Stanley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, California.
- Location
- 14102 Springdale Street, Westminster, California 92683
- CMS Provider Number
- 555651
- Inspections on file
- 17
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Stanley Healthcare Center during CMS and state inspections, most recent first.
The facility failed to verify the identity and CNA licensure of a registry staff member, allowing an unverified male individual to work a CNA shift under a female CNA’s name. The DSD/IP oriented this individual and had another CNA provide a brief resident-care orientation without checking a government ID, CNA license, or competency evaluation. The facility relied solely on the registry company to confirm identity and licensure and did not maintain personnel files or conduct its own verification for registry staff, resulting in an unidentified person providing direct care under another CNA’s credentials.
Surveyors found that the facility did not ensure safe and appropriate respiratory care for four residents, including missing physician orders for suctioning, improper storage of oxygen cannula tubing, failure to change nebulizer equipment as required, and lack of cleaning for CPAP components. These deficiencies were identified through direct observation, staff interviews, and review of medical records and facility policies.
The facility did not provide written information about bed-hold options to three residents or their responsible parties when they were transferred to an acute care hospital. Instead, an LVN only discussed the bed-hold option verbally and did not supply the required written documentation, as confirmed by both medical record review and staff interviews.
A resident with an indwelling urinary catheter did not have any physician's orders documented for the catheter's use, care, or maintenance. This was confirmed through medical record review and interviews with an LVN and the DON, who both acknowledged the absence of required orders despite the resident being observed with a urinary drainage bag.
A resident's annual and discharge return-anticipated MDS assessments were not completed within the required 14-day period after the ARD. Both assessments remained in progress well past the deadline, as confirmed by the DON during record review and interview.
A physician's order for wound care did not specify the location of a Stage 3 pressure ulcer for a resident. Medical records indicated the presence of the ulcer, but the order itself omitted this critical detail, which was confirmed by the DON during review.
Staff did not follow Enhanced Barrier Precautions when providing incontinence care to a resident with an indwelling urinary catheter. Despite facility policy and posted signage requiring both gloves and gowns for high-contact care, staff were observed wearing only gloves. The infection preventionist confirmed that proper PPE was not used as required.
The facility failed to maintain sanitary conditions in the kitchen, with a dirty microwave, residue on the stove hood, and damaged utensils. Utensils were partially melted, chipped, or discolored, and cutting boards were heavily marred. These deficiencies risked cross-contamination and foodborne illnesses, as acknowledged by the Dietary Supervisor.
The facility failed to follow infection control practices, including not notifying physicians when infections didn't meet criteria, not implementing contact isolation for a resident with C. difficile, and using non-cleanable equipment. Additionally, staff did not adhere to Enhanced Barrier Precautions for residents at risk of MDRO transmission.
A facility failed to meet professional standards of care when an LVN improperly obtained a resident's blood pressure by placing the cuff and stethoscope over the resident's clothing instead of directly on the skin. This was contrary to the facility's policy, which requires direct skin contact for accurate readings. The LVN and other staff confirmed the correct procedure during interviews.
A resident with limited mobility and ROM functions did not receive the necessary treatment and services to maintain or improve her ROM. Despite the care plan indicating daily ROM exercises, there was no documentation of these exercises being provided. Interviews with facility staff confirmed the lack of ROM exercises, and the resident had not been evaluated for physical therapy. This failure had the potential to cause a decline in the resident's physical abilities.
A facility failed to complete a smoking assessment for a resident upon admission, as required by their policy. Despite the resident being supervised while smoking, the necessary assessment was not documented in the medical record. This oversight was confirmed by an LVN and acknowledged by the DON, posing a potential risk for accidents or injuries.
The facility failed to follow physician's orders for oxygen therapy for two residents. One resident received oxygen at a higher rate than prescribed, while another was not using the prescribed continuous oxygen therapy. The discrepancies were confirmed by staff, and the residents' oxygen saturation levels were affected.
The facility failed to ensure proper use and documentation of side rails for four residents, leading to potential accident hazards. A resident's informed consent was incomplete, another's care plan lacked side rail use details, and assessments were missing for two residents. These deficiencies were confirmed by the DSD/IP.
A facility failed to ensure proper pharmaceutical services when an LVN administered laxatives to a resident without assessing bowel status or reviewing medical records, contrary to physician orders. The resident, unable to make medical decisions, had specific orders to hold laxatives for loose stool, which were not followed. The LVN admitted to not checking the resident's bowel status, and the Administrator and DON acknowledged the deficiency.
The facility failed to address the Pharmacy Consultant's recommendations for two residents, risking adverse medication consequences. One resident's recommendations for Preparation H and Benadryl were not documented as addressed, while another resident's lorazepam order lacked a required stop date evaluation. Despite claims of physician contact, no evidence was found in the medical records.
Two LVNs at the facility were observed making medication administration errors, resulting in a medication error rate of 11.11%. One LVN incorrectly reconstituted polyethylene glycol for a resident, while another LVN made the same error and failed to administer a vitamin B12 supplement to another resident. The errors were acknowledged by the LVNs and the DON.
The facility failed to ensure proper documentation and care plans for two residents receiving hospice services. A resident's hospice visit calendar and updated care plan were missing, while another resident lacked a care plan and visit schedule. Staff confirmed these deficiencies, posing risks to hospice care coordination.
The facility failed to implement QAPI action plans to monitor the effectiveness of pharmacy consultant recommendations, as required by their POC. The DON did not assign the charge nurse to review and address the DRR, resulting in a lack of follow-up and communication with the physician. This oversight violated the facility's POC and had the potential to affect the quality of care for all residents.
The facility failed to ensure a glucometer was maintained in safe operating condition. Quality control records for February and March 2025 did not match the glucometer's saved results, with several documented results missing from the device's memory. This issue was verified by an LVN and acknowledged by the DON.
The facility failed to accurately complete entrapment assessments for four residents, leading to potential safety risks. Observations showed discrepancies in bed measurements, confirmed by the Maintenance Supervisor and acknowledged by the Administrator. Residents with elevated side rails for mobility assistance had inaccurate bed measurements, increasing the risk of entrapment.
A facility failed to update a resident's POLST and obtain a copy of their advance directive. Despite the resident's family executing an advance directive, the POLST did not reflect this, and the facility did not follow up to obtain the document. The Social Services/Activities Director confirmed these findings during an interview.
The facility failed to provide timely written notification of transfer or discharge to two residents and their representatives, as well as to the LTC Ombudsman. One resident was transferred to a hospital due to a possible G-tube issue without proper notification, and another was discharged home without notifying the Ombudsman. Staff confirmed the lack of documentation for these notifications.
The facility failed to complete and transmit the MDS for discharge for a resident who was readmitted after an acute care hospital stay. The oversight was confirmed during an interview with the Administrator.
A facility failed to accurately code the MDS for a resident's RNA services, leaving Section O blank despite existing physician's orders for orthosis and range of motion exercises. The MDS Coordinator lacked access to the EHR, leading to the omission, which was confirmed by the DSD/IP. This posed a risk of the resident not receiving a tailored care plan.
The facility failed to revise the care plan for a resident with moderately impaired cognition after the resident reported an abuse allegation against a CNA. Interviews confirmed that no new or revised care plan was created following the incident, despite facility policies requiring updates to care plans to address identified problems and risk factors.
Unverified Registry CNA Worked Under Another Individual’s Identity
Penalty
Summary
The facility failed to ensure that an individual working as a CNA held a valid and up-to-date license and met competency evaluation requirements for training. A complaint forwarded to CDPH indicated that a CNA from a registry was scheduled for an afternoon shift, but a male individual arrived and claimed to be that CNA, even though the actual CNA was a female. The male individual signed the staffing assignment sheet, received facility orientation from the DSD/IP, and then received a brief resident-care orientation from another CNA. The DSD/IP did not check or verify the individual’s identity using a government-issued ID or confirm the CNA license prior to or at the start of the shift. Interviews with the DSD/IP, DON, and Administrator revealed that the DSD/IP was responsible for verifying employees’ identity and licenses, conducting background checks, and providing orientations, but she did not verify the identity, license, certification, or competency evaluations of this individual or any registry staff prior to the incident. The Administrator stated that the facility relied on the registry company to verify identity and licensure and did not require its own verification of registry staff. The DSD/IP acknowledged she did not know whether the male individual who worked the shift had a valid CNA license or competency evaluation and that, prior to this event, the facility did not maintain personnel files or conduct identity and license checks for registry staff. The facility’s failure to verify the identity and licensure of the individual resulted in an unverified, potentially unlicensed person working under another CNA’s name and providing direct care to residents, with the DSD/IP later learning from the actual CNA that she had not accepted or worked the shift.
Failure to Provide Safe and Appropriate Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory care and services for four residents, as evidenced by multiple deficiencies in following physician orders and facility policies. For one resident, there was no physician's order for suctioning, despite the presence of a suction machine and care plan interventions that required suctioning if secretions could not be cleared. The suction equipment was observed to have fluid residue and was not properly labeled or changed according to policy. Another resident's oxygen nasal cannula tubing was not stored in accordance with facility policy, as part of the tubing was left out of the storage bag and was touching the floor, creating an infection control concern. The resident's care plan also did not address the use of oxygen, despite an active physician's order for PRN oxygen administration. A third resident's nebulizer administration set-up was not changed every seven days as required by facility policy, and the storage bag for the nebulizer tubing was not labeled with the resident's name. For a fourth resident, there was no documentation that the CPAP machine's washable filter, mask, nasal pillows, and tubing were cleaned according to the manufacturer's guidelines and facility policy during the resident's stay. These failures were confirmed through observation, interviews with staff, and review of medical records and facility policies.
Failure to Provide Written Bed-Hold Information Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written information regarding bed-hold options to residents or their responsible parties upon transfer to an acute care hospital, as required by facility policy. For three sampled residents who were transferred to the hospital, medical record reviews showed no documentation that written bed-hold information was given. The facility's policy specifies that prior to transfer, residents and their representatives must receive detailed written information about bed-hold rights, payment policies, and per diem rates for holding a bed beyond the state's bed-hold period. The Bedhold Notification Upon Transfer form, which is intended to document this process, was not found in the records of the affected residents. Interviews with the LVN responsible for the residents during their transfers revealed that while the nurse obtained physician orders for bed-holds and verbally asked residents or their responsible parties if they wanted a bed-hold, no written information was provided. The LVN was unaware of the specifics regarding bed-hold payments and only discussed the option verbally. The facility administrator confirmed that all residents should be offered written information about bed-hold options upon transfer, but this was not done for the residents in question.
Lack of Physician Orders for Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident admitted with an indwelling urinary catheter did not have any physician's orders documented for the use, care, or maintenance of the catheter. During medical record review, it was confirmed that there were no orders present for the indwelling urinary catheter, despite the resident being observed with a urinary drainage bag in place. An LVN verified the absence of these orders and stated that catheter care should be performed every shift and documented in the Treatment Administration Record (TAR). The Director of Nursing also acknowledged that the resident was admitted with the catheter and confirmed the lack of corresponding physician's orders.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete both the annual and discharge return-anticipated Minimum Data Set (MDS) assessments for a long-term resident within the required 14 calendar days after the Assessment Reference Date (ARD). Specifically, the annual MDS assessment had an ARD of 4/25/25 and remained incomplete 21 days after the ARD, while the discharge return-anticipated MDS assessment had an ARD of 4/29/25 and was incomplete 17 days after the ARD. The resident had been readmitted to the facility and was later transferred to an acute care hospital with the expectation of returning. The Director of Nursing confirmed that these assessments were overdue and should have been completed within the mandated timeframe.
Incomplete Wound Care Order Documentation
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately maintained. Specifically, a physician's order for wound care did not include the location of the wound. Medical record review showed that the resident had a Stage 3 pressure ulcer to the medial sacrum, but the corresponding physician's order for wound care omitted this location detail. During an interview and concurrent record review, the DON confirmed that the wound care order lacked the required wound location information.
Failure to Follow Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
Facility staff failed to maintain infection control practices for a resident with an indwelling urinary catheter during incontinence care. According to the facility's Enhanced Barrier Precautions (EBP) policy, gloves and gowns are required for high-contact care activities, including hygiene and changing briefs, to reduce the spread of multi-drug-resistant organisms. During an observation, staff were seen providing incontinence care to the resident while wearing only gloves, despite EBP signage indicating the need for both gloves and gowns. The Director of Staff Development/Infection Preventionist confirmed that the staff should have been wearing isolation gowns in addition to gloves during this care activity. The resident involved had an indwelling urinary catheter and was under EBP due to this condition. The failure to follow established EBP protocols was verified through direct observation and staff interview, as well as a review of facility policy.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a kitchen tour. The microwave used for warming food was found to be dirty with white crumbs on the glass plate. Additionally, the hood over the stove was observed to have black, dirt residue, despite the facility's policy requiring it to be cleaned every two weeks. The last service sticker on the hood indicated it was last cleaned in October 2024, suggesting a lapse in regular maintenance. The facility also failed to ensure that kitchen utensils and equipment were in good condition and clean. Several utensils, including slotted scoops, spatulas, and tongs, were found to be partially melted, chipped, or discolored. A basting brush had frayed bristles, and a cheese grater was cracked and chipped. These items were not replaced as required by the facility's policy, which mandates that unsanitary or hazardous items be discarded. The presence of these damaged utensils posed a risk of cross-contamination and foodborne illnesses. Furthermore, the facility did not maintain clean food-contact surfaces, as evidenced by utensils with dry water spots, fuzzy film, and crusted residue. Cutting boards were heavily marred with deep grooves, making them difficult to clean and sanitize. The Dietary Supervisor acknowledged these findings, confirming that the dirty utensils should have been sanitized, and the cutting boards replaced every three months to prevent bacterial growth. These deficiencies highlight a failure to adhere to professional standards for food safety and sanitation, potentially compromising the health of the residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as evidenced by several deficiencies in their infection prevention and control program. Physicians were not notified when infections in residents did not meet McGeer's criteria, affecting residents 2, 6, 9, 18, and 22. Additionally, Resident 627, who was diagnosed with a Clostridium difficile infection, did not have contact isolation precautions in place, and their infection was not accurately documented in the Infection & Control Surveillance Log for February 2025. The facility's Director of Staff Development/Infection Preventionist (DSD/IP) confirmed these oversights during a review of the facility's infection control documentation. The facility also failed to ensure proper cleaning and disinfection of equipment. Observations revealed that Licensed Vocational Nurses (LVNs) used a blood pressure wrist machine with a Velcro and cloth material closure, which was not suitable for disinfection with the facility's germicidal wipes intended for non-porous surfaces. This practice was acknowledged as inappropriate by the LVNs involved, as the equipment's material was not cleanable, posing an infection control issue. Furthermore, the facility did not consistently implement Enhanced Barrier Precautions (EBP) for residents at risk of multidrug-resistant organism (MDRO) transmission. A hospice LVN failed to wear a gown while providing wound care to Resident 20, who was on EBP due to bilateral lower extremity open wounds. Similarly, CNA 3 did not wear a gown while assisting Resident 7, who was on EBP due to an indwelling urinary catheter. These lapses in following EBP protocols were acknowledged by the staff involved and confirmed by the DSD/IP.
Improper Blood Pressure Measurement Procedure
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of care when a Licensed Vocational Nurse (LVN) did not properly obtain the blood pressure of a resident during medication administration. The LVN placed the blood pressure cuff and the diaphragm of the stethoscope over the resident's long sleeve shirt instead of directly on the skin, as required by the facility's policy and procedure for measuring blood pressure. This action was observed during a medication administration observation, where the resident's blood pressure was recorded as 152/90 mm/Hg. Interviews with the LVN, the Director of Staff Development/Infection Preventionist (DSD/IP), and the Director of Nursing (DON) confirmed that the correct procedure for obtaining blood pressure involves placing the cuff and stethoscope diaphragm directly on the skin. The LVN acknowledged that placing the equipment over clothing could lead to inaccurate readings and difficulty in hearing the pulsation. The DSD/IP confirmed that licensed nurses are trained on the correct procedure during orientation, and the DON acknowledged the findings of the deficiency.
Failure to Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) for Resident 8, who had limited mobility and ROM functions. Despite the facility's policy stating that residents with limited ROM should receive treatment to prevent further decline, Resident 8 did not receive physical therapy or ROM exercises since her admission. The resident expressed her desire for therapy to regain her ability to walk, but there was no evidence of physical therapy orders or RNA services in her medical records. The care plan for Resident 8 included daily ROM exercises, both active and passive, but there was no documentation to show these exercises were provided. Interviews with facility staff, including RNA 1, CNA 2, LVN 1, and the DON, confirmed that Resident 8 did not receive the necessary ROM exercises. RNA 1 stated that long-term residents receive RNA services after evaluation by the PT, but Resident 8 had not been evaluated. CNA 2 mentioned that CNAs help maintain ROM for residents who do not qualify for PT, but there was no documentation of such exercises for Resident 8. LVN 1 and the DON verified the lack of documentation and acknowledged that Resident 8 should have been receiving daily ROM exercises. This oversight had the potential to lead to a decline in Resident 8's physical abilities.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident upon admission, as required by their Smoking Policy revised in July 2017. This policy mandates that residents who smoke must be assessed with a safe smoking assessment tool upon admission to determine if they are safe to smoke. Despite the resident being taken to the smoking area by staff and supervised while smoking, the necessary assessment was not documented in the resident's medical record. This oversight was confirmed during an interview with the LVN, who was unable to locate the assessment in the resident's records, and acknowledged by the DON. The resident, who was admitted to the facility on an unspecified date, was found to have the capacity to understand and make decisions according to their H&P examination dated May 8, 2024. However, the absence of a documented safe smoking assessment posed a potential risk for accidents or injuries. The facility had recently transitioned to a new EHR system, which may have contributed to the oversight, but this does not negate the requirement for the assessment to be completed and documented as per the facility's policy.
Failure to Follow Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to potential negative impacts on their medical conditions. For Resident 13, the oxygen concentrator was set at 5 liters per minute, contrary to the physician's order of 4 liters per minute as needed to maintain oxygen saturation levels above 90%. This discrepancy was confirmed by the Director of Staff Development/Infection Preventionist (DSD/IP) during an observation and interview, acknowledging that the staff should have followed the physician's order. Resident 17 was observed without the prescribed continuous oxygen therapy of 2 liters per minute via nasal cannula, as per the physician's order for dyspnea. The resident was seen without the nasal cannula on multiple occasions, and the Certified Nursing Assistant (CNA) confirmed that the resident removed it due to personal discomfort, although this refusal was not documented. The Licensed Vocational Nurse (LVN) verified the resident's oxygen saturation level was 82% on room air, which improved to 100% when oxygen was administered at the prescribed rate.
Deficiencies in Side Rail Use and Documentation
Penalty
Summary
The facility failed to ensure the safety and proper use of side rails for four residents, leading to potential accident hazards. For Resident 13, the Facility Verification of Informed Consent was incomplete, lacking a physician's signature and date, and there was no physician's order for the use of bilateral half side rails. Despite the resident's diagnosis of Alzheimer's disease, which allowed for decision-making capacity, these procedural oversights were confirmed by the DSD/IP during an observation and interview. Resident 20's care plan did not address the use of bilateral half side rails, despite a physician's order for their use to aid in bed mobility and repositioning. The resident had the capacity to understand and make decisions, yet the absence of a care plan meant that staff were not adequately informed on how to care for the resident regarding side rail use. This was verified by the DSD/IP during an interview. For Resident 12, the facility failed to complete a side rail assessment and did not provide the manufacturer's manual to ensure compatibility between the bed and side rails. The resident, diagnosed with advanced dementia and Parkinson's-type tremors, lacked decision-making capacity. Additionally, Resident 1's assessment did not document alternative, least restrictive measures or assess the risk of entrapment. The DSD/IP confirmed that no alternatives were tried, and no care plan or risk assessment was completed for the resident's side rail use.
Failure to Assess Bowel Status Before Administering Laxatives
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for Resident 8, as observed during a medication administration session. Licensed Vocational Nurse (LVN) 1 administered laxative medications, including polyethylene glycol and Senna, without assessing the resident's bowel status or reviewing the medical record for bowel elimination, as required by the physician's orders. The facility's policy and procedure for administering medications, revised in April 2019, mandates that medications be administered in accordance with prescriber orders, which was not adhered to in this instance. Resident 8, who was readmitted to the facility on an unspecified date, had a history and physical examination indicating the ability to communicate needs but an inability to make medical decisions. The physician's orders specified that the laxatives should be held in the case of loose stool, a directive that was not followed by LVN 1. During an interview, LVN 1 confirmed the failure to assess the resident's bowel status, attributing it to the resident's consistent request for laxatives and stool softeners. The Administrator and Director of Nursing (DON) were informed of these findings and acknowledged the deficiency.
Failure to Address Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's drug recommendations were addressed for two residents, leading to potential adverse consequences related to their medications. For Resident 17, the facility did not address the Pharmacy Consultant's recommendations regarding the duration of therapy for Preparation H and the suggestion to switch from Benadryl to a less sedating antihistamine. Despite the Director of Nursing (DON) stating that the process involved notifying the physician and documenting the actions taken, there was no evidence in the medical record that these recommendations were addressed until after the surveyor's inquiry. For Resident 1, the facility did not document any follow-up on the Pharmacy Consultant's recommendation to evaluate the need for a stop date for the PRN psychotropic medication lorazepam, as per CMS guidelines. Although the Director of Staff Development/Infection Preventionist (DSD/IP) claimed that the physician was contacted, there was no documented evidence to support this. Additionally, an LVN confirmed that Resident 1 had not shown signs of anxiety or required lorazepam administration during the day shift in the past two months, yet the recommendation remained unaddressed in the medical record.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 11.11%. Two licensed vocational nurses (LVNs) were involved in medication administration errors. LVN 1 did not follow the physician's order for Resident 8 by reconstituting polyethylene glycol medication with five ounces of water instead of the prescribed eight ounces. This discrepancy was confirmed during an interview with LVN 1, who admitted to using the incorrect amount of water due to the size of the plastic cup used. Similarly, LVN 2 made errors during medication administration for Resident 3. LVN 2 also reconstituted polyethylene glycol with five ounces of water instead of the required eight ounces. Additionally, LVN 2 failed to administer the prescribed vitamin B12 supplement to Resident 3, despite signing the medication administration record (MAR) as if it had been given. LVN 2 acknowledged the error, stating the vitamin B12 was not available in the medication cart. The Director of Nursing (DON) was informed and acknowledged these findings.
Deficiencies in Hospice Care Documentation and Coordination
Penalty
Summary
The facility failed to ensure that two residents receiving hospice services had the necessary documentation and care plans in place. For Resident 1, the hospice visit calendar was missing from the medical record, and there was no accurate documentation of hospice staff visits. Additionally, the care plan was not updated to reflect the hospice services being provided. Interviews with facility staff confirmed the absence of the hospice visit calendar and the lack of documentation for hospice aide visits as ordered. Resident 1's medical record also lacked an updated physician certification and hospice plan of care beyond November 2024, despite the resident being under hospice care. The facility's Director of Staff Development/Infection Preventionist (DSD/IP) acknowledged these deficiencies, noting that the care plan should have been updated to include visits from various hospice staff. The absence of these documents posed a risk of delayed communication and provision of hospice care. Similarly, for Resident 13, the hospice visit calendar was not available in the medical record, and there was no care plan addressing the hospice services provided. The DSD/IP confirmed that a care plan should have been in place to ensure facility staff were aware of the resident's hospice care plan. The lack of a calendar also meant that facility staff were not informed of the hospice staff's scheduled visits, which could impact the coordination of care for the resident.
Failure to Implement QAPI Action Plans for Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented action plans to monitor the effectiveness of those plans in achieving and sustaining improvement for a repeated deficient practice cited at F756. This deficiency was identified during a review of the facility's policies and procedures, which outlined the QAPI plan's process for identifying and correcting quality deficiencies. Key components of this process included tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing underlying causes, developing corrective actions, and monitoring the effectiveness of these actions. However, the facility did not adhere to these components, as evidenced by the failure to implement a monitoring system for the pharmacy consultant recommendations. During an interview with the Administrator and the Director of Nursing (DON), it was revealed that the DON did not assign the charge nurse to review and address the Drug Regimen Review (DRR) cited in the previous recertification survey. The DON admitted to placing the DRR in a binder but failed to assign it to a licensed nurse for follow-up and communication with the physician. This oversight was a direct violation of the facility's Plan of Correction (POC) from the last recertification survey, which required routine weekly audits of the pharmacy consultant recommendations to ensure completion on a monthly basis. The failure to implement these corrective actions had the potential to affect the quality of care for all residents in the facility.
Glucometer Quality Control Discrepancy
Penalty
Summary
The facility failed to maintain essential equipment, specifically a glucometer, in safe operating condition. During an inspection, it was found that the quality control records for February and March 2025 did not match the saved results on the glucometer with serial number 1040-4333929. The documented quality control results for several dates in February and March were not observed on the device's memory. For instance, the normal control result of 96 mg/dl and the high control result of 256 mg/dl documented on February 1, 2025, were missing from the glucometer's saved results. This discrepancy was verified by an LVN and acknowledged by the DON.
Inaccurate Bed Measurements Pose Entrapment Risk
Penalty
Summary
The facility failed to ensure accurate completion of entrapment assessments for four residents, which could potentially lead to serious harm. Observations and reviews revealed that the bed measurements, including bed frame lengths, mattress lengths, and mattress heights, were inaccurately recorded. This discrepancy was confirmed by the Maintenance Supervisor and acknowledged by the Administrator, who noted the importance of accurate measurements for resident safety. The facility's policy on the proper use of side rails requires assessments to determine the risk of entrapment, but these assessments were not accurately completed for the residents involved. Resident 13, who has Alzheimer's disease, was observed with elevated side rails, intended to aid in mobility and repositioning. Similarly, Resident 20 had a physician's order for side rails to assist with mobility, yet the bed measurements were inaccurate. Resident 12 and Resident 1 also had discrepancies in their bed measurements, specifically regarding mattress height. These inaccuracies in bed system assessments could lead to potential entrapment, posing a risk of serious injury or death to the residents.
Failure to Update POLST and Obtain Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders for Life-Sustaining Treatment (POLST) was updated and that a copy of the advance directive form was obtained. This deficiency was identified for one of the twelve sampled residents. The medical record review for the resident showed that the POLST, dated August 2, 2024, indicated no advance directive, despite an Advance Directive Acknowledgement form dated August 5, 2024, showing that the resident's family had executed an advance directive. During an interview and concurrent medical record review, both the Licensed Vocational Nurse (LVN) and the Social Services/Activities Director confirmed that the resident's family had executed an advance directive. However, the POLST was not updated to reflect this, and the facility did not follow up with the family to obtain a copy of the advance directive. The Social Services/Activities Director acknowledged these findings.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the residents and their representatives, as well as to the LTC Ombudsman, for two residents. Resident 21 was transferred to an acute care hospital due to a possible G-tube infection or dislodgement, but there was no documented evidence that the resident or their representative received a written notification of the transfer and its reason. Additionally, the facility did not send a copy of the notice to the LTC Ombudsman. Interviews with the Office Manager and LVN 1 confirmed these findings, and they were unable to provide documentation of the required notifications. Similarly, for Resident 26, who was discharged to home, the facility failed to send a copy of the Notice of Transfer/Discharge to the LTC Ombudsman. The section for sending a copy to the Ombudsman was left blank on the notice. The Social Services/Activities Director confirmed that the notice was not sent and could not provide documentation to show that the Ombudsman was notified about the resident's discharge. These failures posed a risk of the residents and their representatives not being informed about the appeal process and the LTC Ombudsman not being aware of the circumstances of the transfers or discharges.
Failure to Complete and Transmit MDS for Discharge
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for discharge was completed and transmitted for one of the sampled residents, identified as Resident 12. This deficiency was identified during a medical record review initiated on March 5, 2025. Resident 12 had been readmitted to the facility after a stay in an acute care hospital from October 14 to October 18, 2024. However, the review of the transmitted MDS assessments revealed that the MDS reflecting Resident 12's discharge in October 2024 was not completed. This oversight was confirmed during an interview with the Administrator on March 4, 2025.
Inaccurate MDS Coding for RNA Services
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident regarding Restorative Nursing Program (RNA) services. Specifically, the MDS quarterly assessments for the resident, dated November 5, 2024, and February 5, 2025, had Section O for RNA left blank. This omission was discovered during a medical record review initiated on March 3, 2024. The resident had physician's orders for RNA services, including wearing a left knee orthosis and bilateral PRAFO, as well as active assist and passive range of motion exercises, which were not reflected in the MDS. Interviews with the MDS Coordinator and the Director of Staff Development/Infection Preventionist (DSD/IP) revealed that the MDS Coordinator did not have access to the electronic health record (EHR) to view the RNA program for the resident, leading to the inaccurate coding. The DSD/IP confirmed that the resident had been receiving RNA services since September 2024, and acknowledged the inaccuracy in the MDS. This failure posed a risk of the resident not receiving an individualized care plan tailored to their specific needs.
Failure to Revise Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to revise the care plan for a resident after the resident reported an abuse allegation against a Certified Nursing Assistant (CNA). The resident, who had a moderately impaired cognition with a BIMS score of 9, alleged that the CNA pushed her off a shower chair and put a hand around her throat. Despite this serious allegation, the care plan for the resident was not updated to reflect the incident or to include any new interventions to address the reported abuse. Interviews with the Licensed Vocational Nurse (LVN), Director of Nursing (DON), and Director of Staff Development (DSD) confirmed that no new or revised care plan was created following the abuse allegation. The facility's policy and procedure for comprehensive, person-centered care plans require that care plans include measurable objectives, describe services to maintain the resident's well-being, and incorporate identified problem areas and risk factors. The failure to update the care plan was acknowledged by the Administrator and DON during the interview.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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