Saylor Lane Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 3500 Folsom Boulevard, Sacramento, California 95816
- CMS Provider Number
- 055417
- Inspections on file
- 21
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Saylor Lane Healthcare Center during CMS and state inspections, most recent first.
The facility was cited for multiple failures in food safety and sanitation, including improper cleaning of the ice machine and freezer, use of damaged equipment such as a worn can opener and grooved cutting boards, improper storage of wet pans, and dietary staff lacking knowledge of correct dishwashing procedures. Additionally, a dietary aide was observed with long artificial nails handling food contact surfaces, all of which had the potential to cause food contamination for all residents receiving meals from the kitchen.
A dumpster located outside the facility was observed with deformed lids that did not close securely, leaving a gap and allowing flies to access the trash inside. Staff confirmed the issue and acknowledged that the dumpster should be tightly sealed, in accordance with facility policy and FDA Food Code requirements.
Nursing staff did not label a gastrostomy tube flush bag with the date and time, failed to document pain assessments before and after administering narcotic pain medication, withheld blood pressure medications based on unverified CNA-obtained vitals, and administered a hazardous chemotherapeutic drug without personal protective equipment. These actions were not in accordance with facility policy or professional standards.
A resident with multiple respiratory and cardiac conditions received oxygen at a higher flow rate than ordered, with no documentation of titration or physician notification, and the nasal cannula was not changed weekly as required. Staff confirmed the oxygen settings and tubing change schedule were not followed, contrary to facility policy and physician orders.
The facility failed to accurately document and account for controlled substances for a resident prescribed tramadol, with discrepancies between the CDR and MAR. Required shift-to-shift controlled drug counts were missing signatures from nursing staff, and a narcotic emergency kit was not replaced promptly after use. Additionally, a resident with diabetes missed a scheduled dose of Ozempic due to lack of medication availability and absence of documented communication with the family.
A resident with diabetes received insulin glargine according to physician orders that required staff to notify the physician or NP if blood sugar readings were below 100 or above 300 mg/dl. On multiple occasions, the resident's blood sugar exceeded 300 mg/dl at the time of scheduled insulin administration, but there was no documentation that the physician or NP was notified. Additionally, while monitoring for hypoglycemia was ordered, there were no parameters for monitoring hyperglycemia, and facility policy for documentation and reporting was not followed.
A medication error rate above 5% was observed when a nurse failed to prime insulin pens before administering insulin lispro to two residents. The nurse was unaware of the priming requirement, which is specified in both manufacturer instructions and facility policy. The DON confirmed that staff are expected to prime insulin pens prior to dosing.
Surveyors found that refrigerated medications, including insulin and flu vaccine, were stored at 28°F, which is below the required range of 36°F to 46°F. The DON confirmed the improper temperature, and facility policy as well as manufacturer instructions specify that these medications should not be frozen and must be discarded if frozen. The deficiency was identified during an inspection of the medication storage room refrigerator.
Dietary aides were unable to accurately describe or demonstrate proper manual and machine dishwashing procedures, including correct sanitizer concentrations and immersion times, despite having attended in-service trainings and being marked as competent. This failure had the potential to place nearly all residents at risk for foodborne illness due to improper sanitization of dishes.
Five residents on mechanical soft diets received smaller portions of meatballs than required, and one resident on a fortified diet did not receive the necessary added gravy and margarine during a lunch meal service. The cook did not follow the facility's menu guidelines for portion sizes and fortification, as confirmed by the RD and facility documentation.
Multiple infection control breaches were observed, including staff handling ready-to-eat food with bare hands, clean linen touching contaminated surfaces, improper cleaning of a shared glucometer, lack of hand hygiene between different medication routes, and failure to change a nebulizer face mask weekly. These actions involved several residents with complex medical needs and were confirmed by staff interviews and policy reviews.
A licensed nurse failed to verify the placement of a PEG tube before administering a bolus feeding to a resident with diabetes and GERD, despite physician orders and facility policy requiring this step. The resident, who was cognitively impaired and dependent on tube feeding, experienced intermittent coughing during the feeding. Facility leadership confirmed that verifying tube placement is the expected standard of practice.
The facility did not maintain documentation of COVID-19 vaccination status for seven staff members, including nurses, CNAs, a laundry aide, and a cook. During interviews and record reviews, it was confirmed that these records were missing despite facility policy requiring vaccination status to be assessed and documented for all employees.
A resident with a history of behavioral outbursts due to Huntington's Disease threw a walker and struck another resident in the rehab room, with staff and other residents present. Despite prior orders to monitor such behaviors, the event was not reported as abuse and was instead treated as a behavioral incident, contrary to the facility's abuse prevention policy.
A resident with Huntington's Disease threw a walker at another resident, striking the individual's knee in the rehab room. The incident was witnessed by the DOR and a PTA, both of whom recognized it as abuse and reported it internally. However, the DON classified the event as a behavioral outburst and did not report it to the Department, contrary to facility policy requiring immediate reporting of abuse allegations.
The facility failed to ensure food safety by not consistently documenting food storage temperature logs and sanitization solution logs. Missing entries were found in the Dry Food Storage Temperature Control Log, Quaternary Ammonium Log, and Cold Storage Temperature Control Log for the month of May 2024, potentially leading to foodborne illnesses for 38 residents.
The facility failed to assess and evaluate the weekly I&O summaries for two residents on fluid restriction, making it difficult to determine their fluid balance and the effectiveness of their fluid restriction orders.
The facility failed to act on the pharmacist's recommendations for a resident's antipsychotic medication monitoring and allowed expired medications to be mixed with current ones in the storage room, leading to unresolved irregularities and potential medication errors.
The facility failed to discard expired flu vaccines, mixing them with non-expired vaccines in the medication refrigerator. A Licensed Nurse confirmed the presence of nine expired syringes from the 2022-2023 season, which should have been discarded according to the facility's policy. This increased the potential for medication errors and compromised drug safety for the residents.
The facility failed to maintain accurate and complete medical records for several residents, leading to potential miscommunication among healthcare providers. Issues included inconsistent documentation of medication administration, failure to properly monitor fluid intake and output, and inaccurate weight records. The DON acknowledged these inaccuracies and the potential confusion they could cause.
The facility failed to maintain an effective infection prevention and control program when a PTA did not wear required PPE while assisting two residents on ESP, and a nasal cannula for another resident was improperly stored, increasing the risk of cross-contamination and infection.
The facility failed to provide proper nail care for two residents, leading to long, unsanitary fingernails with blackish substances underneath. Both residents required assistance with personal care, and the lack of nail care was confirmed through observations and interviews with staff.
The facility failed to follow wound care procedures for two residents, resulting in unlabeled dressings and a stage 3 pressure ulcer not being covered as per physician's orders. The DON confirmed that the dressings should have been labeled and in place according to the facility's policy.
A resident with respiratory failure and COPD did not have an 'oxygen in use' sign on their room door, and their oxygen concentrator was set at 3 lpm instead of the physician-ordered 2 lpm. Both the DON and staff confirmed these discrepancies, which were against the facility's policies.
The facility failed to ensure consistent documentation of a resident's post-dialysis weight and completion of dialysis communication sheets, as required by professional standards, facility policies, and physician's orders. These lapses were confirmed by the DON and an LN, who noted missing or incomplete records on multiple occasions.
The facility failed to protect resident confidentiality when meal tray tickets containing personal information were discarded in the general trash. Kitchen aides were observed throwing away these tickets, and the Dietary Supervisor confirmed this was against policy, which requires shredding of such documents.
Multiple Food Safety and Sanitation Failures in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, or distributed in accordance with professional standards of food safety. Observations revealed that the ice machine was not properly cleaned according to the manufacturer's instructions, with visible black and pink substances present on internal components, and some parts not being removed and sanitized as required. The reach-in freezer was found with sticky brown liquid spills from a soda can explosion that had not been promptly cleaned, and the blade of the can opener was discolored and worn, with the potential for metal shavings to contaminate food. Additionally, two cutting boards had deep grooves, making them difficult to clean and increasing the risk of harboring bacteria, while several metal pans were stacked wet in clean storage areas, contrary to air-drying requirements. Dietary staff demonstrated a lack of knowledge regarding proper manual dishwashing procedures using the 2-compartment sink, including incorrect steps, water temperatures, immersion times, and sanitizer concentrations. One dietary aide was unable to correctly test and identify the proper sanitizer concentration for the dishwashing machine, and used test strips incorrectly during the demonstration. These lapses in knowledge and procedure were confirmed by interviews with the dietary manager and registered dietitian, who acknowledged the importance of proper dishwashing to prevent foodborne illness. Further, a dietary aide was observed with long artificial nails with gem decorations, handling food contact surfaces and clean utensils with bare hands. This was in violation of facility policy and FDA Food Code requirements, which prohibit artificial nails and require short, well-groomed fingernails for food handlers. The report notes that these failures had the potential to cause food contamination and foodborne illness for all residents consuming food from the facility kitchen.
Improperly Sealed Dumpster Creates Environmental Deficiency
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors when the only outdoor garbage dumpster was not securely closed due to deformed lids. During observation, the dumpster was found with both lids bowed away from the edges, leaving a one- to two-inch gap, and several bags of trash inside attracted flies. Staff confirmed that the lids were deformed and did not close tightly, acknowledging that the dumpster should be securely covered. The facility's policy requires dumpster lids to remain closed at all times and for weekly inspections to be documented. The FDA Food Code also mandates that outside receptacles for refuse containing food residue must have tight-fitting lids.
Failure to Follow Professional Standards in Medication Administration and Safety
Penalty
Summary
Nursing staff failed to follow professional standards in several areas, as observed and documented during the survey. For one resident with a gastrostomy tube, the flush bag used for hydration was not labeled with the date and time it was hung, contrary to facility policy and staff expectations. Both a licensed nurse and the nurse consultant confirmed that the flush bag should have been labeled, and the facility's policy on enteral feedings required documentation of the date and time. In another instance, a nurse did not document a pain assessment before or after administering a scheduled narcotic pain medication to a resident, despite stating that the assessment was performed. The Director of Nursing confirmed that staff are expected to document pain assessments before and after administering pain medication to ensure effectiveness and proper pain management. Additionally, during medication administration, nurses withheld blood pressure medications based on vitals obtained by CNAs without verifying or rechecking the measurements, even when the readings were outside the parameters set by physician orders. The DON stated that vitals should be obtained within 30 minutes of medication administration and that it was acceptable to use CNA-obtained vitals if within this timeframe, but did not expect nurses to verify them. Furthermore, a nurse prepared and administered a hazardous chemotherapeutic medication without wearing gloves or any personal protective equipment, stating she was unaware of special handling requirements and did not see such instructions in the physician's order. The DON acknowledged that special handling instructions were not entered for this medication and that staff are expected to consult the pharmacy if unfamiliar with a medication's handling requirements. OSHA guidelines require safe handling for all hazardous drugs, regardless of administration route.
Failure to Follow Physician Orders and Infection Control for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident by not following the physician's order for oxygen therapy and not adhering to the required schedule for changing the oxygen nasal cannula. The resident, who had diagnoses including congestive heart failure, COPD, pleural effusion, and malignant neoplasm of the pleura, was observed receiving oxygen at a flow rate of 4.5 liters per minute (lpm) via nasal cannula, despite a physician's order specifying continuous oxygen at 3 lpm with titration to maintain oxygen saturation above 92%. Multiple observations confirmed the oxygen was set at 4.5 lpm, and there was no documentation of titration or communication with the physician regarding adjustments, as required by the order. Additionally, the resident's physician's order required the oxygen tubing and nasal cannula to be changed once a week and labeled accordingly. However, the nasal cannula in use was labeled with a date more than two weeks prior, indicating it had not been changed as ordered. Staff interviews confirmed awareness of the requirement to change the nasal cannula weekly for infection control, but this was not done for the resident in question. Facility policy and procedures for oxygen administration and infection prevention were not followed, as staff did not verify or adhere to the physician's orders for oxygen flow rate, titration, and documentation, nor did they ensure timely replacement of the nasal cannula. These failures were confirmed through staff interviews and review of facility policies, which outlined the expectations for oxygen therapy and infection control practices.
Deficiencies in Controlled Substance Accountability and Medication Availability
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substances for a resident with a physician's order for tramadol. There were discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR), with instances where medication was removed from the cart but not documented on the MAR, and vice versa. Both the licensed nurse and the Director of Nursing confirmed that facility policy required documentation on both records immediately after administration, and that these discrepancies were present for the resident in question. Additionally, the facility did not consistently obtain signatures from both off-going and on-coming nurses on the controlled drug shift-to-shift count records for multiple medication carts. Several shifts were missing required signatures, which are necessary to confirm that controlled medication counts were completed and that no discrepancies were identified during shift changes. Both nursing staff and the Director of Nursing acknowledged that this was not in accordance with facility policy, which mandates special handling and record keeping for controlled substances. The facility also failed to replace a narcotic emergency kit (e-kit) in a timely manner after it was opened, as required by policy. The opened kit was found with a red plastic tie and logs indicating medication had been removed, but the kit had not been reordered from the pharmacy. Furthermore, a resident with diabetes did not receive a scheduled dose of Ozempic because the medication was pending delivery from the pharmacy, and there was no documentation that the family had been contacted to supply the medication, despite the expectation that such communication should occur and be documented.
Failure to Notify Physician of Elevated Blood Sugar and Inadequate Monitoring for Insulin Administration
Penalty
Summary
A resident with multiple diagnoses, including diabetes type 2, was prescribed insulin glargine with specific physician orders to notify the physician or nurse practitioner if fingerstick blood sugar (FSBS) readings were below 100 or above 300 mg/dl. The resident's medical records showed several instances where FSBS readings exceeded 300 mg/dl at the time insulin was scheduled to be administered. Despite these elevated readings, there was no documentation that the physician or nurse practitioner was notified as required by the orders. Additionally, the resident's orders included monitoring for signs and symptoms of hypoglycemia, but there were no documented parameters or orders for monitoring hyperglycemia. The facility's policies required prompt reporting of abnormal blood sugar results and appropriate documentation, but these procedures were not followed in this case. The Director of Nursing confirmed the lack of documentation and monitoring for hyperglycemia, as well as the absence of required notifications to the physician or nurse practitioner.
Failure to Prime Insulin Pens Results in Medication Error Rate Above Threshold
Penalty
Summary
A medication error rate of 5.56% was identified during a medication pass observation, with two errors out of 36 opportunities involving two residents. During the observed medication administration, a licensed nurse prepared insulin lispro pens for both residents but failed to prime the pens before dialing the prescribed dose. The nurse removed the cap, attached the needle, and dialed the dose directly, omitting the priming step required to ensure accurate dosing. Upon interview, the nurse confirmed not priming the insulin pens and was unaware that priming was a necessary step. The Director of Nursing stated that staff were expected to prime insulin pens with 2 units before dialing the dose. Manufacturer instructions for the insulin lispro pen specify that priming is essential before each injection to ensure correct dosing. The facility's policy also requires medications to be administered safely and as prescribed.
Improper Refrigeration of Medications and Biologicals
Penalty
Summary
Surveyors observed that refrigerated medications and biologicals, including various types of insulin and Afluria Quadrivalent (flu vaccine), were stored in a medication storage room refrigerator at a temperature of 28°F. This temperature was confirmed by the DON and was within the freezing range, which is outside the required storage range of 36°F to 46°F as specified by both the facility's policy and the manufacturers' labeling. The DON acknowledged the improper storage temperature during the inspection. A review of facility policy indicated that medications requiring refrigeration must be kept between 36°F and 46°F, with temperature monitoring in place. Additionally, manufacturer instructions for both insulin and the flu vaccine specifically state not to freeze these products and to discard them if frozen. The facility's policy also requires monthly monitoring of medication storage conditions and corrective action if problems are identified. The improper storage of these medications was directly observed and confirmed during the survey.
Dietary Aides Lacked Competency in Dishwashing and Sanitization Procedures
Penalty
Summary
The facility failed to ensure that dietary aides had the necessary skills and knowledge to safely and effectively perform food and nutrition service functions. During interviews and observations, one dietary aide was unable to accurately describe the proper procedure for manual dishwashing using the 2-compartment sink, including the correct water temperatures, immersion time, and sanitizer concentration. The dietary manager had to prompt the aide using posted instructions, and confirmed that staff, especially dishwashers, needed to be knowledgeable about these procedures. Another dietary aide provided incorrect information regarding the manual dishwashing process and sanitizer concentration, and both aides had attended relevant in-service trainings. Further observations revealed that a dietary aide was unable to properly demonstrate and verbalize the correct method for testing and achieving the appropriate sanitizer concentration when using the dishwashing machine. The aide incorrectly used the test strips and was unable to state the correct concentration required for sanitization. The registered dietitian acknowledged that staff should be able to properly wash and sanitize dishes to prevent foodborne illness. Facility policies and procedures specified the correct steps and concentrations for both manual and machine dishwashing, which were not followed or understood by the aides. A review of employee files showed that both dietary aides had been marked as competent in relevant procedures by the dietary manager, and had attended in-service trainings on dishwashing procedures. However, during the survey, they were unable to demonstrate or verbalize the correct procedures as outlined in facility policies. This failure had the potential to place 31 out of 33 highly susceptible residents at risk for foodborne illness due to improper dishwashing and sanitization practices.
Failure to Follow Prescribed Diet Menus and Portion Sizes
Penalty
Summary
During a lunch meal service, five residents on mechanical soft (MS) texture diets received a smaller portion of meatballs than specified in the facility's menu guidelines. The cook used a #16 scoop (two ounces) instead of the required #10 scoop (three ounces) for these residents, as indicated in the facility's Spring Cycle Menus spreadsheet. Additionally, one resident on a fortified diet did not receive the prescribed extra one ounce of gravy on the meatballs and an extra half ounce of melted margarine on the vegetables, as required for fortified meals. These discrepancies were confirmed through interviews with the cook and the registered dietitian, as well as a review of the facility's menu documentation. The registered dietitian acknowledged that the correct portion sizes and fortification procedures were not followed during the meal distribution. Facility policies and job descriptions for dietary staff require adherence to prescribed menus, portion control, and physician's orders for therapeutic and regular diets. The failure to follow these established procedures resulted in six residents not receiving meals that met their prescribed dietary needs during the observed lunch service.
Infection Control Failures in Food Handling, Linen Management, and Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices involving both staff and residents. Staff were observed handling residents' ready-to-eat food with bare hands, including a certified nurse assistant (CNA) who assisted a visually impaired resident and another resident with their meals without using gloves or utensils. In one instance, the CNA had a cut on her finger covered with a dressing while handling food, and the resident expressed discomfort with this practice. Facility policy and FDA Food Code require the use of utensils or gloves when handling ready-to-eat foods, and that any bandaged hand must be covered with a single-use glove. In the laundry area, a laundry aide was seen allowing clean linen to touch both her clothing and the floor while folding, contrary to facility policy and supervisor expectations. The supervisor and director of nursing (DON) confirmed that clean linen should not come into contact with potentially contaminated surfaces, and that linen touching the floor should be rewashed. Additionally, during medication administration, a licensed nurse was observed using a shared glucometer between residents, cleaning it with a single disinfecting wipe for multiple surfaces, and not sanitizing the insulin pen's rubber seal before attaching a needle. The nurse was unaware of the need to disinfect the pen seal and had not received specific training on proper sanitizing procedures for blood glucose monitors. Further deficiencies included nursing staff failing to perform hand hygiene or change gloves between different routes of medication administration, such as oral, inhaled, and eye medications, and after handling contaminated devices. A nebulizer face mask for a resident with chronic respiratory conditions was not changed every seven days as required by facility policy, with the equipment in use for over three weeks. These failures were confirmed by staff interviews and policy reviews, and resulted in increased risk for cross-contamination and potential exposure to infectious agents among residents, staff, and visitors.
Failure to Verify PEG Tube Placement Prior to Enteral Feeding
Penalty
Summary
A deficiency occurred when a licensed nurse administered a bolus feeding to a resident with a percutaneous endoscopic gastrostomy (PEG) tube without first verifying the tube's placement, as required by physician orders and facility policy. The nurse checked for bowel sounds and residual amount but omitted the step of confirming PEG tube placement prior to starting the enteral feeding. During the feeding, the resident exhibited intermittent coughing. The nurse later acknowledged not checking the tube placement and recognized the importance of this step to ensure the tube was correctly positioned in the stomach before administering the feeding. The resident involved had a history of diabetes mellitus, gastroesophageal reflux disease, and required ongoing attention to a gastrostomy. The resident was cognitively moderately impaired and dependent on tube feeding and water flushes, as documented in the care plan. Facility policy and physician orders specifically required verification of tube placement before each feeding, but this protocol was not followed during the observed incident. Interviews with facility leadership confirmed that checking tube placement is the expected standard of practice to prevent complications.
Failure to Document COVID-19 Vaccination Status for Staff
Penalty
Summary
The facility failed to document and maintain records of COVID-19 vaccination status for seven out of eighty staff members, including licensed nurses, a laundry aide, certified nursing assistants, and a cook. During a concurrent interview and record review, the Director of Staff Development and the Infection Control Nurse confirmed that they could not locate COVID-19 vaccination records for these staff members in the Employee Records. The Director of Staff Development stated that immunizations, including COVID-19, are offered to new hires during their first day of orientation, but documentation for these seven staff members was missing. Interviews with the Administrator and Nurse Consultant confirmed that the facility encourages staff to receive the COVID-19 vaccine for safety and that vaccination is recommended to prevent respiratory infections. A review of the facility's policy indicated that vaccination status should be assessed and documented prior to or upon an employee's duty assignment. Despite this policy, the records for the identified staff members did not include documentation of their COVID-19 vaccination status.
Failure to Protect Resident from Physical Abuse in Rehabilitation Room
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident, who had a history of behavioral outbursts related to Huntington's Disease, threw a walker and struck the resident on the left knee in the rehabilitation room. Both residents involved were cognitively intact according to their most recent assessments. The incident was witnessed by the Director of Rehab and a Physical Therapy Assistant, who confirmed that the action was unprovoked and that other residents were present during the event. After the initial assault, the aggressor attempted to attack the same resident again and was restrained by staff. Despite the aggressor's known history of throwing objects and a physician's order to monitor and document such behaviors, the facility did not classify the event as resident-to-resident abuse, instead treating it as a behavioral outburst. The Director of Nursing and other staff interviews revealed that the incident was not reported to the Department as abuse, and the facility's policy on abuse prevention, which mandates protection from all forms of abuse, was not followed in this case.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the Department as required by policy and regulation. The incident involved a resident with Huntington's Disease, who had a history of behavioral outbursts, throwing a walker at another resident in the rehabilitation room, striking the second resident's left knee. Both residents were assessed as cognitively intact. The event was witnessed by the Director of Rehab (DOR) and a Physical Therapy Assistant (PTA), both of whom confirmed the altercation and acknowledged their status as mandated reporters. The DOR reported the incident to the facility's Administrator and DON, who indicated it would be handled, but the incident was not reported to the Department as required. Interviews with staff, including the DOR, PTA, and a licensed nurse, confirmed that the event was recognized as a resident-to-resident altercation and should have been reported. However, the DON stated the facility did not consider the incident as abuse, but rather as a behavioral outburst, and therefore did not report it to the Department. Review of the facility's policy indicated that all alleged violations involving abuse must be reported immediately or within specified timeframes, but this procedure was not followed in this case.
Failure to Document Food Storage and Sanitization Logs
Penalty
Summary
The facility failed to ensure food safety by not consistently documenting food storage temperature logs and sanitization solution logs. During an observation and interview with a cook, it was found that the Dry Food Storage Temperature Control Log had four missing entries for the month of May 2024. The cook acknowledged that missing entries were unacceptable and could lead to food safety concerns. Similarly, the Kitchen Aid confirmed that the Quaternary Ammonium Log had seven missing entries for the same month, and the Cold Storage Temperature Control Log had 14 missing entries. The Dietary Supervisor also confirmed these discrepancies and stated that the logs were expected to be completed twice daily to prevent potential resident harm. The facility's policies and procedures were reviewed, revealing that the logs were supposed to be maintained to minimize the risk of foodborne illness. The policy on preventing foodborne illness indicated that food temperatures should be monitored and documented at designated intervals throughout the day. The Quaternary Ammonium Log Policy required the concentration of the ammonium in the sanitizer to be tested and recorded at least every shift. The failure to adhere to these policies had the potential to lead to foodborne illnesses for the 38 residents eating facility-prepared meals.
Failure to Monitor Fluid Intake for Residents on Fluid Restriction
Penalty
Summary
The facility failed to assess and evaluate the Intake and Output (I&O) weekly summaries for two residents who were on fluid restriction. Resident 20, diagnosed with hemodialysis, heart disease, and lung problems, had a fluid restriction order of 2000 ml per 24 hours. Resident 23, diagnosed with chronic kidney disease and on anticoagulant therapy, had a fluid restriction order of 1500 ml per 24 hours. Despite these orders, there was no documented evidence that Licensed Nurses (LNs) summed up the residents' 24-hour fluid intake totals or completed the weekly fluid intake summaries for either resident. During interviews, LN 2 confirmed that the weekly I&O summaries were not completed for Resident 20 and Resident 23, acknowledging the importance of these summaries in determining fluid balance and evaluating the effectiveness of fluid restriction orders. The Director of Nursing (DON) also verified the absence of weekly I&O evaluations for the residents, stating that without these evaluations, it was difficult to understand the accurate fluid status of the residents.
Failure to Act on Pharmacist's Recommendations and Manage Medication Storage
Penalty
Summary
The facility failed to provide thorough drug regimen reviews (DRR) for one of 15 sampled residents when it did not act on the facility pharmacist's (FP) report on irregularities and allowed expired medications to be mixed with other medications in the medication storage room refrigerator. This resulted in unresolved irregularities of antipsychotic medication therapy for the resident and increased the potential for medication errors. Resident 23, a long-term resident with unspecified memory problems and behavioral disturbances, was on antipsychotic medication monitoring every shift. The resident had two physician orders for Risperidone that were discontinued, but the facility did not act upon the FP's recommendation to remove the associated side effect and behavior monitoring. The facility's failure to act on the FP's March DRR recommendation led to continued monitoring despite the discontinuation of the medication. Additionally, during a medication storage room observation, expired flu vaccines were found mixed with current vaccines. The FP acknowledged that checking the medication storage room was part of the monthly DRR process and that expired medications should have been identified and removed. The facility's failure to act on the FP's recommendations and properly manage medication storage resulted in unresolved irregularities and potential confusion among healthcare providers.
Expired Flu Vaccines Mixed with Non-Expired Vaccines
Penalty
Summary
The facility failed to discard expired medications, specifically flu vaccines, for a census of 38 residents. During an observation of the medication storage room, it was found that expired flu vaccines from the 2022-2023 season were mixed with non-expired flu vaccines from the 2023-2024 season in the medication refrigerator. There were nine pre-filled syringes of the expired vaccine with an expiration date of 6/30/23. The facility's policy from March 2018 requires outdated medications to be immediately removed from stock and disposed of properly. A Licensed Nurse confirmed the presence of the expired vaccines and acknowledged that night shift nurses were responsible for discarding expired medications. The failure to separate and discard expired medications increased the potential for medication errors and compromised drug safety for the residents.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to maintain accurate, consistent, and complete medical records for several residents, leading to potential miscommunication among healthcare providers. For Resident 23, the medical records were inconsistent regarding the administration of Risperidone, an antipsychotic medication, which was discontinued but still documented as being monitored. Additionally, the resident's fluid intake and output (I&O) were not properly evaluated weekly as required by the facility's policy. The Director of Nursing (DON) acknowledged these inaccuracies and the potential confusion they could cause among healthcare providers. Resident 4's medical record inaccurately reflected the administration of a liquid protein supplement, which the resident had refused. The Licensed Nurse (LN) responsible for administering the medication did not document the refusal or notify the DON or Registered Dietician (RD), contrary to the facility's practice. The DON confirmed that all medication refusals, including supplements and over-the-counter medications, should be documented and reported. Resident 20's medical records showed significant weight fluctuations, which were inaccurately documented, and the resident's fluid restriction therapy was not properly monitored. The RD explained that a recorded weight of 50.7 lbs was likely a typo and should have been in kilograms. Additionally, the weekly I&O evaluations were not conducted as required. For Resident 3, the medical records continued to monitor for side effects of Abilify, an antipsychotic medication, even after it had been discontinued. The DON verified these inaccuracies and acknowledged that the medical records were incomplete and inconsistent with the care provided, potentially misleading healthcare providers about the residents' health status.
Failure to Follow Infection Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a census of 38 residents. Specifically, a Physical Therapy Assistant (PTA) did not wear the required personal protective equipment (PPE) when assisting two residents, both on enhanced standard precautions (ESP) due to their medical conditions. The PTA was observed assisting Resident 233 with mobility exercises and checking their oxygen level without wearing a gown or gloves, despite the resident having a stage 3 pressure ulcer and an occipital abscess. Similarly, the PTA assisted Resident 234 with sit-to-stand mobility exercises without wearing a gown or gloves, even though the resident had a surgical site on the left knee and was under ESP. Both residents had clear signage and care plans indicating the need for PPE during mobility assistance, which the PTA failed to follow. Additionally, the facility failed to properly store a nasal cannula for Resident 14, who had respiratory failure, COPD, heart failure, and was dependent on supplemental oxygen. The nasal cannula was left uncovered and hanging on the resident's bedside rail when not in use, instead of being placed inside a bag as required for infection control. This was confirmed by a Licensed Nurse (LN) who acknowledged that the nasal cannula should have been bagged when not in use. Interviews with the Chief Clinical Officer (CCO) and the Director of Nursing (DON) confirmed that the facility was aware of the new guidelines regarding ESP and that staff should follow these precautions to prevent the spread of infections. The facility's policy and procedure documents also supported the need for enhanced standard precautions and proper storage of medical devices to reduce the risk of cross-contamination and infection among residents, staff, and visitors.
Failure to Provide Proper Nail Care for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident 232 and Resident 23, received proper nail care as part of their Activities of Daily Living (ADLs). Resident 232, who had diagnoses including chronic obstructive pulmonary disease and atrial fibrillation, was observed with long fingernails and a blackish substance underneath them. Despite having a moderate cognitive impairment and requiring assistance with personal hygiene, there was no documented refusal of nail care. Both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN) confirmed the lack of nail care, and the Director of Nursing (DON) emphasized the importance of maintaining clean and short nails for infection control. The resident's care plan was updated only after the observation to include the need for nail care to reduce the risk of injury and infection. The facility's policy on ADLs also indicated the need for appropriate hygiene care, which was not followed in this case. Similarly, Resident 23, who had muscle weakness and required assistance with personal care, was found with long, unsanitary fingernails containing a black substance. The resident expressed discomfort and inconvenience due to the long nails, which were getting caught in blankets and clothes. A Licensed Nurse verified the condition of the nails and stated that nail trimming was supposed to occur every Sunday, indicating a lapse in the scheduled care. Both residents' conditions and the lack of proper nail care were confirmed through observations, interviews, and record reviews, highlighting a failure in the facility's adherence to its own policies and care plans.
Failure to Follow Wound Care Procedures
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice and the facility's policy and procedure. Resident 233 had a physician's order for the treatment of a stage 3 pressure ulcer on the coccyx, which required cleansing with normal saline, patting dry, applying calcium alginate, and covering with a dry dressing daily and as needed if soiled or dislodged. However, during an observation, it was found that Resident 233's stage 3 pressure ulcer was not covered with a dry dressing as per the physician's order. The Director of Nursing confirmed that the dressing should have been in place according to the physician's order and the facility's wound care policy, which mandates verifying physician's orders and using appropriate dressing materials. Additionally, the dry dressings on Resident 233's head and inner right thigh were not labeled with the nurse's initials, date, and time of application, which was also confirmed by the Licensed Nurse and the Director of Nursing as a requirement for proper wound care management. Resident 234, who was admitted with diagnoses including the need for orthopedic aftercare and assistance with personal care, had a physician's order for the treatment of a surgical site on the left knee. The order specified cleansing with normal saline, patting dry, applying Xeroform, and covering with a dry dressing daily and as needed if soiled or dislodged. During an observation, it was found that the dry dressings on Resident 234's left knee were not labeled with the nurse's initials, date, and time of application. Resident 234 confirmed the observation, and the Director of Nursing stated that the dressings should be labeled properly to keep track of dressing changes and ensure compliance with the physician's order. The facility's policy and procedure for wound care, revised in October 2010, indicated that dressings should be labeled with the nurse's initials, time, and date of application. The failure to follow these procedures for both Resident 233 and Resident 234 had the potential to impact their wound healing and overall well-being. The Director of Nursing acknowledged that the dressings should have been labeled and in place as per the physician's orders and the facility's policy.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper handling and delivery of respiratory care for Resident 14, who had diagnoses including respiratory failure, COPD, heart failure, and dependence on supplemental oxygen. The deficiencies included the absence of an 'oxygen in use' sign on the outside of Resident 14's room entrance door, which was confirmed by Licensed Nurse 4 during an observation. The Director of Nursing (DON) acknowledged that the sign is a precautionary measure to prevent potential harm to patients and staff. The facility's policy and procedures for oxygen administration, revised in October 2010, required the placement of such a sign, but this was not followed in Resident 14's case. Additionally, Resident 14's physician's orders for oxygen therapy were not adhered to. The physician's order specified that oxygen should be administered at 2 liters per minute (lpm) via nasal cannula continuously. However, during an observation, it was found that the oxygen concentrator was set at 3 lpm. Both Resident 14 and Certified Nurse Assistant 3 confirmed this discrepancy. Licensed Nurse 4 and the DON both stated that the staff should follow the physician's orders, and the DON highlighted that administering 3 lpm instead of 2 lpm could cause hyperoxygenation. The facility's policy and procedures also required staff to adjust the oxygen delivery device to ensure the proper flow of oxygen, which was not done in this instance.
Failure to Document Dialysis Care Consistently
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care services received care consistent with professional standards of practice, facility policies, and physician's orders. Specifically, the resident's post-dialysis weight was not consistently documented in the resident's chart on multiple occasions, including specific dates in May. The Director of Nursing (DON) and a Licensed Nurse (LN) confirmed the absence of these documented weights, which are crucial for monitoring significant weight changes as per the physician's order. Additionally, the facility did not consistently complete the dialysis communication sheet for the resident. The sheet, which should be filled out before and after dialysis sessions, was found incomplete or missing on several occasions. The DON and LN confirmed these lapses, with the LN noting that the dialysis communication sheet binder sometimes gets lost. The facility's policy and procedure, as well as the resident's care plan, require the completion of these sheets to document vital signs, changes in condition, and other relevant information pre- and post-dialysis.
Failure to Protect Resident Confidentiality
Penalty
Summary
The facility failed to ensure residents' rights to personal privacy and confidentiality of their personal medical information when meal tray tickets containing residents' names, diets, and room numbers were found discarded in the general trash. During observations, kitchen aides were seen throwing away these meal tickets into the kitchen garbage can, which was later emptied into an outside garbage bin. The Dietary Supervisor confirmed that this practice was against the facility's policy, which requires meal tickets to be collected for shredding to protect residents' confidential information. The facility's policy on confidentiality and personal privacy, revised in October 2017, mandates that access to resident personal and medical records be limited to authorized staff.
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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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