San Pablo Healthcare & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Pablo, California.
- Location
- 13328 San Pablo Avenue, San Pablo, California 94806
- CMS Provider Number
- 056359
- Inspections on file
- 33
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at San Pablo Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with encephalopathy, traumatic brain injury, unsteadiness of feet, and type 2 DM with kidney disease, and documented moderate cognitive decline, had a known history of elopement and goal-directed wandering with expressed desire to go home. Despite prior elopement through an emergency door and assessments identifying high elopement risk, the care plan for wandering/elopement did not include a wander guard intervention. On one morning, kitchen staff unlocked the main entrance to allow another staff member in and failed to relock it, leaving the front door unmanned while staff attended to other care tasks. The resident removed the wander guard and exited through the unlocked front door without supervision or authorization, later confirmed by CCTV. Facility policy required staff to accompany residents who exit and to complete thorough unusual occurrence investigations with staff interviews, but the investigation lacked written interviews from the staff member who had unlocked the door.
Staff failed to follow the facility’s policy for investigating injuries of unknown origin when a resident was found with a complete avulsion of the right great toenail and no one knew how it occurred. The resident had mild cognitive impairment and aphasia, limiting the ability to explain the event. A CNA discovered the missing toenail and notified an LVN, who asked other nurses but obtained no explanation. Documentation noted the resident often dangled feet off the bed and sometimes hit hard surfaces, and the LVN assumed this might be the cause. However, the DON confirmed that no formal investigation was conducted and the IDT did not review the unexplained injury, despite policy requirements for thorough investigation of such injuries.
A resident with mild cognitive impairment, aphasia, and a seizure disorder frequently dangled her feet outside the bed, sometimes striking hard parts of the bed and a nearby table, which was documented as causing damage to her skin and nails. Staff later discovered a complete avulsion of the resident’s right great toenail, with no one able to explain how it occurred, and an LVN assumed it might be related to the foot-dangling behavior. Observation showed the resident in bed with her feet near the footboard and no protective devices in place. The DON acknowledged that, despite awareness of the behavior and its effects, the IDT had not incorporated this behavior into the resident’s care plan with specific interventions.
The facility failed to follow its abuse prevention policy by hiring and retaining a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on OIG/medical exclusion and State Board lists, without obtaining required reference checks or making reasonable efforts to uncover past criminal prosecutions. This CNA was later involved in an incident in which a cognitively intact, paraplegic resident reported verbal and physical abuse after requesting assistance with clothing and water, stating the CNA refused proper help and spilled water on the wheelchair, damaging items in the resident’s wallet, while the CNA gave a differing account of items sliding off a bedside table.
A resident with mild cognitive impairment and anxiety disorder reported that a staff member may have used their bank card for unauthorized online purchases. Although the facility assisted the resident in replacing the card and changing passwords, the administrator did not report the allegation to law enforcement or regulatory agencies as required by policy, instead handling the matter internally.
Surveyors found a reddish-brown residue inside and around the ice chute dispenser of the residents' ice machine during an inspection with the MD and RD. The residue was confirmed by wiping with a paper towel, and both the MD and DON acknowledged that the ice machine should have been clean and free of dirt to prevent foodborne illness. Facility policy and FDA Food Code require routine cleaning and sanitizing of food-contact equipment, which was not followed in this instance.
A deficiency was identified when an LVN pre-poured medications for multiple residents instead of preparing them immediately before administration, as required by facility policy. The LVN carried a tray with several pre-labeled medication cups and administered them after preparing them in advance, stating this made her medication pass faster. The DON confirmed that this practice was not permitted and posed risks for medication errors and infection control breaches, as outlined in the facility's medication administration policy.
Several residents reported that meals were consistently bland and lacked flavor, prompting them to use extra salt and pepper. During a meal observation, a resident complained to staff about the lack of taste. A test tray tasting by surveyors and dietary staff confirmed that the food was bland. The Dietary Services Supervisor acknowledged the importance of flavorful meals, and facility policy required recipe concerns to be reported for evaluation.
A staff member discussed a resident's Parkinson's diagnosis, hand tremors, and hearing impairment out loud during lunch in front of another resident and within earshot of others. This public disclosure of confidential health information violated the resident's right to privacy and dignity, as confirmed by the DON and facility policy.
A resident with Depression and PTSD was not referred for a Level II PASARR evaluation after a positive Level I screening. The MDS coordinator acknowledged missing the required follow-up, despite facility policy requiring coordination of Level II PASARR recommendations with resident assessment and care planning.
A resident with a gastrostomy tube did not receive the prescribed amount and schedule of enteral nutrition due to an LVN's lack of awareness of the physician's order, resulting in continuous feeding at an incorrect rate. Staff interviews confirmed that the enteral feeding orders were not followed, and facility policy required adherence to physician orders for tube feeding.
Twelve rooms with multiple beds were found to provide less than the required 80 square feet per resident, with measurements ranging from 71.54 to 79.6 square feet per bed. Despite this, observations indicated that care provision, personal space, and storage for belongings were adequate, and no complaints or safety concerns were reported.
Two residents were not protected from physical abuse by other residents, including one being struck in the head and another having lemonade thrown at her. In both cases, the aggressors had histories of behavioral issues, and lapses in supervision contributed to the incidents. Facility investigations classified these as negative interactions, and the abuse prevention policy required intervention in such situations.
A resident with mild cognitive impairment and a history of stroke alleged that a CNA hit him after refusing to wear a sock. The DON did not interview the alleged CNA or the assigned caregiver, and the alleged abuser was not suspended as required by facility policy. The CNA continued to provide care to the resident, and the investigation summary lacked documentation of necessary staff interviews.
A resident with morbid obesity and intact cognition, who required partial assistance with walking, did not receive restorative nursing services as recommended by therapy upon discharge. Although therapy staff referred the resident for RNA to maintain mobility and strength, RNA staff were unaware of the referral, and the responsible LVN did not follow up due to absence, resulting in the resident not receiving the necessary restorative care.
A resident with congestive heart failure and type 2 diabetes was not assisted in changing into a hospital gown upon request, despite expressing discomfort in street clothes. The CNA cited cold weather as a reason, and the resident reported similar refusals in the past, affecting his dignity. Staff interviews confirmed the resident should have been assisted, and the facility's policy emphasizes honoring resident preferences.
A resident in an LTC facility experienced delays in call light response, leading to feelings of neglect. Despite being at risk of falls and needing assistance, the resident's call light went unanswered for 20 minutes, with staff passing by without responding. The facility's policy requires prompt responses to call lights to ensure resident safety and well-being.
A resident's room was found with an uncovered trash bin overflowing with soiled diapers and dirty gloves, and a mesh bag of dirty laundry on the floor. The resident, with congestive heart failure and type 2 diabetes, was distressed by the unsanitary conditions. A CNA confirmed the items were left by the previous shift, and the DON stated CNAs are responsible for maintaining cleanliness. The facility's policy emphasizes a clean and homelike environment, which was not upheld, posing a potential infection risk.
Two residents did not receive showers consistently as scheduled, impacting their grooming and hygiene. One resident, with conditions including diabetes and depression, reported receiving showers only once every three weeks instead of twice weekly. Another resident needed to remind staff multiple times for showers, receiving only two in 30 days. Facility records lacked documentation for missed showers, despite a policy emphasizing regular bathing.
The facility failed to maintain a clean environment in a resident room and shared bathroom. Observations revealed a dirty bathroom with unflushed urine and a dirty trash can, while the room floor was unswept. Residents reported infrequent cleaning unless requested. A CNA and the Housekeeping Supervisor confirmed the unclean state, and the Infection Preventionist and DON emphasized the need for continuous cleanliness. Facility policies outlined the requirement for maintaining sanitary conditions.
Two residents in a facility engaged in physical altercations due to inadequate separation after an initial incident. Despite policies requiring immediate separation and supervision, staff returned one resident to the shared room, leading to further conflict. The residents involved had significant medical and cognitive conditions, and the staff's actions did not align with the facility's procedures for handling such situations.
The facility failed to follow its infection control policies, leaving COVID-19 positive resident room doors open and not maintaining ventilation systems as required. The Infection Preventionist confirmed that none of the residents were fall risks, yet doors were left open. Additionally, the portable AC unit in the COVID-designated area was turned off, and air filters were not cleaned weekly as recommended, compromising the facility's ability to control the virus spread.
A registry CNA worked at the facility without a background check or abuse prevention training, leading to a deficiency. The Staffing Coordinator failed to verify the CNA's documents, and the CNA confirmed she did not receive the necessary training. The facility's policy required these screenings and training, which were not conducted, potentially endangering residents.
A resident with multiple complex medical conditions did not receive prescribed hydromorphone for severe pain as ordered, leading to uncontrolled pain, increased agitation, and verbal aggression. The resident's request for pain medication was not properly communicated or addressed by the staff, resulting in a significant delay in pain relief.
The facility failed to accurately record the administration of hydromorphone for a resident, leading to confusion and delays in pain management. The resident, with multiple diagnoses and intact cognitive status, reported severe pain and delays in receiving medication, which was corroborated by nursing staff interviews. The facility's policy required proper documentation of administered drugs, which was not followed.
Failure to Secure Main Entrance and Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the main entrance secured and to provide adequate supervision to prevent elopement for a resident with known elopement risk. The resident was admitted with encephalopathy, traumatic brain injury without loss of consciousness, unsteadiness of feet, and type 2 diabetes with kidney disease. An MDS dated 11/3/25 showed a BIMS score of 11/15, indicating moderate cognitive decline, and documented that the resident required supervision, verbal cues, and touching assistance for functional activities. An SBAR dated 10/31/25 documented that the resident had previously exited the facility unattended through an emergency door and was observed walking away from the facility, requiring three staff to follow and attempt to redirect him back. An elopement evaluation dated 10/31/25 indicated the resident had a history of elopement or attempts to leave without informing staff, expressed a desire to go home, and had goal-directed wandering likely to affect safety. Despite this, the care plan for risk of wandering/elopement initiated on 10/31/25 and reviewed on 12/2/25 did not include the use of a wander guard as an intervention. On 11/25/25, at approximately 6:30 a.m., staff discovered during routine rounding that the resident was not present on the unit, and there were no witnesses to the resident’s departure. Review of closed-circuit television confirmed the resident had eloped through the front main door. The facility’s investigative summary dated 11/27/25 documented that the resident had removed his wander guard and exited through the unlocked front door without supervision or authorization. The DON reported that kitchen staff had unlocked the front door to allow another kitchen staff member to enter and forgot to relock it as it was close to 7:00 a.m., leaving the front door unmanned while staff were busy with other resident care activities. A subsequent elopement evaluation dated 11/27/25 again documented the resident’s history of elopement, wandering, expressed desire to go home, and goal-directed wandering likely to affect safety, and a progress note dated 11/28/25 recorded ongoing noncompliance with wearing the assigned wander guard and a pattern of exit-seeking behaviors. Review of the facility’s policies on wandering/elopement and unusual occurrence reporting showed that staff were expected to follow or accompany residents who exit despite efforts to stop them and to conduct and document investigations including staff and witness interviews, but the DON acknowledged that written interviews from the staff who unlocked the main door were missing from the investigation summary and further attempts to interview that staff member were unsuccessful.
Failure to Investigate Injury of Unknown Origin Involving Toenail Avulsion
Penalty
Summary
Facility staff failed to follow the facility’s policy and procedure for investigating injuries of unknown origin when a resident was found with a complete avulsion of the right great toenail and the source of the injury was unknown. The resident’s MDS showed mild cognitive impairment with a BIMS score of 11, difficulty recalling the day of the week, and some difficulty communicating, including aphasia noted at the time of the injury, which prevented the resident from describing what happened. A CNA discovered the resident’s right great toenail was completely off, with the nail bed dry and red, and reported this to an LVN. The LVN asked other nurses about the cause, but no one knew how the toenail came off. The COC note documented that the resident often dangled her feet outside the bed and sometimes hit hard parts of the bed and nearby table, causing skin and nail damage. Despite the unexplained nature of the injury and the resident’s inability to explain the cause, the facility did not initiate or conduct a thorough investigation as required by its policy titled “Injury of Unknown Origin-Investigation.” The LVN stated he assumed the toenail avulsion may have occurred because the resident dangled her feet and hit hard surfaces, but this was not confirmed. The DON acknowledged that the facility did not investigate the source of the toenail injury and that the IDT did not review the injury. The facility’s policy defined an injury of unknown source as one where the source was not observed or could not be explained by the resident and was suspicious due to extent, location, number, or incidence over time, yet no formal investigation or IDT review was completed for this resident’s unexplained toenail avulsion.
Failure to Care Plan for Resident’s Repetitive Foot-Dangling Behavior and Resulting Toe Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete care plan with measurable interventions to address a resident’s behavior of dangling her feet outside the bed and striking hard surfaces. The resident had a BIMS score of 11, indicating mild cognitive impairment, and had difficulty recalling the day of the week and communicating without prompting. The MDS also documented a diagnosis of seizure disorder or epilepsy. A Change in Condition Evaluation (COC) dated 2/13/26 documented that the resident often dangled her feet outside the bed and at times hit the hard parts of the bed and a nearby table, causing damage to her skin and nails. On that same date, CNA 1 reported a complete nail avulsion of the resident’s right great toe, described as dry and red in appearance, and the resident was aphasic and unable to describe what had happened. On observation on 2/19/26, the resident was seen lying in bed with the bed in a low position and a dressing on the right great toe; her feet were close to the footboard, and there were no devices in place to prevent her feet from hitting the footboard. CNA 1 stated she found the resident’s right great toenail off and did not know how it occurred. LVN 1 reported that CNA 1 informed him of the toenail avulsion, that other nurses also did not know how it happened, and that he assumed it may have been related to the resident dangling her feet outside the bed. During record review with LVN 1 and the DON, the COC and the care plan for the right great toenail avulsion were reviewed, and the DON acknowledged there was an assumption that the resident sometimes hit her leg on hard parts of the bed. The DON further stated that the interdisciplinary team had not addressed the resident’s behavior of dangling her feet outside the bed and hitting her legs on hard parts of the bed with care plan interventions.
Failure to Screen and Exclude CNA with Prior Abuse Finding Leading to Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse prevention policy by hiring and continuing to employ a CNA who had a documented finding of patient abuse on the state nurse aide registry and was listed on the OIG/medical exclusion and State Board lists. The CNA’s background screening report, completed prior to hire, clearly indicated a finding of patient abuse, yet the facility proceeded with employment. The facility also failed to obtain and document reference checks from previous and/or current employers or make reasonable efforts to uncover information about any past criminal prosecutions for this CNA, despite policy requirements to screen potential employees for a history of abuse, neglect, or mistreatment. The Administrator later stated he was not aware of the CNA’s abuse finding and that the facility does not hire nursing staff with such findings. The deficiency was further evidenced by an incident involving a resident with paraplegia and intact cognition, as shown by a BIMS score of 15 and clear communication abilities. According to an SBAR progress note, the resident reported that the CNA verbally and physically abused him, and the resident appeared anxious, intimidated, and uncomfortable with care. In an interview, the resident stated he had asked the CNA for help with clothing and water, and the CNA told him to stand up and help himself, then spilled water on the resident’s wheelchair and damaged items in his wallet, leaving the resident upset and anxious. In a separate interview, the CNA described an event in which a bottle of hot sauce and water slid from a bedside table and broke while the CNA was moving the table. These events, combined with the documented abuse finding on the CNA’s background screening and the lack of reference checks, demonstrate the facility’s failure to implement its abuse prevention policy not to employ or continue to employ anyone found guilty of abuse.
Failure to Report Alleged Financial Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and regulatory requirements to report an allegation of financial abuse and misappropriation of resident property to the appropriate agencies. Specifically, a resident with mild cognitive impairment and a history of anxiety disorder reported concerns that a staff member who assisted with online purchases may have used the resident's bank card for unauthorized transactions. The facility assisted the resident in replacing the debit card and changing online account passwords but did not notify law enforcement or the licensing department as required. Interviews with staff confirmed that the incident was not reported to authorities because the facility believed there was no missing money from the resident's account. Documentation showed that the resident had difficulty recalling certain information and required assistance with online purchases due to vision and communication challenges. The staff member involved admitted to helping the resident with online purchases and receiving items on the resident's behalf. The facility's own policy required reporting all allegations of abuse and criminal activity, but the administrator assigned the investigation to social services and limited the response to internal actions, failing to meet mandatory reporting obligations.
Unsanitary Ice Machine with Residue Found During Inspection
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the storage and preparation of ice supplied to residents. During an inspection, the Maintenance Director (MD) and Registered Dietician (RD) opened the residents' ice machine and found a reddish-brown residue inside the back part of the ice container and around the ice chute dispenser. The RD wiped the residue with a paper towel, confirming its presence. Both the RD and MD acknowledged that the residue should not have been present, and the MD stated that the ice machine should have been maintained and cleaned to prevent any residue. The DON also confirmed that the ice machine should always be clean to prevent foodborne illnesses and acknowledged that the residue could have caused food poisoning. A review of the facility's policy and procedure for ice machine operation and cleaning indicated that the machine should be cleaned routinely, with the inside washed and sanitized at least monthly. Additionally, the FDA Food Code requires that equipment food-contact surfaces and utensils be clean to sight and touch. The presence of residue in the ice machine demonstrated a failure to follow these established cleaning protocols and professional standards, resulting in unsanitary conditions for the ice supplied to residents.
Failure to Follow Medication Administration Standards Due to Pre-Pouring by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to adhere to professional standards during medication administration for four residents. The LVN was observed carrying a medication tray containing multiple pre-poured medication cups labeled with room numbers, rather than preparing medications immediately before administration as required by facility policy. The LVN administered medications to residents after preparing them in advance, a practice known as pre-pouring, which is not permitted according to the facility's guidelines. The LVN stated during interviews that she routinely prepared medications ahead of time to expedite her medication pass and was unaware of the facility's policy prohibiting pre-pouring. She also indicated that she memorized the medications for each resident and did not perceive any risk of medication errors with this method. The LVN further explained that if medication cups were mixed up, she would discard the medications and start over, but did not acknowledge the potential for error inherent in this process. The Director of Nursing (DON) confirmed that the facility's policy requires medications to be prepared and administered to one resident at a time, with verification of the resident's identity prior to administration. The DON emphasized that pre-pouring medications is not allowed due to the risk of medication errors and infection control breaches. The facility's written policy also specifies that medications are to be administered at the time they are prepared and not pre-poured, and that documentation should occur immediately after administration.
Failure to Provide Palatable and Flavorful Meals
Penalty
Summary
Surveyors identified that the facility failed to provide palatable and flavorful food to four sampled residents. Multiple residents reported that the food served was consistently bland and lacked taste, with one resident keeping extra salt and pepper on hand to compensate. During interviews, residents expressed dissatisfaction with the taste of the meals, describing them as flavorless and unappetizing. These observations were corroborated during a dining observation, where a resident was seen complaining to staff about the lack of flavor in their meal. A review of the facility's menu confirmed the items served, and a test tray tasting conducted by surveyors, the Registered Dietician, and the Dietary Services Supervisor found that the food, specifically the fish and scalloped potatoes, was bland and lacked flavor. The Dietary Services Supervisor acknowledged the importance of providing flavorful meals to support residents' food preferences and dignity. The facility's policy indicated that recipe accuracy concerns should be reported to the Dietician for evaluation and modification as necessary.
Staff Disclosed Resident's Diagnosis in Presence of Others, Violating Privacy and Dignity
Penalty
Summary
A staff member failed to treat a resident with dignity and respect by disclosing the resident's medical diagnosis and condition in the presence of another resident and within earshot of others during a mealtime. Specifically, the Activity Assistant (AA) stated out loud that the resident had Parkinson's disease, pointed out the resident's hand tremors, and mentioned the resident's hearing impairment while feeding the resident lunch. This disclosure was made without being prompted and occurred in a public setting where other residents were present. The resident involved had been admitted with diagnoses of Parkinsonism and dementia. The AA later acknowledged that sharing the resident's medical information in this manner was inappropriate and recognized it as a violation of privacy. The Director of Nursing confirmed that staff are not permitted to disclose residents' diagnoses or personal information in public areas, as this could affect the resident's dignity and self-esteem. Facility policy also requires that confidential clinical information be protected and that communication about residents be conducted outside the hearing range of others.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR evaluation after the resident was identified as positive during the Level I PASARR screening. The resident was admitted with diagnoses of Depression and Post Traumatic Stress Disorder (PTSD), both of which are considered serious mental health conditions. The Level I PASARR screening indicated a positive result, which should have triggered a referral for a Level II evaluation to determine the need for specialized mental health services or a higher level of care. During an interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed responsibility for reviewing PASARR results and following up with Level II evaluations as needed. The MDSC acknowledged that the Level II evaluation was not completed for this resident, stating it was missed. The facility's policy requires coordination of recommendations from Level II PASARR determinations with resident assessment and care planning, but this process was not followed in this case.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subarachnoid hemorrhage and gastrostomy status did not receive the prescribed amount of enteral nutrition as ordered by the physician. The physician's order specified that the resident should receive Jevity 1.5 at 75 ml/hour for 20 hours daily, with the feeding paused from 8:00 a.m. to 12:00 p.m. However, observation revealed that the resident was receiving tube feeding at a rate of 60 ml/hour continuously over 24 hours, and the feeding was not stopped during the specified time frame. The nurse responsible for the resident was unaware of the correct order and believed the feeding was to be administered at 60 ml/hour without interruption. Interviews with facility staff, including the LVN, Registered Dietician, and DON, confirmed that the prescribed enteral feeding orders were not followed. The LVN admitted to not knowing the correct rate or schedule and only replaced the formula bottle when it was nearly empty. The Registered Dietician and DON both stated that the resident was at risk for inadequate nutrition due to not receiving the recommended amount of enteral feeding. Review of facility policy indicated that enteral feeding should be administered as ordered by the physician, with careful calculation and verification of the amount to be given per shift.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility was found to have 12 resident rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. During an observation, specific rooms were measured and found to provide between 71.54 and 79.6 square feet per bed, which is below the regulatory standard. Despite these measurements, observations conducted over several days indicated that there was sufficient space for care provision, no heavy equipment obstructed care, and each resident had adequate personal space and privacy. There were no complaints from residents regarding space for belongings, and no negative consequences or safety concerns were observed or reported during the survey period.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents. In the first incident, a resident with heart failure and generalized weakness was struck twice in the head by her roommate after waiting outside the bathroom. The resident reported pain and distress following the incident. Documentation and interviews revealed that the aggressor had previously been on 1:1 observation for behavioral concerns, but this supervision was not provided during the night shift when the incident occurred. The Director of Nursing confirmed that 1:1 observation was not guaranteed during night shifts, and the aggressor did not have a sitter at the time of the event. In the second incident, a resident with respiratory failure and chronic pain syndrome had lemonade thrown at her by her roommate, who exhibited ongoing verbal and physical aggression. Staff responded to the altercation after hearing screaming and separated the residents. Documentation indicated that the aggressor continued to display aggressive behaviors in the days following the incident, ultimately resulting in a psychiatric hold. In both cases, the facility's investigations concluded the events as negative interactions between residents, and the facility's abuse prevention policy required the identification and intervention in situations where abuse was more likely to occur.
Failure to Investigate and Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its policy and procedure for investigating an allegation of abuse involving a resident with mild cognitive impairment and a history of cerebrovascular accident. The resident, who was dependent on staff for assistance with socks, alleged that a CNA hit him on the right leg after he refused to wear a sock. The care plan for the resident specified that the alleged abuser should be suspended during the investigation, but this intervention was not implemented. The Director of Nursing did not interview the alleged CNA or the staff member assigned to the resident's care, nor was the alleged abuser suspended from duty. The CNA continued to provide care to the resident and was not informed of the allegation. The investigation summary lacked documentation of interviews with the involved staff, and the DON stated that these steps were not taken because the resident was considered a poor historian. The facility's policy required suspension and removal of the staff member from the premises during the investigation, which was not followed.
Failure to Provide Restorative Nursing Services After Therapy Discharge
Penalty
Summary
A deficiency occurred when a resident with morbid obesity and intact cognitive status, who required partial assistance with ambulation, did not receive restorative nursing services as recommended by occupational and physical therapy upon discharge. The resident's Minimum Data Set indicated a need for partial assistance with walking, and therapy discharge summaries recommended restorative nursing assistance (RNA) for bilateral upper extremity exercises and walking with a front wheel walker to maintain mobility and strength. However, the resident reported not receiving any restorative nursing interventions to help with walking. Interviews with staff revealed that the process for transitioning residents from therapy to restorative nursing involved a referral to the nursing department, but the RNA staff were unaware of the referral for this resident. The Licensed Vocational Nurse responsible for following up on the RNA referral acknowledged that the follow-up did not occur due to her absence from work. The facility's policy indicated that the DON or a licensed nurse designee manages the restorative nursing program, but the referral was not acted upon, resulting in the resident not receiving the necessary restorative care.
Failure to Honor Resident's Choice in Dressing
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice, as evidenced by the incident involving a resident who was not assisted in changing into a hospital gown upon request. The resident, who had been admitted with multiple diagnoses including congestive heart failure and type 2 diabetes, expressed a preference to change into a hospital gown for comfort at night. However, a Certified Nurse Assistant (CNA) from the night shift did not assist the resident, citing the cold weather as a reason to remain in street clothes. This lack of assistance was not an isolated incident, as the resident reported similar refusals in the past, which affected his self-esteem and dignity. Interviews with facility staff, including a CNA and a Registered Nurse (RN), confirmed that the resident should have been assisted with changing clothes to ensure comfort and to allow for skin checks. The RN noted that if the resident had refused assistance, it should have been documented, but there was no indication that the resident had a history of refusing activities of daily living (ADLs). The Director of Nursing (DON) acknowledged that changing into a hospital gown was a resident preference and should have been honored, emphasizing the importance of documentation if a resident refuses ADLs. The facility's policy and procedure on Residents Rights - Quality of Life, revised in March 2017, states that each resident should be cared for in a manner that promotes dignity, respect, and individuality. The policy emphasizes that residents should be groomed according to their wishes, including dressing preferences. The lack of documentation and failure to assist the resident in changing clothes as requested highlights a deficiency in adhering to these policies, potentially causing physical discomfort and emotional distress to the resident.
Delayed Response to Call Light in LTC Facility
Penalty
Summary
The facility failed to provide timely response to a resident's call light, which is a deficiency in providing care according to professional standards. The resident, who was admitted with diagnoses including congestive heart failure and type 2 diabetes, expressed concerns about the slow response to call lights, particularly during the PM shift. The resident, who was at risk of falls and required assistance with activities of daily living, reported feeling neglected due to the delayed responses. On the day of observation, the resident's call light was activated and remained unanswered for 20 minutes, despite being located across from the nurse's station and within view of staff. During this time, multiple staff members, including a licensed nurse, were observed passing by the room without responding to the call light. This delay in response was confirmed by a CNA who eventually attended to the resident, stating that she was not informed of the call light being on. The facility's policy requires call lights to be answered promptly, ideally within 15 minutes, to ensure residents' needs are met and to prevent potential emergencies. The Director of Nursing acknowledged the failure to adhere to this policy, emphasizing the importance of prompt responses to avoid emergencies or worsening conditions. The facility's policy and procedure documents also highlight the importance of maintaining residents' quality of life and dignity, which was compromised in this instance.
Unsanitary Conditions in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, identified as Resident 1, whose room was found to have an uncovered trash bin overflowing with soiled diapers and dirty gloves. This trash bin was located under the edge of Resident 1's bed, and a mesh bag containing Resident 1's dirty laundry was found on the floor next to the overflowing trash. Resident 1, who was admitted to the facility with diagnoses including congestive heart failure and type 2 diabetes, expressed distress upon discovering the unsanitary conditions in his room, stating that it made him feel sick to his stomach and upset. During an interview, a Certified Nurse Assistant (CNA) acknowledged that the uncovered and overflowing trash, along with the mesh bag of clothes, were present when she arrived for her shift. The CNA indicated that the previous shift's CNAs likely left the items in Resident 1's room. She confirmed that the trash bin should not have been left exposed and overflowing, and that the soiled diapers should have been disposed of immediately after care was provided. Additionally, the CNA stated that Resident 1's clothes should have been placed in a plastic bag and taken to the laundry room, as leaving them on the floor could contribute to the spread of infection. The Director of Nursing (DON) confirmed that CNAs are responsible for ensuring rooms are clean and sanitary. The DON stated that the CNA assigned to Resident 1 should have disposed of the trash with soiled diapers before leaving the room and should have placed the resident's laundry in a plastic bag rather than leaving it on the floor. The facility's policy and procedure, titled 'Resident Rooms and Environment,' emphasizes providing a safe, clean, comfortable, and homelike environment, with a focus on cleanliness and order. The failure to adhere to these procedures resulted in a potential risk of infection due to the unsanitary conditions in Resident 1's room.
Inconsistent Shower Schedule for Residents
Penalty
Summary
The facility failed to ensure that two residents received the necessary services to maintain good grooming and personal hygiene, as they were not receiving showers consistently and as scheduled. Resident 1, who was admitted with diagnoses including diabetes, severe obesity, generalized weakness, and depression, required substantial assistance for bathing. Despite being scheduled for showers twice a week, Resident 1 reported receiving a shower only once every three weeks, which was upsetting to him. The facility's records confirmed that Resident 1 missed several scheduled showers without any documented reason for refusal or unavailability. Similarly, Resident 3, who also required assistance for bathing, reported needing to remind staff multiple times to receive his showers. The facility's records indicated that Resident 3 only received two showers in a 30-day period, despite being scheduled for twice-weekly showers. Interviews with staff, including a CNA and the DON, revealed that while there was a shower schedule in place, there was no documentation to explain the missed showers for these residents. The facility's policy emphasized the importance of regular bathing for cleanliness and comfort, yet the facility did not adhere to this policy for the residents in question.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in one resident room and a shared bathroom used by five residents. During an observation, the bathroom was found to be dirty, with a raised toilet seat over the toilet bowl that had dried brown/black substances and yellowish liquid resembling urine. The trash can in the bathroom was without a liner and appeared dirty, and the bathroom floor was also unclean. Interviews with residents revealed that the bathroom was not cleaned regularly unless housekeeping was specifically called to do so. One resident mentioned having to clean the bathroom themselves before use due to its persistent uncleanliness. Further observations noted that the resident room floor was dirty, unswept, and had scratches or marks. A CNA acknowledged the bathroom's dirtiness, noting that the dirt around the toilet bowl seemed old. The Housekeeping Supervisor confirmed the bathroom's unclean state and that the room had not been mopped. The Infection Preventionist stated that bathrooms and rooms should be cleaned and sanitized continuously. The Director of Nursing emphasized the expectation for all staff to ensure cleanliness to prevent any risk to residents. The facility's policy and procedure documents outlined the need for maintaining a clean and sanitary environment, including specific cleaning tasks for restrooms and resident rooms.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in altercations between them. Resident 1, who has a history of chronic obstructive pulmonary disease, major depressive disorder, and cerebrovascular disease, hit Resident 2 on the leg while Resident 2 was sleeping. Resident 2, diagnosed with encephalopathy and cognitive communication deficit, retaliated by punching Resident 1 on the chest during a second altercation. The incidents occurred because the staff did not adequately separate the residents after the initial altercation, despite the facility's policy requiring immediate separation and supervision for safety. The staff, including CNAs and the Director of Nursing, acknowledged that Resident 1 should not have been returned to the same room as Resident 2 after the first incident. The CNAs moved Resident 1 to the nurse's station for monitoring but later returned him to the room due to a lack of available beds and the need to provide personal care. This decision led to a second altercation, highlighting a failure to adhere to the facility's policies on resident-to-resident altercations and emergency room changes for health and safety.
Inadequate Infection Control and Ventilation Management
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, specifically in managing the spread of COVID-19. Observations revealed that resident room doors in the COVID-19 positive wing were left open, contrary to the facility's policy which required these doors to remain closed unless the resident was a fall risk. Interviews with the Infection Preventionist (IP) confirmed that none of the COVID-positive residents were fall risks, yet multiple room doors were observed open. Additionally, a Housekeeping Aide reported finding doors open at various times, indicating a lack of consistent enforcement of the policy. Further deficiencies were noted in the management of ventilation measures within the COVID-designated area. The facility's policy required the use of portable air conditioning units with air filters to prevent virus transmission. However, the unit in the COVID-designated area was found turned off, and the air filters had not been cleaned according to the manufacturer's recommendation of weekly maintenance. The Maintenance Manager admitted to cleaning the filters only monthly and lacked a maintenance log or specific policy for the AC units. This oversight in maintaining proper ventilation measures contributed to the facility's failure to control the spread of COVID-19 effectively.
Failure to Screen and Train Registry CNA on Abuse Prevention
Penalty
Summary
The facility failed to ensure that all registry employees were properly screened for background checks and trained on abuse prevention. This deficiency was identified when a registry Certified Nurse Assistant (CNA) was found to have worked at the facility without a background check or abuse prevention training. The Director of Nursing (DON) confirmed that the CNA was involved in an alleged employee-to-resident abuse incident. Despite requests, the facility could not produce the CNA's certification or evidence of abuse prevention training. Interviews revealed that the Staffing Coordinator (SC) was responsible for screening and scheduling registry CNAs but admitted to not checking the required documents for the CNA in question. The CNA confirmed that she worked at the facility for one day without receiving abuse prevention training or undergoing a background check. The facility's policy required such screenings and training, but these procedures were not followed, potentially putting residents at risk.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 1, who was admitted with multiple complex medical conditions including peripheral vascular disease, chronic kidney disease, polyneuropathy, cellulitis, depression, and angina pectoris. Despite having a care plan that included administering hydromorphone for severe pain, the resident did not receive the medication as ordered on the evening of 4/18/24. The resident requested pain medication around 9-9:30 p.m., but the medication was not administered until 3:45 a.m. the following day, resulting in uncontrolled pain, increased agitation, and verbal aggression. The resident's care plan, initiated on 3/25/24, aimed for satisfactory pain control through both non-medication interventions and prn medications. However, on the evening of 4/18/24, the resident's request for pain medication was communicated by a CNA to LVN 1, who did not enter the resident's room or speak to the resident but instead assessed from a distance and concluded that the resident was not in pain. LVN 1 did not inform LVN 2, who was responsible for administering medications to the resident, about the pain medication request. As a result, the resident did not receive the hydromorphone dose from 9:30 p.m. to 12 midnight, with the last dose being administered at 5:49 p.m. The resident's pain escalated, leading to agitation and verbal aggression, and the resident eventually called 911 multiple times. The night shift nurse, LVN 3, noted that the resident usually received hydromorphone every four hours and had only received one dose that evening. LVN 3 had to request the RN to administer the medication due to the resident's severe agitation and aggression.
Failure to Accurately Record Administration of Controlled Drugs
Penalty
Summary
The facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration of controlled drugs for one resident. Specifically, the administration of hydromorphone, a controlled opioid medication, was not accurately recorded in the Medication Administration Record (MAR). This discrepancy was identified during a review of the resident's records, which showed that doses of hydromorphone were popped from the bubble pack on several dates and times but were not signed off as administered in the MAR. The resident reported severe pain and delays in receiving pain medication, which was corroborated by interviews with nursing staff who indicated that the medication was removed from the bubble pack but not properly documented in the MAR by the administering nurse. The resident involved had multiple diagnoses, including peripheral vascular disease, chronic kidney disease, polyneuropathy, cellulitis, depression, acquired absence of the right toe, and angina pectoris. The resident's cognitive status was intact, as indicated by a BIMS score of 15. The failure to accurately record the administration of hydromorphone led to confusion and delays in pain management, as the resident reported waiting several hours and even calling the police multiple times before receiving the medication. The facility's policy and procedure required that the time and dosage of administered drugs be recorded by the person who administered them, which was not followed in this case.
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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