The Shores Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 2828 Meadowlark Drive, San Diego, California 92123
- CMS Provider Number
- 555585
- Inspections on file
- 47
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Shores Post-acute during CMS and state inspections, most recent first.
A resident with hemiplegia who tested positive for Influenza A was placed on contact/droplet precautions with posted signage indicating the need for a surgical mask, gown, and gloves. Despite this, a CNA entered the resident’s room, interacted with the resident, and handled the lunch tray without wearing a gown or gloves, then exited without doffing PPE or performing the full required protocol. The CNA later stated she had not realized the room was under contact/droplet precautions but understood the expectation to use full PPE and hand hygiene. The IP and DON confirmed that staff were required to follow posted transmission-based precaution signage and the facility’s PPE policy, which specifies PPE use based on the type of isolation and potential exposure.
A resident deposited $1000 in cash with facility staff for placement in the facility safe, and the deposit was correctly recorded in the safe log. When the resident later requested to withdraw the funds, the money was missing and there was no documentation of any authorized access, withdrawal, or release of the funds. Social services staff could not account for the missing money or provide records explaining its disposition, despite a facility policy requiring that all resident funds be handled to ensure the safety and integrity of each transaction.
A resident with a history of psychiatric disorders and high risk for wandering was admitted without a baseline care plan addressing their elopement risk. Despite assessments indicating the need, no interventions or instructions were documented, resulting in the resident eloping while under staff escort for an outpatient appointment.
A resident with a history of psychiatric disorders and high risk for wandering was not provided with a care plan addressing her elopement risk and was left unsupervised during an outpatient appointment. The CNA escort briefly fell asleep and later left the resident unattended, resulting in the resident leaving the clinic unnoticed. The resident was missing for over 24 hours, traveled a significant distance, consumed alcohol and medications, and was eventually found at a hospital with pneumonia and altered mental status.
A resident with Parkinsonism and End Stage Renal Disease was discharged to an assisted living facility, requiring ongoing dialysis. The case manager communicated the resident's care needs to the receiving facility via email and text, but failed to document this coordination in the resident's EHR at the time of discharge. The required documentation was only entered weeks later, contrary to facility policy and expectations.
A resident with a history of stroke and significant care needs was discharged from an LTC facility without adequate caregiver support, leading to re-hospitalization. The Social Service Director failed to ensure a safe discharge plan, relying on a care management company that did not provide 24-hour care. The resident's son requested a caregiver, but the facility did not arrange for proper support or training, resulting in the resident's return to the hospital.
The facility failed to develop and implement comprehensive care plans for residents, leading to potential risks and inconsistent care. A resident on fluid restrictions lacked a care plan for fluid overload, resulting in fluid intake exceeding limits. Another resident, identified as a smoker, did not have a safe smoking care plan. A third resident had two medication patches applied simultaneously and an incorrectly set pressure-relieving mattress. Lastly, a resident's care plan lacked personalized activities, contributing to social isolation.
The facility failed to follow safe food handling practices, including unlabeled and undated food in refrigerators, incomplete temperature logs, and inadequate hand hygiene by dishwashers after trash disposal. These actions were against the facility's policies, risking food safety and cross-contamination.
The facility failed to maintain infection control practices, including improper handling of urinary catheter tubing, unsanitary wrist splint maintenance, undated oxygen tubing, and lack of gown use for residents on Enhanced Barrier Precautions. These actions increased the risk of infection and cross-contamination among residents and staff.
A resident with a urinary catheter bag was observed without a dignity bag covering it, contrary to the facility's policy and care plan. Staff interviews confirmed the oversight, noting the resident had returned from the hospital the previous night and the dignity bag should have been applied to protect the resident's privacy.
A facility failed to provide a written notice of transfer to a resident's responsible party and the LTC Ombudsman. The deficiency was identified when Resident 296 was transferred to the hospital after being found unconscious, but no documentation of the required notice was found. The DON confirmed the oversight, which was against the facility's policy requiring written notice in cases of immediate transfer due to urgent medical needs.
A resident experienced an unwitnessed fall resulting in a wrist sprain, which was not reported to CMS as required. The MDS assessment failed to capture the fall, leading to an incomplete report of the resident's condition. Interviews with staff confirmed the oversight, highlighting a lapse in following reporting protocols.
A resident with dementia and a history of falls did not have their care plan updated to include a positioning aide, such as a pillow under the sheet, to prevent falls. Staff interviews revealed inconsistent use of this intervention, and the Director of Nursing confirmed the care plan should have been updated according to facility policy.
A resident admitted with multiple pressure injuries did not receive a low air loss (LAL) mattress as ordered by the physician. The resident was observed on a regular mattress, and staff acknowledged the oversight. The facility's policy and care plan indicated the need for a LAL mattress to prevent further skin breakdown, but it was not provided, posing a risk to the resident's condition.
The facility failed to conduct a quarterly smoking assessment for a resident with chronic kidney disease, potentially compromising safety. Additionally, another resident with balance issues was observed eating in an unsafe manner due to improper meal tray setup. The facility lacked a policy for meal tray arrangements, contributing to the oversight.
A resident with hypertensive chronic kidney disease did not receive prazosin as ordered due to a nurse holding the medication without physician approval. The nurse failed to notify the physician, contrary to facility policy, which requires immediate notification if medications are held without parameters.
A resident's medication was left unattended at the bedside, posing a risk of misuse or unauthorized access. A nurse found an unlabeled pill on the resident's table, which was against the facility's policy. Interviews with staff confirmed that medications should not be left unattended, as it could lead to safety concerns or medication divergence.
A resident with a history of CHF was served coffee despite it being listed as a food intolerance. Interviews with CNAs and a Licensed Nurse revealed that the responsibility for checking meal tickets was not properly executed, leading to the resident's dissatisfaction. The DON confirmed the expectation to honor food preferences.
The facility failed to accurately document the care of two residents, leading to deficiencies. A resident with a central line for dialysis was incorrectly documented as having a shunt, while another resident prescribed a low air loss mattress was observed on a regular mattress, with inaccurate records indicating otherwise. Interviews revealed a lack of training and understanding among staff, and the DON stressed the need for accurate documentation.
A survey found that 113 rooms in the facility did not meet the minimum space requirement of 80 square feet per resident. Despite this deficiency, no adverse effects on residents' health, safety, or quality of life were observed. A room size waiver is recommended to continue, as the current room sizes are deemed acceptable under the circumstances.
The facility failed to implement its elopement policy when a resident with paranoid schizophrenia and moderate cognitive impairment eloped. Staff did not initiate the required emergency procedures immediately upon noticing the resident was missing, delaying the search and notification process.
A resident admitted with sepsis and pyomyositis had an IV antibiotic order incorrectly transcribed as an intramuscular injection. The error was identified during a review with the ADON and RN, who could not explain the discrepancy. The facility's policy on reconciling medication lists was not followed, potentially leading to a medication error.
Failure to Use Required PPE for Resident on Contact/Droplet Precautions for Influenza A
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently used required personal protective equipment (PPE) for a resident on contact/droplet precautions for Influenza A. Resident 10, admitted with hemiplegia, tested positive for Influenza A following persistent cough and flu-like symptoms and was placed on contact/droplet precautions with isolation in their room. Facility signage at the room indicated droplet/contact precautions and displayed required PPE, including a surgical mask, gown, and gloves. The Infection Preventionist (IP) reported that multiple Influenza A cases had occurred among residents and a staff member, that positive residents were isolated in their rooms, and that mandatory masking and specific PPE requirements for contact/droplet isolation rooms were in place. During an observation of Resident 10’s room, a CNA was seen entering and interacting with the resident without wearing a gown or gloves, despite the posted droplet/contact precaution signage and PPE requirements. The CNA handled the resident’s lunch tray and spoke with the resident, then exited the room without donning or doffing the required gown and gloves. In an interview, the CNA stated she did not realize the room was under contact/droplet precautions but acknowledged that the expectation was to sanitize hands, don full PPE (mask, gown, gloves) before entering, and remove PPE and perform hand hygiene upon exit, and that failure to wear PPE could result in catching or spreading the virus. The IP and DON both confirmed that staff were expected to follow the signage and wear the required PPE for the assigned isolation type, consistent with the facility’s PPE policy, which states that PPE is based on the type of transmission-based precaution and that employees who fail to use PPE when indicated may be disciplined.
Failure to Safeguard and Account for Resident Trust Funds
Penalty
Summary
The facility failed to honor a resident’s right to manage personal financial affairs when cash entrusted to the facility for safekeeping went missing. According to interviews with the Administrator (ADM) and Director of Nursing (DON), the resident deposited $1000 in cash into the facility safe through the social services office on 9/25/25, and the funds were correctly logged as received in the safe log. When the resident later attempted to withdraw the money on 2/17/26, the funds were not in the safe, and there was no documentation of any authorized access, withdrawal, or release of the money. Social services staff were unable to account for the missing funds or provide any documentation showing an authorized transaction. Review of the facility’s resident trust policy indicated that all resident funds received in the facility were to be handled in a manner that ensured the safety and integrity of the transaction. This deficiency centers on the lack of documentation and accountability for the resident’s deposited funds, as evidenced by the safe log showing only the initial receipt entry with no corresponding record of withdrawal or release, and the inability of staff to explain or substantiate what happened to the money.
Failure to Develop Baseline Care Plan for High-Risk Wandering Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was identified as high risk for wandering and elopement. Despite the resident's documented history of psychiatric conditions, including bipolar disorder, psychosis, major depressive disorder, and a history of increased agitation and auditory hallucinations, no care plan was created to address the resident's high risk of wandering. The resident's clinical record and assessments indicated a high risk for wandering, but this was not reflected in a care plan with specific interventions. On the day of the incident, the resident was escorted by a CNA to an outpatient appointment but was lost during the outing. Staff interviews revealed that while the resident was considered alert and ambulatory, there was an expectation that staff would closely monitor residents, especially those at high risk. However, the lack of a care plan meant there were no documented interventions or instructions for staff to follow, which contributed to the resident's successful elopement from the facility. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident in question.
Failure to Supervise High-Risk Resident During Outing Leads to Elopement and Hospitalization
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and accident hazard prevention for a resident under conservatorship with a known high risk for wandering. The resident, who had diagnoses including convulsions, bipolar disorder, psychosis, and major depressive disorder, was placed in a locked unit due to her risk of elopement. Despite this, there was no care plan developed to address her high risk for wandering, as confirmed by record review and staff interviews. On the day of the incident, a CNA was assigned to escort the resident to an outpatient appointment. While waiting at the clinic, the CNA briefly fell asleep and later left the resident unattended to use the bathroom without arranging for another staff member to supervise. Upon returning, the CNA assumed the resident had been called in for her appointment, but later realized she was missing. The resident was not found for over 24 hours, during which time she traveled more than 11 miles from the facility, consumed alcohol, took her prescribed antipsychotic and antidepressant medications, and was eventually found at a hospital emergency department with pneumonia and altered mental status. Interviews with staff revealed that the expectation was for residents to never be left unattended during outings, and that staff should notify others if they needed to step away. The facility's policies required identification of residents at risk for wandering and the development of care plans with specific interventions, but these were not followed in this case. The lack of a resident-centered care plan and failure to maintain supervision directly led to the resident's elopement and subsequent hospitalization.
Failure to Timely Document Discharge Coordination in Medical Record
Penalty
Summary
The facility failed to ensure that documentation regarding the coordination of care during the discharge process was entered into the medical record in a timely manner for one resident. The resident, who had diagnoses including Parkinsonism and End Stage Renal Disease, was discharged to an assisted living facility and required transportation to dialysis. Although the case manager communicated the resident's needs to the receiving facility via email and text message, this communication was not documented in the resident's electronic health record at the time of discharge. The case manager acknowledged that all relevant information was kept in personal emails and text messages rather than being properly charted in the resident's medical record. A review of the records showed that the case manager's progress note documenting the coordination of care was created and signed several weeks after the resident's discharge. The facility's policy required that details of transfers or discharges be documented in the medical record and communicated to the receiving provider. The DON confirmed that documentation should have been entered into the resident's record and stated that, despite the late entry, the expectation was for timely documentation of such communications.
Inadequate Discharge Planning Leads to Re-hospitalization
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to the resident's re-hospitalization. The resident, who had a history of cerebral infarction with left hemiplegia and hemiparesis, was discharged home without adequate caregiver support. The Social Service Director (SSD) had initially discussed the discharge with the resident's son, who requested a 24-hour caregiver due to his inability to provide the necessary care. However, the resident did not qualify for such services, and the SSD relied on a care management company that did not provide 24-hour care. Upon discharge, the resident found herself without the promised caregiver support, as her former roommate, who was supposed to assist, was not capable of providing the required care. The SSD failed to confirm the son's availability on the discharge date and did not document attempts to ensure a safe discharge plan. The resident required significant assistance with daily activities, including toileting, transfers, and dressing, and was unable to walk, necessitating a wheelchair. The lack of proper caregiver arrangements and training for the resident's son or former roommate contributed to the resident's re-hospitalization. The facility's discharge care plan was outdated and did not reflect the resident's current needs or the arrangements for her care. The Director of Nursing (DON) noted the absence of documentation supporting an updated discharge plan and emphasized the importance of thorough planning and caregiver training to prevent re-hospitalizations. The facility's policy required teaching and discharge instructions for residents being discharged home, which were not adequately provided in this case.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks and inconsistent care. Resident 264, who was on fluid restrictions due to emphysema and arteriosclerotic heart disease, did not have a care plan addressing fluid overload or non-compliance with fluid restrictions. This oversight resulted in the resident exceeding the fluid limit on multiple occasions without proper documentation or physician notification, increasing the risk of respiratory and heart problems. Resident 283, identified as a smoker requiring supervision, lacked a care plan for safe smoking. Despite an initial smoking assessment indicating the need for a plan of care, no documented evidence of such a plan was found. This omission posed a risk to the resident's safety, as confirmed by interviews with nursing staff and the Director of Nursing. Resident 95 experienced two deficiencies: the failure to remove an old medication patch before applying a new one, and the incorrect setting of a pressure-relieving mattress. The presence of two rivastigmine patches on the resident's shoulder indicated a lapse in medication administration protocol. Additionally, the mattress was set to an incorrect setting, contrary to the physician's order, which could affect the resident's comfort and wound management. Lastly, Resident 145's care plan did not reflect personalized activities, such as music and outdoor activities, which the resident enjoyed. This lack of personalization contributed to the resident's social isolation and dissatisfaction with the facility's activity offerings.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to ensure safe food handling practices in several instances. In the kitchen's reach-in refrigerator, containers of cut and peeled cantaloupe and watermelon were found without labels or dates, making it impossible to determine when the fruit was received, cut, or prepared. This was against the facility's policy, which requires all prepared foods to be covered, labeled, and dated. Additionally, in one of the resident refrigerators, a jar of cheese dip was not labeled with the date it was opened, and the resident's name on the jar did not match any current resident, indicating it should have been discarded. The facility's policy mandates that resident food be labeled and monitored, with unused food discarded within two days. Furthermore, the temperature log for another resident refrigerator was incomplete, with no entries for specific shifts, which could lead to food spoilage if the refrigerator temperature was not properly maintained. Additionally, two dishwashers failed to perform hand hygiene after disposing of trash, risking cross-contamination. One dishwasher returned to cleaning dishes without removing gloves or washing hands, while the other handled pots with bare hands after trash disposal without performing hand hygiene. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of handwashing to prevent infection spread.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention practices for several residents, leading to potential health risks. Resident 218's urinary catheter tubing was observed to be in contact with the floor, which was against the facility's policy and increased the risk of infection. Both a Certified Nursing Assistant and a Licensed Nurse acknowledged the issue, and the Director of Nursing confirmed that the tubing should never have been on the floor. Resident 75's wrist splint was not maintained in a sanitary manner, as it was observed to be dirty with dark smudges. Despite being aware of the condition, the nursing staff did not contact the physician in a timely manner to address the issue, which could have led to cross-contamination. The Director of Nursing admitted that the splint should have been replaced or cleaned to prevent potential infection. For Residents 65 and 8, the oxygen tubing was not dated, which is a critical step in infection control to ensure timely replacement. The facility's policy required nasal cannulas to be changed every two weeks, but the lack of dating made it impossible to track when replacements were due. Additionally, staff failed to use disposable gowns for residents on Enhanced Barrier Precautions, increasing the risk of spreading multidrug-resistant organisms. The facility's policies and training emphasized the importance of gown use during high-contact activities, but staff did not adhere to these guidelines.
Failure to Maintain Resident Dignity with Urinary Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident 218, who was readmitted with a urinary tract infection and had an indwelling urinary catheter. During an observation, it was noted that the urinary catheter bag was visible and not covered with a dignity bag, as required by the facility's policy and the resident's care plan. The catheter bag was clipped to the bed frame and contained cloudy, pale-colored urine, which was visible upon entering the room. Interviews with staff, including a CNA and the Director of Nursing, confirmed that the dignity bag was not in place, and it should have been used to protect the resident's privacy. The CNA mentioned that Resident 218 had returned from the hospital the previous night, and the dignity bag should have been placed upon their return. The facility's policy explicitly prohibits practices that compromise dignity and mandates that urinary catheter bags be covered to maintain residents' dignity.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident's responsible party (RP) and the Long-Term Care Ombudsman for one of the residents reviewed for closed records. This deficiency was identified during an interview and record review, which revealed that Resident 296 was transferred to the hospital for evaluation after being found unconscious. However, there was no documentation indicating that a written notice of transfer was provided to the resident's RP or sent to the Long-Term Care Ombudsman. The director of nursing (DON) confirmed during an interview that Resident 296's clinical record lacked documentation of the required written notice of transfer. According to the facility's policy, a written notice should have been completed by the nursing staff and provided to both the resident's RP and the Long-Term Care Ombudsman. The policy specifies that in cases of immediate transfer due to urgent medical needs, the notice should be given as soon as practicable, including details such as the reason for transfer, effective date, location, and the resident's right to appeal the transfer.
Failure to Report Significant Change in Condition
Penalty
Summary
The facility failed to report a significant change in condition for a resident to the Centers for Medicare and Medicaid Services (CMS). The resident, who was readmitted to the facility with a sprain to the left wrist following a fall, was observed with a splint on the wrist. The clinical record indicated an unwitnessed fall occurred, resulting in wrist pain and a subsequent emergency room visit that confirmed soft tissue swelling and severe osteoarthrosis. However, the Minimum Data Set (MDS) assessment did not capture this fall, and it was not reported to CMS as required. Interviews with the MDS Nurse and the Director of Nursing revealed that the fall should have been included in the Significant Change of Condition report but was missed. The MDS Nurse acknowledged that the omission meant CMS did not have an accurate picture of the resident's current health status. The facility's policy and the Resident Assessment Instrument require that any fall, including those with minor injuries, be reported to CMS, but this protocol was not followed in this instance.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 273, to include a positioning aide to prevent falls. Resident 273 was admitted with diagnoses including dementia, weakness, and repeated falls, indicating a high risk for falling. During an observation, it was noted that a pillow was placed under the sheet at the exit of the bed, but there were no orders or care plans documenting this intervention. Interviews with staff revealed inconsistent use of the pillow as a positioning aide, with some staff members using it and others not. The Director of Nursing acknowledged that the care plan should have been updated to include the use of a pillow as a positioning aide. The facility's policy on comprehensive, person-centered care plans requires that the care plan describe the services to be furnished to maintain the resident's highest well-being. The lack of documentation and inconsistent application of the positioning aide could lead to the resident not receiving the necessary intervention to prevent falls.
Failure to Provide Low Air Loss Mattress for Resident with Pressure Injuries
Penalty
Summary
The facility failed to provide a low air loss (LAL) mattress for Resident 105, who was admitted with multiple pressure injuries and a physician's order for such a mattress. On observation, Resident 105 was found lying on a regular mattress, contrary to the physician's order dated 10/22/24, which specified the use of a LAL mattress for wound management and preventive measures. The Treatment Nurse acknowledged that Resident 105 should have had a LAL mattress upon admission, as it was a physician's order, but was overlooked. Interviews with the Wound Nurse Practitioner and the Director of Nursing confirmed the importance of a LAL mattress for Resident 105 to help distribute weight and relieve pressure points, which are crucial for preventing further skin breakdown. The facility's policy also indicated that individuals at risk for pressure ulcers should be placed on a redistribution support surface like a LAL mattress. Despite these guidelines and the resident's care plan, the necessary equipment was not provided, leading to a potential risk for the resident's condition to worsen.
Failure to Conduct Smoking Assessment and Ensure Safe Eating Environment
Penalty
Summary
The facility failed to conduct a quarterly safe smoking assessment for a resident, which is required to ensure the resident's ability to smoke safely. Resident 283, who was admitted with chronic kidney disease and had an intact cognitive score, was identified as a smoker needing supervision. However, the quarterly smoking assessment due in October 2024 was not completed. Interviews with the Licensed Nurse, Minimum Data Set Nurse, and Activities Director revealed that the assessment was missed, which could have led to potential harm due to the resident's health possibly declining without reassessment. Additionally, the facility did not ensure a safe eating environment for Resident 259, who had mild neurocognitive disorder, malnutrition, and gout. The resident, who had balance issues and primarily used a wheelchair, was observed eating while standing in a hunched position because the meal tray was placed on a low table without a seating arrangement. The CNA responsible did not adjust the table or inquire about the resident's preference for eating while seated, leading to an unsafe situation where the resident had to maintain balance while eating. The Director of Nursing acknowledged that the lack of a quarterly smoking assessment and improper meal setup could pose safety risks to the residents. The facility's smoking policy required quarterly evaluations, but there was no policy for setting up meal trays, contributing to the oversight in Resident 259's case.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a physician's order was followed during medication administration for a resident diagnosed with hypertensive chronic kidney disease. On the observed date, a Licensed Nurse (LN) did not administer prazosin, a medication prescribed to manage high blood pressure in patients with kidney disease, to the resident. The medication was scheduled to be given at 9 A.M., but the LN held the medication without any hold parameters or physician's order to do so. The LN did not notify the physician about holding the medication, which was against the facility's policy. The Director of Nursing (DON) confirmed that it was expected for nurses to notify the physician immediately if a medication was held without hold parameters to prevent delays in medication administration. The facility's policy on administering medications emphasized that medications should be administered according to prescriber orders and within one hour of the prescribed time.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medication for one of the sampled residents, identified as Resident 145. During an observation, a licensed nurse (LN 56) found an unlabeled medication cup containing an oval-shaped yellow pill left unattended on the bedside table of Resident 145, who was asleep at the time. LN 56 acknowledged that leaving medication unattended was not a safe practice and could pose a safety concern for other residents or visitors who might take the pill without permission, potentially leading to an allergic reaction. LN 56 emphasized the importance of adhering to the five rights of medication administration to ensure the medication is taken correctly and monitored for side effects. Further interviews with another licensed nurse (LN 52) and the Director of Nursing (DON) confirmed that medications should not be left unattended for any reason. LN 52 reviewed a picture of the unattended medication and reiterated the importance of witnessing the resident take the medication for safety reasons. The DON stated that leaving medications unattended could lead to medication divergence or allergic reactions if taken by someone other than the prescribed resident. The facility's policy on medication storage, revised in November 2020, mandates that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 51, who was readmitted with a history of congestive heart failure. Despite having a documented dislike and intolerance for coffee, Resident 51 was served coffee on his meal tray. This oversight was observed during an interview and record review, where Resident 51 expressed dissatisfaction with receiving coffee, which was clearly listed as a food intolerance on his nutritional evaluation. Additionally, Resident 51 mentioned that his preference for two butter packets with pancakes was often overlooked by the facility staff. Interviews with facility staff, including CNAs and a Licensed Nurse, revealed that the responsibility for checking meal tickets and ensuring preferences were honored lay with the CNAs. However, the CNAs admitted to failing to adhere to Resident 51's preferences, acknowledging that coffee should not have been placed on his tray. The Director of Nursing confirmed that it was expected for the nursing staff to honor Resident 51's food preferences and recognized that the failure to do so led to Resident 51's understandable frustration.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to accurately document the medical status of two residents, leading to deficiencies in their care. Resident 183, who was admitted with acute kidney failure, had a central line for dialysis. However, the post-dialysis assessments inaccurately documented the presence of a thrill and bruit, which are characteristics of a shunt, not a central line. Interviews with licensed nurses revealed a lack of understanding and training regarding the differences between central lines and shunts, resulting in incorrect documentation. Resident 105, admitted with hemiplegia and pressure ulcers, was prescribed a low air loss mattress to manage and prevent wounds. Despite this, the resident was observed on a regular mattress, and the electronic Medication Administration Records inaccurately documented the presence and functionality of the low air loss mattress for over a month before it was actually provided. Licensed nurses admitted to documenting the mattress's presence and settings without verifying them, acknowledging the potential harm this could have caused to the resident. The Director of Nursing emphasized the importance of accurate documentation to reflect the actual care and interventions provided to residents. The facility's policies on hemodialysis access care and charting and documentation were not adhered to, as evidenced by the inaccurate records for both residents. This lack of accurate documentation could have significant implications for the residents' health and safety.
Room Size Deficiency Without Adverse Impact
Penalty
Summary
The facility was found to have 113 resident rooms that did not meet the minimum requirement of 80 square feet per resident in multiple occupancy rooms. This deficiency was identified during a survey that included both observation and record review. The rooms in question varied slightly in size, with each providing less than the required space per resident, ranging from approximately 73.88 to 78.91 square feet per resident. Despite this deficiency, the survey did not observe any adverse effects on the residents' health, safety, quality of care, or quality of life. The report notes that the variations in room size did not appear to impact the residents negatively during the survey period. This suggests that while the facility did not meet the regulatory space requirements, the residents' well-being was not compromised as a result. The report recommends the continuance of a room size waiver, indicating that the facility may have previously been granted an exception to the standard room size requirements. This recommendation is based on the lack of observed negative impact on residents, suggesting that the facility's current room sizes, although non-compliant, are deemed acceptable under the circumstances.
Failure to Implement Elopement Policy
Penalty
Summary
The facility failed to implement its elopement policy when a resident with a history of paranoid schizophrenia and moderate cognitive impairment eloped from the facility. The resident was admitted with a moderate risk for elopement, as indicated by an Elopement Risk assessment. On the night of the incident, the certified nursing assistant (CNA) did not see the resident during her shift and only realized the resident was missing during her final rounds. The licensed nurse/charge nurse (LN) also noticed the resident was not in the facility but did not initiate the facility-wide emergency procedure or notify the Director of Nursing (DON) immediately, as required by the facility's policy. The DON confirmed that the LN should have initiated a Code [NAME] and started searching for the resident as soon as it was noticed that the resident was missing. The facility's elopement policy clearly states that a missing resident is considered a facility-wide emergency, and immediate actions should be taken to locate the resident. The failure to follow these procedures delayed the search and notification process, potentially affecting the resident's health and safety.
Failure to Accurately Transcribe Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to accurately transcribe an admission order for an intravenous (IV) antibiotic for a resident admitted with diagnoses of sepsis and pyomyositis. The resident was transferred from another facility with medication orders that included Ertapenem 1 gram IV every 24 hours. However, upon admission, the order was incorrectly transcribed as Ertapenem 1 gram intramuscularly once a day. This discrepancy was identified during a concurrent interview and record review with the Assistant Director of Nursing (ADON), who confirmed that the report from the transferring facility included orders for IV antibiotics, not intramuscular injections. Further investigation revealed that the Registered Nurse (RN) responsible for transcribing the admitting orders did not know how the error occurred. The facility's policy on admission assessment and follow-up, which requires nurses to reconcile medication lists from the medication history, admitting orders, and discharge summary from the previous institution, was not followed. This failure had the potential to result in a medication error for the resident, as confirmed by the ADON and the Director of Nursing (DON).
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
