Somerset Subacute And Care
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 151 Claydelle Ave, El Cajon, California 92020
- CMS Provider Number
- 555871
- Inspections on file
- 29
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Somerset Subacute And Care during CMS and state inspections, most recent first.
The facility failed to maintain a safe, homelike environment by not adequately addressing ongoing ceiling leaks in multiple resident rooms and the physical therapy room. A maintenance director and a roof contractor acknowledged roof fissures and limited inspection, while residents reported water leaking onto their beds and ceilings visibly drooping and soft when probed. Staff placed buckets and trashcans to catch water and reported the leaks to maintenance, and therapy staff noted leaks from an air vent in the PT room with visible discoloration. Several affected residents had COPD or chronic respiratory failure with hypoxia. Nursing staff and the DON stated that unresolved leaks could lead to ceiling collapse, safety hazards, mold concerns, and an environment that was not homelike.
The facility failed to maintain food safety and sanitation practices, as expired food items were stored and used in the kitchen, and the Kitchen Supervisor did not follow proper hand hygiene after handling garbage. These actions were acknowledged by the Kitchen Supervisor and Registered Dietician Specialist, indicating non-compliance with facility policies and FDA guidelines.
The facility failed to follow infection control procedures, including not wearing PPE during high-contact activities for a resident on EBP, improper storage of urinary catheter bags for two residents, and incorrect storage of a nasal cannula. These actions were contrary to the facility's policies, potentially leading to cross-contamination and infection risks.
The facility failed to ensure call lights were within reach for two residents, both unable to make decisions, and did not provide an appropriate call bell for a resident with contractures. Observations revealed call devices were inaccessible, and the DON acknowledged the importance of having call lights within reach, as per facility policy. Resident Council Meetings highlighted ongoing issues with call lights being out of reach.
The facility failed to protect residents' PHI when a vital signs sheet with sensitive information was found in a medication cart's trash bin. A Licensed Nurse acknowledged the error, stating the document should have been shredded. The DON confirmed the need for confidentiality and proper disposal of such documents, as per facility policy.
The facility failed to implement care plans for two residents regarding call light accessibility, leaving them unable to request assistance. Additionally, a resident with metastatic prostate cancer did not receive consistent wound treatment and measurement as per physician's orders. These deficiencies were acknowledged by the facility's staff.
A facility failed to follow its policy for verifying g-tube placement before feeding a resident. The resident, with a history of respiratory failure and epilepsy, was at risk due to a nurse's failure to auscultate the stomach after administering air to the g-tube. The nurse assumed the placement was correct based on a previous medication administration, contrary to the facility's policy.
A resident with heart failure, hypertension, and edema did not have a compression stocking applied as per the physician's order, which was intended to manage swelling. The resident was unaware of the need to wear the stocking, and nursing staff failed to implement the order. The DON confirmed that the order should have been followed according to the facility's policy.
A resident with metastatic prostate cancer did not receive wound treatment as ordered by the physician. The treatment for a wound on the left buttocks was not documented on several occasions, as confirmed by the MDS Coordinator. The facility's policy requires accurate transcription and implementation of physician orders, which was not followed in this case.
Facility staff failed to consistently monitor and document urine output for three residents with urinary catheters, as per policy. A resident with encephalopathy and UTI had inconsistent urine output measurement, documented by frequency of changes rather than milliliters. Another resident with metastatic prostate cancer had similar documentation issues, despite a physician's order. A third resident with anemia and atrial fibrillation had a catheter without a physician's order, and inconsistent output documentation. The DON and MDS Coordinator acknowledged these discrepancies.
A resident with End Stage Renal Disease had a bandage left on her dialysis access site longer than instructed, contrary to both the dialysis center's and physician's orders. The responsible nurse was unaware of the instructions, leading to a potential risk of clotting. The facility's policy required licensed nurses to provide care for the vascular access site, which was not adhered to.
The facility failed to accurately document controlled medications, as discrepancies were found between the documented and actual counts of tablets during a handoff between two LNs. The DON confirmed that the facility's policy required immediate documentation of CMs on the CS and EMAR, which was not followed.
A facility failed to monitor the target behavior for an antidepressant prescribed to a resident with major depressive disorder. The resident, who was confused and agitated, was not appropriately monitored for the medication's effectiveness. Staff interviews revealed a lack of communication and understanding regarding behavioral monitoring, and the Director of Nursing acknowledged the oversight in verifying the target behavior.
A facility was found to have a medication error rate of 6.45%, exceeding the acceptable 5% threshold. Errors included a missed dose of Lexapro due to a misplaced medication card and an incorrect dosage of Potassium Chloride administered to two residents. The DON confirmed the importance of following physician orders and verifying them before administration.
The facility failed to ensure safe medication storage, with an IV cart left unlocked, a medication room key left in the doorknob, and medications left unattended at the nursing station. These actions could have allowed unauthorized access to medications.
A resident with chronic respiratory failure and ventilator dependence fell from bed due to inadequate assistance during a brief change. Despite requiring two-person assistance for ADLs, a CNA attempted the task alone, leading to the resident rolling off the bed and sustaining injuries. The facility's care plan lacked specific guidance on staff assistance, and the fall prevention policy did not include preventive measures.
A resident with a history of suicidal ideations and chronic respiratory failure was not readmitted to the facility after hospitalization, despite being cleared for discharge. The facility failed to document the reasons for refusal, and the interdisciplinary care team did not properly record their discussions or decisions. The facility's policy on transfer and discharge was not followed, and the necessary documentation and physician involvement were lacking.
A facility failed to have a written transfer agreement with a hospital when a resident with suicidal ideations and chronic respiratory failure required transfer for medical and psychological treatment. The resident was transferred to a hospital after consuming hydrogen peroxide oral rinse, but the facility lacked a formal agreement to ensure continuity of care, as confirmed by staff interviews and the absence of a policy on transfer agreements.
The facility failed to prevent the development of pressure injuries in two residents due to inconsistent implementation of a turning and repositioning protocol. Both residents, who were at high risk for pressure injuries, developed stage 4 pressure injuries on the right trochanter. Observations and interviews revealed that the turning protocol was not consistently followed, contributing to the development of the injuries.
The facility failed to provide RNA services for six residents due to staffing shortages, leading to a potential reduction in range of motion and an increase in contractures. Residents received fewer RNA sessions than prescribed, as confirmed by staff interviews and record reviews.
The facility failed to document the administration of controlled medications for three residents, leading to potential risks for medication diversion and errors. Discrepancies were found between the Controlled Drug Record and the Medication Administration Record (MAR) for Tramadol, Oxycodone, and Lorazepam.
The facility failed to store and label medications according to policy and manufacturer's specifications, and did not dispose of medications appropriately. An inspection revealed an expired Levalbuterol solution and loose pills on the medication room floor, which were not properly disposed of.
The facility failed to maintain an effective QAPI program, particularly in addressing pressure injuries. The DON admitted that a complete analysis of the pressure injury concerns was not conducted, and a root cause analysis was not attempted. Additionally, sufficient staffing was not considered as a probable cause for the increase in pressure injuries.
The facility failed to maintain the dignity and respect of two residents. One resident was inappropriately dressed and had an uncovered urinary catheter bag during an outside appointment, while another resident was exposed during a shower with the door wide open. Staff admitted to not following proper procedures to ensure privacy and dignity, leading to potential embarrassment for the residents.
A resident with severe cognitive deficits and a history of traumatic brain injury was not provided with an appropriate call light type, leading to frustration and physical aggression. Despite staff acknowledging the resident's inability to use a standard call light, no modifications were made, and there was no documented evidence of the required 15-minute safety checks.
A resident with severe cognitive impairment and multiple stage 4 pressure ulcers had their low air loss (LAL) mattress set incorrectly at 150 lbs instead of their actual weight of 95.5 lbs. This failure, confirmed by both a CNA and an LN, compromised the prevention and healing of the resident's pressure ulcers, as per the manufacturer's recommendations and facility policy.
The facility failed to provide adequate staffing to meet the needs of three residents for basic nursing care and RNA services. Observations revealed that residents were not repositioned every two hours as required, and RNA services were not provided as prescribed due to staffing shortages. Interviews with staff confirmed the high acuity and low census led to staff cuts and overworked full-time staff.
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.45%. Errors included incorrect dosages of Ivermectin and Vitamin C administered to two residents, as confirmed by interviews and record reviews.
The facility failed to designate a qualified individual with specialized training in Infection Prevention and Control. The IP, who also served as the DSD, had not completed the necessary credentialing and had to cancel scheduled training. The DON acknowledged the need for a full-time IP due to the extensive responsibilities involved.
The facility failed to post actual staffing hours for four consecutive days, making staff and hours worked inaccessible to residents and visitors. Observations revealed only projected staffing hours were posted. Interviews indicated a lack of awareness and training on the requirement, and the Human Resources Specialist admitted to not posting the actual hours. The facility did not have a written policy on this matter.
Failure to Address Ongoing Ceiling Leaks in Resident Rooms and Therapy Area
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and well-kept physical environment by not adequately addressing ongoing ceiling leaks during periods of heavy rain. The Maintenance Director (MNTD) reported that roofing contractors came to the facility after heavy rain but only performed a limited walk-through and inspected only two rooms, leaving other areas unchecked. The roof contractor identified fissures in the roof membrane and roof penetrations that could lead to leaks but did not conduct a thorough inspection of the building. Surveyors observed active and recent leak damage in multiple resident rooms. In one room, a resident reported noticing leaks on his blankets, and another resident in the same room stated there had been significant leaking overnight, with staff placing a bucket on the floor to catch the water. The resident pointed out a rippling droop in the ceiling, which the MNTD tested with a broomstick; the ceiling material was soggy and soft, easily penetrated, and debris crumbled off, creating a hole. Both residents in this room had a history of COPD. In another room, a resident reported a leak dripping from the ceiling near his roommate’s bed, with staff again placing a bucket under the leak. The MNTD observed brownish discoloration and a drooping ceiling area that was soft when probed. The residents in this room had histories of chronic respiratory failure with hypoxia and COPD. Staff interviews confirmed that leaks were present not only in resident rooms but also in the physical therapy (PT) room. A CNA stated there were leaks in specific resident rooms and the PT room, and that staff had been using buckets or trashcans to catch water from the ceiling during recent rains and had informed the MNTD. The PT assistant and speech therapist reported leaks in the PT room coming from an air vent, with a black linear line visible on the air filter vent. The MNTD acknowledged receiving resident complaints about water leaks starting around early December and stated he did not contact roof contractors until after subsequent rainy days. Nursing staff and the DON stated that unresolved leaks could lead to ceiling collapse, safety risks from falling debris and accidents, mold concerns, and that the situation was not a homelike environment. Facility policy indicated that equipment and environmental conditions needing repair should be logged and acted upon within a reasonable timeframe.
Food Safety and Sanitation Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen, as evidenced by the storage and use of expired food items. During an observation, several expired food items were found in the kitchen storage, including mustard, salad dressings, milk, and bread, among others. The Kitchen Supervisor acknowledged the presence of these expired items, and the Registered Dietician Specialist confirmed that expired food should have been disposed of after the expiration date. The facility's policy and procedure guidelines were not followed, which state that no food should be kept longer than the expiration date on the product. Additionally, the Kitchen Supervisor did not adhere to proper hand hygiene practices after handling garbage. The KS was observed taking out the trash and returning to the kitchen without removing soiled gloves or washing hands, subsequently touching kitchen surfaces. The Registered Dietician Specialist acknowledged that the KS should have removed gloves and performed hand hygiene upon reentering the kitchen. This failure to follow hand hygiene procedures, as outlined in the facility's policy and the FDA Food Code, exposed residents to potential contamination and foodborne illness.
Infection Control Lapses in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to adhere to infection control procedures in several instances, leading to potential cross-contamination and infection risks. In one case, a Licensed Nurse and two Certified Nursing Assistants did not wear gowns while transferring a resident on Enhanced Barrier Precautions (EBP), despite the presence of a sign indicating the requirement for personal protective equipment (PPE). The staff members involved either forgot or were unaware of the necessity of wearing PPE during high-contact activities, such as transferring a resident with medical devices like a gastrostomy tube. Additionally, the facility did not maintain proper catheter care for two residents, as their urinary catheter bags were observed touching the floor. This was acknowledged by both the Certified Nursing Assistant and the Licensed Nurse, who confirmed that the bags should not touch the floor to prevent contamination and infection. The facility's policy on catheter care explicitly states that the drainage bags should be kept from touching the floor, yet this was not adhered to during multiple observations. Furthermore, a resident's nasal cannula was improperly stored on top of slippers, rather than in a clean, plastic bag as required to prevent cross-contamination. The respiratory therapist and the Infection Preventionist both acknowledged the improper storage and the need for the nasal cannula to be kept in a storage bag when not in use. These lapses in infection control procedures highlight the facility's failure to follow its own policies and protocols, potentially compromising resident safety.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which is a critical aspect of resident safety and communication. Resident 10, who was readmitted with epilepsy and required assistance with personal care, was observed with a call light dangling from the bed's side rails, out of reach. Similarly, Resident 26, who also required assistance and had a history of respiratory failure and epilepsy, was found with a call device hanging from the bed frame, inaccessible to the resident. Both residents were unable to make their own decisions, emphasizing the importance of having call lights within reach. The Director of Nursing acknowledged the importance of this practice, as per the facility's policy, which mandates that call devices be placed within residents' reach before leaving the room. Additionally, the facility did not provide an appropriate call bell for Resident 17, who had contractures and a history of communication deficits and brain damage. Resident 17 was given a push button call light, which she was unable to press due to her condition. The Licensed Nurse confirmed that a soft pad call light would have been more suitable for Resident 17's needs. The Director of Nursing admitted that all residents should be provided with the appropriate call light to ensure dignity and access to assistance. The facility's policy on accommodating residents' needs was not adhered to, as evidenced by the ongoing issues discussed in Resident Council Meetings, where multiple residents reported similar problems with call lights being out of reach.
Failure to Protect Residents' Confidential Health Information
Penalty
Summary
The facility failed to protect the confidentiality of residents' protected health information (PHI) when a vital signs sheet (VSS) containing residents' names, diagnoses, and treatment details was found in the open trash bin of a medication cart. This incident was observed during a medication observation and interview with a Licensed Nurse (LN), who acknowledged that the VSS should have been shredded to prevent unauthorized access to residents' PHI. The Director of Nursing (DON) confirmed that resident PHI should be kept confidential and disposed of in the facility's confidential bin for proper shredding. The facility's policy on safeguarding resident data emphasizes the protection of such information from accidental or malicious exposure.
Failure to Implement Care Plans and Physician's Orders
Penalty
Summary
The facility failed to implement care plans for two residents regarding the accessibility of call lights, which are crucial for residents to request assistance. Resident 10, who was readmitted with epilepsy and required personal care assistance, was observed with a call light dangling from the bed side rails, out of reach. Similarly, Resident 26, also readmitted with respiratory failure and epilepsy, had a call device hanging from the bed frame, inaccessible to the resident. Both residents' care plans explicitly stated that the call light should be within reach to ensure their safety, but this was not implemented, as confirmed by the Director of Nursing and a Licensed Nurse. Additionally, the facility did not adhere to a physician's order for wound treatment and measurement for Resident 37, who was admitted with metastatic prostate cancer. The care plan required treatments to be administered as ordered and wounds to be measured and monitored. However, there was no documented evidence of treatment on specific dates, and the initial wound measurement was delayed. The MDS Coordinator acknowledged these lapses, indicating that the care plan interventions were not consistently implemented, which was contrary to the facility's policy of developing and implementing a comprehensive care plan.
Failure to Verify G-Tube Placement Before Feeding
Penalty
Summary
The facility failed to adhere to its policy and procedure for administering tube feeding to Resident 26, who was readmitted with diagnoses including respiratory failure and epilepsy, and required a gastrostomy tube (g-tube) for nutrition. According to the physician's order, the placement of the g-tube should be checked via air auscultation before administering medication or starting tube feeding. However, on March 11, 2025, a Licensed Nurse (LN 2) did not auscultate Resident 26's stomach after administering air to the g-tube, as required by the facility's policy. Instead, LN 2 assumed the placement was correct because medications had been administered via the g-tube 30 minutes earlier. During an interview, LN 2 acknowledged the oversight and admitted that auscultation should have been performed to ensure the g-tube's proper placement and prevent potential aspiration. The Director of Nursing confirmed that LN 2 should have listened to the resident's stomach to verify the g-tube's placement for the resident's safety. The facility's policy on enteral feeding administration explicitly states that the placement of the feeding tube should be checked before initiating feeding, which was not followed in this instance.
Failure to Apply Compression Stocking as Ordered
Penalty
Summary
The facility failed to follow a physician's order for a resident who was admitted with medical diagnoses including heart failure, hypertension, and edema. The physician's order, dated April 16, 2024, specified that a compression stocking should be applied above the knee to the resident's right lower extremity every morning shift for 12 hours to manage swelling. However, during an observation and interview on March 10, 2025, the resident was found not wearing the compression stocking, and the resident was unaware of the need to wear it. Further observation and interviews revealed that the nursing staff did not apply the compression stocking as ordered. A Licensed Nurse confirmed that the compression stocking should have been applied to decrease swelling. The Director of Nursing also acknowledged that the physician's orders should have been implemented by the nursing staff, and the day shift staff should have applied the compression stocking as ordered. The facility's policy on physician orders emphasizes the accurate transcription and implementation of such orders.
Failure to Document and Complete Wound Treatment
Penalty
Summary
The facility failed to ensure that wound treatment for a resident with metastatic prostate cancer was completed as ordered by the physician. The resident was admitted with a treatment order for a wound on the left buttocks, which included cleansing with Normal Saline, applying Medihoney and Xeroform, and covering with a dry dressing. This order was later updated to include cleansing with Dakins. However, a review of the electronic treatment administration record (eTAR) revealed that there was no documentation of the wound treatments being completed on several specified dates. During an interview, the MDS Coordinator confirmed that the treatments were not consistently documented, acknowledging that they should have been completed and recorded as per the facility's policy on accurately transcribing and implementing physician orders.
Inconsistent Monitoring and Documentation of Urinary Output
Penalty
Summary
The facility staff failed to consistently monitor and document urine output for three residents with urinary catheters, as per the facility's policy. Resident 8, who was readmitted with encephalopathy and a UTI, had a urinary catheter attached to their wheelchair. Observations and interviews revealed that the CNAs did not consistently measure Resident 8's urine output in milliliters, instead documenting the frequency of changes. This inconsistency was acknowledged by the Licensed Nurse and the Director of Nursing, who confirmed that urine output should be measured in milliliters to prevent urinary retention and UTIs. Resident 37, admitted with metastatic prostate cancer, also had a urinary catheter. Despite a physician's order to monitor intake and output every shift, the documentation did not consistently reflect urinary output in milliliters. Instead, it recorded the number of times the catheter was emptied. The MDS Coordinator and the Director of Nursing acknowledged the discrepancy, emphasizing the need for accurate measurement to ensure the resident did not experience urinary retention. Resident 40, admitted with anemia and atrial fibrillation, had a urinary catheter without a corresponding physician's order in their medical records. Despite a physician's order to monitor intake and output, the documentation was inconsistent, recording only the frequency of catheter emptying. The MDS Coordinator and the Director of Nursing confirmed that a physician's order should have been obtained and documented, and that urinary output should be measured in milliliters to ensure appropriate treatment.
Failure to Follow Dialysis Access Site Care Instructions
Penalty
Summary
The facility failed to ensure proper care for a dialysis access site for Resident 246, who was admitted with End Stage Renal Disease. Observations revealed that the resident consistently had a bandage wrapped around her left arm dialysis access site, even after returning from dialysis sessions. The dialysis communication record indicated specific instructions to remove the bandage after a certain number of hours post-dialysis, which were not followed. The physician's order also specified that the dressing should be removed two hours after dialysis, but this was not adhered to. Licensed Nurse 1, responsible for monitoring the resident's access site, was unaware of the special instructions from the dialysis center and did not remove the bandage, believing it was the dialysis center's responsibility. The Director of Nursing confirmed that the dressing should have been removed according to the physician's order to prevent clotting. The facility's policy on renal dialysis care emphasized the importance of licensed nurses providing care for the vascular access site, which was not followed in this case.
Controlled Medication Documentation Discrepancy
Penalty
Summary
The facility failed to ensure that controlled medications (CMs) were accurately accounted for, as observed during a handoff between two licensed nurses (LNs). During the handoff, discrepancies were noted between the number of tablets documented on the controlled drugs accountability sheet (CS) and the actual count of tablets in the medication card for four out of ten CMs. Specifically, there was a discrepancy of one tablet each for Lacosamide, Briviact, Lorazepam, and Oxycodone. LN 14 acknowledged that CMs taken out of the medication card should be immediately documented on the CS and that the time of administration should be recorded on the Electronic Medication Administration Records (EMAR). The Director of Nursing (DON) confirmed that the facility's policy required all LNs to document CMs taken from medication cards on the CS and to record the administration on the EMAR. The DON acknowledged that the documented quantities on the CS did not match the actual quantities in the medication cards. The facility's policy on controlled medications, dated May 2007, specified that the administering nurse should immediately document the date, time, amount administered, and their signature on the accountability record after the medication is administered.
Failure to Monitor Antidepressant Use in Confused Resident
Penalty
Summary
The facility failed to appropriately identify and monitor the target behavior for the use of an antidepressant medication in a resident diagnosed with major depressive disorder. The resident, who was readmitted with encephalopathy and a UTI, was prescribed Escitalopram Oxalate for self-isolation related to depression. However, the target behavior for the medication was not clearly defined or monitored, as evidenced by the lack of behavioral monitoring and communication among staff. During observations, the resident exhibited confusion and agitation, which were not aligned with the documented target behavior of feeling sad. Interviews with facility staff, including a CNA and a licensed nurse, revealed a lack of awareness and understanding regarding the monitoring of the resident's behavior. The CNA was not informed about the need for behavioral monitoring, and the licensed nurse expressed uncertainty about the appropriateness of the target behavior for the medication, given the resident's confusion. The Director of Nursing acknowledged that the licensed nurses should have verified the target behavior for the antidepressant and corrected the physician's order to prevent unnecessary psychotropic medication use. The facility's policy on psychotropic medications emphasizes the necessity of treating specific diagnosed conditions and monitoring behaviors, which was not adhered to in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 6.45% during a medication administration observation, exceeding the acceptable threshold of 5%. This was due to two medication errors involving two residents. The first error occurred when a Licensed Nurse (LN) failed to administer Lexapro to a resident as per the physician's order. The medication card was misplaced in the afternoon drawer, leading to the missed morning dose. The Director of Nursing (DON) confirmed that the medication should have been administered according to the physician's orders. The second error involved the administration of an incorrect dosage of Potassium Chloride (KCL) to another resident. The LN administered 20 ml instead of the prescribed 15 ml, resulting in the resident receiving more than the prescribed dose. The LN acknowledged the mistake and the potential harm it could have caused. The DON emphasized the importance of verifying physician orders before medication administration. The facility's policy on medication administration requires reviewing and verifying medical orders and following the six rights of medication administration.
Medication Storage Deficiencies Observed
Penalty
Summary
The facility failed to ensure the safe and appropriate storage of medications, as observed in three separate incidents. An intravenous medication cart was left unlocked and unattended in the facility hallway, allowing the drawers containing IV medications, needles, and tubing to be easily accessed. This was confirmed by a licensed nurse who acknowledged that the cart should have been locked to prevent unauthorized access. Additionally, a medication room key was found inserted in the doorknob and left unattended, which could have allowed unauthorized individuals to access the medications and supplies inside. The Director of Nursing confirmed that the key should have been with the licensed nurse at all times and not left in the doorknob. Furthermore, multiple medications were observed stacked unattended on top of the nursing station counter. These medications had been delivered by the pharmacy and should have been immediately stored in the medication room for safekeeping. The Director of Nursing stated that all medications should be stored immediately after delivery to ensure safety. The facility's policy and procedure on Medication Administration and Storage clearly indicated that medication carts should be locked when unattended, the medication room should be locked when not in use, and drugs should not be left unsecured or unattended.
Inadequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to a resident who required total dependence with activities of daily living (ADLs), resulting in the resident falling from bed. The resident, who was admitted with chronic respiratory failure and was dependent on a ventilator, required two-person assistance for ADLs due to their size, tracheostomy, and episodes of combativeness. On the day of the incident, a Certified Nurse Assistant (CNA) attempted to change the resident's brief without additional assistance, despite the resident's known need for two-person assistance. During the process, the resident moved and rolled off the bed, resulting in injuries including skin tears and redness. Interviews with staff revealed that the resident was known to be at high risk for falls, as indicated by a fall assessment score and care plans that highlighted the resident's total dependence on staff for ADLs. However, the care plan did not specify the number of staff required for assistance. The Director of Nursing acknowledged that it was best practice to have two people assist the resident for safety. The facility's fall prevention policy did not include specific fall preventive measures, contributing to the oversight in providing adequate supervision and assistance to the resident.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, despite the resident being deemed medically and psychologically safe for discharge back to the facility. The resident, who had a history of suicidal ideations and chronic respiratory failure requiring a tracheostomy and ventilator, was initially admitted to the facility and later transferred to a General Acute Care Hospital (GACH) after attempting self-harm. The facility had previously accepted the resident back after a similar incident and implemented safety interventions. However, after a subsequent incident where the resident attempted to harm himself by drinking hydrogen peroxide oral rinse, the facility did not document a reason for refusing to readmit the resident. Interviews with facility staff revealed that the resident had a seven-day bed hold and that the facility had been notified by GACH 2 that the resident was cleared for discharge. Despite this, the facility's case manager/social services director communicated to the hospital that the facility did not feel they could accept the resident back, citing concerns about the resident's stability and the facility's ability to meet his needs. The facility's documentation did not reflect the reasons for the refusal to readmit the resident, and the interdisciplinary care team did not document their discussions or decisions regarding the resident's care. The facility's policy on transfer and discharge requirements was not followed, as the necessary documentation and physician involvement were lacking. The facility had empty beds available, but the decision not to readmit the resident was not properly documented or justified according to the facility's policy.
Lack of Written Transfer Agreement with Hospital
Penalty
Summary
The facility failed to have a written transfer agreement with a General Acute Care Hospital (GACH) when a resident required transfer for medical and psychological treatment. The resident, who was admitted with suicidal ideations and chronic respiratory failure requiring a tracheostomy and ventilator, was transferred to GACH 2 after verbalizing a desire to die and consuming a bottle of hydrogen peroxide oral rinse. The transfer was ordered by the nurse practitioner, but the facility did not have a formal agreement in place with the hospital to ensure a smooth transition of care. Interviews with facility staff, including a licensed nurse and the Director of Nursing (DON), confirmed the absence of a written transfer agreement with GACH 2 or any other GACH. The DON acknowledged that the facility's contract department did not have any such agreements on file, and the facility was unable to provide a policy on transfer agreements when requested. This lack of a formal agreement could potentially place residents at risk for inadequate continuity of care and treatment.
Failure to Prevent Pressure Injuries
Penalty
Summary
The facility failed to provide interventions to prevent the development of pressure injuries for two residents, Resident 17 and Resident 26. Resident 17, who was at high risk for pressure injuries due to limited mobility and other medical conditions, developed a stage 4 pressure injury on the right trochanter. Despite having a care plan that included turning and repositioning every two hours, observations and documentation revealed that Resident 17 was not consistently turned and repositioned as required. The Wound Care Nurse confirmed that the turning and repositioning protocol was only implemented two months prior and was not consistently followed, contributing to the development of the pressure injury. Resident 26, who had diagnoses including moderate protein calorie malnutrition and quadriplegia, also developed a pressure injury on the right trochanter. Observations showed that Resident 26 was frequently found lying on her back, contrary to the posted turning schedule. The Wound Care Nurse indicated that the pressure injury developed due to a combination of a tight brief causing a skin tear and lack of consistent turning and repositioning. Interviews with CNAs and the DON confirmed that the turning protocol was only strictly enforced in the past couple of months and that prior to this, turning was inconsistent. The DON acknowledged that the turning protocol should have always been in place and that the lack of consistent turning and repositioning contributed to the development of pressure injuries in both residents. The DON also noted that care plans indicating turning every shift were incorrect, as this would leave residents in the same position for too long. The facility's failure to consistently implement and document the turning and repositioning protocol led to the development of avoidable pressure injuries in both residents.
Failure to Provide RNA Services Due to Staffing Shortages
Penalty
Summary
The facility failed to provide RNA services for six residents, leading to a potential reduction in range of motion and an increase in contractures. Resident 2, who was readmitted with diagnoses including generalized muscle weakness, had an order for RNA services four times per week. However, the resident only received these services twice per week due to staffing issues. The Director of Rehabilitation (DOR) and the Director of Nursing (DON) confirmed the shortfall, attributing it to RNA staff being pulled to cover CNA duties. Resident 3, admitted with abnormalities of gait and mobility, also had an order for RNA services four times per week but received them only twice per week for the same staffing reasons. The DOR and DON acknowledged the deficiency, emphasizing the importance of RNA services in maintaining residents' range of motion and preventing decline. Residents 26, 27, 28, and 12 also did not receive their prescribed RNA services due to staffing shortages. Resident 26 had only six RNA encounters instead of the required twelve, while Resident 27 had seven instead of twelve. Resident 28's RNA records were missing, but it was assumed they received fewer services than required. Resident 12, with a history of traumatic brain injury, missed RNA services on three specific dates. Interviews with staff and record reviews confirmed these deficiencies, highlighting the critical role of RNA services in preventing contractures and maintaining mobility.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to document the administration of controlled medications on the Controlled Drug Record for three unsampled residents, leading to a potential risk for diversion of these medications. Specifically, for Resident 37, there were instances where Tramadol 50 mg was pulled from the Controlled Drug Record but not documented on the Medication Administration Record (MAR). Similarly, for Resident 12, Oxycodone 5 mg was pulled from the Controlled Drug Record without corresponding documentation on the MAR. Additionally, Resident 20 received Lorazepam 2 mg without proper documentation on the Controlled Drug Record, and the doses administered did not match the physician's orders. During an interview and record review with the Director of Nursing (DON), Resource Nurse, and Licensed Nurse (LN) 15, it was confirmed that the LNs did not follow the facility's policies for documenting controlled medication administration. The DON acknowledged that the Controlled Drug Record should match the MAR to ensure that medications were administered as ordered. The facility's policies on medication administration and controlled medication storage and reconciliation were not adhered to, resulting in discrepancies and potential medication errors for the residents involved.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled according to the manufacturer's specifications and policy, and that medications were disposed of appropriately. During an inspection of the respiratory cart, it was found that a resident's Levalbuterol solution had been opened and not discarded within the two-week period as specified by the manufacturer. The respiratory therapist acknowledged the oversight and confirmed that the medication should have been discarded and reordered. Additionally, an inspection of the medication room revealed loose pills and unidentified debris on the floor. Licensed nurses verified the presence of 6 1/2 pills on the floor and acknowledged that medications should be disposed of properly in the medication disposal bin to prevent diversion. The Director of Nursing confirmed that the medication room should only contain stock medications and emphasized the importance of maintaining a clean environment to prevent unauthorized access to medications.
Failure to Maintain Effective QAPI Program for Pressure Injuries
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, particularly in addressing pressure injuries. During an interview with the Administrator, Director of Nursing (DON), and facility consultants, it was revealed that although pressure injuries were being reviewed in QAPI meetings, the facility could not provide data or action plans discussed during these meetings. The DON admitted that a complete analysis of the pressure injury concerns was not conducted, and a root cause analysis was not attempted to identify the causes of acquired pressure injuries in the facility. Additionally, the DON acknowledged that sufficient staffing was not considered as a probable cause for the increase in pressure injuries. A review of the facility's undated 2024-2025 QAPI Plan indicated that the facility claimed to use a systemic approach to determine when in-depth analysis is needed and to apply a thorough and structured approach to identify problems caused by the organization or delivery of care. However, the facility failed to follow its own policies and procedures regarding the use of root cause analysis when problems were identified. This lack of adherence to the QAPI plan and failure to conduct a root cause analysis contributed to the deficiency in addressing the increase in pressure injuries effectively.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, Resident 20 and Resident 17. Resident 20 was observed inappropriately dressed in a hospital gown and covered with a shower blanket on a stretcher in the nursing hallway for an outside appointment. Additionally, Resident 20's urinary catheter bag was not covered with a dignity bag. Interviews with staff revealed that Resident 20 was not asked about his clothing preference and was not dressed in his own clothes, which could have prevented embarrassment. The Director of Rehabilitation (DOR) admitted to not offering Resident 20 his clothing choice and acknowledged the importance of using dignity bags for urinary catheters to promote privacy and self-esteem. The Director of Nursing (DON) confirmed that residents should be properly dressed in their own clothing before leaving their rooms to avoid public exposure and embarrassment. Resident 17 was observed in the shower room with the doors wide open, exposing his feet while being showered by a Certified Nursing Assistant (CNA). The Respiratory Therapist (RT) and CNA involved admitted that the shower door should have been closed to provide privacy and prevent potential embarrassment for Resident 17. The DON stated that staff should ensure the door is closed during showers to respect the resident's dignity and privacy. The facility's policy on dignity and privacy emphasizes the importance of appropriately dressing residents and maintaining their privacy during personal hygiene activities. Both incidents highlight the facility's failure to adhere to its own policies and procedures regarding resident dignity and privacy. The staff's actions and inactions led to situations where the residents' rights to be treated with respect and dignity were compromised. The observations and interviews indicate a lack of consistent implementation of the facility's policies, resulting in potential emotional discomfort and embarrassment for the residents involved.
Inadequate Call Light Accommodation for Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of traumatic brain injury and severe cognitive deficits was provided with an appropriate call light type to call staff when needed. Despite the resident's inability to use a standard push button call light due to his condition and the use of a padded right-hand mitten, the facility did not provide a modified call light. Instead, the resident resorted to banging on bed rails to get staff attention, which led to physical aggression and frustration. Staff interviews confirmed that the resident's current call light was not suitable for his needs, and there was no documented evidence of the 15-minute safety checks that were supposed to be in place. The resident's care plan indicated the need for the call light to be within reach and encouraged its use, but this was not feasible given the resident's physical limitations. Multiple staff members, including CNAs and the Director of Nursing, acknowledged the resident's inability to use the standard call light and suggested that a pressure sensor call light might be beneficial. However, no such modification was made, and the resident continued to experience frustration and physical harm due to the lack of appropriate accommodations.
Improper Setting of Low Air Loss Mattress for Resident
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set according to the physician's order for a resident with multiple stage 4 pressure ulcers. Resident 30, who was readmitted to the facility with severe cognitive impairment and a high risk for developing pressure ulcers, had a physician's order for a LAL mattress to aid in skin maintenance. However, during an observation, it was found that the LAL mattress was set at 150 lbs, despite the resident's weight being 95.5 lbs. This incorrect setting was confirmed by both a CNA and an LN, who acknowledged that the improper setting could compromise the prevention and healing of the resident's pressure ulcers. The Director of Nursing (DON) confirmed that the LAL mattress should be set according to the resident's weight as per the manufacturer's recommendations. The facility's policy on pressure injury prevention and management also indicated the importance of evaluating treatment effectiveness. The failure to set the LAL mattress correctly increased the risk of skin breakdown for Resident 30, who already had multiple severe pressure ulcers. This deficiency was identified through a combination of observation, interviews, and record reviews, highlighting a lapse in adherence to professional standards of quality care.
Inadequate Staffing and RNA Services
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of three residents (Residents 26, 27, and 28) for basic nursing care and RNA services. Observations from March 18, 2024, to March 21, 2024, revealed that these residents were mostly positioned on their backs without the required position changes every two hours. Interviews with the WCN and DON indicated that the high acuity of residents and low census led to staff cuts, resulting in full-time staff working double shifts and struggling to meet care requirements. The DON acknowledged that despite staff claims of turning patients, residents were often found in the same positions, primarily on their backs. Additionally, the DOR confirmed that Residents 26, 27, and 28 had physician orders to receive RNA services four times per week, but these services were not provided due to staffing shortages. Documentation showed that Resident 26 received only six RNA encounters and Resident 27 received seven encounters between March 1, 2024, and March 21, 2024, instead of the expected 12 encounters. RNA records for Resident 28 were missing. The facility's staffing waiver indicated the use of licensed vocational nurses and registered nurses when certified nurse assistant direct care service hours could not be met, but the facility did not have a written policy regarding staffing based on resident needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than five percent, resulting in a medication error rate of 6.45%. During the medication administration process, two errors were observed out of 31 opportunities. One error involved a Licensed Nurse (LN) administering only three tablets of Ivermectin 3 mg to a resident, instead of the prescribed five tablets to make up the correct dose of 15 mg. This discrepancy was confirmed through interviews and record reviews with the Director of Nursing (DON) and another LN, who verified that the correct dose was not administered as per the physician's order. Another error was observed when an LN administered a half tablet of Vitamin C (250 mg) to a resident instead of the prescribed two tablets of 250 mg each, totaling 500 mg. This error was also confirmed through interviews and record reviews with the DON and the involved LN. The facility's policies on medication administration and physician orders were not followed, leading to these medication errors.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual with specialized training in Infection Prevention and Control to be responsible for the facility's Infection Control Program. During an interview, the Infection Preventionist (IP), who also served as the Director of Staff Development (DSD), admitted to having taken the Center for Disease Control (CDC) online course but had not completed the test to obtain the credential. Additionally, the IP was scheduled to take the San Diego County Infection Control training but had to cancel. The facility was unable to provide any proof of specialized Infection Control training for the IP. The Director of Nursing (DON) acknowledged the need for a full-time IP due to the extensive responsibilities involved in the role.
Failure to Post Actual Staffing Hours
Penalty
Summary
The facility failed to post actual staffing hours for four consecutive days, resulting in the total number of staff and actual hours worked by staff not being accessible to residents and visitors. Observations on 3/18/24, 3/19/24, 3/20/24, and 3/21/24 revealed that only projected staffing hours for RNAs, CNAs, LVNs, and RNs were posted, with no actual staffing hours displayed. During an interview on 3/20/24, a staff member indicated a lack of awareness about the requirement to post actual staffing hours and mentioned not receiving specific training. Another interview with the Human Resources Specialist revealed that the actual staffing hours were not posted in the last few days. A review of the staffing waiver dated 7/17/23 indicated that the facility should post information about staffing levels in a prominent place accessible to residents and visitors. The facility did not have a written policy regarding the posting of actual staffing hours.
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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