Sundance Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Banning, California.
- Location
- 5800 West Wilson Street, Banning, California 92220
- CMS Provider Number
- 555309
- Inspections on file
- 42
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Sundance Creek Post Acute during CMS and state inspections, most recent first.
A resident with cognitive impairment and lower extremity wounds experienced documented deterioration of diabetic heel wounds and new discoloration on the dorsum of the foot over several occasions. Although COC notes showed that physicians were notified and the resident was informed, the resident’s designated representative was not notified, despite facility policy and staff acknowledgment that changes in condition should be communicated to the resident representative and documented accordingly.
Two residents were involved in a physical altercation when a cognitively impaired resident with delusional and impulse disorders, known to wander and enter others’ rooms, went into another resident’s room, attempted to take personal items, and punched the resident in the face, causing minor injuries. The aggressive resident’s care plan identified risk for elopement and wandering but contained only general interventions without specifying the level of supervision or monitoring required, despite a physician order to monitor for impulse control disorder with wandering and danger to self and others. Staff, including an RN, LVN, and CNAs, reported awareness of the resident’s wandering and occasional aggression but were unaware of specific written interventions, there was no documented CNA monitoring of wandering behavior, and the resident was not listed on the facility’s internal communication board as at risk for wandering at the time of the incident.
Two residents with significant mobility impairments were unable to have their transfer needs and preferences met due to an insufficient number of Hoyer lifts. This resulted in delays, missed activities, and disruption of daily routines, as confirmed by staff and resident interviews and record reviews.
A resident with a history of diabetes, end stage renal disease, and hemodialysis was not assessed or monitored for circulatory insufficiency after a DVT diagnosis, despite care plan interventions and facility protocols requiring monitoring for pain, swelling, discoloration, and pedal pulses. Nursing staff and the DON confirmed that no documentation of such monitoring existed, and the deficiency was identified after the resident developed necrosis and was hospitalized for gangrene.
A resident with diabetes and fluctuating capacity experienced significant changes in skin condition, including a reclassified sacral pressure wound and new deep tissue injuries, as identified by wound care specialists. Despite these findings and new treatment orders, nursing staff did not complete required skin and wound evaluations or update the weekly summaries to reflect these changes, resulting in incomplete and inaccurate medical records. Both the LVN and DON confirmed that documentation should have included updated wound descriptions and measurements, in accordance with facility policy.
A resident with severe cognitive impairment and communication challenges was allegedly struck by another resident with a mental health disorder. The incident was witnessed by a third resident and reported to nursing staff, but the required report to CDPH and the Ombudsman was not made within the mandated two-hour timeframe. Staff interviews revealed miscommunication and lack of follow-through, resulting in delayed notification to the DON and failure to comply with facility policy.
A resident with fluctuating capacity to make medical decisions experienced a right shoulder prosthesis dislocation, an injury of unknown source, which was not reported to CDPH, police, or the Ombudsman within the required two-hour timeframe. Despite facility policy mandating immediate reporting to rule out abuse, the incident was not communicated as required, potentially affecting the resident's well-being.
A resident experienced a dislocation of their right shoulder prosthesis, which was not investigated by the facility despite being an injury of unknown origin. The resident was admitted without initial shoulder issues, but later complained of pain and swelling, leading to an X-ray that confirmed the dislocation. The facility's policy requires investigations for such injuries, but no investigation was conducted, as confirmed by the DON.
A resident with fluctuating decision-making capacity was transferred to a hospital without receiving a written transfer notice, and the LTC Ombudsman was not informed. The facility's policy requires such notices to be provided to both the resident and the Ombudsman, but this was not documented or executed.
A resident with significant mobility impairments and a history of stroke did not receive scheduled showers or bed baths as per their care plan. Despite being dependent on assistance for all ADLs, documentation showed missed showers and bed baths on several occasions, with no record of refusal. Interviews with staff and the DON confirmed lapses in following the care plan and documentation protocols.
A resident with hemiplegia and high risk for pressure ulcers was not repositioned every two hours as required, leading to the development of a pressure ulcer. Facility staff failed to document repositioning, and there was no schedule in place to ensure compliance with the facility's policy.
A resident reported missing finances, including a bank card and $600, to a Social Service Assistant (SSA) in an LTC facility. The SSA failed to report the financial abuse allegation to the California Department of Public Health (CDPH) within the required two-hour timeframe, instead reporting it 25 hours later. The facility's policy mandates immediate reporting of such incidents to ensure resident safety and prevent further abuse.
A resident was not monitored for emotional and psychosocial wellbeing after reporting financial abuse by a family member. Despite the facility's standard practice of 72-hour monitoring following abuse allegations, this was not conducted, and there was no specific policy to ensure such monitoring.
A Physical Therapy Assistant in an LTC facility failed to perform hand hygiene when entering and exiting the rooms of two residents under Droplet Precaution. Despite facility policies and signage requiring hand hygiene to prevent infection spread, the PTA did not comply, as confirmed by the Infection Preventionist.
A resident's family member filed a grievance about the resident being left unattended in a shower. The facility investigated the complaint but failed to document the investigation or inform the family member of the findings, contrary to their grievance policy. The resident had severe cognitive impairment, making family communication essential.
A resident was issued an incomplete discharge notice, lacking the discharge date and location, due to the Social Service Director leaving these fields blank as the resident had not decided on his next living arrangement. The resident, unable to read the notice due to poor eyesight, was unaware of his discharge location, leading to a deficiency in the facility's compliance with notification requirements.
A resident with Type II Diabetes Mellitus and Essential Hypertension did not receive a follow-up ophthalmology consult, as required by their care plan. Despite the resident's capacity to make decisions and their expressed need for an ophthalmologist, the Social Service Director failed to arrange the necessary appointment, as confirmed by interviews with the Director of Nursing and the SSD.
The facility failed to document the administration of narcotic pain medications for 20 residents, leading to potential discrepancies and possible diversion of controlled substances. Licensed nurses signed out medications but did not consistently document their administration in the eMAR, affecting residents with conditions like muscle wasting and chronic pain. Interviews with LVNs confirmed the lack of documentation, highlighting a failure to follow the facility's process for administering PRN narcotic pain medications.
A facility with 132 beds failed to employ a qualified full-time social worker. The Social Service Director lacked the necessary bachelor's degree and was not a licensed medical social worker, nor supervised by one. This deficiency was confirmed by the Administrator, contradicting the facility's job description and policy requirements.
The facility failed to ensure effective narcotic medication accountability and pain assessment. Narcotic medications were signed out by LNs but not documented in the e-MAR, and pain assessments were not conducted after medication administration. Despite identifying these issues, the facility did not monitor or re-evaluate the effectiveness of interventions, risking medication diversion and unmanaged pain.
The facility failed to promptly respond to call lights for several residents, with wait times ranging from 10 to 30 minutes, despite previous discussions in Resident Council meetings. Additionally, a resident consistently received her meal after another resident, impacting her dignity and meal intake. Staff interviews confirmed the expectation for prompt response and simultaneous meal service, but these were not met.
The facility failed to conduct self-administration assessments for three residents, leading to medications and supplements being left at their bedsides without proper authorization or physician orders. LVNs acknowledged the oversight, and the DON emphasized the importance of following facility policies to ensure safe medication administration.
The facility failed to provide education and resources for Advance Directives (AD) to 15 residents and their representatives, as required by policy. Despite some residents having the capacity to make decisions, there was no documentation of AD education in their records. The Social Service Director admitted to not providing the necessary education or follow-up, resulting in a deficiency.
The facility failed to conduct pain assessments and evaluate the effectiveness of PRN narcotic pain medications for 20 residents, including those with osteomyelitis, diverticulosis, and chronic pain syndrome. Licensed nurses did not document pain levels before or after administering medications like Tramadol and oxycodone-acetaminophen, compromising effective pain management.
The facility failed to ensure Food and Nutrition Service employees followed proper procedures, leading to deficiencies. Employees did not clean kitchen equipment correctly, using only sanitizer instead of detergent and sanitizer. Staff also misunderstood the correct chlorine concentration for dish machines, risking cross-contamination. Additionally, a cook did not follow a recipe for pureed Bread Stuffing, resulting in overly salty servings for residents on a pureed diet.
The facility failed to provide appetizing food at appropriate temperatures, affecting nine residents. Observations and interviews revealed issues such as cold meals, bland and tough meat, and improperly seasoned pureed meals. A test meal evaluation confirmed that food temperatures did not meet policy standards, with cold items served warmer and hot items cooler than required. The meal service process was inefficient, contributing to these discrepancies.
The facility failed to maintain sanitary conditions in the kitchen, with mold, dust, and hair found in the walk-in refrigerator, calcium buildup on the hot water spout, and wet containers improperly stored. Dust and rust were observed on equipment, and chipped paint was noted on a mixer and utensil hanger. An unsanitary microwave was also found, posing a risk of contamination.
A resident with hypotension experienced disturbances during sleeping hours due to noise from another resident gardening early in the morning. Despite multiple complaints, the facility failed to maintain a quiet environment, as confirmed by an LVN and acknowledged by the DON. The facility's policy emphasized the need for comfortable noise levels to ensure a homelike setting.
A resident with pulmonary hypertension was not accurately assessed for smoking habits, despite admitting to occasional smoking and being observed by staff. The facility's smoking policy was not followed, as the resident's use of electronic cigarettes was not documented or assessed for safety, posing potential injury risks.
A resident with respiratory issues was receiving oxygen at 4 LPM instead of the prescribed 2 LPM, as observed during an interview with an LVN. The incorrect flow rate was confirmed by an RN, who noted the potential for oxygen toxicity. The facility's policy requires verification of physician orders for safe oxygen administration, which was not followed.
The facility failed to provide proper post-dialysis assessment for a resident with ESRD and did not follow a physician's order to discontinue fluid restriction for another resident. The lack of post-dialysis assessment and incomplete I&O monitoring documentation were confirmed by staff, indicating a failure to adhere to facility policies and physician recommendations.
A resident with schizophrenia was prescribed Olanzapine for auditory hallucinations, but the LTC facility failed to monitor the resident's behavior as required. The Director of Nursing confirmed the absence of a care plan for the resident's hallucinations, despite facility policies mandating such monitoring and care planning.
The facility failed to properly store discontinued medications, as two vials of Lorazepam and an Insulin Lispro Injection pen marked as discontinued were found in the medication room refrigerator. The RN stated that these medications should have been discarded by the night shift nurses, while the DON confirmed that discontinued medications should be placed in a discontinue bin and destroyed monthly with the pharmacist consultant.
A resident with End-Stage Renal Disease did not receive meals according to the physician's NAS diet order, which included specific food preferences and restrictions. The dietary department failed to adhere to these instructions, serving meals with items the resident disliked. Additionally, the RD's recommendation to fortify the resident's diet due to weight loss was not communicated to the physician or implemented, contrary to facility policy.
A CNA failed to disinfect a Hoyer lift between resident uses, and an RN did not wear PPE while caring for a resident with an ESBL infection. Both actions were against the facility's infection control policy, risking the spread of infection.
The facility failed to maintain an effective pest control program, leading to house flies being observed in the kitchen and East activity room. A fly was seen on a cleaned container in the kitchen, attributed to a delivery man propping the door open. Another fly was observed on a resident's food in the East activity room, entering when residents opened the door to smoke. The Registered Dietitian confirmed that flies carry bacteria, and the facility's policies emphasize the need for pest control to maintain sanitation standards.
A Treatment Nurse failed to perform hand hygiene between glove changes during wound care for a resident with a sacral wound, contrary to facility policy. The resident had a complex medical history, including a stage 4 pressure ulcer. The Infection Preventionist confirmed the protocol breach.
The facility failed to employ a dedicated Dietary Manager, leading to lapses in food safety practices such as missing use-by dates on food items. Duties were shared among a Dietary Corporate Consultant, a Registered Dietitian, and a DM from a sister facility, resulting in negative impacts on staff work and oversight issues.
The facility failed to store food items according to professional standards, as observed when Italian dressing and egg salad in the refrigerator were missing use-by or expiration dates. The DCC confirmed that all food items should be labeled with these dates, but the dietary staff member responsible for the egg salad forgot to do so. The task of checking expiration dates was not completed due to the absence of a DM, and the DCC had not yet checked the dates upon starting her shift.
A facility failed to ascertain the current condition of a resident before refusing re-admission after hospitalization. The decision was based on the resident's previous behavior and a psychologist's note, without proper follow-up to determine if the behavior had stabilized. This action was contrary to the facility's policy on bed-holds and returns.
The facility failed to provide bed hold information and the Notice of Proposed Transfer/Discharge to a resident's family member after the resident was transferred to a hospital for psychiatric evaluation. The decision to not provide a bed hold was made due to the resident's aggressive behavior, and the facility did not follow up with the hospital to check if the behavior had stabilized.
Failure to Notify Resident Representative of Wound Deterioration
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of multiple documented changes in condition related to deteriorating lower extremity wounds. A resident admitted with acute osteomyelitis of the left ankle and foot had a history and physical dated October 7, 2025, indicating a change in cognitive function that affected her ability to make informed medical decisions, and her grandson was designated as the responsible party for medical decision-making. Review of the resident’s change of condition (COC) documentation from November through December 2025 showed that on November 21, 2025, staff noted deterioration of right and left heel diabetic wounds during wound rounds, with the primary care provider notified and the resident updated. On December 5, 2025, the right heel diabetic wound was again documented as deteriorating by a wound specialist, with updated treatment orders and a notation that the family or resident was notified, marked as “self.” On December 8, 2025, during wound care, dark brown/purple discoloration was observed on the right dorsum of the foot, the MD was notified, and documentation again indicated the family or resident was notified, marked as “self.” There was no documented evidence that the resident’s representative was notified of these changes in condition on November 21, December 5, and December 8, 2025. During an interview and concurrent record review, the LVN who completed the COC entries stated she recalled providing wound care and completing the COCs, and explained that the process for communicating a change in condition was to notify the resident, family or resident representative, and the primary care and wound care physicians. She acknowledged that on the three dates in question she notified only the resident and did not notify the resident’s representative, and stated she should have communicated the changes to the representative. In a separate interview and record review, the DON confirmed that the resident experienced changes in condition on those dates and that the resident’s representative should have been notified, consistent with the facility’s policy titled “Change in a Resident’s Condition or Status,” which requires the nurse to notify the resident’s representative and document information related to significant changes in the resident’s condition or status.
Failure to Implement Effective Wandering Interventions Resulting in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent resident-to-resident physical altercations, specifically related to a resident with known wandering and impulse control issues. One resident with intact decision-making capacity reported that another resident entered his room, attempted to take his cup and blanket, and then punched him twice in the face when he tried to stop the behavior. As a result, he sustained swelling of the right upper lip and a scratch on the nose. He stated that he pressed his call light but did not receive an immediate staff response and had to yell for help before staff intervened. The resident who initiated the altercation had documented diagnoses of delusional disorder and impulse disorder and was noted in the medical record to be unable to make decisions. The care plan for this resident, dated several months prior, identified risk for elopement and wandering related to altered cognitive status and forgetfulness, with a goal that the resident’s safety would not be endangered by these behaviors. However, the care plan only contained a general intervention for elopement/wandering and did not specify the type or level of supervision or monitoring needed to address the resident’s wandering behavior. A physician’s order in the eMAR directed staff to monitor this resident for episodes of impulse control disorder manifested by wandering and danger to self and others, but there was no documentation that such behaviors were monitored or addressed on the date of the incident. Staff interviews further showed gaps in implementation and communication of interventions for the wandering resident. The DON acknowledged that the care plan for elopement and wandering lacked specific prevention interventions and that there was no CNA documentation that monitoring of wandering behavior had been completed. The DON also stated that the internal communication board did not list this resident as at risk for wandering prior to the incident. Nursing staff, including an LVN and the charge RN on duty at the time of the altercation, reported awareness of the resident’s history of wandering into other residents’ rooms and occasional aggression, but were unaware of any written interventions to address this behavior. A CNA assigned to the wandering resident on the evening of the incident stated that the resident frequently wandered and needed to be checked every 15 to 30 minutes, and that while she was on her lunch break, no one was assigned to check on the resident, during which time the altercation occurred.
Failure to Provide Adequate Hoyer Lifts for Resident Transfers
Penalty
Summary
The facility failed to make reasonable accommodations to meet the needs and preferences of two residents who required a Hoyer lift for transfers. Both residents had medical conditions necessitating total assistance with transfers: one with morbid obesity and chronic pain syndrome, and the other with hemiplegia and hemiparesis following a stroke. Observations, interviews, and record reviews revealed that there were only three functioning Hoyer lifts available for over 100 residents, with at least ten residents in one station alone requiring the device. Staff and residents reported frequent delays in transfers due to the limited number of lifts, resulting in residents having to wait for extended periods or missing scheduled activities. Resident A reported disruptions to his established daily routine, including delays in being transferred to and from bed, which sometimes resulted in not being up at his preferred time. Resident B experienced missed activities, specifically being unable to attend scheduled smoking times on multiple occasions due to the unavailability of a Hoyer lift. Staff interviews confirmed that these delays were common and directly related to the insufficient number of mechanical lifts. Facility policies required accommodation of resident needs and preferences to the extent possible, but the lack of adequate equipment led to unmet care plans and resident dissatisfaction.
Failure to Monitor Resident Following DVT Diagnosis
Penalty
Summary
The facility failed to assess and monitor a resident for signs and symptoms of circulatory insufficiency in the right lower leg after the resident tested positive for deep vein thrombosis (DVT). The resident, who had a history of diabetes, end stage renal disease, and was on hemodialysis, was admitted with a diagnosis of DVT in the right popliteal vein. The care plan included interventions to monitor for swelling, pain, discoloration, and changes in the ability to move the lower extremity. However, there was no documentation that these assessments or monitoring were performed following the DVT diagnosis. Interviews with nursing staff and the DON confirmed that standard care and facility protocol required monitoring for pain, swelling, temperature changes, skin discoloration, and checking pedal pulses after a DVT diagnosis. Despite this, there was no evidence in the resident's records that such monitoring occurred. The lack of assessment and documentation was identified after the resident developed necrosis of the right foot, leading to hospital admission with a diagnosis of gangrene affecting multiple toes. The DON acknowledged the absence of a specific DVT management policy but stated that monitoring was an expected standard of practice.
Failure to Accurately Document Skin Changes and Wound Care
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurate and complete in accordance with accepted professional standards and practices. Specifically, for one resident with a history of diabetes and fluctuating decision-making capacity, the nursing weekly summary and skin evaluations did not reflect significant skin changes that occurred over a ten-day period. Documentation showed that the resident was seen by wound care specialists who identified and reclassified a sacral pressure wound and noted new deep tissue injuries (DTIs) on the right heel and right lateral malleolus, with new treatment orders issued. However, there were no corresponding skin and wound evaluations or updated measurements recorded on the dates when these changes were identified, as required by facility protocol. Additionally, the nursing weekly summaries during this period consistently indicated that there were no new skin changes or breakdowns, despite the documented findings and new treatment orders from the wound care team. Interviews with the LVN and DON confirmed that skin evaluations and documentation should have been completed to reflect the changes in the resident's condition, including wound descriptions and measurements. The facility's own policy required that all changes in a resident's medical condition be documented in the clinical record, but this was not done, resulting in incomplete and inaccurate medical records for the resident.
Failure to Timely Report Alleged Physical Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse within two hours to the California Department of Public Health (CDPH) as required by policy and regulation. On the evening of March 28, 2025, a resident (who is deaf and nonspeaking, with severe cognitive impairment) was allegedly struck on the back of the head by another resident with schizoaffective disorder and moderate cognitive impairment. The incident was witnessed by a third resident, who reported it to the nurse's station, where both an LVN and an RN were present. Documentation in the medical record confirmed the incident and subsequent monitoring of the resident, but there was no evidence that the required report to CDPH or the Ombudsman was made at that time. Interviews with staff revealed that the LVN informed the RN of the incident and relied on the RN for direction, but no further action was taken to report the abuse within the mandated timeframe. The RN assumed the LVN would handle the reporting, but did not follow up to ensure it was completed. The Director of Nursing was not informed of the incident until the following morning, well beyond the two-hour reporting window. Facility policy clearly states that all allegations of abuse must be reported to the appropriate authorities immediately, and within two hours if the incident involves abuse or results in serious bodily injury. The failure to report the alleged abuse in a timely manner was confirmed through record review, staff interviews, and review of facility policy. The delay in reporting had the potential to place the affected resident at continued risk of abuse and negatively impact her emotional and psychosocial well-being, as noted in the findings.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report a significant injury of unknown source for a resident, which involved a total right shoulder prosthesis dislocation. This incident was not reported to the California Department of Public Health (CDPH), police, or the Ombudsman within the required two-hour timeframe after the facility became aware of the injury. The resident, who had fluctuating capacity to make medical decisions, was admitted to the facility and later experienced pain and swelling in the right shoulder, leading to an X-ray that revealed the dislocation. Despite the facility's policy requiring immediate reporting of such injuries to rule out abuse, the incident was not reported as mandated. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that the injury was of unknown source and should have been reported promptly to ensure resident safety and prevent further harm. The facility's policy on reporting injuries of unknown origin was not followed, as the injury was not communicated to the necessary authorities. This oversight had the potential to impact the resident's physical, emotional, and psychosocial well-being, as the injury could have been related to abuse.
Failure to Investigate Prosthesis Dislocation
Penalty
Summary
The facility failed to investigate the dislocation of a right shoulder prosthesis for a resident, which was identified as an injury of unknown source. The resident was admitted to the facility with no initial signs of limited range of motion, edema, or skin concerns. However, six days after admission, the resident complained of pain and swelling in the right shoulder, leading to an X-ray that revealed a dislodgement of the glenoid fossa portion of the prosthesis and a total shoulder dislocation. The resident was subsequently sent to the emergency room for further evaluation. Interviews with the Registered Nurse and the Director of Nursing revealed that the facility did not conduct an investigation into the cause of the prosthesis dislocation, despite the facility's policy requiring investigations for injuries of unknown origin to rule out possible abuse. The Director of Nursing acknowledged that the incident should have been investigated, as the facility was unaware of how the dislocation occurred, and there were no documented falls or injuries prior to the event. The facility's policy mandates that all reports of resident abuse, including injuries of unknown origin, be thoroughly investigated and reported to the appropriate agencies within five working days.
Failure to Provide Transfer Notice to Resident and Ombudsman
Penalty
Summary
The facility failed to provide a written copy of the transfer or discharge notice to a resident and their representative, as well as to the LTC Ombudsman, for a resident who was transferred to a hospital. The resident, who had fluctuating capacity to make medical decisions, was transferred due to a dislodgement and dislocation of a right shoulder prosthesis. Despite the facility's policy requiring that such notices be provided as soon as practicable, there was no documentation indicating that the resident received a written notice of the transfer or discharge. Additionally, the facility did not send a copy of the transfer or discharge notice to the LTC Ombudsman, which is required to ensure advocacy and oversight of the resident's discharge plan. The Director of Nursing and the Social Service Director acknowledged that the notice was not sent to the Ombudsman, as required by the facility's policy. The Social Service Director mistakenly believed that the hospital would send the notice, but admitted that it was his responsibility to ensure the Ombudsman was informed.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to provide scheduled showers and bed baths for a resident, identified as Resident A, who was admitted with bilateral lower extremities contractures and a history of cerebrovascular accident with left-sided deficits. Resident A's care plan indicated a risk for decline in activities of daily living (ADLs) and required assistance due to hemiplegia, hemiparesis, muscle weakness, and atrophy. Despite this, documentation revealed that on several scheduled shower days in July and August 2024, Resident A received bed baths instead of showers, and on one occasion, neither a shower nor a bed bath was provided. There was no documentation indicating that Resident A refused showers on these days. Interviews with facility staff, including CNAs and an LVN, confirmed that Resident A was dependent on assistance for all ADLs and preferred bed baths. The Director of Nursing (DON) acknowledged that Resident A had a scheduled shower routine and that refusals should be documented and included in the care plan. However, the DON admitted that there were instances when Resident A was not provided with either a shower or a bed bath, contrary to the facility's protocol. This lack of adherence to the care plan and documentation requirements led to the deficiency identified in the report.
Failure to Reposition Resident Leads to Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident A, was repositioned and turned every two hours, which resulted in the development of a pressure ulcer. Resident A was admitted with diagnoses including hemiplegia and hemiparesis on the left side of the body, and was assessed as being at high risk for pressure ulcers according to the Braden Scale. The resident was completely immobile and required moderate to maximum assistance for movement. Despite these needs, the facility did not maintain a log or documentation to confirm that Resident A was repositioned as required. Interviews with facility staff, including a CNA and the Treatment Nurse, revealed that there was no documentation or schedule in place to track when Resident A was last turned. The Director of Nursing acknowledged gaps in the documentation and stated that if repositioning was not documented, it was assumed not to have been done. The facility's policy required repositioning every two hours for residents at risk of pressure ulcers, but this was not adhered to, leading to the progression of Resident A's pressure ulcer from Stage I to Stage II.
Failure to Timely Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of misappropriation of property, a form of financial abuse, to the California Department of Public Health (CDPH) within the required two-hour timeframe. This incident involved a resident who reported missing finances, including a bank card and approximately $600, to a Social Service Assistant (SSA) on October 9, 2024, at around 2 p.m. The SSA did not report the incident to CDPH until October 10, 2024, at 3:16 p.m., which was 25 hours after the facility was made aware of the allegation. Both the SSA and the Director of Nursing (DON) acknowledged that the incident should have been reported within two hours to ensure the resident's safety and prevent further abuse. The facility's policy, titled 'Abuse Prevention,' mandates that all employees are required to report any allegations of abuse, including misappropriation of resident property, within two hours, even if there is no reasonable suspicion. The DON confirmed that all staff are mandated reporters and that any type of abuse, including financial abuse, should be reported promptly to CDPH, the ombudsman, and the police. The failure to adhere to this policy resulted in a delay in reporting the financial abuse allegation, potentially affecting the resident's emotional and psychosocial well-being.
Failure to Monitor Resident After Financial Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident after an allegation of financial abuse, which had the potential to affect the resident's emotional and psychosocial wellbeing. The incident was reported on October 9, 2024, when the resident informed the social services that a family member had taken their wallet, resulting in missing cash and cards. A police report was filed, but the resident was not assessed or monitored for any negative psychosocial effects following the allegation. Interviews with the Social Service Director and the Director of Nursing revealed that the facility's standard practice was to monitor residents for 72 hours after any abuse allegations to assess for emotional distress and changes in behavior. However, this practice was not followed for the resident in question, and there was no specific policy in place to ensure such monitoring. The facility's existing policy on abuse prevention did not explicitly address the need for a 72-hour monitoring period, leading to a lapse in care for the resident involved in the financial abuse allegation.
Infection Control Deficiency Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented, as observed during a survey. A Physical Therapy Assistant (PTA) was seen not performing hand hygiene upon exiting and entering the rooms of two residents who were under Droplet Precaution, a type of transmission-based precaution (TBP). The PTA acknowledged the requirement to wash hands before entering and upon exiting these rooms to prevent the spread of pathogens and infections but admitted to not doing so. The facility's signage and policy on Droplet Precaution and Handwashing/Hand Hygiene clearly indicated the necessity of hand hygiene as a primary method to prevent the spread of infections. The Infection Preventionist (IP) confirmed that staff should perform hand hygiene when entering and exiting a resident's room, emphasizing its importance in preventing the spread of infection and disease. The failure of the PTA to adhere to these protocols was identified as a deficiency in the facility's infection control practices.
Failure to Notify Family of Grievance Investigation Results
Penalty
Summary
The facility failed to notify a resident's family member of the findings and results of a grievance investigation. The family member had filed a complaint regarding the resident being left unattended in a shower with cold running water. Despite the complaint being received and acknowledged by the facility, there was no documented evidence that the family member was informed of the investigation's outcome. The resident, who had severe cognitive impairment, was unable to advocate for themselves, making the family member's involvement crucial. Interviews with facility staff, including the Director of Nursing (DON) and the Quality Assurance Nurse (QAN), revealed that the investigation was conducted but not documented on a grievance form, nor were the findings communicated to the family member. The facility's grievance policy requires that grievances be investigated and the findings communicated to the complainant within five working days, which was not adhered to in this case. This oversight could lead to ongoing dissatisfaction from the family member, as they were left unaware of whether the complaint was addressed.
Incomplete Discharge Notice for Resident
Penalty
Summary
The facility failed to provide a complete written notice of transfer or discharge for a resident, which is a requirement for ensuring residents are informed about their future living arrangements. The deficiency was identified when a resident, who had been issued a discharge notice, stated that he could not read the notice due to poor eyesight and was unaware of his discharge location. The resident's record indicated that he was advised by the Ombudsman and CDP not to sign the notice but to appeal it instead. The Notice of Proposed Transfer/Discharge was found to be incomplete, lacking both the effective date of transfer/discharge and the discharge location. Interviews with the Director of Nursing (DON) and the Social Service Director (SSD) revealed that the SSD had provided the incomplete notice to the resident. The SSD admitted to leaving the discharge date and location blank because the resident had not yet decided on his next living arrangement, whether it would be a board and care or assisted living. The facility's policy requires that the discharge location be documented, but this was not adhered to in this case, leading to the deficiency.
Failure to Follow-Up on Ophthalmology Consult
Penalty
Summary
The facility failed to ensure a follow-up ophthalmology consult was provided for a resident, which increased the risk of the resident not receiving necessary care for their medical condition. The resident, who was admitted with diagnoses including Type II Diabetes Mellitus and Essential Hypertension, expressed the need to see an ophthalmologist, but reported that the facility had not taken any action. The resident's records indicated a need for an eye health and vision consult with follow-up treatment, as documented in the Order Summary Report and Care Plan. However, there was no documentation of a follow-up by the Social Service Director (SSD) for a consult with an optometrist or ophthalmologist from February to August 2024. Interviews with the Director of Nursing (DON) and the SSD revealed that the SSD did not make a follow-up on the resident's consult with the optometrist or ophthalmologist. The DON stated that the SSD should have ensured the follow-up and scheduled the appointment if the resident needed to be seen by an ophthalmologist. The facility's job description for the SSD emphasized the responsibility to assist residents in achieving the highest practicable level of self-care and well-being, which includes providing medically related social services.
Narcotic Medication Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper accountability for narcotic pain medications for 20 residents, leading to potential medication discrepancies and possible diversion of controlled substances. The report highlights multiple instances where licensed nurses signed out narcotic medications from the medication count sheet but failed to document their administration in the electronic Medication Administration Record (eMAR). This lack of documentation was observed across various residents, including those with conditions such as muscle wasting, chronic pain, and severe pain management needs. For example, Resident 58, who was admitted with diagnoses including muscle wasting and polyneuropathy, had several doses of Oxycodone-Acetaminophen signed out by nurses without corresponding documentation in the eMAR. Similarly, Resident 65, with necrotizing fasciitis and polyneuropathy, had multiple instances where Oxycodone-Acetaminophen was signed out but not documented as administered. These discrepancies were confirmed through interviews with the involved Licensed Vocational Nurses (LVNs), who acknowledged the failure to document the administration of these medications. The report further details similar issues with other residents, such as Resident 19, whose hydrocodone/acetaminophen doses were inconsistently documented, and Resident 83, who had numerous doses of hydrocodone-acetaminophen signed out without eMAR documentation. The facility's process for administering PRN narcotic pain medications requires nurses to sign out the medication, administer it, and document the administration in the eMAR. However, this process was not consistently followed, leading to significant gaps in medication administration records and raising concerns about potential medication errors and resident safety.
Facility Lacks Qualified Social Worker for 132-Bed Capacity
Penalty
Summary
The facility, which has a licensed capacity of 132 beds, failed to employ a full-time qualified social worker, as required for facilities with more than 120 beds. During an interview and record review, it was revealed that the Social Service Director (SSD) had been employed for over a year but did not possess a bachelor's degree in social work or a related human services field, nor was she a licensed medical social worker. Furthermore, the SSD was not supervised by a qualified social worker, which is a requirement for her role. The SSD admitted to not being qualified to perform psychosocial assessments, which could potentially lead to physical and psychosocial distress among residents. The facility's job description for social service staff, dated March 2017, clearly stated the requirement for a bachelor's degree in social work or human services. Additionally, the facility's policy and procedure document from October 2010 specified that the Director of Social Services should be a qualified social worker to provide medically related social services, ensuring residents attain or maintain their highest practicable physical, mental, or psychosocial well-being. The Administrator confirmed that the SSD was not qualified to fulfill the responsibilities of a social worker for the facility, highlighting a significant deficiency in meeting the required standards for resident care.
Failure in Narcotic Accountability and Pain Assessment
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed issues related to narcotic medication accountability and pain assessment. During QAPI meetings held in February and April 2024, concerns were raised about narcotic medications being signed out by Licensed Nurses (LNs) on the narcotic count sheet but not documented as administered in the Electronic Medication Administration Record (e-MAR). Additionally, it was noted that pain assessments, monitoring, and evaluations were not being conducted by LNs after administering pain medication. Despite these issues being identified, the facility did not monitor or re-evaluate the effectiveness of the interventions implemented to address them. The Director of Nursing (DON) acknowledged that the facility should have re-evaluated and monitored these interventions to ensure the safety and accountability of narcotic medications and to manage residents' pain effectively. This oversight had the potential to lead to the diversion of controlled medications and unrelieved pain among residents, which could compromise their overall health and wellbeing.
Delayed Call Light Response and Meal Service Issues
Penalty
Summary
The facility failed to ensure the residents' rights were promoted and respected, as evidenced by the delayed response to call lights for several residents. Residents 23, 29, 59, 106, and 126 reported that their call lights were not answered promptly, leading to potential risks of not receiving timely care. During interviews, these residents expressed concerns about waiting times ranging from 10 to 30 minutes for assistance after activating their call lights. The issue was previously discussed in Resident Council meetings but remained unresolved. Staff interviews confirmed the expectation for prompt response to call lights, yet the facility's policy was not adhered to, as evidenced by the residents' experiences. Additionally, the facility failed to serve meals simultaneously to residents dining together, impacting Resident 112's dignity and meal intake. Resident 112 observed that Resident 41 consistently received her meal first, causing Resident 112 to feel upset and left out. The Registered Dietitian acknowledged that both residents should have received their meals at the same time, and the facility's policy emphasized treating residents with dignity and respect. This oversight in meal service had the potential to affect Resident 112's enjoyment and intake of her meals.
Failure to Conduct Self-Administration Assessments for Medications
Penalty
Summary
The facility failed to conduct assessments for the safe self-administration of medication for three residents. One resident had a pink medication pill left on their overbed table by a nurse, which the resident did not take because they were sleepy. This resident had no documented self-administration assessment in their medical record. Another resident had an opened bottle of eyedrops on their overbed table, which they used to relieve irritation and itchiness, but there was no physician's order or self-administration assessment documented. A third resident had an opened bottle of dietary supplements on their overbed table, which they took daily with the staff's awareness, yet there was no physician's order or self-administration assessment documented. The Licensed Vocational Nurses (LVNs) involved acknowledged the lack of assessments and physician orders for the medications and supplements found at the residents' bedsides. The Director of Nursing (DON) stated that the facility's policy and procedure require medications to be administered according to physician orders and that self-administration assessments should be conducted to ensure safety. The facility's policy also specifies that medications should not be left with residents unless they have been approved for self-administration, and any unauthorized medications found at the bedside should be turned over to the nurse in charge.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to provide education and resources for Advance Directives (AD) to 15 out of 25 residents, as well as their Resident Representatives (RP). This deficiency was identified through interviews and record reviews, revealing that residents and their representatives were not informed about ADs, which are crucial for understanding and documenting a resident's wishes regarding medical treatment. The lack of documentation and education was evident in the medical records of the affected residents. Several residents, including those with dementia and Alzheimer's disease, were found to have no documented evidence of receiving information or education about ADs. For instance, Resident 15, who was diagnosed with dementia, did not have the capacity to make decisions, yet there was no record of AD education provided to the resident or their RP. Similarly, Resident 60, who had the capacity to make decisions, also lacked documentation of AD education, despite the resident's ability to understand and make informed choices. The Social Service Director (SSD) acknowledged during interviews that she did not provide the necessary AD education or follow-up to the residents and their representatives. This oversight was consistent across multiple cases, where residents either had the capacity to make decisions or were unable to do so due to cognitive impairments. The facility's policy required that residents be provided with written information about their right to formulate an AD upon admission, but this was not adhered to, leading to the deficiency.
Failure in Pain Management Documentation and Assessment
Penalty
Summary
The facility failed to ensure proper pain management for 20 residents who required such services. The deficiency was identified through observations, interviews, and record reviews, revealing that licensed nurses did not conduct pain assessments prior to administering PRN narcotic pain medications, nor did they evaluate the effectiveness of the medications after administration. This lack of documentation and assessment was consistent across multiple residents, including those with conditions such as osteomyelitis, diverticulosis, muscle wasting, atrophy, polyneuropathy, necrotizing fasciitis, and chronic pain syndrome. For instance, Resident 18, who was admitted with osteomyelitis and diverticulosis, had multiple doses of Tramadol administered without prior pain assessment or post-administration evaluation. Similarly, Resident 58, diagnosed with muscle wasting and polyneuropathy, received oxycodone-acetaminophen without documented pain assessments or evaluations of the medication's effectiveness. Interviews with licensed vocational nurses confirmed the absence of necessary documentation and assessments, acknowledging the failure to follow the facility's pain management protocols. The deficiency extended to other residents, such as Resident 65 with necrotizing fasciitis, Resident 19 with knee pain, and Resident 278 with idiopathic neuropathy, all of whom received narcotic pain medications without proper assessments. The lack of documentation and evaluation potentially compromised the residents' pain management, as the facility's process for administering PRN narcotic pain medications was not adhered to, placing residents at risk of experiencing unrelieved and unmanaged pain.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that Food and Nutrition Service employees were able to carry out their functions safely and effectively, leading to several deficiencies. Firstly, multiple employees were observed not following the proper cleaning procedures for kitchen equipment. Specifically, Diet Aide 1 and Cook 1, among others, were using only sanitizer instead of first cleaning with detergent and then sanitizing, as per the facility's policy. This improper cleaning method was acknowledged by the Registered Dietitian and Dietary Service Supervisor, who confirmed that the correct procedure involves removing debris, washing with detergent, rinsing with water, and then sanitizing. Secondly, there was a lack of knowledge regarding the correct concentration of chlorine for the dish machine among the staff. Diet Aides 3 and 4 were observed checking the chlorine levels incorrectly, believing it should be 200 ppm, while the Dietary Service Supervisor clarified that the correct range is 50-100 ppm. This misunderstanding could lead to a strong chloride odor being transferred to clean kitchenware, as the concentration was too high. Lastly, Cook 1 did not follow the recipe for making pureed Bread Stuffing, resulting in overly salty servings for eight residents on a pureed diet. Instead of using milk as specified in the recipe, chicken broth was used, which combined with the bread stuffing, led to a high salt content. The Registered Dietitian confirmed that the failure to follow the recipe and sample the food before serving contributed to the issue.
Deficiency in Meal Service Temperature and Palatability
Penalty
Summary
The facility failed to adhere to its MEAL SERVICE policy, resulting in the provision of unappetizing food at inappropriate temperatures for nine residents. Observations and interviews revealed that residents consistently received cold meals, bland and tough meat, and vegetables that appeared old and reheated. Additionally, milk was served warm, and pureed meals were excessively salty due to improper recipe adjustments. These issues were confirmed through resident interviews and a test meal evaluation conducted with the Registered Dietitian (RD) and Dietary Services Supervisor (DSS). The test meal evaluation showed that food temperatures did not meet the facility's policy standards, with cold items being served warmer than recommended and hot items cooler than required. The RD acknowledged that the meal service process was inefficient, with meal carts left open during delivery, contributing to temperature discrepancies. The facility's policy specified that cold desserts should be served at 50 degrees Fahrenheit or less, milk and cold beverages at 45 degrees Fahrenheit or less, and vegetables at 120 degrees Fahrenheit or more, but these standards were not met during the survey.
Unsanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as evidenced by multiple observations of unsanitary conditions. Mold, dust, and hair were found in the walk-in refrigerator, with the Dietary Service Supervisor (DSS) confirming the presence of these contaminants. The Registered Dietitian (RD) verified the mold and dust, acknowledging that no staff member was assigned to clean the storage shelves in the refrigerator. Additionally, calcium buildup was observed on the hot water spout, which the RD stated could contaminate the hot water. Further observations revealed that wet plastic containers were improperly stacked with dry ones, which the DSS and RD agreed could promote microbial growth. Dust was also found on various kitchen equipment, including fans and shelves, which the DSS confirmed could contaminate food and clean dishes. Rust was observed on several pieces of equipment, such as storage shelves and a can opener base, with the RD stating that rust should not be present as it could cause cross-contamination. Chipped paint was noted on kitchen equipment, including a mixer and utensil hanger, which the RD indicated needed repair or replacement to prevent contamination. An unsanitary microwave was found in a pantry room, with black and brown particles inside, which the RN confirmed was an infection control issue. The facility's policies and procedures emphasized the importance of keeping equipment clean and free from corrosion, yet these standards were not met, posing a risk of foodborne illness to the residents.
Failure to Maintain Homelike Environment Due to Noise Disturbance
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident 107, who complained about uncomfortable noise levels during sleeping hours. Resident 107, who was admitted with a diagnosis of hypotension, reported being disturbed by noise from another resident gardening early in the morning. This issue was documented in the resident's care plan and health status notes, indicating repeated complaints about the noise disrupting sleep. During an interview, the resident expressed being woken up early due to banging noises outside. A Licensed Vocational Nurse (LVN) confirmed that Resident 107 had made multiple complaints about the noise, emphasizing the need for a quiet and comfortable environment to promote rest. The Director of Nursing (DON) acknowledged the expectation for staff to maintain acceptable noise levels during sleeping hours, in line with the facility's policy on providing a homelike environment. The facility's policy, dated May 2017, highlighted the importance of person-centered care and maintaining comfortable noise levels.
Failure to Conduct Accurate Smoking Assessment for Resident
Penalty
Summary
The facility failed to conduct an accurate smoking assessment for a resident who uses electronic cigarettes. The resident, who was admitted with a diagnosis of pulmonary hypertension and was assessed as cognitively intact, was not properly evaluated for smoking habits. Despite the resident's admission record indicating no use of tobacco products, the resident admitted to smoking occasionally when stressed and was observed smoking in a non-designated area. Staff, including an LVN, were aware of the resident's smoking habits, as evidenced by the smell of smoke on the resident after gardening. The Activity Director, responsible for conducting smoking assessments, did not update the resident's smoking status despite being informed of the resident's smoking behavior. The facility's smoking policy, which includes guidelines for the use of electronic cigarettes, was not adhered to, as the resident was not assessed for safe handling of the device, nor was the use documented in the resident's care plan. This oversight had the potential to result in injury to the resident due to the risks associated with electronic cigarette use.
Failure to Adhere to Oxygen Therapy Order
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 52, by not adhering to the physician's order for oxygen therapy. Resident 52 was admitted with diagnoses involving the circulatory and respiratory systems and had a care plan indicating a potential for shortness of breath, with an intervention of oxygen at 2 liters per minute (LPM) via nasal cannula. However, during an observation and interview, it was found that Resident 52 was receiving oxygen at a flow rate of 4 LPM, which was not in accordance with the physician's order. Licensed Vocational Nurse (LVN) 1 confirmed that the oxygen flow rate was set incorrectly at 4 LPM instead of the prescribed 2 LPM. Registered Nurse (RN) 1 also acknowledged that the resident should have been receiving oxygen at the correct flow rate of 2 LPM, and that the increased flow rate had the potential to cause oxygen toxicity. The facility's policy on oxygen administration, dated October 2010, requires verification of the physician's order to ensure safe oxygen administration, which was not followed in this instance.
Failure in Dialysis Care and Fluid Management
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for Resident 100, who was diagnosed with end-stage renal disease and required hemodialysis. On August 17, 2024, Resident 100 returned from a dialysis appointment, but there was no documented post-dialysis assessment conducted by a licensed nurse, as required by the facility's policy. Both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the assessment was not performed, which was necessary to monitor for potential dialysis complications. For Resident 23, the facility did not adhere to the physician's recommendation to discontinue fluid restriction, nor did it consistently monitor the resident's intake and output (I&O). Despite a physician's order dated June 21, 2024, to discontinue the fluid restriction, staff continued to restrict fluids, as indicated by the green dot sticker on the resident's door and the absence of a water pitcher at the bedside. The facility's records showed incomplete documentation of I&O monitoring, which was crucial for managing the resident's condition, given the diagnosis of end-stage renal disease and dependence on dialysis. Interviews with various staff members, including LVNs and CNAs, revealed a lack of communication and understanding regarding Resident 23's fluid management plan. The staff was unaware of the updated physician's orders and failed to document fluid intake accurately, as required by the facility's policy. This oversight in monitoring and documentation could lead to complications related to fluid imbalance, such as fluid overload or dehydration, for Resident 23.
Failure to Monitor Behavior for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to conduct behavior monitoring for a resident receiving Olanzapine, a medication used to treat schizophrenia. The resident, who was admitted with a diagnosis of schizophrenia, had a physician order for Olanzapine to manage auditory hallucinations. However, there was no documentation of behavior monitoring for these hallucinations in the resident's medical record. This lack of monitoring was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan addressing the resident's auditory hallucination behavior. The facility's policies on psychotropic medication use and care planning emphasize the importance of monitoring the effectiveness of medications and assessing for adverse consequences. Despite these policies, the resident's behavior was not monitored, and a care plan was not developed upon admission. The MDS coordinator also confirmed that licensed nurses should have been monitoring the resident's behavior to provide a basis for gradual dose reduction and potential medication adjustment by the doctor.
Improper Storage of Discontinued Medications
Penalty
Summary
The facility failed to ensure that discontinued medications were stored properly and not readily available for use. During an observation in the Westside medication room, two vials of Lorazepam and an Insulin Lispro Injection pen, both marked as discontinued, were found in the medication room refrigerator. The Registered Nurse (RN) present stated that the facility's process for discontinued medication is to either give it to the resident at discharge or destroy it, and acknowledged that the medications should not have been left in the refrigerator. The RN was unsure why the medications were still there and mentioned that the night shift nurses should have discarded them. The Director of Nursing (DON) confirmed that discontinued medications should not be kept in the refrigerator and should be placed in a designated discontinue bin. The DON also stated that narcotic medications require destruction with two nurse signatures and that she, along with the pharmacist consultant, destroys medications once a month. The facility's policies indicate that discontinued or outdated drugs should be stored in a secured area until picked up by the pharmaceutical disposal service or pharmacy personnel, and that the facility shall not use discontinued, expired, or deteriorated drugs.
Failure to Implement Therapeutic Diet and Fortification for a Resident
Penalty
Summary
The facility failed to implement the therapeutic diet order prescribed by the attending physician for Resident 23, who was diagnosed with End-Stage Renal Disease and was on hemodialysis. Despite the physician's order specifying a No Added Salt (NAS) diet with certain food preferences and restrictions, the dietary department did not adhere to these instructions. Observations revealed that Resident 23 was served meals that included items he disliked, such as rice, which was explicitly mentioned in his dietary preferences as something to avoid. This inconsistency between the physician's diet order and the meals provided to Resident 23 was confirmed by the Registered Dietician (RD), who noted that the dietary department was not following the prescribed diet order. Additionally, the RD had recommended fortifying Resident 23's diet due to his poor appetite and weight loss, which was documented in the progress notes. However, there was no evidence that this recommendation was communicated to the physician or implemented. The RD stated that after making such a recommendation, the nursing staff should have followed up with the physician and the Director of Nursing (DON) to ensure the diet was fortified. The lack of follow-up on the RD's recommendation meant that Resident 23's diet was not adjusted to provide the extra nutrients he needed. The facility's policy on therapeutic diets, which requires that diet orders match the terminology used by the food and nutrition services department and be determined in accordance with the resident's preferences and treatment goals, was not adhered to in this case. The failure to implement the physician's diet order and the RD's recommendation for fortification had the potential to impact Resident 23's nutritional status and overall health.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a Certified Nursing Assistant (CNA) did not clean and disinfect a Hoyer lift before and after using it to transfer a resident. The CNA acknowledged the oversight and admitted that the lift should have been cleaned to prevent the spread of infection. The resident involved was on enhanced barrier precautions due to an Extended Spectrum Beta Lactamase (ESBL) infection, which requires specific measures to prevent transmission. In the second instance, a Registered Nurse (RN) did not wear personal protective equipment (PPE) while administering intravenous medication and changing the dressing of a resident with an ESBL infection. The RN admitted to not wearing PPE and acknowledged the necessity of doing so to prevent the spread of pathogens. The Infection Preventionist Nurse and the Director of Nursing confirmed that the staff should have followed the facility's infection control policy, which mandates the use of PPE and disinfection of equipment to prevent infection transmission.
Pest Control Deficiency Due to House Flies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of house flies in the kitchen and East activity room. On August 19, 2024, a house fly was observed landing on a cleaned plastic container in the kitchen's prep juice area during an observation and interview with the Dietary Service Supervisor (DSS). The DSS indicated that the delivery man had propped the door open, allowing the fly to enter. On August 20, 2024, another house fly was seen landing on a resident's served food in the East activity room during an observation and interview with Certified Nurse Assistant (CNA) 3. CNA 3 noted that the fly entered when residents opened the door to go outside to smoke. An interview with the Registered Dietitian (RD) on August 21, 2024, confirmed that house flies carry bacteria that could contaminate food, emphasizing that the facility should be free of pests. A review of the facility's Policy and Procedure (P&P) on pest control, revised in May 2008, stated that the facility should maintain an ongoing pest control program to keep the building free of insects. Additionally, the P&P on miscellaneous areas, dated 2023, highlighted that flies are carriers of disease and pose a threat to sanitation standards in the Food & Nutrition Services Department.
Failure to Follow Hand Hygiene Protocol During Wound Care
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during wound care for a resident, leading to a potential risk of contamination. During an unannounced visit, a Treatment Nurse (TN) was observed providing wound care to a resident with a sacral wound. After removing her gloves, the TN did not perform hand hygiene before donning a new pair of gloves, which is against the facility's policy. This lapse occurred while the TN was handling wound care materials, including gauze and wound cleanser, for the resident's sacral wound. The resident involved had a complex medical history, including sepsis, osteomyelitis, hemiplegia, and a stage 4 pressure ulcer in the sacral region. The facility's policy requires hand hygiene to be performed after removing gloves and before putting on a new pair, which the TN acknowledged she failed to do. The Infection Preventionist confirmed that the staff should follow this protocol during wound care. The resident's medical records indicated ongoing treatment for the sacral pressure injury, which required careful handling to prevent infection.
Lack of Dedicated Dietary Manager Leads to Food Safety Oversight Issues
Penalty
Summary
The facility failed to employ a dedicated Dietary Manager (DM) to oversee the food and nutrition services, which led to a lack of oversight in food safety practices. During an unannounced visit, it was observed that the facility did not have a dedicated DM, and the duties were being shared among a Dietary Corporate Consultant (DCC), a Registered Dietitian (RD), and a DM from a sister facility. This arrangement resulted in lapses in food safety practices, such as missing use-by dates on food items in the refrigerator, including Italian dressing and egg salad. Interviews with staff revealed that the absence of a dedicated DM negatively impacted their work, as they experienced issues like running out of supplies. The DCC admitted that checking expiration dates was the DM's responsibility, but due to the lack of a dedicated DM, this task was not consistently performed. The Administrator confirmed the absence of a dedicated DM, highlighting the facility's failure to ensure proper staffing for food and nutrition services.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were stored in accordance with professional standards for food service safety. During an observation and interview on July 18, 2024, it was noted that certain food items in the refrigerator, such as Italian dressing and egg salad, were missing use-by or expiration dates. The Dietary Care Coordinator (DCC) acknowledged that all food items should have received, open, and use-by dates, and confirmed that the egg salad prepared that morning was missing an expiration date. The dietary staff member responsible for preparing the egg salad admitted to forgetting to label the container with an expiration date. Further interviews revealed that it was the responsibility of the Dietary Manager (DM) to check expiration dates on all foods in the kitchen, including those in the refrigerator. However, this task was not completed because there was no DM present at the time. The DCC, who had just started her shift, had not yet had the opportunity to check the expiration dates. The facility's policy and procedure on labeling and dating foods, dated 2023, clearly indicated that all food items in storage areas need to be labeled and dated, but this was not adhered to, leading to the deficiency.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to ascertain the current condition of a resident prior to refusing the resident's re-admission after hospitalization. The resident, who had been living at the facility for several years, was transferred to the emergency room for psychiatric evaluation and treatment following a major behavioral outburst. Despite the resident's long-term stay and the absence of a bed-hold policy, the facility did not follow up with the hospital to determine if the resident's behavior had stabilized before deciding not to readmit him. The decision was made based on the resident's previous behavior and a psychologist's note indicating that the resident was a danger to himself and others. Interviews with facility staff, including the Medical Records Director, Licensed Vocational Nurse, Director of Nursing, and Administrator, revealed that the decision not to readmit the resident was made without proper assessment of his current condition. The Director of Nursing admitted to not following up with the hospital regarding the resident's behavior improvement. The Administrator stated that the decision was made in the best interest of other residents and employees. The facility's policy on bed-holds and returns, which requires residents to be permitted to return following hospitalization, was not adhered to in this case.
Failure to Provide Bed Hold Information and Notice of Proposed Transfer/Discharge
Penalty
Summary
The facility failed to ensure that information related to bed hold policies was provided to the family member of a resident who was transferred to a hospital for psychiatric evaluation and treatment. The resident, who had a history of traumatic brain injury and adjustment disorder, was transferred under a 51-50 code due to aggressive behavior. The facility did not provide a bed hold for the resident, and the Notice of Proposed Transfer/Discharge (NOPTD) was not given to the resident or the responsible party within the required 24-hour period. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that the decision to not provide a bed hold was made as a team due to the resident's increasingly difficult behavior. The DON also admitted to not following up with the hospital to check if the resident's behavior had stabilized. The facility's policy requires that all residents or their representatives be provided with written information about bed hold policies at least twice, well in advance of any transfer and at the time of transfer, or within 24 hours in case of an emergency transfer. This policy was not followed in this case.
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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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