Vale Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Pablo, California.
- Location
- 13484 San Pablo Avenue, San Pablo, California 94806
- CMS Provider Number
- 056389
- Inspections on file
- 32
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Vale Healthcare Center during CMS and state inspections, most recent first.
The facility failed to protect a resident from abuse when two residents were involved in a physical altercation after one, known to use alcohol and exhibit aggression, entered another resident’s room, refused to leave despite repeated requests, and punched the resident in the face, causing facial redness and emotional upset. Records showed the aggressive resident had alcoholic cirrhosis, had previously been observed with slurred speech and suspected alcohol use, and was later found with a bottle of alcohol in their room. The SW and ADM acknowledged awareness of this resident’s alcohol use and aggression and stated that monitoring should have occurred, while facility policy required protecting residents from abuse by anyone, including other residents.
A resident with schizophrenia, alcohol dependence, psychoactive substance abuse, and moderately impaired cognition was assessed as not at risk for elopement despite being ambulatory and having a recent history of wanting to leave. The resident was last seen by an LVN going toward the smoking area after a snack and was later discovered missing when a CNA noted the resident had not returned to the room or eaten lunch. Staff searched resident areas and then initiated a missing-resident code when the resident could not be found. A prior progress note documented the resident asking about going home, and a later entry recorded that the resident had eloped and was subsequently located by authorities for public intoxication and taken to a family member’s home.
The facility failed to report an allegation of verbal abuse and a death threat made by one cognitively intact resident against another to the State Agency, local law enforcement, and the LTC Ombudsman, as required by facility policy. One resident reported that his roommate threatened to kill him, called him a derogatory name, and threw items, while staff documentation showed the roommate became upset about morning phone calls and threw a breakfast tray, requesting a room change. A social services assistant documented the threat and acknowledged that such threats constitute abuse that must be reported, but did not document notifying the administrator, and the DON confirmed the incident was not reported externally because an internal investigation deemed it unsubstantiated, contrary to the written abuse reporting policy.
A resident with dementia and altered mental status was discharged from a hospital to Facility 2 with an approved admission, but upon arrival staff decided the resident was not an appropriate fit. Although prior notifications and transport documentation confirmed the expected admission and arrival, Facility 2 did not create a medical record, did not perform a nursing assessment or initiate clinical care, and did not complete required transfer/discharge documentation. The resident was given food and then sent back to the hospital the same day without proper admission, discharge, or communication of the resident’s condition to the sending facility.
A resident's room was found to have a large dent and exposed wall area behind the bed, which the resident described as unsightly and not reflective of a homelike setting. The Environmental Director confirmed the wall should not be in that condition, and the facility's policy supports residents' rights to a dignified and comfortable environment.
Two residents with long, untrimmed toenails did not receive timely podiatry referrals or foot care, despite one resident's clear request and another having a physician order for podiatry due to nail fungus. Facility policy required regular podiatry scheduling and documentation, but these steps were not followed, resulting in unmet care needs.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with severe cognitive impairment, dysphagia, and no lower teeth did not receive an annual dental exam as required by facility policy. The resident was observed with swollen gums and reported pain while eating. Documentation of dental services was missing from the EHR, and staff could not locate recent dental records, with the last exam documented over a year prior.
Surveyors observed multiple opened food items in dry storage and refrigerators without required open or use-by dates, including cheesecake, cereal, milk, and juice. A paper bag with a ham sandwich and fruit cups for a resident was also improperly labeled and stored. The RD confirmed these items should have been labeled according to facility policy, and unsanitary conditions were noted with food waste found among sealed items.
Surveyors identified infection control deficiencies when a specimen refrigerator containing biological samples was stored in the same room as an ice container used for resident consumption, with the ice scooper exposed to air. Additionally, a medication storage drawer was found disorganized, with medications, specimen containers, needles, and sterile dressing kits mixed together, increasing the risk of cross-contamination.
Three rooms with multiple beds were found to provide less than the required 80 sq. ft. per resident, with each resident receiving only 77.2 sq. ft. Interviews with residents and a CNA indicated no complaints or care issues related to space, and no heavy medical equipment was present to interfere with care.
A resident's code status and advance directives were not documented in the medical record, orders, or face sheet, despite the existence of a signed POLST form indicating DNR and comfort-focused care. The POLST was not signed by the medical provider until after the resident's death, and the DON confirmed that code status was not visible in the EHR or orders prior to the event.
A resident with intact cognition reported $500 missing and stated he informed the DON, but no documentation or investigation of the grievance was found in his records. The facility's policy requires prompt investigation and documentation of such reports, but this was not followed, resulting in the resident's grievance going unresolved.
A resident with multiple medical conditions was admitted and allowed to keep cigarettes at the bedside and smoke independently, without a completed safe smoking assessment or a baseline care plan addressing smoking. Facility staff did not follow policy requiring assessment and care planning for smoking, resulting in the lack of interventions to promote safe smoking.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to accident prevention.
The facility did not provide necessary behavioral health care and services to residents who required them, resulting in unmet behavioral health needs.
A resident with multiple chronic conditions was not kept informed about the status of her power wheelchair, which had been broken for an extended period. Despite documentation of some actions taken by staff, there was no record of the outcome of a scheduled DME assessment or evidence that the resident was notified of an insurance denial for the equipment. The resident remained unaware of the denial and believed efforts to obtain the wheelchair were ongoing.
A resident with multiple medical conditions, including COPD and bilateral arm fractures, was found without a functioning call system in their room. The resident reported not having a call bell for a long time and had to wheel themselves to the nurses' station to request assistance, contrary to facility policy requiring a working call system for residents.
Two residents who required assistance with oral hygiene lost their dentures while in the facility, and staff failed to track, locate, or replace the dentures or provide adequate follow-up. As a result, both residents experienced difficulty eating and speaking, emotional distress, and a negative impact on their dignity and psychosocial well-being.
The facility failed to provide adequate care and documentation for residents, including not referring a psychology consult for a resident after an abuse allegation, not updating a care plan after a physical altercation, and lacking interdisciplinary team signatures on Risk Meeting Notes.
A resident in an LTC facility experienced delays in medication administration, with multiple medications given late over several days. The resident had serious health conditions, and staff interviews revealed that nurses were rushed and unfamiliar with residents, leading to documentation delays. The facility's policy required timely administration and immediate documentation, which was not consistently followed.
Expired medications and COVID test kits were found stored with ready-to-use medications in a facility. An E-kit in Nursing Station One's refrigerator contained expired medications, and the RN Supervisor was unaware of when it was opened or if the pharmacy was contacted for exchange. The ADON was aware of expired E-kits but not the one in Nursing Station One. Expired IV antibiotics, fluids, and heparin syringes were also found, along with expired COVID test kits that were still in use.
The facility failed to provide adequate personal hygiene and mobility care for two residents. One resident had long, dirty fingernails despite being dependent on staff for hygiene due to cognitive impairment. Another resident, with multiple health conditions, had neglected foot care and was not assisted out of bed for activities, contrary to their care plan. These deficiencies highlight unmet basic needs and communication issues within the facility.
A facility failed to act on a pharmacist's Medication Regimen Review recommendations for a resident with Alzheimer's and dementia. The resident was on psychoactive medications and Lisinopril, but the facility did not monitor behavior and side effects as recommended, nor did they address the unnecessary pulse monitoring parameter for Lisinopril. The ADON confirmed these oversights, which were against the facility's policies.
The facility exceeded the acceptable medication error rate, with errors involving incorrect administration of medications and failure to follow physician's orders. An LVN did not flush a GT with the prescribed amount of water and administered Famotidine at the wrong time. An RN failed to instruct a resident to rinse their mouth after using a steroid inhaler, as required.
The facility failed to ensure safe and sanitary food storage, as a thawed pork loin was found on a dirty platform, tied with a disposable glove, and lacking proper labeling. It was later found partially refrozen in the freezer with leaking liquid. The facility's policies and FDA guidelines were not followed, posing a risk of foodborne illness to residents.
A resident with severe left foot pain did not receive appropriate pain management in an LTC facility. Despite reporting constant 9/10 pain, staff failed to assess or document pain levels accurately. Observations showed the resident was left in pain without timely intervention, and staff interviews revealed poor communication and documentation practices. The facility's pain management policy was not followed, resulting in inadequate care.
A deficiency was identified in three resident rooms that did not meet the required 80 square feet per resident. Observations and interviews revealed mixed opinions on space adequacy, with no heavy medical equipment interfering with care. Despite the deficiency, no complaints or negative consequences were reported, and a waiver for room size may be recommended.
Failure to Prevent Resident-to-Resident Physical Altercation Related to Alcohol Use
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and interventions to prevent a resident-to-resident physical altercation. Resident 1, who had a diagnosis of rectal cancer and depression and a BIMS score of 15 indicating intact cognition, reported that while sitting in a wheelchair in their room, Resident 2 entered the room in a wheelchair, appeared to be under the influence of alcohol, and spoke loudly. Resident 1 stated they repeatedly asked Resident 2 to leave, but Resident 2 did not comply, then stood up, approached, and punched Resident 1 on the right side of the face, resulting in facial redness and causing Resident 1 to feel upset. Resident 1 stated the facility was aware of Resident 2’s alcohol use and associated behaviors but failed to adequately monitor and implement interventions to prevent Resident 2’s physical aggression. Record review showed Resident 2 had a diagnosis of alcoholic cirrhosis of the liver with ascites, and progress notes documented that staff had previously noted Resident 2 with slurred speech and had intervened regarding alcohol use. An SBAR note documented that the altercation occurred at 4:30 p.m., that Resident 1 reported Resident 2 looked drunk, entered the room, talked loudly, and hit Resident 1 in the face, and that Resident 2 was suspected of consuming alcohol earlier that afternoon. The Social Worker stated they were aware of Resident 2’s alcohol use and aggression and that staff should have monitored Resident 2 if alcohol use was suspected due to unpredictable behavior toward others. The Administrator stated they were aware of Resident 2’s alcohol use, observed Resident 2 partially inside Resident 1’s doorway just before hearing yelling, then found Resident 1 with redness on the right side of the face and later found a full bottle of alcohol in Resident 2’s room. The facility’s Abuse Prevention Program policy stated residents have the right to be free from abuse by anyone, including other residents.
Failure to Identify and Care Plan Elopement Risk Leading to Unauthorized Exit
Penalty
Summary
The facility failed to identify and care plan an elopement risk for a resident who subsequently left the facility without authorization. The resident was admitted with diagnoses including cellulitis of the left lower limb, unspecified behavioral and emotional disorder, psychoactive substance abuse, schizophrenia, and alcohol dependence. An MDS dated 01/25/2026 showed a BIMS score of 08, indicating moderately impaired cognition. An Elopement Risk Assessment dated 11/13/2025 documented that the resident was ambulatory and had a history of wanting to leave the facility within the last 30 days, yet the assessment indicated the resident did not have substance abuse or psychiatric history and concluded the resident was not at risk for elopement. The facility’s policy stated it would provide a safe environment and preventative measures for elopement, with monitoring and documentation of patients at risk. On 01/12/2026, after a morning snack, the resident was last seen by LVN 1 heading toward the smoking area between 10:00 a.m. and 10:30 a.m. Lunch trays were passed between 11:30 a.m. and 12:00 p.m., and while LVN 1 was eating lunch between 12:30 p.m. and 1:00 p.m., a CNA reported that the resident was not in her room and had not eaten lunch. LVN 1 then checked the resident’s room, bathrooms, shower rooms, and the smoking area and, when the resident could not be found, notified her supervisor and a Code Yellow for a missing resident was called. A progress note from the morning of 01/12/2026 documented that the resident had asked when she was going home and was told she would not be moving with family that day. A subsequent late-entry progress note recorded that the resident had eloped from the facility and was later located by authorities due to public intoxication and transported to her sister’s home.
Failure to Report Resident-to-Resident Verbal Abuse and Threats to Required Authorities
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse and threat of harm made by one resident against another to the State Agency, local law enforcement, and the Long-Term Care Ombudsman. Resident 1, who was cognitively intact with a BIMS score of 15/15, reported that his former roommate, Resident 2, threatened to kill him, called him a derogatory name, and threw items across the room, breaking dishes. Resident 1 stated that staff initially moved Resident 2 to another room, then returned Resident 2 to the original room and moved Resident 1 instead. When Resident 1 expressed concern for his safety, he reported that staff responded by asking him what else he wanted them to do. Progress notes dated 11/3/25 documented that the Social Services Assistant (SSA) spoke with Resident 1 about the altercation, including Resident 2 calling him a derogatory name and threatening to kill him, and noted that the roommate had already been moved and staff were aware of the altercation. Resident 2, who also had a BIMS score of 15/15, was documented by an LVN as having become upset about Resident 1 being on the phone in the mornings and throwing his breakfast tray on the floor, stating he wanted to change rooms. The SSA stated that threats between residents are considered abuse and must be reported to the State agency, local law enforcement, and the Ombudsman, and did not recall notifying the Administrator, who was the Abuse Coordinator, and had no documentation of doing so. The DON confirmed that the incident was not reported to any external authorities because an internal investigation found the allegation unsubstantiated, despite facility policy requiring all allegations of resident abuse to be promptly reported to appropriate agencies and thoroughly investigated.
Improper Handling of Interfacility Admission and Same-Day Return Without Assessment or Documentation
Penalty
Summary
Facility 2 failed to ensure that a transfer/discharge met a resident’s needs and preferences and that the resident was prepared for a safe transfer/discharge. A resident with multiple diagnoses, including dementia and altered mental status, was discharged from an acute care facility (Facility 1) to Facility 2 with an approved admission and insurance authorization. Text messages and an email showed Facility 2 staff were notified in advance of the expected admission time, and an interfacility transport document, signed by the Assistant Director of Nursing, confirmed the resident’s arrival at Facility 2. Despite this, the Director of Nursing stated that when the resident arrived, staff determined the resident was not an appropriate fit for Facility 2. Facility 2 did not create a medical record for the resident, did not perform a nursing assessment, and did not initiate clinical care such as taking and recording vital signs as required by its admission policy. The resident was offered food and then sent back to Facility 1 the same day, without being properly admitted or discharged from Facility 2 and without documentation of why the resident was deemed inappropriate for the facility. Facility 2 also failed to provide required transfer/discharge documentation, including the reason for transfer/discharge, the effective date, the receiving location, and the resident’s appeal rights, and failed to appropriately communicate information about the resident’s condition to Facility 1 prior to returning the resident. Records from Facility 1 showed the resident returned there approximately seven hours after the initial discharge.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
A moderate dent and exposed wall area were observed behind the head of a resident's bed during a facility survey. The resident, who had been admitted several months prior, expressed dissatisfaction with the condition of the wall, stating that it looked awful and was not reflective of a homelike environment. The Environmental Director, when interviewed in the room, acknowledged that the wall should not be in that condition. The facility's policy on resident rights affirms the right to a dignified existence and a homelike environment, but the observed damage to the wall had not been repaired at the time of the survey.
Failure to Provide Timely Podiatry Referrals and Foot Care
Penalty
Summary
The facility failed to provide necessary podiatry referrals and foot care for two residents with long, untrimmed toenails. One resident, who was cognitively intact and able to express her needs, reported that her toenails were curling over her skin and had not been clipped, stating she had not seen a podiatrist in approximately one and a half years. Nursing documentation indicated a referral was given to the social services office, but there was no evidence of follow-up or that podiatry services were provided as needed. The facility's policy required regular scheduling and coordination of podiatry visits, but this was not followed for this resident. Another resident, with moderate cognitive impairment and multiple diagnoses including congestive heart failure and onychomycosis, was observed with long, curved, and jagged toenails. Despite a physician order for a podiatry referral due to a history of nail fungus infection, there was no documentation that the referral was completed or that podiatry services were provided. The Social Services Director confirmed responsibility for coordinating podiatry referrals but could not provide evidence that the required services were delivered according to facility policy.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory standards for the labeling and secure storage of medications and biologicals.
Failure to Provide Annual Dental Services for Resident
Penalty
Summary
The facility failed to provide up-to-date annual dental services for a resident with significant medical conditions, including altered mental status, dementia, muscle weakness, dysphagia, and visual impairment. The resident was admitted in 2018 and had a care plan that included an annual dental consult. During the survey, the resident was observed to have swollen gums and no teeth on the bottom row, and reported pain while eating. The Minimum Data Set (MDS) and electronic health record (EHR) lacked current documentation in the oral/dental status section, and there was no evidence of a recent dental exam. Interviews with the social worker revealed that dental records for the resident could not be located, and the last documented dental exam was from 2022, despite the facility's policy requiring annual dental services. The social worker indicated a misunderstanding regarding the need for dental exams for edentulous residents and was unable to confirm when the last annual dental exam occurred. The facility's policy stated that routine and emergency dental services should be available and that social services would assist with appointments, but these procedures were not followed for this resident.
Failure to Ensure Safe and Sanitary Food Storage and Labeling
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in accordance with professional standards and its own policies and procedures. During an observation in the kitchen, multiple opened food items in both dry storage and refrigerators were found without open dates or use-by dates, including an opened box of cheesecake, prepared bowls of dry cereal, an opened gallon of milk, and an orange juice pitcher. Additionally, a storage container was found to contain two eaten banana peels and a soiled paper cup among sealed items. The Registered Dietician (RD) confirmed that these items should have been labeled with preparation and use-by dates, and was unable to identify when some items were opened. Facility policies reviewed indicated that all open food items must be labeled with open and use-by dates per manufacturer guidelines, and that storage areas should be clean and free of contamination. Further observation revealed a paper bag in the refrigerator labeled for a resident, containing a ham sandwich and two fruit cups, with instructions for use the next day. The RD stated the ham sandwich was good for seven days, but the labeling and storage did not align with facility policy, which requires luncheon meats to be stored until their expiration date or for no more than seven days after opening. These findings demonstrate a lack of adherence to established food storage and labeling protocols, as well as lapses in maintaining sanitary storage conditions.
Infection Control Lapses in Specimen and Medication Storage Areas
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two main deficiencies. First, the specimen refrigerator, which contained biological samples such as stool, urine, and blood, was stored in the same room as the ice container used for residents' oral consumption. The ice scooper was observed hanging on the wall, exposed to air, next to the ice container. Both the Registered Nurse Supervisor and the Infection Preventionist acknowledged that this arrangement posed a risk of infection spread and cross-contamination to residents consuming the ice. Second, in the medication storage room at Station 2, a drawer was found to be disorganized, containing a mix of lidocaine patch medications, specimen sample containers, unused needles, test tubes, a pair of unused socks, and a central line dressing kit. The Registered Nurse and Infection Preventionist confirmed that medications, needles, and sterile dressing kits should not be mixed with specimen containers and other items due to the risk of cross-contamination and infection. The Director of Nursing also acknowledged the infection control risk associated with this storage practice. The facility's infection control policy emphasized the importance of proper procedures and organization to prevent infection.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Three resident rooms (Rooms 35, 41, and 43) were found to have multiple beds with less than 80 square feet per resident, which does not meet the required minimum space standard for multiple occupancy rooms. Each of these rooms contained three beds with a total area of 231.6 square feet, resulting in only 77.2 square feet per bed. This was identified during an observation conducted on 7/24/25 at 3:15 p.m. Interviews with residents occupying these rooms indicated that they did not find the space bothersome and felt they had enough room for their personal belongings. Additionally, a CNA who worked in these rooms stated that the room size was adequate for providing care and for residents' belongings, and reported no issues with resident transfers or the use of wheelchairs in the rooms. Observations of the rooms during the survey did not reveal any heavy medical equipment that could interfere with resident care. There were no complaints from residents in the affected rooms regarding insufficient space for their belongings, and no negative consequences or safety concerns were attributed to the decreased space. The deficiency was based solely on the measured square footage per resident being below the regulatory requirement.
Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to update and document the code status for a resident, resulting in the absence of clear information regarding the resident's wishes for resuscitation and life-sustaining measures. The resident's face sheet, orders, and progress notes did not contain any documentation of advance directives or code status at the time of admission or prior to the resident's death. Although a POLST form indicating Do Not Resuscitate (DNR) and comfort-focused care was prepared and signed by the resident, it was not signed by the medical provider until after the resident had expired. The Director of Nursing confirmed that the code status was not visible in the electronic health record and that there was no order for code status in the resident's records prior to death. The lack of timely documentation and communication of the resident's code status led to a situation where staff would have assumed full code status in the absence of clear orders, contrary to the resident's expressed wishes. The facility's policy requires that the POLST form reflect careful decision-making and be completed in consultation with the physician, but this process was not completed before the resident's death. The deficiency was identified through interviews and record reviews, which confirmed that the resident's preferences were not properly documented or accessible to staff at the time of the event.
Failure to Investigate and Document Resident Grievance Regarding Missing Money
Penalty
Summary
A resident with intact cognition, as indicated by a BIMS score of 15, reported that $500 was stolen from him a few months prior and that he had informed the Director of Nursing (DON) about the missing money. The resident stated that nothing had been done regarding his grievance. Upon review, there was no documentation in the resident's records regarding the missing money or any grievance filed about the incident. The DON confirmed being informed of the missing money but could not provide documentation of any grievance or investigation related to the incident. The facility's policy and procedure on misappropriation of resident property requires that reports of misappropriation be promptly and thoroughly investigated and documented either in the progress notes or through the grievance process. The Administrator stated that if a grievance had been filed, there should have been an investigation and documentation, but there was no record of such actions for this incident. As a result, the resident's grievance regarding the missing money went unresolved, and the facility failed to follow its own grievance policy.
Failure to Develop Baseline Care Plan for Smoking Upon Admission
Penalty
Summary
A deficiency was identified when the facility failed to develop a baseline care plan to address the smoking needs of a newly admitted resident within 48 hours of admission. The resident, who had diagnoses including osteomyelitis, severe sepsis, and generalized anxiety disorder, was observed with an open pack of cigarettes at the bedside and reported smoking independently four times a day. Facility staff allowed the resident to keep cigarettes at the bedside, contrary to facility policy, and there was no documentation in the Baseline Care Plan Summary addressing the resident's smoking. Interviews with staff revealed that a safe smoking assessment was initiated but not completed, and the admitting nurse did not develop a baseline care plan for smoking as required. The facility's policy required a safe smoking assessment and the development of care plans based on the assessment and interdisciplinary team findings, as well as the storage of smoking materials at the nurse station. These steps were not followed, resulting in the lack of interventions to promote safe smoking for the resident.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents who needed them. As a result, residents with behavioral health needs did not receive the appropriate care and services as required by regulations.
Failure to Inform Resident of Power Wheelchair Status
Penalty
Summary
The facility failed to ensure that a resident was kept informed regarding the status of her power wheelchair, which had been broken for about a year. The resident, who had multiple diagnoses including COPD, diabetes mellitus type 2, chronic pain, anxiety disorder, major depressive disorder, hypertension, osteoarthritis, generalized muscle weakness, and severe morbid obesity, reported difficulty being as mobile as she was with her power wheelchair and expressed that she had not received any updates about its status. Documentation in the resident's chart showed several actions taken by staff, such as weighing the resident, faxing paperwork to the DME provider, and scheduling an assessment appointment. However, there was no documentation of the outcome of the scheduled DME visit, and the social worker could not locate any record of it in the chart. Further review revealed that the resident's insurance had denied authorization for the power wheelchair, but there was no documented follow-up or evidence that the resident was informed of this denial. The resident stated she was unaware of any denial and believed that efforts to obtain the power wheelchair were ongoing. Facility policies required social services to maintain records and meet residents' medically-related social service needs, including communication about adaptive equipment, but these requirements were not met in this case.
Resident Lacked Access to Call System in Room
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including COPD, bilateral humerus fractures, vertigo, anxiety, and depression, was found without access to a functioning call system in their room. During an observation, no call light was present above the bed, attached to the wall, or on the bedside table. The resident reported not having a call bell for an extended period and stated that to request medications such as pain or sleep aids, they had to use their wheelchair to go to the nurses' station. A Licensed Vocational Nurse confirmed the absence of a call light and acknowledged the importance of having one available, especially if the resident was unable to get up. Review of the facility's policy indicated that residents should have access to a communication system to request assistance and that the system should remain functional at all times, with routine maintenance and testing by the maintenance department. The lack of a call system in this case was contrary to facility policy and created a situation where the resident could not easily summon help for their needs.
Failure to Track and Replace Lost Dentures for Two Residents
Penalty
Summary
The facility failed to track, locate, replace, and follow up on lost dentures for two residents, resulting in both individuals being without their dentures for an extended period. One resident, admitted for heart failure and with intact cognition, required assistance with oral hygiene and had upper dentures on admission. Her dentures were lost approximately two months prior to the survey, and despite repeated inquiries, the facility did not provide updates or facilitate replacement, leaving her to eat only soft foods and feel blamed for the loss. The resident reported emotional distress due to the situation, and staff confirmed awareness of the missing dentures but had not resolved the issue. Another resident, admitted with cerebral infarction and end-stage renal disease on hemodialysis, also required assistance with oral hygiene and had both upper and lower dentures on admission. His dentures were lost, and although a dental appointment was scheduled, neither he nor his family received follow-up communication from the facility. The resident was forced to use ill-fitting temporary partials, which impaired his ability to eat and speak, and negatively affected his social interactions and self-esteem. Staff interviews revealed a lack of a tracking log for lost dentures and uncertainty about whether the issue was discussed in interdisciplinary meetings. The facility's policy required investigation and documentation of lost property, but this process was not followed for these cases.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that residents received care and services in accordance with professional standards of practice. For one resident, the Interdisciplinary Team's recommendation for a psychology consult related to an abuse allegation was not referred by the Social Services Department. This oversight was confirmed during interviews with the Social Services Assistant and Director, who acknowledged that the department was aware of the physician's order for a psychology referral but could not find documentation that the referral was sent in a timely manner. Another deficiency involved the lack of an appropriate physical abuse care plan for a resident who had a physical altercation with another resident. The Minimum Data Set Coordinator was unable to locate a care plan for the altercation, and the Director of Nursing confirmed that the existing care plan was incorrect and should have been updated promptly. The facility's policy requires that each resident have a comprehensive care plan developed by an interdisciplinary team, which was not adhered to in this case. Additionally, the facility's Risk Meeting Notes for four residents showed only one member's signature, indicating that the interdisciplinary team members did not document their attendance or contributions to the meeting. The Director of Nursing and Assistant Director of Nursing confirmed that the notes should have included signatures from all team members to reflect their participation in reviewing and updating care plans. The facility's policy mandates that all team members sign the Risk Meeting Notes to ensure comprehensive care planning.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications timely for a resident, leading to a deficiency in pharmaceutical services. The resident, who was readmitted to the facility with multiple serious health conditions including HIV, COPD, ESRD, hypertension, hyperlipidemia, and C-diff, experienced delays in receiving prescribed medications. The medications, which included Amlodipine, Biktarvy, Clopidogrel, Metronidazole, and Sevelamer HCI, were administered late on multiple occasions, ranging from 21 to 326 minutes past the scheduled times. Interviews with facility staff revealed that the delays were due to nurses being rushed and unfamiliar with residents, as well as issues with documentation practices. One nurse admitted to being too busy to document medication administration at the time it occurred, which could lead to errors such as double dosing. Another nurse, who was a registry nurse, indicated that she was sometimes unfamiliar with the residents, contributing to the delays. The facility's policy and procedure for medication administration required medications to be given within 60 minutes of the scheduled time, and documentation to be completed immediately after administration. However, this standard was not consistently met, as evidenced by the late administration of medications and delayed documentation. The Assistant Director of Nursing acknowledged that the standard practice was not followed, which contributed to the deficiency.
Expired Medications and COVID Test Kits Found in Storage
Penalty
Summary
The facility failed to ensure that expired medications and COVID test kits were discarded, as they were found stored with ready-to-use medications in medication storage areas. During an observation and interview, an Emergency kit (E-kit) in Nursing Station One's refrigerator was found to contain expired medications, including Levemir, Novolog, Novolin R, and Novolin N, with expiration dates ranging from February 2023 to March 2024. The RN Supervisor acknowledged the presence of expired medications and was unaware of when the E-kit was opened or if the pharmacy had been contacted to exchange it. The Assistant Director of Nursing (ADON) was aware of expired E-kits in the facility and had contacted the pharmacy to replace them, but was not aware of the expired E-kit in Nursing Station One's refrigerator. Further observations revealed an expired E-kit bin in Nursing Station Three's Medication Room containing expired intravenous antibiotics, IV fluids, and heparin syringes. Additionally, nine expired COVID test kits were noted, and the RN Supervisor admitted to using them despite their expiration dates, expressing uncertainty about their effectiveness. The facility's policy and procedure on medication storage, dated 2007, indicated that outdated, contaminated, discontinued, or deteriorated medications should be immediately removed from stock, which was not adhered to in this case.
Deficiencies in Personal Hygiene and Mobility Care
Penalty
Summary
The facility failed to provide adequate care for activities of daily living for two residents, resulting in unmet basic needs necessary for quality of life. Resident 73 was observed with long fingernails and black debris under them, indicating a lack of personal hygiene care. Despite being dependent on staff for maintaining personal hygiene due to severely impaired cognition, the resident's fingernails were not cleaned, posing an infection control issue. The facility's policy on fingernail care was not followed, as the procedure to clean under the fingernails was not executed. Resident 36, who has diagnoses including dementia, hemiplegia, hemiparesis, and diabetes, was found with long, thick toenails and dry, cracked skin around the feet. The resident was dependent on staff for personal hygiene, yet foot care was not provided as per the facility's policy. The Certified Nursing Assistant (CNA) stated she was not allowed to cut the resident's toenails and would inform the nurse, but no further action was documented. The policy required a licensed nurse, therapist, or podiatrist to trim the toenails of diabetic residents, which was not adhered to. Additionally, Resident 36 was not assisted to get out of bed and into a wheelchair for an extended period, despite the cessation of a COVID-19 outbreak that had temporarily halted activities. The resident's care plan indicated they should be out of bed to a chair twice a day, but this was not followed. The activities manager and assistant confirmed that activities had resumed, and CNAs were expected to prepare residents for participation, yet Resident 36 remained in bed. The resident's responsible party expressed concern over the lack of mobility and engagement, highlighting a communication breakdown between staff and family members.
Failure to Act on Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to respond to a pharmacist's Medication Regimen Review (MRR) recommendations for a resident with Alzheimer's Disease and dementia. The resident was receiving psychoactive medications, including Seroquel, Escitalopram, and Lamotrigine, as well as Lisinopril for hypertension. The pharmacist recommended monitoring the resident's behavior and side effects for the psychoactive medications and questioned the necessity of a pulse monitoring parameter for Lisinopril. However, the facility did not act on these recommendations. A review of the resident's electronic Medication Administration Record (eMAR) showed no documentation of behavior and side effects monitoring for the psychoactive medications, and the pulse monitoring parameter for Lisinopril remained in place. The Assistant Director of Nursing (ADON) confirmed the lack of monitoring and documentation during an interview. The facility's policies and procedures required monitoring for drug side effects and acting upon MRR recommendations, but these were not followed, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 8.57% during a medication pass. This was due to three medication errors out of thirty-five opportunities involving two residents. One error involved a Licensed Vocational Nurse (LVN) who did not follow the physician's orders for flushing a gastrointestinal tube (GT) with the correct amount of water before and after medication administration. The LVN used 30 milliliters of water instead of the prescribed 50 milliliters, stating they were unaware of the specific order and were following their standard procedure. Another error occurred when the same LVN administered Famotidine to a resident in the morning instead of at bedtime as prescribed. Additionally, a Registered Nurse (RN) failed to instruct a resident to rinse their mouth after using a steroid inhaler, as required by the physician's orders and the manufacturer's instructions. The RN was unaware of the reason for this instruction and incorrectly informed the resident that rinsing was necessary because the medicine tasted bad.
Improper Food Storage and Handling
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food, specifically concerning a thawed pork loin. During an inspection of the kitchen walk-in refrigerator, a pork loin was found resting on a dirty plastic platform, tied closed with a disposable glove, and lacking a label indicating the thaw or use-by date. The Certified Dietary Manager (CDM) confirmed that the pork loin was previously frozen and thawing in the refrigerator but was unable to provide information on when it was pulled out to thaw. The facility's policy requires all meat and perishable food placed in the refrigerator for thawing to be labeled with the date it was transferred, along with a pull-by and use-by date. The FDA Food Code also mandates that food packages be in good condition to prevent contamination and that temperature-controlled foods be clearly marked with a consumption or discard date. Further inspection revealed that the same pork loin was later found in the walk-in freezer, partially refrozen, with red liquid leaking from the package. The kitchen manager acknowledged that refreezing the pork loin was inappropriate and disposed of it. The facility's policy states that frozen food thawed in the refrigerator should be used within 72 hours and not refrozen. The FDA Food Code highlights that improper thawing and refreezing can lead to cross-contamination and the preservation of harmful bacteria or toxins. These failures in food handling and storage practices had the potential to place all residents receiving meals from the kitchen at risk for foodborne illness.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide accurate pain assessment and management for a resident, identified as Resident 18, who was experiencing severe pain in the left foot. Despite having a history of Crohn's disease, peripheral vascular disease, and unspecified atrial fibrillation, Resident 18's pain was not regularly assessed using an appropriate pain scale. The resident reported constant 9/10 throbbing pain, which frequently increased to 10/10, yet the staff did not assess or reassess the pain severity after administering pain medications. Observations revealed that Resident 18 was often left in pain without timely intervention. On one occasion, the resident was heard moaning in bed and requested pain medication, but the staff did not assess the pain level or offer non-pharmacological relief. The medication administration records showed that pain assessments were not documented accurately, and the severity of the pain was often omitted. The resident expressed that the pain management regimen was ineffective and that requests for better pain relief were not addressed. Interviews with the nursing staff indicated a lack of communication and documentation regarding the resident's pain levels. Certified Nursing Assistants and Licensed Vocational Nurses failed to document pain assessments or communicate the severity of the pain to the attending provider. The Assistant Director of Nursing confirmed that pain evaluations were not consistently documented, and the facility's policy on pain management was not followed, leading to inadequate pain management for Resident 18.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility was found to have a deficiency related to room size requirements, as three resident rooms (Rooms 35, 41, and 43) with multiple beds provided less than the required 80 square feet per resident. This deficiency was identified through observations and interviews conducted on May 22 and 23, 2024. During these observations, it was noted that the rooms did not contain heavy medical equipment that might interfere with resident care. Interviews with residents and staff revealed mixed opinions about the adequacy of space, with one resident feeling cramped but manageable, while a Certified Nursing Assistant (CNA) from a registry company stated that the room size was adequate for care and storage of belongings. The Environmental Manager acknowledged the limited space and mentioned efforts to create more storage space for residents' belongings. Despite the deficiency, there were no complaints from residents regarding insufficient space, and no negative consequences or safety concerns were reported. The report suggests that a waiver for room size requirements may be recommended, as the deficiency did not result in any adverse outcomes for the residents involved.
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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