The Win Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Clara, California.
- Location
- 410 North Winchester Boulevard, Santa Clara, California 95050
- CMS Provider Number
- 055645
- Inspections on file
- 30
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Win Post-acute during CMS and state inspections, most recent first.
A resident with BPH, type II DM, and a lumbar compression fracture had a physician order for daily Finasteride 5 mg, but the medication was not administered on two consecutive days. Nursing staff documented in the EMAR that the drug was "awaiting supply," yet the DON later confirmed there was no actual medication shortage and no documentation that staff contacted the pharmacy, used the emergency medication supply, or arranged for emergency delivery as required by facility policy. This failure to follow up and to administer the ordered medication in accordance with professional standards resulted in a cited deficiency.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Three residents received oxygen therapy that did not follow physician orders: one received a higher flow rate than ordered, another was given oxygen without any physician order, and a third received a higher flow rate than prescribed despite multiple medical conditions. Staff and the DON confirmed that oxygen administration did not match the documented orders, contrary to facility policy.
The facility did not complete or document annual performance reviews for 40 out of 69 CNAs employed for over one year, as confirmed by employee file reviews and interviews with the DSD and DON.
A review of controlled medication records revealed that staff failed to consistently document the administration of narcotics in both the Controlled Drug Record (CDR) and Medication Administration Record (MAR). In some cases, medication was given but not signed out in the CDR, while in others, medication was signed out but not recorded on the MAR. The DON confirmed these discrepancies, which resulted in inaccurate accountability of controlled substances.
A resident was administered Midodrine HCl multiple times when their systolic blood pressure was above the physician-ordered threshold, contrary to the medication order and facility policy. An LVN confirmed the medication should have been held in these instances, but it was given on 14 occasions outside the prescribed parameters.
The facility did not identify that 40 of 69 CNAs lacked documented annual performance reviews because required random personnel file audits were not performed or documented, and this deficiency was not detected or addressed through the QAPI monitoring process.
A CNA failed to perform hand hygiene between feeding two residents, contrary to facility policy, and an LVN confirmed that a resident's IV tubing was left uncapped and exposed to air when not in use, both representing failures to follow infection prevention and control procedures.
A resident with Type 2 Diabetes Mellitus and a history of foot issues was observed to have thickened, discolored, and overgrown toenails, with no care plan or medical orders in place for preventive foot care or podiatry services. The DON confirmed the lack of a care plan addressing these needs, despite facility policy requiring comprehensive care planning.
Two residents experienced falls, but their care plans were not updated or revised by the interdisciplinary team as required by facility policy. The DON confirmed that no new interventions or changes were documented in the care plans following these incidents.
A resident with multiple medical conditions and at risk for skin breakdown was not provided with physician-ordered heel protectors, despite having stage 1 pressure ulcers on both heels. Staff confirmed the absence of the protective boots during several observations, and the devices could not be located, resulting in noncompliance with the facility's pressure injury prevention policy.
A bottle of expired Mirtazapine 15 mg was discovered in a medication cart during an inspection, with both an LVN and the DON confirming it should have been removed according to facility policy. Review of procedures showed that expired or discontinued medications are to be secured and marked for destruction, but the expired drug remained in the cart.
Surveyors found that several two-resident rooms provided only 71.5 square feet per resident, below the required 80 square feet. Residents reported no concerns about space, and the Administrator stated that regular checks with residents and families had not identified any issues. The Administrator also noted a room waiver was in place.
A resident with severe cognitive impairment and multiple health issues was found with significant injuries, including facial bruises and chipped teeth, while in bed at an LTC facility. Staff interviews indicated the resident was unable to self-harm or move independently, and the injuries were discovered later in the evening. The resident was hospitalized and later died, with the cause of death determined as blunt force injury of the head, classified as a homicide.
Failure to Follow Up on Ordered Medication and Ensure Administration
Penalty
Summary
The deficiency involved the facility’s failure to ensure that care and services were provided in accordance with professional standards of practice when nursing staff did not follow up on a prescribed medication for one resident. The resident was admitted with diagnoses including benign prostatic hyperplasia (BPH), type II diabetes mellitus, and a wedge compression fracture of the first lumbar vertebra. A physician’s order dated 11/11/25 directed that the resident receive Finasteride 5 mg by mouth once daily for BPH. Review of the Medication Administration Record showed that Finasteride was not administered on 11/12/25 and 11/13/25. The EMAR administration note dated 11/13/25 documented that the Finasteride 5 mg tablet was “awaiting supply.” During interview and concurrent record review, the DON confirmed that the Finasteride doses were not given and that there was no shortage or inadequate supply of the medication. The DON stated that nursing staff had documented the medication as being on order and acknowledged there was no documentation that staff followed up with the pharmacy. Review of the facility’s “Medication Shortages/Unavailable Medications” policy indicated that nurses should call the pharmacy to determine order status, obtain medication from the emergency supply if delivery delays would cause a missed dose, arrange for emergency delivery if not available in the emergency supply, and document any unavoidable missed dose and explanation on the MAR/TAR and in nurse’s notes. These required follow-up and documentation steps were not carried out or documented by nursing staff for this resident’s Finasteride doses.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow professional standards of practice for oxygen administration for three residents. One resident was observed receiving oxygen at a flow rate higher than the physician's order, with the nasal cannula set between 2.5 and 3 liters per minute (LPM) instead of the ordered 2 LPM. Another resident was administered oxygen at 4 LPM without any physician's order for oxygen therapy, as confirmed by both observation and review of the resident's medical orders. A third resident, who had multiple diagnoses including spinal cord injury, diabetes, chronic kidney disease, myelofibrosis, and anemia, was observed receiving oxygen at 4 LPM, while the physician's order specified 2 LPM. In each case, staff acknowledged the discrepancies between the administered oxygen and the physician's orders. The facility's policy and procedure for oxygen administration requires staff to check the physician's order for the correct liter flow and method of administration. Despite this, staff failed to ensure that oxygen was administered according to the prescribed orders for these residents. The Director of Nursing confirmed that oxygen orders should always be followed, and staff interviews further verified that the observed oxygen administration did not match the documented orders.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct and document annual performance reviews for 40 out of 69 Certified Nursing Assistants (CNAs) who had been employed for over one year, as required by federal regulation. During a review of employee files, it was found that no annual performance reviews were documented for multiple CNAs, including those hired as far back as 2017 and 2021. Interviews with the interim Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that there was no evidence of completed annual performance reviews for these staff members, and the current DSD was unaware of the previous process for conducting such reviews. A list compiled by the DON further verified that 40 CNAs had not received their required annual performance evaluations.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents during a random audit. For one resident, Hydrocodone-Acetaminophen was documented as administered on the Medication Administration Record (MAR), but the dose was not signed out on the Controlled Drug Record (CDR). The responsible RN confirmed during interview that the medication was given but the CDR was not signed at the time of administration. For two other residents, controlled medications (Norco and Oxycodone Hydrochloride) were signed out of the CDR, indicating removal from the medication cart, but the administration was not documented on the MAR. The Director of Nursing (DON) acknowledged during interviews that the medications were not properly accounted for in the MAR. A review of the facility's policies confirmed that staff are required to document the administration of controlled substances both in the narcotic book (CDR) and on the MAR, in accordance with applicable law and facility procedures. The failure to consistently document controlled medication administration in both records resulted in inaccurate accountability of these medications.
Failure to Hold Medication per Physician-Ordered Blood Pressure Parameters
Penalty
Summary
A deficiency was identified when a resident received the medication Midodrine HCl outside of the physician-ordered parameters. The resident had an order for Midodrine HCl 5 mg by mouth three times daily for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 120 mmHg. Despite this, the medication administration record (MAR) showed that the resident received Midodrine on multiple occasions when the SBP exceeded 120 mmHg, specifically on five occasions in March and eight occasions in April, as well as once in May. During an interview and record review, an LVN confirmed that the medication should not have been administered when the SBP was above the ordered threshold, acknowledging that the medication was given inappropriately on 14 separate incidents. The facility's medication administration policy required staff to obtain and record vital signs and to hold medications when vital signs were outside the physician's prescribed parameters, which was not followed in these instances.
Failure to Identify Missing CNA Annual Performance Reviews in QAPI Monitoring
Penalty
Summary
The facility failed to identify and address the lack of annual performance reviews for Certified Nursing Assistants (CNAs) within its Quality Assurance Performance Improvement (QAPI) Plan. The QAPI plan, last updated in 2017, required quarterly random personnel file reviews to ensure compliance with training, documentation, and regulatory requirements, with findings to be reported to the QA&A Committee. However, there was no documentation that these random audits of personnel files were performed, and the facility was unaware that annual performance reviews for CNAs were not being completed. As a result, 40 out of 69 CNAs employed by the facility did not have documented annual performance reviews, which was not identified or addressed through the facility's QAPI monitoring process.
Failure to Follow Infection Prevention Practices During Resident Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed feeding two residents during lunch without performing hand hygiene between resident contacts. The CNA stated that she washed her hands prior to feeding but did not clean her hands between feeding two residents at the same time. The facility's hand hygiene policy requires hand hygiene to be performed between resident contacts, which was not followed in this instance. Additionally, a Licensed Vocational Nurse (LVN) confirmed that the tip of a resident's intravenous (IV) tubing was left uncapped and exposed to air when not in use. The resident had a history of post digestive system surgery, severe protein-calorie malnutrition, and a gastrostomy tube, and was receiving IV hydration as ordered by a physician. The facility's infection prevention and control policy requires all staff to follow procedures to prevent infection, which was not adhered to in this case.
Failure to Develop and Implement Preventive Foot Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of foot problems and a diagnosis of Type 2 Diabetes Mellitus. Observations revealed that the resident had skin buildup on both feet, with thickened, discolored, and overgrown toenails. Interviews with a confidential friend indicated concerns about the resident's long toenails and a history of fungal infections, emphasizing the need for preventive foot care to avoid recurrence. A review of the resident's care plan and medical orders showed that there was no care plan or physician order in place for preventive foot care or podiatry services. The Director of Nursing confirmed the absence of a care plan addressing preventive foot care for the resident, despite the facility's policy requiring comprehensive care planning to maintain optimal health and quality of life.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update the care plans for two residents following documented fall incidents. For one resident, a fall occurred on 2/21/25 at 4:30 p.m., but a review of the care plans showed that the last revision was dated 11/25/24, with no updates or new interventions documented after the fall. The Director of Nursing confirmed during an interview that the care plan was not updated following this incident. Facility policies require care plans to be reviewed and revised by the interdisciplinary team after significant changes in condition or incidents such as falls, but this was not followed. Similarly, another resident experienced a fall on 1/12/25 at around 7:40 a.m., but the care plan reviewed on 5/8/25 did not include any updates or interventions related to the fall. The Director of Nursing also confirmed that the care plan was not updated for this incident. The facility's policies and procedures specify that care plans should be modified as necessary after significant events, including falls, but there was no evidence of such revisions in these cases.
Failure to Implement Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
Staff failed to follow physician orders for pressure ulcer prevention for one resident with a history of heart failure, pancytopenia, encephalopathy, and muscle weakness. The resident was identified as at risk for skin breakdown, with a Braden Scale score of 17 and documented stage 1 pressure ulcers on both heels. Physician orders were in place for the application of skin barrier film every shift and for protective boots to be worn on both feet every shift to prevent further skin breakdown. Despite these orders, multiple observations over several days found the resident lying in bed without heel protectors. Interviews with nursing staff confirmed the resident was not wearing the prescribed heel protective boots, and staff were unable to locate the devices in the resident's room. The Director of Nursing also confirmed the existence of the physician's orders and acknowledged that the boots should have been in use. Facility policy required interventions such as offloading heels to prevent pressure injuries, but these were not implemented as ordered.
Expired Medication Found in Medication Cart
Penalty
Summary
A deficiency was identified when a bottle of Mirtazapine 15 mg, used to treat depression, was found in one of the facility's medication carts (med cart AA) with an expiration date that had already passed. During an inspection, a Licensed Vocational Nurse (LVN) confirmed the medication was expired and acknowledged it should have been removed from the cart. The Director of Nursing (DON) also confirmed in an interview that expired medication should not remain in the medication cart. A review of the facility's policies and procedures revealed that discontinued or outdated medications are to be placed in a designated, secure location for destruction, and all medications must be labeled and stored according to state and federal regulations. The facility's policy also requires routine inspection by the consultant pharmacist to identify and remove outdated or deteriorated medications. Despite these policies, the expired medication remained accessible in the medication cart.
Insufficient Square Footage in Multiple-Resident Rooms
Penalty
Summary
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident, as required. Observations conducted in nine two-resident rooms revealed that each room measured 13 feet by 11 feet, totaling 143 square feet, which equates to only 71.5 square feet per resident. Residents occupying these rooms reported having sufficient space and did not express concerns regarding room size. During an interview, the Administrator stated that social services regularly inquire about room size concerns with residents and families, and no issues had been reported. The Administrator also indicated that the smaller room size did not interfere with resident care and mentioned the existence of a room waiver.
Resident Suffers Fatal Injuries in LTC Facility
Penalty
Summary
A resident in a long-term care facility was not protected from physical abuse, as evidenced by the discovery of multiple injuries including bruises on the face and arms, swelling on the nose and eyebrow, a cut on the lower lip, blood in the mouth, and chipped teeth. The resident, who had severe cognitive impairment and was dependent on staff for mobility, was found in this condition while in bed. The resident's medical history included significant health issues such as osteomyelitis, COPD, severe malnutrition, muscle weakness, atrial fibrillation, stage 4 pressure ulcer, congestive heart failure, osteoporosis, and osteoarthritis. Interviews with facility staff revealed that the resident was last seen without injuries by a certified nursing assistant (CNA) and registered nurses (RNs) earlier in the evening. The injuries were discovered later that night, and staff members confirmed that the resident did not have behaviors of self-harm and was unable to get out of bed independently. The facility's investigation summary noted that the resident was sent to an acute hospital for further evaluation following the discovery of the injuries. The resident was later declared deceased at the hospital, with the cause of death determined to be blunt force injury of the head, complicating existing cardiovascular conditions. The death was classified as a homicide, with the injuries occurring in the resident's shared room at the facility. The facility's policy on abuse and crime reporting emphasized the residents' right to be free from abuse, highlighting a failure to protect this resident from harm.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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