South Coast Global Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Ana, California.
- Location
- 2701 South Bristol Street, Santa Ana, California 92704
- CMS Provider Number
- 555567
- Inspections on file
- 17
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at South Coast Global Medical Center D/p Snf during CMS and state inspections, most recent first.
The facility failed to protect the confidentiality of 27 residents' PHI when a computer displaying sensitive information was left unattended in a hallway. The facility's policy requires that medical records be kept confidential and accessed only by authorized users. Interviews confirmed that computer screens should be locked when not in use.
The facility's assessment failed to involve direct care staff, residents, or their representatives, and lacked plans for staffing resources, recruitment, retention, and contingency for staffing needs. The DON/Interim CNO and Director of Sub-Acute Unit confirmed the assessment was outdated and did not follow CMS's 2024 guidance.
The facility failed to maintain an accurate infection control surveillance program and did not properly disinfect shared glucometers, leading to potential infection risks. The infection control data from October to December 2024 was incomplete, and specific cases showed that criteria for true infections were not consistently applied. Additionally, a glucometer was not disinfected according to the manufacturer's instructions, as observed during a procedure, potentially exposing residents to blood-borne pathogens. These issues were confirmed by the Infection Preventionist and the Director of the Sub-Acute Unit.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for residents whose conditions did not meet McGeer's criteria. Despite policies requiring monitoring and intervention, many residents were prescribed antibiotics without proper justification. The Infection Preventionist and Director of the Sub-Acute Unit acknowledged issues with form completion and tracking compliance, resulting in continued inappropriate antibiotic use.
The facility failed to provide necessary respiratory care and services for several residents, including unlabeled and unchanged respiratory equipment, unclean tracheostomy sites, and improperly set ventilator alarms. These deficiencies were confirmed through observations and staff interviews, with the Director of the Sub-Acute Unit acknowledging the findings.
The facility failed to provide written notification of bed hold rights to three residents or their representatives upon transfer to a hospital. Despite the facility's policy requiring such notification, documentation was missing for all three cases. The Social Service Staff acknowledged the oversight, and the Director of the Sub-Acute Unit confirmed the findings.
A facility failed to ensure the accuracy of a PASRR Level 1 assessment for a resident, which inaccurately indicated no serious mental illness or psychotropic medication use. The resident's records showed severe cognitive impairment, a psychotic disorder, and antipsychotic medication use. The discrepancy was confirmed by the Director of the Sub-Acute Unit, revealing a failure in the facility's screening and review procedures.
A resident's low air loss mattress was incorrectly set for a higher weight range than appropriate, potentially affecting pressure ulcer care. The resident, weighing 117.5 pounds, was observed on a mattress set for 265-330 pounds. The error was confirmed by an LVN, who noted the resident's inability to communicate discomfort due to cognitive impairment.
Two residents with limited ROM did not receive RNA services as ordered, including passive ROM exercises and splint applications. Documentation showed missed and inconsistent care, with no physician notification of discrepancies. Staffing issues contributed to the failure to provide the required care.
A resident with a seizure disorder was observed without a required helmet while in a wheelchair, contrary to a physician's order. Staff, including a CNA and an LVN, confirmed the absence of the helmet, which was meant to ensure safety during transfers and while the resident was out of bed. The Director of the Sub-Acute Unit verified the findings and emphasized the importance of adhering to safety protocols.
The facility failed to provide proper care for residents with feeding tubes. A resident's head of bed was not elevated to the required angle before medication administration, risking aspiration. Another resident received enteral feeding at an incorrect rate, and the water flush bag was unlabeled. These issues were acknowledged by the facility's director.
A facility failed to maintain a clean environment for a resident, as evidenced by dry, brownish residues on the resident's enteral feeding pump. Despite the facility's policy on infection control, licensed nurses did not clean the device, which was used to infuse Glucerna 1.2. Observations confirmed the oversight, and the Director of the Sub-Acute Unit acknowledged the responsibility of licensed nurses to maintain cleanliness.
A resident was transferred to an acute care unit without written notification to their representative, violating the requirement to inform them of the transfer, reasons, and appeal rights. The Social Service Staff confirmed that only verbal communication was made, and the Director of the Sub-Acute Unit acknowledged the deficiency.
The facility failed to ensure accurate medication administration routes for two residents, leading to errors in administering medications via gastrostomy tube (GT) instead of orally as ordered. The errors were confirmed by nursing staff and the pharmacist, who noted limitations in the electronic health record system. The Director of the Sub-Acute Unit acknowledged the findings.
A facility failed to limit a resident's PRN order for lorazepam to 14 days, as required for psychotropic medications. The absence of physician documentation justifying the extension of this medication was confirmed by staff, including an LVN and the Director of Pharmacy. This oversight could lead to unnecessary medication use, potentially affecting the resident's well-being.
A medication cart in an LTC facility was found unlocked and unattended, containing various medications for multiple residents. The cart's locking mechanism was malfunctioning due to debris obstructing it, allowing unauthorized access to medications. The issue was identified and confirmed by the LVN, Director of Sub-Acute Unit, and Engineering team.
The facility failed to ensure the cook followed the recipe for pureed Swiss steak, potentially affecting a resident's nutritional needs. The cook did not measure the beef broth and used insufficient thickener, contrary to the facility's policy. The RD confirmed the cook should have adhered to the instructions.
The facility failed to follow food safety and sanitation guidelines, as observed during a survey. A steel tray and a red blender were stored wet, contrary to USDA Food Code requirements. A rack for clean pots and pans was unsanitary, and four cutting boards were heavily marred, hindering proper cleaning. These deficiencies could lead to foodborne illnesses for residents.
A facility failed to maintain accurate and complete documentation for a resident using bilateral soft hand mittens. The Restraint Assessment/Restraint Flowsheet was incomplete on several occasions, with missing entries for entire shifts and lack of documentation on whether the mittens were reapplied or assessed for continued need. Staff interviews confirmed the expectation for accurate documentation, highlighting the potential impact on the resident's care needs.
The facility failed to properly record a resident's personal belongings, as evidenced by incomplete inventory forms and missing items. Interviews confirmed that the inventory process was not consistently followed, leading to difficulties in tracking the resident's belongings.
The facility failed to provide necessary care and services for four residents, including missed showers, improper transfers, and inadequate nail care. Staffing shortages were confirmed by family members and staff, contributing to these deficiencies.
Failure to Protect Residents' PHI
Penalty
Summary
The facility failed to maintain the confidentiality of residents' Protected Health Information (PHI) for 27 residents. During an observation in Hallway 1, a computer was found displaying the names, dates of birth, and ages of all residents currently residing in the facility. This computer was left unattended, and multiple staff members were observed walking past it without securing the information. The facility's policy on confidentiality, revised in August 2023, mandates that medical records are to be kept confidential and accessed only by authorized users on a need-to-know basis. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit confirmed that the computer screens should be locked when not in use to prevent unauthorized access to resident information.
Facility Assessment Lacks Comprehensive Planning and Stakeholder Involvement
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for resident care during regular operations and emergencies. The assessment did not actively involve direct care staff, residents, or their representatives in its development. Additionally, the assessment lacked a detailed plan for staffing resources, particularly for weekends, and did not include strategies for recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and document review, the Director of Nursing (DON)/Interim Chief Nursing Officer (CNO) and the Director of the Sub-Acute Unit confirmed that the facility assessment was outdated, based on regulations from 2016, and did not incorporate the revised guidance issued by CMS in 2024. They acknowledged the absence of active involvement from key stakeholders and the lack of necessary plans and resources to ensure adequate care for residents, particularly during weekends and unforeseen staffing shortages.
Infection Control Deficiencies in Surveillance and Equipment Disinfection
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by deficiencies in maintaining an accurate infection control surveillance program and improper disinfection practices. The infection control surveillance data from October to December 2024 was incomplete and inaccurate, failing to determine whether residents' infections met McGeer's criteria for true infections. Specific cases, such as those of Residents 2, 14, 17, 26, and 27, showed that the section on the form to indicate whether the infection met the criteria for a true infection was not selected, leading to potential mismanagement of infections. Additionally, the facility did not adhere to proper disinfection protocols for shared medical equipment, specifically glucometers. An observation revealed that a glucometer was not cleaned and disinfected according to the manufacturer's instructions after use on a resident. The Licensed Vocational Nurse (LVN) responsible for the procedure did not ensure the glucometer remained wet for the required two minutes with the disinfectant wipe, as per the manufacturer's guidelines, potentially exposing residents to blood-borne pathogens. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit confirmed these findings. The IP acknowledged the incomplete surveillance data and the failure to apply McGeer's criteria consistently. The Director of the Sub-Acute Unit was informed of the improper disinfection practices and acknowledged the potential risk of infection transmission due to these lapses in protocol.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, leading to the inappropriate use of antibiotics for residents whose conditions did not meet the McGeer's criteria for true infections. The facility's policy required that culture and sensitivity results be monitored by the pharmacy, with interventions to inform physicians of results and recommendations for antibiotic therapy. However, the facility's Infection Control Surveillance Dashboard revealed that a significant number of residents were prescribed antibiotics for infections that did not meet the McGeer's criteria over a three-month period. Interviews with the Infection Preventionist (IP) and the Director of the Sub-Acute Unit revealed that the licensed nurses were responsible for completing the Healthcare Associated Infections (HAI) forms, which were then reviewed by the IP to determine if the McGeer's criteria were met. However, the forms were not accurately completed, as selections for the type of infection or criteria for infection were often not made. This led to the continuation of antibiotic treatments without proper justification, as seen in the cases of Resident 27 and Resident 28, who were prescribed antibiotics without meeting the necessary criteria. The Director of the Sub-Acute Unit acknowledged the high prevalence of antibiotic use that did not meet the McGeer's criteria and admitted to incorrectly tracking antibiotic stewardship compliance. Despite discussions in QAPI meetings and awareness by the Medical Director, the facility did not take effective action to address the issue, resulting in continued inappropriate antibiotic use and a failure to adhere to the established antibiotic stewardship program.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide necessary respiratory care and services for several residents, as evidenced by multiple observations and interviews. For Resident 18, the Trach-Bar aerosol tubing set-up was not labeled with the date, and there was no documentation that the aerosol set-up was changed weekly as required. Similarly, Resident 26's yanker was not labeled with the opened date, and the T-Bar aerosol set-up was also undated. Resident 28's T-Bar aerosol tubing set-up and sterile water connected to the oxygen flowmeter were not labeled with the opened date, and the yanker was not changed according to the facility's policy. The facility also failed to change the suction canister and tubing as per policy for Residents 2 and 8, and the yankauer tube was not labeled for these residents. Additionally, Resident 8's tracheostomy site was not clean, and the tracheostomy dressing was not changed as required. Resident 6's ventilator machine alarms were not set for high pressure alarms, and there was no documentation that the alarms were checked every shift as per the physician's order. The care plans for respiratory status did not include interventions for monitoring the mechanical ventilator and settings, posing a risk of delayed intervention in emergencies. Furthermore, Resident 27's set-up bag was not changed weekly as required. The facility's policies and procedures for oxygen therapy and changing disposable equipment were not followed, leading to potential negative effects on the residents' medical conditions. Interviews with staff, including licensed nurses and respiratory therapists, confirmed these deficiencies, and the Director of the Sub-Acute Unit acknowledged the findings.
Failure to Provide Bed Hold Notification to Residents' Representatives
Penalty
Summary
The facility failed to notify three residents or their representatives in writing about their rights to a bed hold policy upon transfer to an acute care hospital. This deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy, revised in July 2005, mandates that residents be informed of their right to a bed hold upon admission and when transferred to an acute care facility or during therapeutic leave. However, for Residents 2, 17, and 27, there was no documented evidence that their representatives were provided with a copy of the Bed Hold Notification form when the residents were transferred to the hospital. Resident 27 was transferred to the hospital on January 22, 2025, but the Social Service Staff acknowledged that the bed hold notification was not given or mailed to the resident's responsible party. Similarly, Resident 17 was transferred on January 16, 2025, and the Social Service Staff confirmed that the notification was not provided because the family member did not request it. For Resident 2, although the representative was informed by phone about the bed hold, there was no written documentation provided. The Director of the Sub-Acute Unit acknowledged these findings during interviews conducted on January 23, 2025.
Inaccurate PASRR Level 1 Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the PASRR Level 1 assessment for a resident, which is a federal requirement to prevent inappropriate placement in nursing homes. The assessment inaccurately indicated that the resident did not have a diagnosed serious mental illness or symptoms of psychosis, and was not prescribed psychotropic medications for serious mental illness. However, the resident's medical records revealed severe cognitive impairment, a psychotic disorder, and the use of antipsychotic medications, including Zyprexa and Seroquel. The discrepancy was identified during a review of the resident's medical records and confirmed through interviews with the Director of the Sub-Acute Unit. The Director acknowledged that the PASRR Level 1 screenings were completed by the discharging facility and reviewed for accuracy by the MDS nurse, DSD, or the Director of Sub-Acute Unit. Despite this process, the assessment for the resident was found to be inaccurate, highlighting a failure in the facility's screening and review procedures.
Improper Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately according to a resident's weight, which is crucial for pressure ulcer care and prevention. The resident, identified as Resident 24, was observed on multiple occasions lying on a low air loss mattress set to a comfort level corresponding to a weight range of 265-330 pounds, while the resident's actual weight was 117.5 pounds. This discrepancy was confirmed by LVN 4, who acknowledged that the mattress should have been set to light 2, appropriate for the resident's weight. Resident 24 was admitted to the facility with a physician's order for a Blue-Chip Power Pro Elite Mattress for wound management. The resident was totally dependent on staff for bed mobility and had severely impaired cognitive skills, making it impossible for them to communicate discomfort. The resident had a pressure ulcer of unknown depth on the left buttocks, documented the day before the observations. The Director of the Sub-Acute Unit was informed of these findings, acknowledging the incorrect mattress setting.
Failure to Provide Ordered RNA Services for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered by the physician for two residents with limited range of motion (ROM). Resident 2 was observed without the necessary splints and had missed four days of RNA services, which included passive ROM exercises and knee splint application. The facility's documentation did not provide any explanation for the missed services, and it was noted that staffing issues contributed to the inability to provide the required care. Resident 18 also did not receive RNA services as ordered. The resident's care plan included passive and active ROM exercises and the application of various splints. However, documentation showed inconsistencies in the application of these splints, with some days missing entirely and others exceeding the prescribed duration. There was no evidence that the physician was informed of these discrepancies or that the resident's inability to tolerate the splints was communicated. Interviews with facility staff, including LVNs and the Director of the Sub-Acute Unit, confirmed the findings. The staff acknowledged the challenges in providing RNA services due to insufficient staffing, which resulted in the failure to administer care as ordered by the physician. The Director of the Sub-Acute Unit was informed of these findings and acknowledged the issues.
Failure to Provide Required Helmet for Resident Safety
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 11, was free from accident hazards by not providing a helmet protective device as per the physician's order. On multiple occasions, Resident 11 was observed in a wheelchair without the required helmet, which was ordered for safety when the resident was out of bed. The medical record review confirmed the physician's order dated 10/28/24, which specified the use of a helmet during transfers and while the resident was in a wheelchair. Despite this, the helmet was not available in the resident's personal belongings, and staff members, including a CNA and an LVN, confirmed the absence of the helmet. Interviews with staff members, including a CNA, the Activity Coordinator, and an LVN, revealed a lack of awareness and adherence to the safety precautions outlined in the care plan for Resident 11. The CNA acknowledged the need for two-person assistance with a mechanical lift but did not mention the helmet requirement. The Activity Coordinator, familiar with the resident's participation in activities, also did not observe the resident wearing a helmet. The LVN verified the physician's order for the helmet but admitted that the resident did not have one during transfers or while in the wheelchair. The Director of the Sub-Acute Unit confirmed the findings and expressed an expectation for staff to observe safety protocols at all times.
Deficiencies in Feeding Tube Care and Administration
Penalty
Summary
The facility failed to provide appropriate care for residents with feeding tubes, as evidenced by two specific incidents involving Resident 12 and Resident 18. For Resident 12, the facility did not ensure that the head of the bed (HOB) was elevated to the required 30 to 45 degrees before administering medication via a gastrostomy tube (GT). During an observation, a licensed vocational nurse (LVN) elevated the HOB to less than 30 degrees, contrary to the physician's order, which could potentially lead to aspiration. The LVN admitted to estimating the angle due to the absence of a measuring device on the bed. In the case of Resident 18, the facility failed to administer enteral feeding according to the physician's orders. The resident was supposed to receive Vital 1.5 at 55 ml per hour, but the feeding pump was set to infuse Pivot 1.5 at 60 ml per hour. Additionally, the water flush bag was not labeled with the resident's name or the ordered rate, which is against the facility's policy. The LVN responsible for the administration acknowledged the discrepancies and admitted to not verifying the physician's order before starting the feeding. Both incidents were acknowledged by the Director of the Sub-Acute Unit, who confirmed that the facility's policies were not followed. The director stated that licensed nurses are expected to review physician orders and ensure correct administration rates, and that all feeding and flush bags should be properly labeled with the resident's details and the ordered rate.
Failure to Maintain Clean Enteral Feeding Pump
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for Resident 26, as evidenced by the presence of multiple dry, brownish residues on the resident's enteral feeding pump device. Observations conducted on two consecutive days revealed that the enteral feeding pump was not cleaned, despite being used to infuse Glucerna 1.2 at a rate of 90 ml/hr. Licensed nurses, who were responsible for the cleaning and daily upkeep of the enteral feeding pump, did not notice or address the stains on the device. This oversight was confirmed by both LVN 6 and RN 3 during interviews and concurrent observations. The facility's policy on Environmental Services/Infection Control, reviewed in August 2023, emphasizes the importance of removing soil and dust from surfaces to prevent nosocomial infections. However, the policy was not adhered to in this instance, as the enteral feeding pump remained unclean. The Director of the Sub-Acute Unit acknowledged that the residents' rooms and environment should be clean and comfortable, and confirmed that the licensed nurses were responsible for cleaning the enteral feeding pump. The failure to maintain the cleanliness of the enteral feeding pump device had the potential to negatively impact Resident 26's safety and quality of life.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the transfer and discharge of the resident to an acute care unit. The resident, who lacked the capacity to understand and make decisions, was transferred based on a physician's order, which included a bed hold for seven days. Although the resident's representative was verbally informed and agreed to the transfer, the facility did not provide the required written notice detailing the transfer, the reasons for it, and the resident's rights to appeal the decision. The deficiency was identified during a review of the resident's medical records, which lacked documentation of the written notification. The Social Service Staff, responsible for issuing such notifications, confirmed that the notice was not provided in writing, acknowledging that only verbal communication was made. The Director of the Sub-Acute Unit was informed of these findings, which highlighted the facility's failure to comply with the requirement to notify residents and their representatives in writing about transfers and discharges, including their appeal rights.
Medication Administration Route Errors for Two Residents
Penalty
Summary
The facility failed to ensure accurate physician's orders for two residents, leading to the administration of medications via the incorrect route. For Resident 23, medications were ordered to be administered orally, but were given via gastrostomy tube (GT) by LVN 6. The medical record review revealed discrepancies in the physician's orders, which specified oral administration for medications such as ferrous sulfate, lactobacillus acidophilus, and Phenobarbital. LVN 6 acknowledged the error and indicated that the charge nurse should have verified the route with the physician. RN 4 confirmed the findings and noted limitations in the electronic health record system, which sometimes lacked an option for GT route, requiring manual entry in the comment section. Similarly, Resident 2's medications were also administered via GT despite the physician's order specifying oral administration. LVN 8 confirmed the error and stated that the RN should have contacted the physician to correct the order. The pharmacist verified the oral orders and acknowledged the limitations of the electronic health record system, which sometimes did not provide an option for GT route. The Director of the Sub-Acute Unit was informed and acknowledged the findings.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Specifically, the facility did not limit the PRN order for lorazepam, an antianxiety medication, to 14 days as required. The resident had an order for lorazepam 1 mg intramuscularly every four hours as needed for seizures, but there was no documentation from the physician or prescribing practitioner justifying the extension of this medication beyond the 14-day limit. This lack of documentation and oversight could potentially lead to the unnecessary use of psychotropic medication, which might negatively impact the resident's mental, physical, and psychosocial well-being. Interviews with facility staff, including an LVN and the Director of Pharmacy, confirmed the absence of necessary documentation for the continued use of lorazepam beyond the 14-day period. The LVN verified that the resident last received the PRN lorazepam on a specific date, but there was no physician documentation providing a rationale for its continued use. The Director of Pharmacy acknowledged the requirement for such documentation and confirmed its absence in the resident's medical record. The Director of the Sub-Acute Unit was informed of these findings and acknowledged the deficiency.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of its medication carts, specifically Medication Cart B, was properly locked and secured when unattended. During an observation, the cart was found unlocked and unattended in a hallway near the activity room. The cart contained various medications, including Valsartan, insulin pens, and other medications for multiple residents. The cart's drawers, except for the one with a lock, could be easily opened, allowing potential unauthorized access to the medications. Upon further investigation, it was discovered that the locking mechanism on the right column of drawers was not functioning properly. The LVN responsible for the cart confirmed that it should have been locked, but the drawers could still be opened after the locks were engaged. The Director of the Sub-Acute Unit and the Engineering team confirmed the malfunction and identified debris, including oral swab sticks, obstructing the locking mechanism. After removing the debris and resetting the drawers, the cart was confirmed to be fully locked.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that the cook followed the recipe when preparing pureed Swiss steak, which could potentially affect the nutritional needs of residents. During an observation, the cook, identified as [NAME] 1, was seen preparing the pureed Swiss steak for a resident. The cook measured 4 oz of Swiss steak but did not measure the beef broth before blending it with the steak. Additionally, only one teaspoon of thickener was added, contrary to the facility's policy which required two to three tablespoons per pound of solid food. The facility's policy on pureed diets, dated June 2023, clearly outlined the procedure for preparing pureed meals, including specific measurements for broth and thickener. The Registered Dietitian (RD) confirmed that the cook should have adhered to these instructions. The failure to follow the recipe as per the facility's policy could lead to the residents' nutritional needs not being met, as the consistency and nutritional content of the meal might not align with dietary requirements.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as observed during a survey. A steel tray and a red blender were found stored while still wet, contrary to the USDA Food Code 2022, Section 4-901.11, which requires equipment and utensils to be air-dried before storage to prevent microorganism growth. The Clinical Dietician confirmed these observations, acknowledging that the items should have been air-dried before being stored in the clean dish storage area and the kitchen, respectively. Additionally, a rack used for storing clean pots and pans was found to be in an unsanitary condition, with white water residue and dry dust on four of its bottom shelves. This was verified by the Clinical Dietician, who stated that the rack should have been cleaned. Furthermore, four cutting boards were heavily marred and discolored, which could hinder proper cleaning and sanitization, as per FDA Food Code 2022, Section 4-501.12. The Clinical Dietician confirmed that these cutting boards needed replacement. These deficiencies had the potential to result in foodborne illnesses for the residents receiving kitchen services.
Incomplete Restraint Documentation for Resident
Penalty
Summary
The facility failed to ensure the medical record for one resident was accurate and complete, specifically regarding the Restraint Assessment/Restraint Flowsheet for a resident using bilateral soft hand mittens. The resident was observed with these mittens to prevent pulling out medical tubing, with a physician's order to release them every two hours for 15 minutes to check circulation and skin condition. However, the flowsheet documentation was incomplete on several occasions, with missing entries for entire shifts and lack of documentation on whether the mittens were reapplied or assessed for continued need. Interviews with staff, including an LVN and the Director of the Sub-Acute Unit, confirmed the expectation that the Restraint Assessment/Restraint Flowsheet should be completed accurately for each shift. The LVN verified the incomplete documentation, and the Director emphasized the importance of accurate and complete nursing documentation to reflect the care provided. The failure to document the restraint assessments accurately had the potential to impact the resident's care needs due to the inaccuracy of their medical information.
Failure to Properly Record Resident's Personal Belongings
Penalty
Summary
The facility failed to ensure the proper recording of a resident's personal belongings, as evidenced by incomplete Resident Inventory of Personal Effects forms for one of the sampled residents. The facility's policy and procedure (P&P) titled 'Handling of Personal Effects' requires that all residents' personal belongings be recorded and signed by both staff and the responsible party upon admission and whenever new items are brought in or removed. However, the review of Resident 1's inventory forms showed multiple instances where either the staff or responsible party's signatures were missing, indicating a lack of proper documentation and accountability for the resident's belongings. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the inventory forms were not consistently filled out as required. Additionally, a family member of Resident 1 reported that several personal items, including blankets and clothes, had gone missing since the resident's admission. The family member acknowledged awareness of the procedure but noted that it was not being consistently followed by the staff, making it difficult to track the missing items. The DON confirmed that some of the missing items had been replaced but acknowledged the deficiencies in the inventory process.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that four sampled residents maintained good grooming, personal hygiene, and proper transfers. Resident 1 did not receive scheduled showers and was not transferred out of bed as planned. The medical record review showed that Resident 1, who had a major stroke and was nonverbal, was supposed to receive showers twice a week and be transferred to a wheelchair three times a week. However, the CNA flowsheet and nurses' progress notes for April 2024 indicated missed showers and transfers. Interviews with family members and staff confirmed dissatisfaction with staffing levels, which led to these deficiencies. Resident 2, who was in a vegetative state and dependent on staff for all activities of daily living, also did not receive scheduled showers. The CNA flowsheet and nurses' progress notes for April 2024 showed missed showers on multiple dates. Additionally, Resident 2 was observed with long fingernails, including a jagged-edged right thumb fingernail with black matter underneath. Interviews with staff revealed that nail care was not consistently provided, and the DON confirmed ongoing staffing challenges. Resident 3, who was rarely able to express ideas or understand others, did not receive scheduled showers and was not transferred to a wheelchair as planned. The CNA flowsheet and nurses' progress notes for April 2024 indicated missed showers and transfers. Family members and staff interviews highlighted the facility's staffing shortages, which contributed to these deficiencies. Similarly, Resident 5 was observed with long fingernails, and interviews with staff confirmed that nail care was not consistently provided. The DON acknowledged the staffing issues and the impact on resident care.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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