Sharp Chula Vista Med Ctr Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Chula Vista, California.
- Location
- 751 Medical Center Court, Chula Vista, California 91911
- CMS Provider Number
- 555216
- Inspections on file
- 21
- Latest survey
- October 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sharp Chula Vista Med Ctr Snf during CMS and state inspections, most recent first.
The facility failed to accommodate residents' preferences for bus outings, which were discontinued during the COVID-19 pandemic. Despite receiving a grant for outings, the facility was unable to secure suitable transportation for residents in wheelchairs. Residents expressed a strong desire for group outings to maintain their independence and experience the outside world, but the facility did not fulfill these needs.
The facility failed to monitor and document target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. A resident was not monitored for behaviors and side effects related to antidepressants and anti-anxiety medication, while two other residents lacked proper monitoring for antidepressant medications. Another resident's antidepressant use lacked appropriate target behavior monitoring, with discrepancies between care plans and physician orders.
The facility's kitchen was found to have multiple deficiencies, including dented and expired food items, improper labeling and storage, unsanitary conditions, and inadequate personal hygiene practices. These issues were acknowledged by the facility's management and pose a risk of foodborne illnesses to residents.
A resident with arteriosclerotic cardiovascular disease transitioned from skilled to custodial care without receiving an Advanced Beneficiary Notice (ABN), despite having remaining Medicare days. The facility issued a Notice of Medicare Non-Coverage (NOMNOC) instead, failing to inform the resident of private pay options or appeal rights. Interviews revealed staff were unaware of the ABN requirement, and the facility's policy was not followed.
A resident with a history of stroke was readmitted to an LTC facility with a new stroke diagnosis, resulting in a decline in ADLs and dependence on tube feeding. Despite these changes, the facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days, as required. Staff interviews confirmed the oversight, noting that the resident's condition had significantly declined and was not expected to return to baseline within two weeks.
The facility failed to implement care plans for three residents regarding RNA ROM exercises. A resident with a traumatic brain injury received fewer passive ROM exercises than prescribed, leading to contractures. Another resident with weakness and confusion did not receive the required active and passive ROM exercises, risking contractures and decline. A third resident with stroke-related hemiparesis received fewer ROM exercises than ordered, risking further decline. Staff interviews and observations confirmed these deficiencies.
A facility failed to provide ordered ROM exercises for three residents, leading to potential worsening of contractures. One resident with a traumatic brain injury received fewer passive ROM exercises than ordered due to staffing issues. Another resident with weakness and confusion did not receive any ROM exercises despite orders. A third resident with stroke-related hemiparesis received fewer exercises than prescribed. The facility's policy emphasized adherence to the written plan for maintaining residents' independence.
The facility failed to properly store and label insulin aspart, with bottles not labeled with open dates, leading to potential interchanging and compromised medication integrity. The DON confirmed that without proper labeling, LNs could not ensure the correct use of insulin, which has a 28-day expiration upon opening.
The facility did not address transportation concerns for outdoor activities raised by the resident council in their QAPI program. Although the DON acknowledged the issue and its potential impact on residents' quality of life, it was not documented or formalized in the QAPI plan. Efforts to restore transportation options post-pandemic were ongoing, but the issue remained unaddressed in the QAPI activities.
The facility failed to implement proper infection prevention and control practices for two residents. A CNA entered a resident's room on contact precautions without PPE, and an LN did not wear a gown or change gloves during high-contact care for a resident on enhanced barrier precautions. These actions violated the facility's infection control policies, posing a risk of infection spread.
The facility failed to implement an effective antibiotic stewardship program, as the Infection Preventionist and pharmacy staff did not adequately track and monitor antibiotic use. A resident was coded for antibiotic use on the MDS but not on the MAR, indicating a gap in oversight. Interviews revealed inconsistencies in tracking processes, and there was no documented evidence of a comprehensive tracking list, contrary to the facility's policy.
A resident reported to their Responsible Party that a CNA had pulled their arm and spoken hurtfully. The Social Worker informed management, but the DON and Clinical Lead were unaware of the abuse allegation. The Clinical Lead investigated other concerns but did not address the abuse allegation, thinking it was an old incident, contrary to the facility's policy requiring immediate investigation.
A resident with a potential malignancy diagnosis was not protected from unauthorized visitors despite an APS case indicating financial exploitation concerns. The facility failed to create a care plan or communicate restrictions to staff, allowing restricted individuals to visit the resident multiple times.
Failure to Provide Resident Outings
Penalty
Summary
The facility failed to accommodate the activity preferences of its residents, specifically regarding bus outings, which were previously available before the COVID-19 pandemic. During a confidential group meeting, six residents expressed dissatisfaction with the discontinuation of these outings, which included trips to stores, parks, and other recreational locations. The facility's bus and driver were no longer available, and efforts to find alternative transportation had been unsuccessful due to cost and capacity issues. The residents emphasized their desire for group outings to experience the outside world and maintain their independence. The facility's records from February to September 2024 indicated ongoing attempts to secure transportation, but no progress was made. Interviews with staff members revealed that the facility had received a grant for bus outings, but they were still unable to find suitable transportation for residents in wheelchairs. The Director of Nursing acknowledged the residents' rights to outings and the facility's failure to accommodate these needs. The facility's policy on activities emphasized the importance of community outings and accommodating residents' preferences, which was not fulfilled in this case.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to appropriately monitor and document the target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. Resident 274 was not monitored for behaviors and side effects related to two antidepressants and one anti-anxiety medication. Interviews revealed that the monitoring was subjective and lacked objective measures, and side effects were not documented in the medication administration record (MAR). The facility's policy required monitoring for suspected adverse drug reactions, which was not adhered to in this case. Residents 35 and 58 also lacked proper monitoring for behaviors and side effects associated with their antidepressant medications. For Resident 35, there was no measurement of sleep hours to evaluate the effectiveness of Trazodone, and the MAR showed zeros for a month of use. Similarly, Resident 58's record did not include a way to measure the behavior for Trazodone, and the MAR also showed zeros for a month's use. The facility's policy emphasized the importance of monitoring for adverse drug reactions, which was not followed. Resident 51's use of antidepressant medication lacked appropriate target behavior monitoring. The care plan and physician's orders did not align, leading to confusion about the target behavior for monitoring. Interviews indicated that there was no clear method to measure depressive behavior, such as continuous crying or refusal of care. The facility's policy required documentation of the necessity for medication and monitoring of its effects, which was not adequately implemented for Resident 51.
Multiple Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen, leading to multiple deficiencies. Observations revealed dented cans of thyme and hoisin sauce, which were acknowledged by the Food Service Manager (FSM) and Food Operations Manager (FOM) as potentially hazardous due to the risk of botulism. Additionally, expired food items such as wonton chips, split peas, corn starch, barley, beans, dried red chili peppers, mango mousse, parmesan cheese, and shredded zucchini were found, which the FSM and FOM agreed should be discarded to ensure food safety. Further deficiencies were noted in the labeling and storage of food items. Unlabeled and improperly sealed food items, including pasta, graham crumbs, chili peppers, bread, hash browns, and various vegetables, were observed. The FSM and FOM acknowledged the importance of labeling to ensure freshness and prevent contamination. The facility's policy on food storage was not adhered to, as evidenced by cracked and loose container lids, dust, and spilled food on container lids, which could lead to contamination. Additional unsanitary conditions included the presence of moldy strawberries, wilted produce, dirty rugs, trash in storage areas, and improper storage of ready-to-eat food above raw meat. Kitchen utensils were found with crusted food debris, and personal items such as employee drinks and belongings were improperly stored in food preparation areas. A Nutrition Assistant was observed preparing food without a hair covering, increasing the risk of contamination. These findings indicate a failure to comply with professional standards and the facility's own policies, potentially exposing residents to foodborne illnesses.
Failure to Provide Advanced Beneficiary Notice for Custodial Care Transition
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident 282, who transitioned from skilled services to custodial care. Resident 282 was admitted with a history of arteriosclerotic cardiovascular disease and had remaining Medicare days when skilled services were discontinued. The facility's Assistant Director (AD 1) acknowledged that a Notice of Medicare Non-Coverage (NOMNOC) was issued instead of an ABN, despite the resident not exhausting Medicare skilled days. This oversight resulted in Resident 282 not being informed of the option to continue services under private pay or the associated costs, nor having the opportunity to appeal the decision. Interviews with facility staff, including AD 1, AD 2, and the Director of Nursing (DON), revealed a lack of awareness and proper procedure regarding the issuance of the ABN. AD 2 confirmed that the ABN provided was unsigned and that the business office had not issued an ABN document before September 2024. The DON expressed that it was crucial for the resident and their responsible party to be notified about the transition to custodial care and the implications of non-coverage. The facility's policy required an ABN to be completed and signed when services were believed to be non-covered, which was not adhered to in this case.
Failure to Complete SCSA for Resident with Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident who experienced a significant change in condition. The resident, who had a history of stroke, was readmitted to the facility with a new stroke diagnosis and exhibited a decline in activities of daily living (ADLs), becoming dependent on tube feeding and unable to participate in the Brief Interview for Mental Status (BIMS). Despite these changes, the facility did not conduct the required SCSA, which is necessary to update the resident's plan of care based on their current health status. Interviews with facility staff, including MDS Coordinators and the Director of Nursing (DON), confirmed that the resident's condition had significantly declined in multiple areas, including mental status, nutrition, and ADLs. The staff acknowledged that an SCSA should have been completed as the resident was not expected to return to their prior levels of function within two weeks. The failure to conduct the SCSA was attributed to the completion of another comprehensive admission MDS instead, which did not adequately reflect the resident's current health status and needs.
Failure to Implement ROM Exercises as per Care Plans
Penalty
Summary
The facility failed to implement care plans for three residents concerning Restorative Nursing Assistant (RNA) range of motion (ROM) exercises. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises daily to prevent further contractures. However, the RNA weekly summary indicated that Resident 1 only received these exercises five times a week instead of the prescribed seven times. Observations showed that Resident 1's hands were contracted, and interviews with staff confirmed the lack of adherence to the care plan. Resident 45, who was admitted with weakness and confusion, required assistance with activities of daily living and was supposed to receive both active and passive ROM exercises five times a week. However, interviews with staff revealed that these exercises were not being provided as per the care plan. The care plan aimed to prevent contractures and decline in ROM, but it was not implemented, as confirmed by the staff and the Director of Nursing (DON). Resident 51, who had a stroke with right-sided hemiparesis, was dependent on staff for most activities and was supposed to receive daily ROM exercises. The RNA weekly summary showed that Resident 51 received these exercises only five times a week instead of daily. Interviews with staff and the DON confirmed that the care plan was not followed, which was necessary to prevent contractures and decline in performing activities of daily living. The facility's policies did not clearly indicate the implementation of care plans, contributing to the deficiency.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
The facility failed to consistently provide Restorative Nursing Assistant (RNA) services for range of motion (ROM) exercises as per physician's orders for three residents with limited ROM. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises seven times a week to prevent worsening of contractures. However, due to insufficient RNA staffing, Resident 1 only received these exercises five times a week, which was not in compliance with the physician's orders. Resident 45, who was admitted with weakness and confusion, was ordered to receive both active and passive ROM exercises five times a week. Despite this, there were no records of ROM exercises being provided to Resident 45 since the order was given. This oversight was confirmed by the staff, who acknowledged that Resident 45 was not enrolled in the RNA program and did not receive the necessary exercises to prevent the development of contractures. Resident 51, who had a stroke with right-sided hemiparesis, was ordered to receive daily ROM exercises. However, the facility only provided these exercises five times a week, contrary to the physician's orders. The staff confirmed the discrepancy, acknowledging that the exercises were not provided as frequently as required. The facility's policy on the Restorative Nursing Program emphasized the importance of following the written plan to help residents achieve and maintain the highest possible levels of independence, which was not adhered to in these cases.
Improper Storage and Labeling of Insulin Aspart
Penalty
Summary
The facility failed to properly store and label house supply/stock medications, specifically insulin aspart, with open dates. During an observation and interview, it was found that two boxes of insulin aspart were stored in a medication refrigerator, each containing one bottle. One box was labeled with an open date, but the bottle inside was not labeled. The other box was labeled with an expiration date, but again, the bottle inside was not labeled with an open date. This lack of labeling could lead to the interchanging of bottles, compromising the integrity of the medication. The Director of Nursing (DON) confirmed that insulin has a 28-day expiration upon opening and acknowledged that without proper labeling, Licensed Nurses (LNs) would not be able to determine which bottle corresponded to the correct box with the open date. This oversight could result in the use of ineffective medication. The facility's policy on drug storage and security requires all medications to be accurately labeled with expiration dates and stored in a manner that reduces the likelihood of error.
Failure to Address Resident Council Concerns in QAPI
Penalty
Summary
The facility failed to identify and address concerns raised in the residents council minutes regarding transportation for outdoor activities within their Quality Assurance and Performance Improvement (QAPI) program. During an interview with the QAPI program members, it was revealed that the team utilized various sources of information, including family and resident feedback, to track performance and make necessary changes to policies and procedures. However, the Director of Nursing (DON) admitted that while concerns from the resident council were discussed, they were not documented or formalized into the QAPI plan. The DON further explained that transportation for activities had been halted during the pandemic, and efforts were being made to restore these options. Despite recognizing that the lack of transportation could affect residents' quality of life, the facility did not formally address the issue in their QAPI activities. A review of the facility's QAPI policy indicated that the program should encompass all segments of care and services impacting clinical care, quality of life, and resident choice, yet the transportation issue was not included.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents, leading to deficiencies in care. For Resident 52, who was on contact precautions due to a history of methicillin-resistant Staphylococcus aureus (MRSA), a CNA entered the resident's room without performing hand hygiene or wearing the required personal protective equipment (PPE), such as a gown and gloves. The CNA admitted to not knowing why the resident was on contact precautions and acknowledged the importance of following these precautions to prevent the spread of infection. Additionally, the Infection Prevention nurse did not have a complete list of residents on infection control precautions, which contributed to the oversight. For Resident 1, who was in a vegetative state and on enhanced barrier precautions (EBP) due to the use of a gastrostomy tube, a licensed nurse (LN) failed to wear a gown and did not change gloves between procedures while administering tube feeding. The LN incorrectly believed that wearing a gown was discretionary and admitted to not changing gloves after touching a potentially contaminated curtain. The Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact activities with residents on EBP to prevent infection spread. The facility's policies on standard and transmission-based precautions, as well as enhanced barrier precautions, were not followed by the staff, leading to potential risks of infection spread among residents, staff, and visitors. The lack of adherence to these protocols highlights a significant deficiency in the facility's infection control practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as per its own policy and procedure. During an interview and record review, the Infection Preventionist (IP) acknowledged that while the pharmacy assisted with logging and tracking antibiotics, there was no comprehensive tracking system in place. The IP was responsible for tracking urinary tract infections (UTIs), but there was no documented evidence of a line tracking list for antibiotics. This lack of documentation and oversight was further highlighted by the fact that a resident was coded for antibiotic use on the Minimum Data Set (MDS) but was not listed on the medication administration record (MAR), indicating a gap in tracking and monitoring antibiotic use. Interviews with pharmacy staff revealed further inconsistencies in the antibiotic tracking process. Pharm 1 stated that he did not track the antibiotic line list and suggested that another pharmacist might be responsible. Pharm 2 mentioned the use of antibiotic escalation but emphasized the need for a collaborative process to ensure all information is available and accessible to the healthcare team. The facility's long-term care policy on antimicrobial stewardship indicated the need for a designated committee to monitor antimicrobial use, but this was not effectively implemented, leading to a deficiency in the facility's antibiotic stewardship program.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse for one of the sampled residents, leading to an increased risk of abuse for the resident. The resident was admitted to the facility and later reported to their Responsible Party (RP) that a Certified Nursing Assistant (CNA) had pulled their arm and spoken to them in a hurtful manner. The RP communicated these concerns to the facility's Social Worker (SW), who then informed the facility's management. However, the Director of Nursing (DON) and the Clinical Lead (CL) were not aware of the abuse allegation. The CL conducted an investigation into the RP's concerns but did not investigate the abuse allegation, mistakenly believing it was related to an old incident. This oversight was contrary to the facility's policy, which mandates immediate investigation of any abuse charges.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to develop a care plan to ensure the safety of a resident who was at risk due to financial exploitation concerns. The resident was admitted with a diagnosis that included an ill-defined liver mass concerning for malignancy. An Adult Protective Services (APS) case was opened after a family member expressed concerns about the resident's financial transactions with neighbors. Despite the APS report and a psychiatrist's determination that the resident lacked the capacity for financial decision-making, the facility did not create a care plan to restrict certain visitors, leading to unauthorized visits by individuals suspected of exploiting the resident. Interviews with facility staff, including the Director of Nursing (DON), Licensed Nurses (LN), and Certified Nurse Assistants (CNA), revealed a lack of awareness and communication regarding the restricted visitors. The visitor logs showed that the restricted individuals visited the resident multiple times after the APS report was filed. The facility's policy required care plans to be reviewed and revised as needed, but no such plan was created for the resident, and there was no documentation of restricted visitors in the resident's records.
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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