ulcers, the care plan for Resident 111 did not include specific interventions for the newly identified pressure ulcer on the left buttock, and the existing care plan for the left heel ulcer was not detailed enough to reflect the physician's orders. This lack of specificity and comprehensiveness in the care plan was acknowledged by the LVN during the review. Similarly, Resident 66, who was admitted with diagnoses including dementia, anxiety, and major depressive disorder, had an order for Lorazepam to treat anxiety. However, there was no care plan developed to address the use of this antianxiety medication. The LVN confirmed the absence of a care plan for Lorazepam during the review. The facility's policy on comprehensive person-centered care planning requires that care plans be periodically reviewed and revised, especially upon the onset of new problems, which was not adhered to in these cases.
Failure to Post Complete Nurse Staffing Data Daily
Penalty
Summary
The facility failed to post complete nurse staffing data daily from 3/11/24 to 3/15/24. During observations on 3/11/24, 3/12/24, and 3/13/24, the posted nurse staffing information was found to be incomplete, missing the total number and actual hours worked by each category of nursing staff. The posted data only included the facility name, date, number of employees for all shifts, and census. This incomplete posting remained unchanged until 3/15/24. Interviews with the Administrator and Staffing Coordinator revealed that the staffing data was prepared by the Staffing Coordinator and left for the NOC shift supervisor to update at midnight, but the correct data was not posted for the specified dates. The facility's policy and procedure, dated 7/2018, requires the posting of specific nurse staffing data daily at the beginning of each shift. This includes the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides, along with the resident census. The failure to comply with this policy was confirmed through interviews and record reviews, indicating a lapse in the facility's adherence to its own staffing posting requirements.
Inaccurate Reconciliation of Controlled Substance
Penalty
Summary
The facility failed to maintain accurate reconciliation for a controlled substance, specifically Hydromorphone, for one of the residents. The policy for controlled medications required that the licensed nurse administering the medication immediately document the date and time of administration, the amount administered, and the signature of the nurse. However, a review of Resident 233's medication administration record indicated discrepancies. The record showed that 2mg of Hydromorphone was administered at 9:00 AM, but during an interview, the LVN stated that she had given two tablets that day. An observation confirmed that the supply contained 24 tablets, while the narcotic record indicated there should be 26 tablets remaining. This discrepancy was acknowledged by the LVN and later confirmed by the Director of Nursing, who reiterated that documentation should be done immediately after administration. The failure to accurately document and reconcile the controlled substance could lead to medication diversion. The inconsistency between the documented number of tablets and the actual count was evident during the surveyor's review and interviews. The Director of Nursing confirmed that the LVN did not follow the policy of immediate documentation after administering the medication. This lapse in proper recordkeeping and adherence to policy was identified as a deficiency during the survey.
Failure to Act on Pharmacy Consultant's Recommendation for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for Resident 255. Resident 255, who was admitted with diagnoses including dementia and anxiety, had an order for Lorazepam 0.5 mg to be taken as needed for anxiety. The Consultant Pharmacist's Medication Regimen Review (MRR) dated 12/30/23 recommended evaluating the necessity of continuing the PRN psychotropic medication and suggested that if continued, the order should be written for a maximum of 14 days with no refills. However, there was no response from the physician to this recommendation in January 2024, and the medication was not discontinued until 3/1/24, well beyond the recommended 14-day period. During an interview, the Licensed Vocational Nurse (LVN) confirmed that the order for Lorazepam was still active until 3/1/24. The Pharmacist acknowledged that the MRR is conducted monthly and that irregularities are communicated to the nurse and physician, but there was no documented response from the physician regarding the recommendation made in December 2023. The facility's policy requires the attending physician to document any action taken in response to identified irregularities, which was not done in this case. This failure had the potential to expose Resident 255 to unnecessary psychotropic medications and adverse health consequences.
Failure to Follow Physician's Order for Pain Medication Administration
Penalty
Summary
The facility failed to follow the physician's order regarding the administration of Hydromorphone for a resident. Specifically, the Licensed Vocational Nurse (LVN) administered an excessive dose of Hydromorphone to Resident 233, who was prescribed 2 mg every four hours as needed for severe pain. The LVN gave two tablets instead of one, despite the resident's pain level being documented as a 7, which is considered moderate pain according to the facility's pain assessment order. The policy required the nurse to document the pain score prior to administering the medication and to adhere to the seven 'rights' of medication administration, including the right dose. The discrepancy between the documented number of tablets in the narcotic record and the actual number of tablets available further indicated a failure in proper medication management. During the review, it was confirmed that the LVN did not follow the physician's order and administered the medication outside the specified parameters. The Director of Nursing (DON) acknowledged that the LVN gave the pain medication outside the prescribed parameters and administered the wrong dose. This failure to adhere to the physician's order and the facility's medication administration policy had the potential to result in an adverse reaction, such as respiratory depression, for the resident.
Improper Disposal of Refuse in Kitchen
Penalty
Summary
The facility failed to ensure proper disposal of refuse in the kitchen, as observed during a survey. A blue-colored recycle container near the flat top griddle was found half-open and almost full of empty chocolate pudding cans with small pudding residue. During the observation, the Clinical Services Manager (CSM) stated that the lid should be closed, while the Director of Food and Nutrition Services (DoFNS) disagreed, indicating that the lid could be closed at the end of the day. This discrepancy in handling the refuse container was noted during an interview with the Infection Preventionists (IP) 2 and 3, who agreed that the half-open container could contaminate food in the preparation area. The facility's policy and procedure (P&P) on infection control in food and nutrition services, which mandates that waste containers should have close-fitting covers, was not followed in this instance. The U.S. Food and Drug Administration's 2022 Food Code also requires that refuse containers containing food residue be kept covered to prevent contamination and attract pests. Both IP 2 and IP 3 verified that the facility's P&P was applicable to the situation observed in the kitchen.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two key deficiencies. First, an unopened Biohazard Spill Kit with an expiration date of four years ago was found in the garage storage. The Infection Preventionist (IP) acknowledged the expired kit and admitted that it should have been discarded. Additionally, there was no specific policy regarding the expiration dates for supplies, although the facility's policy on medication storage could be applied to cleaning supplies like the Biohazard Spill Kit. This oversight indicates a lapse in the facility's protocol for managing expired supplies, which could compromise infection control measures. Second, the facility did not implement the correct cleaning and disinfecting practices for a glucometer used to test a resident's blood sugar. A Licensed Vocational Nurse (LVN) was observed cleaning the glucometer with a green non-bleach Clorox wipe, which is not approved for use on the device. The glucometer manufacturer’s manual and the facility's policy both specify the use of specific germicidal wipes for cleaning the glucometer. The IP confirmed that the green non-bleach Clorox wipes should not be used on the glucometer, highlighting a failure to adhere to proper disinfection protocols for critical medical equipment.
Lack of Training and Protocols for Oral Suctioning
Penalty
Summary
The facility did not ensure staff were trained on infection control practices for oral suctioning, as evidenced by the lack of knowledge among nurses regarding the protocol for changing tubes and cleaning the canister. During observations, a resident's bedside table was found with a suction machine and a suction tip that was not dated, mixed with other personal hygiene items. Interviews with various staff members, including CNAs, LVNs, and the Infection Preventionist, revealed that there was no specific policy or procedure for oral suctioning, and staff were unsure about the proper protocols for using and maintaining the suction equipment. The resident's son, who is the responsible party, preferred to handle the suctioning himself, but there was no documentation or clear communication about the maintenance of the equipment. Interviews with multiple LVNs indicated that they either had never used the suction machine or were unsure about the facility's protocol for its use and maintenance. Some staff mentioned that they would refer to the facility's policy, but no such policy was found. The Infection Preventionist confirmed that the responsibility for cleaning and changing the suction machine's tubing lies with the licensed nurse, but acknowledged the absence of specific policies and procedures for suctioning. This lack of training and clear guidelines could lead to breaks in infection control practices, potentially spreading infections among 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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