Skyline Healthcare Center - San Jose
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 2065 Forest Avenue, San Jose, California 95128
- CMS Provider Number
- 055318
- Inspections on file
- 61
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Skyline Healthcare Center - San Jose during CMS and state inspections, most recent first.
A resident with vertebral osteomyelitis and coccyx/left buttock wounds, cognitively intact per BIMS, reported that an LVN repeatedly punched, slapped, and squeezed his wound during ordered dressing changes, once captured on video showing the LVN making a fist and striking the wound through the dressing, causing the resident to cry out in pain. The resident also stated the LVN sometimes left him with pants down, curtain and door open, causing humiliation. Another resident corroborated witnessing the LVN hit, squeeze, or slap the wound and strike him across the backside. These actions occurred despite a facility abuse prevention policy stating residents have the right to be free from abuse and that administration will protect residents from abuse by anyone.
Surveyors found that food items, including cottage cheese past their use-by dates and unlabeled beverages, were improperly stored in facility refrigerators, some of which were operating at temperatures above the required range. Staff confirmed that these practices did not meet facility policies for food safety, labeling, and timely disposal.
Two dumpsters were found overfilled with garbage and their lids not fully closed, with additional trash bags left outside the covered dumpsters. Both the maintenance assistant and maintenance director confirmed that dumpsters should not be overfilled and all trash should be placed inside covered units, in accordance with facility policy and FDA Food Code requirements.
Staff were observed standing while feeding a resident instead of sitting at eye level, and two residents waited for their meal trays while another at the same table was already eating, contrary to facility policy. Additionally, a resident's urinary drainage bag was left uncovered and visible. These actions did not uphold resident dignity and comfort as required.
Several residents who were alert and cognitively intact reported not knowing the results of previous state surveys or the location of the survey binder. Key staff, including the Activity Director, were also unaware of the binder's location. Facility policy required survey results to be accessible and communicated to residents, but this was not done, as confirmed by interviews and record review.
Two LVNs did not wear gloves while handling a hazardous medication, despite clear labeling and facility policy requiring PPE use. Additionally, a resident with paraplegia did not have weekly weight monitoring as ordered by the physician, with the last weight recorded more than a month prior. Both deficiencies were confirmed by supervisory staff and were not in accordance with facility policies.
A review of medication records revealed that staff failed to accurately document the administration and removal of controlled medications for several residents. In some cases, medications were recorded as given in the MAR but not signed out in the CDR, while in other cases, medications were signed out in the CDR but not documented in the MAR. These discrepancies were confirmed by staff interviews and record reviews, resulting in inaccurate accountability of controlled substances.
Surveyors found that medications and biologicals were improperly stored, with different routes of administration and both active and discontinued drugs kept together in a medication room bin, and opened bottles of normal saline left unattended at the bedside tables of two residents. Staff confirmed these practices were not in line with facility policy, which requires proper storage and restricted access to medications.
Surveyors identified multiple infection control lapses, including used urinals and soiled linens improperly stored, medical equipment covered with used items, and improper storage of suction devices. A resident with a biliary catheter did not have required enhanced barrier precaution signage or PPE at the room entrance. Staff, including a treatment nurse and two kitchen employees, were observed not wearing face masks properly during wound care and food preparation. These deficiencies were confirmed by staff and were not in accordance with facility policy.
Surveyors observed that the dishwashing area floor was very wet and lacked a caution sign to warn staff or others entering the kitchen. Both the dietary manager and registered dietitian confirmed that safety signage should have been present, and facility policy requires prompt use of wet floor signs to maintain a safe environment.
The facility did not ensure that laundry staff consistently documented the cleaning of dryer lint as required by facility policy, with logs left blank for several hours on multiple days. The housekeeping supervisor and infection preventionist confirmed the expectation for hourly documentation, but records showed noncompliance.
A resident with epilepsy and developmental disorders was found asleep with her call light button on the floor, making it inaccessible. An LVN confirmed the inaccessibility and acknowledged the need for a more appropriate device, as required by facility policy for residents unable to use the standard call system.
Two residents were not given a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when Medicare Part A services were discontinued, despite having benefit days remaining and continuing to reside in the facility. Facility records and staff confirmed that the required notice was not provided, as mandated by CMS guidelines.
A resident did not have an annual MDS assessment completed within the required timeframe. Review of the medical record and confirmation by the MDS Coordinator showed that the assessment was missed, in violation of CMS requirements for annual comprehensive assessments.
Two residents' MDS assessments were inaccurately coded: one resident's multiple falls were not recorded, and another resident's tobacco use was omitted, despite documentation in their medical records and assessments. MDS Coordinators confirmed these errors during record review.
Two residents were admitted without timely development of required baseline care plans. One resident with significant communication deficits did not have a communication care plan initiated, and another resident with a cancer diagnosis was not assessed for activities and lacked an activity care plan. Staff interviews and record reviews confirmed that these baseline care plans were not created within 48 hours of admission, as required by facility policy.
Two residents did not have their care plans properly updated: one resident's care plan was not revised after multiple falls and changes in cognitive status, and another resident's care plan for an antibiotic remained active after the medication was completed. These lapses were confirmed by the ADON and DON, and were not in accordance with facility policy requiring timely care plan updates.
A resident with a diagnosis of malignant neoplasm was found using bilateral half side rails without a physician's order, as required by facility policy. The resident was confused and unable to answer questions, and review of medical records confirmed the absence of an order authorizing side rail use.
Two residents consistently received their lunch meals late and at a cold temperature, as confirmed by both resident interviews and direct observation. Lunch trays were delivered well after the facility's established meal service window, contrary to policy and staff confirmation of expected meal times.
A resident with Type 2 diabetes did not receive timely insulin and the correct dosage of Myfortic due to a nurse's failure to follow physician orders. Insulin was administered late, and blood sugar checks were delayed, while only one of three prescribed Myfortic tablets was given on time. The DON confirmed these lapses, which were against the facility's medication administration guidelines.
A registered nurse left medications unattended on a bedside table in a resident's room. The resident, diagnosed with dementia and anxiety disorder, was not present at the time. The medications, vitamin B-12 and gabapentin, were left without supervision, contrary to the facility's policy requiring controlled storage accessible only to authorized personnel.
Two residents with psychiatric conditions did not receive necessary follow-up psychiatric services as recommended in their care plans. Despite evaluations indicating the need for follow-up within two to four weeks, the facility failed to provide these services, as confirmed by the social service assistant and assistant director of nursing. This oversight was contrary to the facility's policy on maintaining residents' mental and psychosocial well-being.
The facility failed to maintain an effective pest control program, with ongoing cockroach sightings in residents' rooms, nursing stations, and the kitchen. Despite a plan of correction requiring immediate treatment upon sightings, only weekly treatments were documented. Staff and residents reported seeing cockroaches, and observations confirmed unclean conditions. The administrator acknowledged the issue as an ongoing project, but the facility's policy for immediate action was not effectively implemented.
The facility failed to properly dispose of kitchen refuse, as observed when a garbage disposal bin was found without its lid, leaving refuse exposed. This was confirmed by the RD, who stated the bin should have been closed. The facility's policy requires waste to be kept in a tightly closed container, aligning with the FDA's 2022 Food Code.
A facility failed to ensure a pest-free environment, as evidenced by fruit flies in a resident's room and hallway. A nurse and CNA observed flies due to old food, but the maintenance supervisor confirmed no reports were made, contrary to the facility's pest control policy.
The facility failed to ensure proper pain management for a resident by not following physician orders for PRN medications, not updating the care plan, and using an incomplete pain scale. The resident had multiple diagnoses, including spinal stenosis and schizoaffective disorder, and experienced various levels of pain that were not adequately managed.
Failure to Prevent Physical Abuse During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse during wound care. The resident had osteomyelitis of the vertebra and physician’s orders for treatment of a coccyx pressure injury and a left buttocks open wound, including cleansing with normal saline or Dakin’s solution, application of Santyl ointment, collagen, calcium alginate, and foam dressings twice daily or as needed. During wound treatment, a licensed vocational nurse (LVN A) was observed on a video recording provided by the resident standing on the left side of the bed while the resident lay face down. After pressing down the tape around the wound dressing with his gloved fingers, LVN A made a fist with his right hand and punched the resident’s wound on top of the dressing, causing the resident to scream in pain and shout obscenities. In interviews, the resident reported that prior to setting up the video recording, LVN A had punched his wound three or four times and, on other occasions, slapped the wound. The resident stated he was afraid to report LVN A and described that sometimes LVN A would perform the wound treatment, then leave the room with the resident’s pants down, the curtain open, and the door open, which the resident found humiliating. Another resident corroborated the abuse, stating he witnessed LVN A hitting, squeezing, or slapping the resident’s wound multiple times and also hitting him across the backside. The facility’s abuse prevention policy states that residents have the right to be free from abuse and that administration will protect residents from abuse by anyone, but the described actions of LVN A toward the resident’s wound and exposure during care constituted abuse that was not prevented.
Improper Food Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility. During inspections of medication rooms and the kitchen, refrigerators designated for resident food storage were found to be operating at temperatures significantly above the required range, with one refrigerator consistently reading 60 degrees Fahrenheit despite being closed for extended periods. Additionally, food items such as a pitcher of pinkish-red fluid and an unopened container of applesauce were stored in these refrigerators. The nurse supervisor confirmed that the refrigerator temperature should be maintained between 35 and 41 degrees Fahrenheit, as per facility policy. Furthermore, ten cups of cottage cheese past their use-by dates were found in the kitchen refrigerator, and both the dietary manager and registered dietitian verified that these items should have been discarded according to policy. Further observations revealed improper labeling and dating of food and beverages. In medication storage rooms, surveyors found a pitcher with brown-colored fluid with no label and an open container of thickened water that had exceeded the 24-hour discard guideline. Another refrigerator contained a pitcher of pinkish-red fluid that was not labeled. Facility policies require all food and beverages in refrigerators to be clearly labeled and dated, and to be discarded within specified timeframes. These deficiencies were confirmed by staff during interviews and were documented as not being in accordance with professional standards for food safety.
Improper Storage and Disposal of Garbage in Dumpsters
Penalty
Summary
Two out of four outside dumpsters at the facility were observed to be overfilled with garbage, with their lids not fully closed. Additionally, plastic bags containing trash were found outside the covered dumpsters rather than being placed inside. These conditions were confirmed during an observation and interviews with the maintenance assistant and maintenance director, both of whom acknowledged that dumpsters should not be overfilled and should remain properly covered, and that all trash should be placed inside the covered dumpsters. The facility's policy on pest control requires that the dumpster area be kept clean and lids remain closed. The United States Food and Drug Administration's 2022 Food Code also mandates that refuse be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The observed failure to comply with these requirements had the potential to attract pests, which could affect the 238 residents residing in the facility.
Failure to Maintain Resident Dignity During Meals and Personal Care
Penalty
Summary
Multiple deficiencies were identified related to the failure to maintain resident dignity and respect during mealtimes and personal care. Certified nursing assistant C was observed feeding a resident while standing over her, rather than sitting at eye level as required by facility policy. This was confirmed by both the nurse supervisor and the director of staff development, who stated that staff should sit at eye level to maintain resident comfort and dignity. The facility's policy on assisting residents to eat also specifies that staff should sit at eye level in front of the resident. In the dining room, two residents were observed waiting for their meal trays while another resident at the same table had already begun eating. Both residents confirmed they were hungry and had to wait while watching another resident eat. The activity director and assistant director of nursing acknowledged that meal trays should be served to all residents at the same table at the same time or in immediate succession, in accordance with the facility's policy to promote dignity and timely service. Additionally, a resident with an indwelling Foley catheter was observed with an uncovered drainage bag, making the contents visible. The infection preventionist confirmed that the drainage bag should have been covered for privacy. The facility's policy on dignity specifies that urinary catheter bags should be kept covered to promote resident well-being and self-esteem. These failures were observed to have the potential to affect the emotional and psychosocial well-being of the residents involved.
Failure to Inform Residents of Survey Results and Binder Location
Penalty
Summary
The facility failed to ensure that residents were aware of and reminded about the results of previous state recertification surveys, as well as the location of the binder containing these results. During a resident council meeting, five residents who were alert, oriented, and had intact cognition scores (BIMS scores ranging from 14 to 15) stated they did not know the results of the previous surveys or where the survey binder was located. These residents had various medical conditions, including acute respiratory disease, chronic pulmonary edema, atrial fibrillation, diabetes mellitus, peripheral vascular disease, cellulitis, hyperlipidemia, osteoarthritis, congestive heart failure, hemiplegia, hypertension, and seizures. Interviews with facility staff revealed further gaps in communication and knowledge. The Activity Director, who had been employed at the facility for twenty-five years, was unaware of the survey results and the location of the survey binder, suggesting it might be in the administrator's office. The administrator confirmed that the Activity Director should know the binder's location to inform and remind residents. The Director of Nursing also verified that all staff should be aware of the binder's location. A review of the facility's policy and procedure on access to survey results indicated that survey results and approved plans of correction should be available in a readable form and accessible to residents without needing to ask staff. The policy also stated that residents should be notified at least annually during Resident Council meetings, and meeting minutes should reflect that survey results were communicated. However, the findings showed that these procedures were not followed, as neither residents nor key staff were aware of the survey results or the binder's location.
Failure to Follow PPE Protocols and Physician Orders
Penalty
Summary
Two Licensed Vocational Nurses (LVNs) failed to wear proper Personal Protective Equipment (PPE), specifically gloves, while handling a medication labeled as a hazardous drug (Divalproex Sodium) for two residents. Both LVNs acknowledged that the medication packaging was marked with a hazardous drug label and admitted they should have worn gloves during administration. The Director of Nursing and Consultant Pharmacist confirmed that gloves are required when handling such medications, and the facility's policy mandates the use of appropriate PPE to minimize exposure to hazardous drugs. Additionally, a resident with a primary diagnosis of unspecified paraplegia had a physician's order for weekly weight monitoring every Saturday at 9:00 a.m. However, the resident's weight was not monitored as ordered, with the last recorded weight taken over a month prior to the review. The nursing supervisor and Director of Nursing both verified that the physician's order for weekly weight checks was not followed, and the facility's policy requires all physician orders to be carried out accurately and promptly.
Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for seven out of twelve residents reviewed during a random audit. Specifically, medications were documented as administered on the Medication Administration Record (MAR) for several residents, but the corresponding doses were not signed out on the Controlled Drug Record (CDR). For example, a resident with a physician's order for Methadone had three tablets unaccounted for in the CDR, and the nurse confirmed that while the medication was documented in the MAR, it was not signed out in the CDR. Similar discrepancies were found for residents receiving Lorazepam and Hydrocodone-Acetaminophen, where the medications were recorded as given in the MAR but not reflected in the CDR. Conversely, there were instances where medications were signed out of the CDR but not documented as administered in the MAR. This occurred with residents prescribed Oxycodone, Tramadol, and other controlled substances. In these cases, nursing staff removed the medications from the locked controlled medication compartment, signed them out in the CDR, but failed to document the administration in the MAR. The Director of Nursing (DON) acknowledged that these controlled medications were not accounted for in the MAR during concurrent interviews and record reviews. A review of the facility's policies and procedures confirmed that staff are required to document the administration of medications immediately in both the MAR and the CDR. The observed failures to follow these procedures resulted in inaccurate accountability of controlled medications, as confirmed by staff interviews and record reviews during the survey.
Improper Storage of Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to store medications and biologicals in accordance with its own policies and accepted professional standards. In one medication room, a clear plastic bin was found containing medications with different routes of administration, including liquid Lithium, Atorvastatin tablets, and a Symbicort inhaler, as well as both active and discontinued medications. The bin also contained house stock normal saline and wound dressings. The nurse supervisor and DON confirmed that these items should not have been stored together, and that discontinued medications should have been removed and disposed of per policy. Additionally, opened bottles of 0.9% sodium chloride (normal saline) were found unattended at the bedside tables of two residents. One resident had both a large and small bottle of normal saline at their bedside, and another had a used bottle of normal saline left at their bedside. The MDS Coordinator confirmed that these items were used for wound treatment and should have been stored in the treatment cart, not left unattended. Facility policy requires that medications and biologicals be stored properly and only accessible to authorized personnel.
Infection Control Lapses in Resident Care and Food Preparation
Penalty
Summary
Multiple infection control deficiencies were identified during observations, interviews, and record reviews within the facility. Used and uncovered urinals were found on bedside tables next to medical equipment such as spirometers, and suction devices were improperly stored, including a yankauer suction tube placed inside an open clean gloves box and a suction machine and nebulizer covered by a used wash basin. Soiled linens were observed on the floor, and urinals were left full and not emptied in resident rooms. These practices were confirmed by staff, including the assistant director of nursing and certified nursing assistants, who acknowledged that these items should have been stored or disposed of according to facility policy to prevent contamination and cross-infection. Further deficiencies included the lack of enhanced barrier precaution (EBP) signage and personal protective equipment (PPE) outside the room of a resident with a biliary catheter, despite facility policy requiring such measures for residents with indwelling devices. Staff interviews confirmed that EBP signage and PPE should have been present. Additionally, a treatment nurse was observed wearing a surgical mask below the nose during wound care, and two kitchen staff were not wearing their face masks properly while preparing food for the tray line. These lapses were acknowledged by the staff involved and by supervisory personnel, who confirmed that masks should cover both the nose and mouth during resident care and food preparation. Review of facility policies indicated requirements for proper storage and handling of soiled linens, urinals, and PPE use, as well as the need for EBP for residents with wounds or indwelling devices. The observed failures to follow these policies were confirmed by staff during interviews and were directly linked to the deficiencies cited in the report.
Failure to Provide Wet Floor Warning in Kitchen Dishwashing Area
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen's dishwashing area, as observed during an initial tour with the dietary manager. The floors in the dishwashing area were found to be very wet, and there was no caution or warning sign present to alert staff or individuals entering the area about the wet floor. This condition was directly observed by surveyors and acknowledged by the dietary manager during the tour. Further confirmation was provided during an interview with the registered dietitian, who verified that kitchen areas, including dishwashing areas, should always be kept safe and that signage for wet floors is necessary to warn staff. A review of the facility's undated Kitchen Safety policy indicated that all dietary and kitchen staff must follow established safety guidelines, including keeping walkways clear and promptly cleaning spills using wet floor signs. The lack of a warning sign and the presence of a wet floor constituted a failure to adhere to these established safety procedures.
Failure to Ensure Laundry Staff Compliance with Dryer Lint Cleaning Documentation
Penalty
Summary
The facility failed to maintain an effective infection control training program for laundry staff, specifically regarding the routine cleaning of dryer lint. Record review showed that the laundry lint cleaning log was left blank for several hours on multiple days, indicating that staff did not document or possibly did not perform the required cleaning during those times. The housekeeping supervisor confirmed the gaps in documentation and stated that the log served as proof of lint cleaning. The infection preventionist stated that laundry staff were required to check and document lint cleaning every hour. The facility's policy required lint traps to be cleaned after each load and for staff to document this action, but the logs did not reflect compliance with this policy on several occasions. No specific residents or their medical histories were mentioned in relation to this deficiency.
Call Light Inaccessibility for Resident with Special Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the call light button for one resident was within reach and appropriate for her condition. The resident, who had a history of epilepsy, lack of coordination, psychological development disorder, and delayed childhood milestones, was observed asleep with her call light button on the floor. During a subsequent observation and interview, an LVN confirmed that the call light was not accessible and acknowledged that the resident should have had a device suitable for her needs. Review of the facility's policy indicated that residents unable to use the standard call system should be provided with an alternative means of communication, documented in the care plan.
Failure to Provide SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two residents who were discharged from Medicare Part A services while still having benefit days remaining and continued to reside in the facility. For one resident, the medical record showed admission under Medicare Part A, with a planned discharge from these services while the resident remained in the facility. The facility's own documentation confirmed that the SNF ABN was not provided to this resident. Similarly, another resident was admitted under Medicare Part A, later discharged from these services with benefit days remaining, and continued to live in the facility without receiving the required SNF ABN. The interim social services director confirmed during an interview that the SNF ABN was not given to either resident. Facility records and CMS guidelines require that a SNF ABN be provided in such circumstances to inform residents of their financial liability and appeal rights when Medicare Part A services are discontinued. The failure to provide this notice was documented in the facility's records and confirmed by staff during the survey.
Failure to Complete Required Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) assessment for one resident as required. Review of the resident's medical record showed that while an annual MDS assessment was completed in May of the previous year, there was no evidence of a completed annual MDS assessment for the following year. During an interview and concurrent record review, the MDS Coordinator confirmed that the annual assessment had not been completed within the required timeframe. According to the CMS RAI Manual, the annual MDS assessment must be completed at least every 366 days, and this requirement was not met for the resident in question.
Inaccurate MDS Coding for Falls and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of falls, medical records and progress notes documented two separate incidents where the resident was found on the floor in her room. However, the MDS for this resident was coded to indicate that no falls had occurred during the specified time frame. The MDS Coordinator confirmed during record review that these falls should have been coded as 'Yes' in section J1800, in accordance with the RAI Manual instructions. For another resident with diagnoses including osteomyelitis and vertebral fractures, a Safe Smoking Assessment Evaluation documented that the resident smoked cigarettes. Despite this, the MDS was coded to indicate that the resident did not use tobacco. The MDS Coordinator confirmed that section J1300 should have been coded 'Yes' to reflect current tobacco use, as supported by the resident's assessment and the RAI Manual guidelines.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop resident-centered baseline care plans within 48 hours of admission for two residents. For one resident with a history of cerebral infarction, aphasia, gait abnormalities, and dysphagia, there was no communication problem care plan initiated upon admission or up to the time of the survey. Clinical records and interviews with the ADON and MDS Coordinator confirmed that the resident's MDS indicated significant communication deficits, yet no baseline care plan addressing these needs was created within the required timeframe. For another resident admitted with a primary diagnosis of malignant neoplasm of the breast, there was no baseline activity care plan developed, and no activity care plan was present at all. The resident's physician order allowed participation in activities as tolerated, but the activity director confirmed that the resident had not been assessed for activities and no baseline activity care plan was created within 48 hours of admission, as required by facility policy. These findings were verified through record review and staff interviews.
Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident with diagnoses including schizophrenia, cerebral infarction, hemiplegia, and impaired cognition, the care plan interventions related to falls and cognitive function were not revised or modified after multiple falls and changes in cognitive status. The assistant Director of Nursing confirmed that the care plan had not been updated to reflect these changes, despite facility policy requiring care plans to be re-evaluated and modified as necessary to reflect changes in care, service, and treatment. For another resident with a history of intracerebral hemorrhage, kidney contusion, and sepsis, the care plan for an antibiotic remained active even after the antibiotic course was completed. The Director of Nursing confirmed that the care plan should have been resolved but was not. These failures were identified through interviews, medical record reviews, and review of facility policies and procedures, and placed the residents at risk of not receiving appropriate, consistent, and individualized care.
Failure to Obtain Physician Order for Bed Rail Use
Penalty
Summary
A deficiency occurred when a resident was observed using bilateral half side rails without a physician's order authorizing their use. The resident, who was admitted with a primary diagnosis of malignant neoplasm of the breast, was found lying in bed with the side rails up. The resident was confused and unable to answer questions at the time of observation. Review of the resident's medical records, including the physician order report covering the relevant period, confirmed that there was no documented physician's order for the use of side rails for this resident. Further review and interview with the nurse supervisor verified the absence of a physician's order for the side rails, despite facility policy requiring such an order, including documentation of diagnosis and medical necessity. The facility's policy treats side rails as physical restraints, necessitating a physician's order prior to use, which was not obtained in this case.
Delayed Meal Service Resulting in Cold Food
Penalty
Summary
The facility failed to ensure that two residents received their lunch meals in accordance with the scheduled meal times, as required by facility policy. Both residents reported that their food consistently arrived late and was cold. Observations confirmed that lunch trays for these residents were delivered significantly after the designated meal service window, with one tray arriving at 1:34 p.m. and another at 1:50 p.m., despite the policy stating that lunch should be served between 11:30 a.m. and 1:00 p.m. The dietary manager confirmed that the last lunch tray should be delivered by 1:00 p.m., and documentation supported the established meal times. These delays resulted in the residents receiving meals outside the scheduled period, with food that was not at an appetizing temperature.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with Type 2 diabetes and other conditions, leading to a deficiency in care. The resident had specific orders for insulin administration and medication dosage, which were not followed correctly. On one occasion, insulin lispro was administered late, and the resident's blood sugar was not checked before lunch as required, resulting in delayed insulin administration. Additionally, the resident was prescribed Myfortic, a medication to prevent organ transplant rejection, to be taken in a specific dosage twice daily. However, the charge nurse administered only one out of the three prescribed tablets at a scheduled time, leading to a delay in the complete dosage being given. This deviation from the prescribed medication schedule was noted in the resident's progress notes and risk meeting notes. The Director of Nursing confirmed these lapses during an interview, acknowledging that the nurse responsible did not follow the physician's orders as documented. The facility's guidelines stipulate that medications should be administered within a specific timeframe relative to meal times, which was not adhered to in this case. These failures in following physician orders had the potential to impact the resident's health adversely.
Unattended Medications in Resident's Room
Penalty
Summary
The facility failed to store medications safely when a registered nurse left medications unattended on a bedside table in a resident's room. The resident, who was not present in the room at the time, had been admitted with diagnoses including dementia and anxiety disorder. The medications left unattended were vitamin B-12 and gabapentin, which were prescribed to the resident. During an observation, it was noted that the medications were left in a medication cup on the bedside table without supervision. The registered nurse responsible for the resident's care confirmed that she left the medications unattended while she was at the nurse's station preparing documents for another resident. The facility's policy on medication storage requires that medications be stored in a controlled environment accessible only to authorized personnel, which was not adhered to in this instance.
Failure to Provide Follow-Up Psychiatric Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable mental and psychosocial well-being for two residents. Resident 1, diagnosed with obsessive-compulsive personality disorder, bipolar disorder, and major depressive disorder, was admitted to the facility and had a psychiatric evaluation on 6/22/23. The psychiatrist recommended a follow-up within two to four weeks, but no follow-up services were provided. Similarly, Resident 2, who was readmitted with a diagnosis of dementia, had an initial psychiatric evaluation on 4/7/22, which also recommended a follow-up within two to four weeks. However, no follow-up psychiatric services were provided for Resident 2 either. Interviews with the social service assistant and the assistant director of nursing confirmed that both residents should have continued receiving psychiatric services as per their psychiatric visit progress reports. The facility's policy and procedure on psychosocial well-being and behavioral health services stated that residents would receive necessary services to maintain their well-being in accordance with their comprehensive assessment and plan of care. The failure to follow up on the psychiatric services for these residents was acknowledged by the facility staff, indicating a lapse in adhering to the established care plans.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing sightings of cockroaches in various areas, including residents' rooms, nursing stations, the kitchen, and activity rooms. Despite having a plan of correction from a previous survey, which included immediate pest treatment upon sightings, the facility did not follow through with these actions. Weekly pest treatments were documented, but there were no records of immediate treatments following the identification of cockroaches. Staff and residents reported seeing cockroaches, and environmental observations confirmed the presence of pests and unclean conditions, such as food residuals and trash on the floors. Interviews with staff, including a licensed vocational nurse, registered nurse, housekeeping supervisor, dietary manager, and certified nursing assistants, revealed that cockroaches were a recurring issue. The administrator acknowledged that addressing the pest problem, particularly with German cockroaches, was an ongoing project. The facility's policy required routine inspections and immediate action upon pest sightings, but these procedures were not effectively implemented, leading to a failure in providing a sanitary environment for residents.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of refuse in the kitchen, as observed during a survey. At 10:55 a.m. on June 6, 2024, three garbage disposal bins were noted in the kitchen, with one bin having a folded box, a cup, two plastic food containers, and a metal food container placed on top of it. Another bin was found without its lid, leaving the refuse exposed to the air. This observation was confirmed by the registered dietitian (RD) during an interview at 11:13 a.m., who acknowledged that the garbage disposal bin should have been closed with its lid. The facility's policy and procedure on Sanitation and Infection Control, dated 2023, requires that kitchen waste not disposed of by mechanical means be kept in a clean, leak-proof, nonabsorbent, tightly closed metal or plastic container with a plastic liner. Additionally, the 2022 Food Code from the Food and Drug Administration specifies that waste handling for refuse should be kept covered. The failure to adhere to these guidelines had the potential to attract pests and affect the 238 residents in the facility.
Pest Control Deficiency Due to Unreported Fruit Flies
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by the presence of multiple flying insects in a resident's room and the hallway. On May 1st, a licensed vocational nurse reported numerous flies in a resident's room due to old food. Concurrently, a certified nurse assistant observed more than ten fruit flies in the same room, confirming the nurse's observation. On June 6th, two fruit flies were seen near bananas on the resident's over-the-bed table, and another fly was observed near the resident in the hallway. The maintenance supervisor confirmed that there were no reports of fruit flies in the resident's room from May 1st to June 6th, despite the facility's policy requiring insect sightings to be reported to the housekeeping/maintenance supervisor.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to pain management for one resident. The licensed nurses did not follow the physician's order to administer PRN pain medications based on the pain assessment documented. Additionally, the licensed nurses did not update the resident's care plan for pain management and administered the wrong medication for severe pain. The pain scale used did not include all pain levels, which could have contributed to improper pain assessment and management. The resident was admitted with diagnoses including generalized muscle weakness, cervical region spinal stenosis, major depressive disorder, and schizoaffective disorder. Despite having physician orders for Morphine and Tylenol for pain management, the licensed nurses failed to administer these medications as prescribed. The ADON confirmed that there was no documented evidence that the resident had refused the PRN pain medication. The care plan was not updated to include the PRN medication, and the pain scale used was incomplete, lacking levels 1, 3, 5, and 7.
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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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