Springs Road Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Vallejo, California.
- Location
- 1527 Springs Road, Vallejo, California 94591
- CMS Provider Number
- 055222
- Inspections on file
- 19
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Springs Road Healthcare during CMS and state inspections, most recent first.
A resident with a history of acute respiratory failure, hypoxia, and dysphagia had a POLST specifying DNR and comfort-focused treatment, along with care plan directions for airway maintenance and suctioning as needed. After developing severe shortness of breath and low O2 saturation, the resident was sent to the ER, where he was found to be ill-appearing, unresponsive to tactile stimulation, and on a non-rebreather mask, and was returned to the facility under DNR/comfort care status. Upon return, there was no documented nursing evaluation, including no vital signs, no respiratory or level-of-consciousness assessment, and no documented comfort measures such as suctioning, despite existing orders and facility policy requiring reassessment and care planning after a marked adverse change. The DON confirmed that assessments and implementation of comfort measures per the POLST were not documented.
A resident with diabetes, neuropathy, and weakness reported left knee pain after bumping the knee at church, with nursing documentation noting increased prominence and discoloration of the left knee and thigh. A physician ordered an x-ray of the left knee and shift monitoring of left thigh discoloration, but due to a data entry error by nursing staff, the diagnostic requisition was entered for the right knee, and the x-ray was performed on the wrong side. No follow-up assessments of the left knee were documented for several days despite ongoing pain requiring PRN Norco. An IDT review later confirmed the wrong-site x-ray and that a subsequent left knee x-ray showed an acute supracondylar distal femur fracture, which the DON and involved nurse acknowledged should have been identified earlier if the original order had been correctly carried out.
Two residents were involved in an incident where one reported being struck with a cane by another. Although staff were promptly informed and the affected resident was relocated, the alleged abuse was not reported to authorities as required by facility policy. The DSD did not submit the report due to uncertainty about the incident, resulting in a delay in agency notification.
Surveyors observed multiple areas around the facility grounds with extinguished cigarette butts, despite a posted non-smoking policy and signage throughout the premises. Maintenance staff confirmed the facility's non-smoking status, but the presence of cigarette butts at several exterior locations indicated a failure to enforce the smoking policy.
During a survey, it was found that two sealed lead acid batteries in the fire alarm control panel failed a required load voltage test and were not replaced, remaining connected to the system. The oversight was confirmed by the fire alarm system technician, and no corrective action was documented, affecting all residents and smoke compartments in the facility.
The facility failed to ensure privacy for four residents, leading to feelings of shame and embarrassment. Residents with memory impairments were exposed due to inadequate curtain coverage and missing blind slats. Despite staff awareness, privacy measures were not fully implemented, leaving residents visible during personal care. The facility's policy on promoting resident privacy was not upheld.
A facility failed to accurately label medications, leading to potential errors. A resident's insulin dosage was not updated on the label, and several medications lacked resident labels or open dates. The DON confirmed these issues, which violated the facility's policy requiring proper labeling and pharmacy verification.
A facility failed to maintain an accurate narcotic inventory for a resident with acute respiratory failure. Two Percocet tablets were removed from the medication card, but their administration was not documented in the MAR, leading to a discrepancy confirmed by the DON. This failure increased the potential for drug diversion and inaccurate medication monitoring.
A resident with severe cognitive impairment and anxiety disorder continued to receive Lorazepam beyond the prescribed 14-day period without a renewal order due to the facility's failure to conduct a monthly drug regimen review. The oversight was confirmed by the DON and Pharmacy Consultant, who acknowledged that the irregularities could have been identified if the MRR had been performed as required by the facility's policies.
The facility failed to maintain infection control standards by allowing two worn-out lounge chairs in the dining/activity room to be used by residents. The chairs, with exposed mesh and foam, could not be properly sanitized. Staff interviews revealed a lack of communication and action regarding the chairs' condition, and the maintenance log showed no requests for repair or replacement, despite the facility's policy to maintain a sanitary environment.
A resident with chronic pain and hemiplegia experienced inadequate pain management due to the facility's failure to follow physician's orders. Despite the resident's severe pain levels, staff administered medication for moderate pain, contrary to the orders. The DON confirmed the discrepancy, highlighting a failure in adhering to the facility's pain management policies.
A resident with muscle weakness, chronic pain, and hemiplegia wished to be discharged from the facility, but the facility failed to update his discharge plan or involve him in its development. The resident was not informed of the final plan, and there was no documentation of discussions about his discharge preferences. The facility's policy required documentation of the resident's intent to leave and a discharge plan, but these were not provided.
A resident with muscle weakness and hemiplegia fell during a transfer from bed to a shower chair when a CNA, assisted by four nursing students, attempted the transfer. The resident required maximal assistance, typically provided by two staff members, but the students, who were only supposed to observe, were uncoordinated, leading to the fall. The facility's policy on fall prevention was not followed, as confirmed by the DON.
Failure to Implement POLST and Provide Post-ER Comfort-Focused Assessment and Care
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s Physician Orders for Life-Sustaining Treatment (POLST) and provide appropriate assessment and comfort-focused care upon return from the emergency room. The resident, who was his own responsible party, had a POLST dated 10/16/2018 indicating Do Not Attempt Resuscitation and comfort-focused treatment, including relief of pain and suffering with medications, and use of oxygen, suctioning, and manual treatment of airway obstruction as needed. His medical history included acute respiratory failure with hypoxia and dysphagia, and a speech therapy discharge summary specified a soft and bite-sized diet with mildly thick liquids and general swallow precautions with upright posture during meals. The care plan for acute respiratory failure with hypoxia, initiated 10/13/24, directed staff to maintain a clear airway and suction as needed if secretions could not be cleared. On 12/22/25, an SBAR form documented that the resident had shortness of breath, a respiratory rate of 30 breaths per minute, and an oxygen saturation of 62%, after which a nurse practitioner was notified and recommended transfer to the ER. ER documentation showed the resident arrived at 3 a.m. with abnormal vital signs, including tachycardia, hypotension, tachypnea, and an O2 saturation of 95% on a non-rebreather mask, and was described as ill-appearing, unresponsive to tactile stimulation, with rhonchi present. ER notes stated that no further treatment would be provided due to his DNR and comfort care status and that he was comfortable and appropriate for return to the facility, and he was discharged back at 5:19 a.m. Upon his return, there was no documented nursing evaluation, including no vital signs, no assessment of respiratory status, no documentation of comfort measures such as suctioning, and no evaluation of level of consciousness. During interview and record review, the DON confirmed the absence of documented assessments and implementation of comfort measures per the POLST and stated her expectation that licensed nurses perform vital signs, assess, treat symptoms, follow physician orders, and document timely. The facility’s POLST policy required updating the plan of care and ongoing reassessment when a resident exhibits a sudden or marked adverse change, which was not reflected in the documentation for this resident.
Incorrect Diagnostic Order Entry and Lack of Follow-Up for Painful Left Knee
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of care and carry out a physician’s diagnostic order correctly for a cognitively intact resident with type 2 diabetes mellitus with diabetic polyneuropathy and weakness. The resident reported bumping the left knee at church and complained of significant left knee pain, with nursing documentation noting the left knee was more prominent than the right, with faint yellowish discoloration on the left lateral thigh. A physician was notified and ordered an x-ray of the left knee related to pain, and a subsequent order directed staff to monitor the left thigh skin discoloration every shift. However, due to a data entry error on the diagnostic requisition, the x-ray was ordered and performed on the right knee instead of the left knee, and no fracture was identified on that incorrect study. From the time of the initial complaint and order, there was no documented follow-up monitoring of the resident’s left knee from several days following the incident, despite ongoing pain requiring PRN Norco once or twice daily. The resident later stated having fallen at church but was unable to describe the circumstances. The error in body part selection for the x-ray was confirmed by the IDT note, which stated that the x-ray was performed on the right knee instead of the left knee, and that the corrected left knee x-ray subsequently revealed an acute mildly displaced supracondylar fracture of the distal femur. The DON and the nurse who wrote the initial note acknowledged that the x-ray order was for the left knee, that another nurse entered the request incorrectly for the right knee, that there were no follow-up notes on the left knee, and that the resident could have been sent to the hospital earlier if the x-ray had been done on the correct body part.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents. One resident, admitted with gastroenteritis, reported being hit on the shin with a cane by another resident, who had a history of congestive heart failure. The incident was reported by the affected resident to staff immediately after it occurred, and the resident was subsequently moved to a different room. However, a review of medical records showed no documentation that the alleged abuse was reported to the appropriate agencies within the required timeframe. Interviews with facility staff revealed that a licensed nurse was notified of the incident and promptly informed the Director of Staff Development (DSD). Despite this, the DSD did not report the alleged abuse to the relevant authorities, stating uncertainty about whether the abuse had actually occurred. The facility's policy required immediate reporting of all alleged abuse, but this protocol was not followed, resulting in a delay in notifying enforcement agencies.
Non-Compliance with Smoking Policy Evidenced by Cigarette Butt Litter
Penalty
Summary
The facility failed to adhere to its smoking policy, as evidenced by multiple observations of extinguished cigarette butts littered on the grounds in several exterior areas, including the south egress entrance, the area by the kitchen egress and inspector test valve, and the generator area. During a tour and interviews with Maintenance Staff, it was confirmed that the facility operates as a non-smoking environment, with signs displayed throughout the premises to remind staff and residents of the policy. The facility's smoking policy, which was undated, explicitly prohibits the use of cigarettes, cigars, pipes, or other tobacco smoking products. Despite the stated non-smoking policy and posted signage, surveyors observed approximately three dozen cigarette butts at the south egress entrance, twelve by the kitchen egress, and eight by the generator area. These findings were confirmed by Maintenance Staff, who reiterated the facility's non-smoking status. The deficiency affected all 59 residents and both smoke compartments of the facility, as the presence of cigarette butts indicated non-compliance with the established smoking regulations.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. No residents were found to be affected at this time. Upon identification of this alleged deficient practice, the facility Maintenance Director and Housekeeping personnel immediately removed the extinguished cigarette buds found on the south egress entrance, the kitchen egress, and the area surrounding the generator. A sweep of the exterior of the entire facility was completed by the Maintenance Director and no other smoking products were found. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were found to be affected at this time. All residents are potentially to be affected by this alleged deficient practice as failure to comply with NFPA 101 and smoking policies could affect patient care and has the potential to cause harm to facility residents, staff, and visitors. The Maintenance Director did a sweep of the facility exterior and found no smoking products. An all-staff inservice was conducted on 03/27/2025 regarding the facility smoking policies and procedures. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. It is the policy of the facility to ensure that emergency procedures, including smoking policies, are followed according to Life Safety Codes. The Director of Staff Development conducted an inservice on 03/27/2025 to all staff regarding the facility smoking policies and procedures. The Maintenance Director will conduct daily rounds of the exterior of the facility x 4 weeks, and weekly thereafter to ensure no smoking products are found on facility grounds. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were found to be affected at this time. All residents are potentially to be affected by this alleged deficient practice as failure to comply with NFPA 101 and smoking policies could affect patient care and has the potential to cause harm to facility residents, staff, and visitors. The Maintenance Director did a sweep of the facility exterior and found no smoking products. An all-staff inservice was conducted on 03/27/2025 regarding the facility smoking policies and procedures. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. It is the policy of the facility to ensure that emergency procedures, including smoking policies, are followed according to Life Safety Codes. The Director of Staff Development conducted an inservice on 03/27/2025 to all staff regarding the facility smoking policies and procedures. The Maintenance Director will conduct daily rounds of the exterior of the facility x 4 weeks, and weekly thereafter to ensure no smoking products are found on facility grounds. How the facility plans to monitor its performance to make sure that solutions are sustained. Maintenance Director/Designee will present any findings from facility safety rounds during our Daily Clinical meetings. Interventions to be reviewed in the facility monthly QAPI meeting x 3 months. Administrator will bring 2567 and POC to the meeting to discuss and ensure understanding. Date of compliance: 03/27/2025
Failure to Replace Deficient Fire Alarm System Batteries
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with regulatory requirements. During a facility tour, document review, and interview with maintenance staff, it was observed that two sealed lead acid (SLA) batteries in the Fire Alarm Control Panel (FACP) failed the semi-annual load voltage test. The inspection records dated 12/3/24 confirmed that both batteries did not meet the required standards during the scheduled testing. Despite the failed test results, the two deficient batteries were not replaced and remained connected to the FACP at the time of the survey. The fire alarm system technician acknowledged during the interview that the failure to replace the batteries was an oversight during the inspection process. No documentation was provided to indicate that corrective action had been taken following the failed battery test. This deficiency affected all 59 residents and both smoke compartments within the facility, as the fire alarm system's operational integrity was compromised by the presence of non-compliant batteries. The facility did not adhere to the required maintenance and testing program as outlined in NFPA 70 and NFPA 72, specifically regarding timely battery replacement following failed performance tests.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. No residents were found to be affected at this time. Upon identification of this alleged deficient practice, the facility fire alarm service vendor, Pacific Signaling, was requested to replace batteries. Pacific Signaling fulfilled the service request on 3/18/2025 by replacing the two SLA batteries with expiration dates of 03/18/2028. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were found to be affected at this time. All residents are potentially to be affected by this alleged deficient practice as failure to comply with NFPA 101 and maintaining the fire alarm system could potentially cause harm in the event of an emergency. The two SLA batteries were replaced on 3/18/2025 and will be checked at least quarterly for proper functioning. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. It is the policy of the facility to ensure that emergency procedures are followed according to Life Safety Codes. The Administrator and Maintenance Director reviewed NFPA 72 codes regarding fire alarm and signaling testing and inspections on 03/27/2025. The Maintenance Director will inspect the fire alarm system, including the SLA batteries, at least monthly in conjunction with the facility fire alarm and signaling vendor, Pacific Signaling. How the facility plans to monitor its performance to make sure that solutions are sustained. Maintenance Director/Designee will present any findings during our Daily Clinical meetings. Interventions to be reviewed in the facility monthly QAPI meeting x 3 months. The Administrator will bring 2567 and POC to the meeting to discuss and ensure understanding. Date of compliance: 03/27/2025
Privacy Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure privacy for four residents, resulting in feelings of shame and embarrassment. Resident 108, who has moderate memory impairment, was observed disrobing at her bedside with curtains that did not fully cover her personal space, leaving her visible from the hallway. Resident 53, also with moderate memory impairment, had a missing slat in the vertical blinds, allowing visibility into her room from the courtyard. Despite having reported the issue to staff, the slat had not been replaced. Resident 1, with moderate memory impairment, expressed discomfort due to a missing slat in the vertical blinds, fearing that people could see into her room at night. Resident 10, with severe memory impairment, was exposed during a change as the privacy curtain was not fully utilized, leaving her perineal area visible from the doorway. CNA 1 acknowledged the exposure but did not adjust the curtain, citing concerns about disturbing a roommate. Resident 10 reported feeling ashamed by the lack of privacy during such personal care. Interviews with the facility's Administrator and Director of Nurses confirmed that the expectation was for privacy to be maintained during resident care. However, a review of the Maintenance Log showed no entries for repairs to the curtains or blinds in the affected residents' rooms. The facility's policy emphasized the importance of promoting and protecting resident privacy, which was not upheld in these instances.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The curtains that were not reaching around, and the missing and/or broken blinds were immediately addressed and repaired by the maintenance director for residents 108, 51, 01, and 10 to preserve their dignity and uphold their rights. To date, the curtains for the affected residents fully close, providing adequate privacy; and the blinds are complete and in working condition. The residents were reassured and expressed satisfaction with the outcomes. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents can potentially be affected by the alleged deficient practice as failure of the facility to ensure that residents were treated with dignity and their privacy was protected when curtains did not reach around the resident's personal space and vertical blinds were broken/missing. Upon identification of alleged deficient practice, the Maintenance Director made rounds to the other rooms and no similar findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure that residents are afforded privacy and dignity through adequate curtain coverage and complete and properly functioning blinds. On 3/11/2025, the Director of Staff Development (DSD) conducted an in-service to Maintenance Director, Housekeeping, Certified Nursing Assistants (CNA), Licensed Nurses (LN), and all other staff regarding policy and procedure on resident's rights with emphasis on dignity, privacy, and call light response through curtains reaching around them, and functional blinds. Licensed Nurses (LNs), Certified Nursing Assistants (CNAs), Housekeeping Staff, interdisciplinary team (IDT) managers, and all other staff will continue to note in the maintenance log any issues regarding curtains and/or blinds in resident's rooms. The Maintenance Director/Designee will review the log on a daily basis and address any concerns. During their rounds, IDT managers will assess the functionality of curtains and blinds and document findings in their room round sheets accordingly, and notify maintenance director/designee immediately. How does the facility plan to monitor its performance to make sure that solutions are sustained? Findings from facility rounds/maintenance log will be discussed during Daily Stand-up meetings. Administrator/designee will monitor for compliance. Interventions to be reviewed in the next QAPI meeting. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/11/2025
Medication Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately label medications for a census of 61 residents, leading to potential medication errors. Specifically, Resident 54's insulin order was not correctly reflected on the medication label. During a medication administration observation, a licensed nurse administered 14 units of Humulin N to the resident, while the medication label indicated a dosage of 10 units. The Medication Administration Record confirmed the physician's order for 14 units every morning and night, but the label had not been updated to reflect this change. The Director of Nursing confirmed that the facility's policy required a 'change in direction' sticker on the medication and a new label from the pharmacy when orders change. Additionally, during an inspection of a medication storage cart, several medications were found without resident labels or open dates, and one label was difficult to read. These included Biktarvy, Breyna Inhalation Aerosol, and Symbicort Inhalation Aerosol, among others. The Director of Nursing confirmed that the labels were illegible or missing, and the medications should have been sent to the pharmacy for proper labeling. The facility's policy indicated that any inadequately or improperly labeled medications should be returned to the issuing pharmacy for correction.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Upon identification of the alleged deficient practice, the following were conducted: a. Resident 54's insulin label was immediately corrected to reflect the correct order. New NPH insulin was also ordered from the Pharmacy with the updated label. Resident 54 was assessed for signs and symptoms of hyper/hypoglycemia, none were observed. b. New Inhaler medications were ordered from the facility pharmacy. c. The three (3) Inhalation Aerosols and Biktarvy were shown to the Pharmacy Consultant, reviewed and verified the medications during his visit on 3/24/2025. All Medications were properly labeled to indicate proper identification, right dosage and expiration. d. The Lidocaine and Inhalation powder that had no open dates were immediately discarded and new medications were ordered from the pharmacy. Pharmacy Consultant informed pharmacy to deliver a new sticker indicating the right identification and dosages of the medication. 1:1 in service education provided by the Director of Nursing Services (DNS) on 03/11/2025 to LN1. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to correctly label medication could result in providing wrong medications, incorrect dosages, and expired medications to residents. An immediate sweep of medication carts station 1 and station 2 was conducted by the Director of Staff Development (DSD) to ensure there were no additional medications with lacking resident labels and open dates, and the label that was unclear and difficult to read. No other residents were found to be affected at this time. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility that medication must be properly labeled consistent to the order, labels must be legible at all times and any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. 1:1 in service education provided by the DNS on 03/11/2025 to Licensed Nurse 1 (LN 1) and to other LNs regarding the policies and procedures on "Labeling of Medication Containers" and "Storage of Medications" with emphasis on the following: a. Ensuring that medications are properly labeled including medications brought by family into the facility. b. Returning to the issuing pharmacy any medications that are improperly labeled. c. Notifying the pharmacy of any changes in the physician's orders. Upon receipt of any delivery of medication from the pharmacy, LNs must ensure medications are properly labeled. The issuing Pharmacy must be notified for any issues. During medication pass, LNs must ensure that medications are properly labeled consistent to the order. Any medication brought by the family to the facility must be verified and ensure that proper labels are available. Any issues will be communicated to the DNS and the facility pharmacy. How the facility plans to monitor its performance to make sure that solutions are sustained: The DNS/Designee will audit Medication carts at Station 1&2 bi-weekly x 3 months to ensure compliance. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/24/2025 During a review of the facility's P&P titled, F 761
Narcotic Inventory Discrepancy for a Resident
Penalty
Summary
The facility failed to maintain an accurate inventory of narcotics for a resident, identified as Resident 35, which led to a discrepancy between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). Specifically, two tablets of Percocet were removed from the medication card on two separate occasions, but there was no documentation in the MAR to confirm that these medications were administered to the resident. This discrepancy was confirmed during a review of the records by the Director of Nursing (DON), who acknowledged that the CDR documentation did not match the MAR documentation, and there was no way to verify if the narcotics were given to the resident. Resident 35, who was admitted to the facility in 2019, had a principal diagnosis of acute respiratory failure. The physician's orders indicated that Percocet was to be administered as needed for pain. However, the facility's failure to document the administration of the narcotics in the MAR as per their policy and procedure titled 'Administering Pain Medications' resulted in an increased potential for drug diversion and inaccurate monitoring of the resident's medication regimen.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 35 was assessed and no concerns were noted. The medical director was notified of the alleged deficient practice. Pharmacy Consultant and the Nurse Practitioner reviewed the current medications order of Resident 35 on 3/24/2025. Licensed Nurses (LNs) who failed to ensure accurate inventory/documentation of narcotic medication received a 1:1 in-service education on 03/24/2025 by the Director of Nursing Services (DNS) related to appropriate procedures on narcotic medication administration and documentation. The DNS provided in-service training to all LNs on 03/24/2025 on the correct procedures on administering and signing off narcotic medications in order to maintain an accurate reconciliation. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the alleged deficient practice as failure to keep accurate inventory of narcotics can lead to potential drug diversion resulting in improper drug usage and harm. Resident 35 narcotics was audited on 3/13/2025 and all residents currently receiving a narcotic pain medication were audited by the DNS/Designee on 03/14/2025 to ensure accurate inventory of narcotics. Effectiveness, location and intensity were documented after the PRN narcotic pain medication to evaluate their pain level. Upon identification of the alleged deficient practice, a new pain assessment was conducted on residents noted to have been given a PRN narcotic pain medications for the last 7 days to evaluate their pain level and ensure accurate inventory of narcotic had been documented in eMAR. No similar issue identified. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure accurate inventory of narcotics are entered in e MAR to prevent the potential for diversion. The DNS provided in-service training to all LNs on 03/24/2025 on the correct procedures on administering and signing off narcotic medications in order to maintain an accurate reconciliation. LNs in their respective shifts will ensure that accurate inventory of narcotics are entered in e MAR to prevent the potential for diversion. The DNS/Designee will conduct medication pass observations daily x 1 week and weekly x 3 months to ensure licensed nurses are following the protocol on narcotic medication administration and documentation. How the facility plans to monitor its performance to make sure that solutions are sustained: The DNS/Designee will monitor for compliance. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/24/2025
Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review (MRR) for one of the sampled residents, Resident 34. This oversight led to the resident receiving Lorazepam, a psychotropic medication, beyond the prescribed 14-day period without a physician's order for continuation. Resident 34, who was admitted with conditions including severe cognitive impairment and anxiety disorder, continued to receive Lorazepam from May 2024 through October 2024, despite the absence of a renewal order after the initial prescription expired on 6/14/24. The Director of Nursing confirmed the lapse in medication management and acknowledged that the irregularities in Lorazepam administration could have been identified if the MRR had been conducted as required. The Pharmacy Consultant also confirmed that the monthly MRR was not performed for Resident 34 during this period and stated that the medication should have automatically stopped after 14 days as per the order. The facility's policies and procedures, which mandate monthly MRRs and limit PRN orders for psychotropic drugs to 14 days, were not adhered to, resulting in this deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 34 was assessed and no concerns were noted. The Medical Director was immediately notified of the alleged deficient practice. Pharmacy Consultant and the Nurse Practitioner reviewed the current medications order of Resident 34 on 03/24/2025. The facility will continually strive to monitor residents' drug regimen reviews and Pharmacy reports regarding recommendations to physicians. The facility has Policies and Procedures designed to maintain these goals. Pharmacy review, consultant reviews, quality assurance monitoring, and staff training are examples of the many components utilized to achieve a complete drug regimen review process. On 03/24/2025, the Pharmacy Consultant reviewed the Psychotropic medication of Resident 34. Additionally, it was also reviewed and addressed by the Nurse Practitioner on the same day. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to follow up psychotropic medications with a stop date as indicated could lead to unnecessary, ineffective, and/or excessive dosage of psychotropic medication. The Pharmacy Consultant was immediately notified about the findings, who subsequently reviewed the psychotropic medication of Resident 34 and other residents. Follow-up meetings with the Nurse Practitioner and Pharmacy Consultant were held on 3/24/2025 in the DNS's office to ensure the monthly drug regimen review process will be implemented. Care was coordinated with hospice and the needs for continuing the psychotropic medication. The drug regimen of each resident must be reviewed at least once a month by a Consultant pharmacist. No other residents were found to be affected at this time. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure residents on psychotropic medications receive a thorough monthly pharmacy medication regimen review (MRR) to prevent the risk for residents receiving unnecessary, ineffective, and/or excessive dosage. The DNS provided an in-service on 03/12/2025 to LNs regarding the policy and procedure for carrying out medication orders, including Psychotropic Medications, with emphasis given on the importance of observing the stop date of PRN psychotropic medications when writing the orders. LNs are to ensure that the stop date of Psychotropic medications are observed. The DNS will review the accuracy of new PRN orders daily. The Pharmacy Consultant will review the medication regimen of each resident at least monthly or as needed and provide a written report to the DNS and the Attending Physicians. DNS/Designee will ensure and verify that monthly Drug regimen reviews will be conducted by the Pharmacy and are implemented. How the facility plans to monitor its performance to make sure that solutions are sustained: The DNS/Designee will monitor for compliance. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/24/2025 F 756
Inadequate Infection Control Due to Worn Lounge Chairs
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the presence of two worn-out lounge chairs in the dining/activity room. These chairs, made of imitation leather, were observed to be threadbare with mesh and foam exposed, making them unsanitary and unsuitable for proper cleaning. Resident 51 was seen using these chairs, which were available for resident use despite their deteriorated condition. The Infection Preventionist (IP) confirmed that the chairs could not be sanitized properly due to the exposed mesh fabric. Interviews with facility staff revealed a lack of communication and action regarding the condition of the chairs. The Director of Nurses (DON) acknowledged the need to replace worn furniture to ensure sanitization, while the Maintenance Supervisor (MS) stated that the deterioration of the chairs had not been reported in the maintenance log. The IP admitted awareness of the chairs' condition and their use by multiple residents. A review of the maintenance log showed no requests for repair or replacement of the chairs, and the facility's infection control policy emphasized the importance of maintaining a sanitary environment, which was not upheld in this instance.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The identified lounge chairs in the dining/activity room were removed by the facility's Maintenance Director immediately upon identification of the alleged deficient practice. No residents were found to be affected. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to provide a clean, sanitary environment could potentially spread communicable diseases. The Infection Preventionist (IP) and Maintenance Director did a facility sweep for any equipment that could possibly pose a risk for the spread of communicable diseases, no similar item found. No other residents were found to be affected by the alleged deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure that a safe and clean environment is provided to the residents and preventative measures are taken to reduce the spread of infections. Inservice was provided to all staff on 03/12/2025 by the IP on the facility policy for infection control with emphasis on the importance of providing a sanitary environment to mitigate the risk for the transmission of communicable diseases. The facility will ensure that all resident equipment is clean, sanitized, and in good working condition daily during manager room rounds. Any issues will be reported to the Administrator/Maintenance Director/Designee. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to provide a clean, sanitary environment could potentially spread communicable diseases. The Infection Preventionist (IP) and Maintenance Director did a facility sweep for any equipment that could possibly pose a risk for the spread of communicable diseases, no similar item found. No other residents were found to be affected by the alleged deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility to ensure that a safe and clean environment is provided to the residents and preventative measures are taken to reduce the spread of infections. Inservice was provided to all staff on 03/12/2025 by the IP on the facility policy for infection control with emphasis on the importance of providing a sanitary environment to mitigate the risk for the transmission of communicable diseases. The facility will ensure that all resident equipment is clean, sanitized, and in good working condition daily during manager room rounds. Any issues will be reported to the Administrator/Maintenance Director/Designee. How the facility plans to monitor its performance to make sure that solutions are sustained: The IP/Designee and/or Maintenance Director will audit all resident equipment weekly for 3 months to ensure that equipment is clean and in good working condition. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/12/2025
Failure to Follow Physician's Orders for Pain Management
Penalty
Summary
The facility failed to ensure that the physician's orders for pain management were followed for a resident, resulting in inadequate pain management. The resident, who was admitted with diagnoses including muscle weakness, chronic pain, and hemiplegia, complained of pain almost daily since admission. The electronic medical record indicated orders for oxycodone to be administered based on the severity of pain, but these orders were not consistently followed. The resident's pain levels were frequently recorded as severe, yet the medication administered was for moderate pain, contrary to the physician's orders. The Director of Nursing confirmed that the facility uses a numeric rating scale to assess pain and that the medication should be administered according to the severity of the pain as per the physician's orders. However, the records showed that the resident received medication for moderate pain even when the pain levels indicated severe pain. Interviews with the resident and the Director of Nursing revealed that the staff did not adhere to the physician's orders, leading to the resident's pain being inadequately managed. The facility's policies on pain assessment and medication administration emphasize adherence to prescriber orders, but these were not followed, resulting in the deficiency.
Failure to Update and Communicate Discharge Plan
Penalty
Summary
The facility failed to ensure an updated discharge plan for a resident, leading to a deficiency. The resident, who had been admitted with diagnoses including muscle weakness, chronic pain, and hemiplegia, expressed a desire to be discharged and return home with his cousin. However, the facility did not regularly re-evaluate the resident to identify changes that required modifications to his discharge plan. As a result, the discharge plan was not updated to reflect these changes. The resident was not involved in the development of his discharge plan and was not informed of the final plan. During an interview, the resident stated that staff did not discuss his discharge plan with him, and he was unaware of the current plan. The Director of Nursing acknowledged the resident's wish to be discharged but was unsure if anyone had spoken to him about his plan to be discharged to his cousin's care. There was no documentation of a new discharge plan in place for the resident. The facility's policy and procedure for resident-initiated transfer or discharge required documentation of the resident's intent to leave, a discharge plan, and discussions with the resident or their representative. However, there was no documentation that the resident had been asked about his plans to return to the community after completing skilled services. This lack of preparation for discharge could result in safety issues and prevent the resident from effectively transitioning to post-discharge care.
Resident Falls Due to Improper Transfer Assistance
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from bed to a shower chair, resulting in a fall. The resident, who had diagnoses including muscle weakness, chronic pain, and hemiplegia, required maximal assistance for transfers. Despite this, a certified nursing assistant (CNA) attempted the transfer with the help of four certified nursing students, who were only supposed to observe and not assist. This lack of proper assistance led to the resident falling during the transfer. Interviews and record reviews revealed that the resident had intact cognition and was aware that the protocol required two staff members to assist with transfers. The resident reported feeling unsafe and noted that the students were uncoordinated, which contributed to the fall. The facility's policy on managing falls and fall risks emphasized the need for staff to identify interventions to prevent falls, which was not adhered to in this instance. The Director of Nursing (DON) confirmed that the resident required assistance from two staff members during transfers and that students were not permitted to assist CNAs. The incident highlighted a breach in protocol, as the CNA was assisted by students instead of another staff member, compromising the resident's safety and leading to the fall.
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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