Vasona Creek Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Gatos, California.
- Location
- 16412 Los Gatos Boulevard, Los Gatos, California 95032
- CMS Provider Number
- 055798
- Inspections on file
- 57
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Vasona Creek Healthcare Center during CMS and state inspections, most recent first.
Staff used an alarmed emergency exit door located next to a resident room for routine entry and exit despite posted signs stating it was for emergency use only and that an alarm would sound. The MD and DON confirmed the door was intended solely for emergencies and that staff were aware an alarm would sound when it was opened, yet some staff continued to use it during non-emergencies. This practice conflicted with the facility’s homelike environment policy, which required maintaining comfortable sound levels.
Staff failed to maintain an emergency exit door alarm in active status when social services staff turned off the alarm on a clearly marked emergency-only exit door near a resident room to hold a conference outside. The MD confirmed the door was intended only for emergencies and that the alarm should sound when opened, and the DON verified during testing that opening the door did not trigger an alarm, contrary to facility expectations that the alarm remain on at all times.
A resident with chronic pain syndrome and rheumatoid arthritis did not receive physician-ordered referrals for retinal screening and rheumatology consults. The social service assistant, responsible for arranging these consults and transportation, missed the orders, and there was no documentation that the referrals were completed, contrary to facility policy.
A resident with multiple mental health and physical care needs did not receive ordered psychiatric and dermatology consults, and was observed with long, untrimmed fingernails and dry skin, despite staff awareness and facility policy requiring proper nail care.
A facility failed to document three doses of intravenous vancomycin for a resident with functional quadriplegia, aphasia, and osteomyelitis of the sacrum. The physician had ordered the antibiotic for sepsis, but the MAR showed missing documentation for specific times. The DON confirmed the missing entries and noted that missed doses should be reported and documented, as per facility policy.
A resident with hypothyroidism did not receive the correct dosage of levothyroxine as ordered by a physician. Despite a tele-visit where the dosage was increased to 150 mcg, the facility continued administering lower doses for several months. This discrepancy was confirmed by an LPN during a record review.
A resident was inappropriately diagnosed with diabetes and received insulin without supporting evidence, as the facility failed to document necessary lab results or symptoms. The attending physician was unaware of the insulin orders made by a covering physician, and the resident's responsible party was not informed of the treatment changes, violating facility policies.
The facility failed to properly store and label medications in three medication carts. Discontinued medications for three residents were not removed, and an insulin pen lacked patient-specific labeling and an open date. LVNs acknowledged the oversight, and the DON confirmed the need for proper medication management.
A resident admitted with a coccyx wound did not have a physician's order for wound treatment documented until eight days later, and treatments were not recorded until the same time. Additionally, there was no documentation of weekly wound assessments during the first week after admission, contrary to facility policies.
A resident received incorrect dosages of prednisone due to the facility's failure to follow physician's orders for a steroid tapering regimen. The resident was given a higher dosage than prescribed for six days and missed one dose entirely. The error occurred because the previous order was not discontinued, and both dosages were administered concurrently. The facility's policy requires clarification of any ambiguities with the physician, which was not done.
A facility failed to administer prescribed respiratory therapy (RT) treatments for six residents, impacting their respiratory function. Despite orders for five daily treatments, residents received RT less frequently, with some receiving it only two or three times a day. The deficiency was confirmed through interviews and record reviews, highlighting a lack of policy for implementing physician's orders.
The facility failed to secure a medication room containing an ADU, leading to potential unauthorized access. Expired medications were found in refrigerators, and temperature logs were incomplete, risking medication efficacy.
A facility failed to ensure immediate reporting of suspected abuse when an LVN documented an incident where a resident's spouse was heard speaking aggressively to the resident over the phone. Despite the facility's policy requiring immediate reporting, the incident was not communicated to the Administrator or DON, leading to a deficiency. The resident had severe cognitive impairment and a history of multiple medical conditions.
The facility failed to resubmit a new Level I PASARR for a resident with mental health diagnoses after 30 days and inaccurately completed a PASARR for another resident by omitting a psychosis diagnosis. The responsibility for ensuring PASARR accuracy lay with the nursing department and admission team, but the omissions were not caught, despite the residents' medical histories and medications.
A resident with severe cognitive impairment and a history of falls sustained a laceration on the forehead after a fall. The LVN cleaned the wound and sent the resident to the hospital, but upon return, no treatment orders were documented. Interviews and observations confirmed the lack of compliance with the facility's wound care policy, as no orders were written for the wound care, despite the resident having a bandage on the forehead.
A facility failed to follow its Enhanced Barrier Precautions (EBP) policy during wound care for a resident with a pressure ulcer. Staff did not wear gowns, as required by the policy, which mandates gown and glove use to prevent MDRO transmission. The resident had a history of congestive heart failure and a stage I pressure injury. Interviews confirmed the resident should have been on EBP, indicating a lapse in infection prevention protocols.
A room in the facility was found to house five residents, exceeding the regulatory limit of four. This was confirmed through interviews with the DON, Maintenance Director, and Administrator, as well as a memorandum. The Administrator noted that the facility had been receiving a yearly waiver for this room.
The facility did not provide the required 80 square feet of living space per resident in 16 rooms, as revealed by a Client Accommodations Analysis. Despite this, staff reported no impact on care provision, and the facility received annual waivers for these rooms.
The facility failed to document scheduled treatments for 13 residents, including topical creams and ointments for rashes and wound healing, as well as heel protectors for skin breakdown. Interviews and observations confirmed that treatments were not administered as ordered, with multiple days lacking documentation. The assistant director of nursing acknowledged the issue, highlighting a systemic problem in care and documentation practices.
The facility failed to document chest percussion therapy for three residents as ordered, with missing records for multiple sessions over several days. A licensed nurse confirmed the lack of documentation and no record of treatment refusal, contrary to the facility's policy requiring all services to be documented.
A resident's responsible party was not informed of a change in the resident's condition and a new medication order for elevated blood pressure. Despite facility policy requiring notification, there was no documentation of communication with the responsible party.
A facility failed to accurately complete an MDS for a resident, compromising intervention development. The resident, admitted with abnormal posture and walking difficulties, experienced an unwitnessed fall. A licensed nurse confirmed the fall should have been coded on the MDS, but it was incorrectly marked as 'No' for falls during the specified time frame.
A resident's clinical record contained inaccurate late entries made by an LPN, documenting care for dates after the resident had been transferred to a hospital. The LPN acknowledged the error, stating the notes were intended for another resident but could not identify which one. This failure to maintain accurate records could compromise care monitoring and intervention.
A facility failed to accurately complete an MDS for a resident with multiple diagnoses, including sepsis and diabetes, who experienced an unwitnessed fall. The fall was not properly coded in the MDS, as confirmed by an MDS nurse during a review.
The facility failed to document weekly Skin & Wound Evaluations for a resident with a skin condition and did not complete Nursing Weekly Summaries for two residents. These omissions were confirmed by an LPN, who acknowledged that both evaluations and summaries should be conducted weekly according to facility policy.
The facility failed to accurately complete the Elopement Risk Observation/Assessment for two residents, leading to incorrect elopement risk scores. One resident, on Seroquel, was reported missing and later returned safely. Another resident, on Trazodone, also had an inaccurate assessment. These errors were confirmed by an LPN during a record review.
The facility failed to notify the Ombudsman office of a resident's hospital transfer, despite the resident's increased confusion and refusal of medication. Interviews and record reviews confirmed the lack of notification, which was contrary to the facility's policy.
A resident with alcohol dependence missed ten doses of Zenpep due to the facility's failure to follow up with the pharmacy in a timely manner. The medication was unavailable from 9/21/23 to 9/24/23, and the facility did not contact the pharmacy until 9/24/23, resulting in multiple missed doses.
A resident with diabetes, anemia, and hyperlipidemia did not receive all the food items listed on his lunch tray slip, missing soup and a second serving of milk. LVN E acknowledged the missing items, and dietary staff confirmed the Standing Orders should have been followed.
The facility failed to ensure proper infection control measures, with staff improperly wearing face masks and not screening a resident's family member for COVID-19 before entry. These lapses were confirmed through observations, staff interviews, and a review of the Visitors Screening Log.
Improper Non-Emergency Use of Alarmed Exit Door Disrupting Homelike Environment
Penalty
Summary
Facility staff failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by using an alarmed emergency exit door for non-emergency purposes, contrary to posted signage and facility policy. During an observation, surveyors noted a door located next to a resident room that led outside and was clearly marked with signs stating it was for emergency exit only and that an alarm would sound if opened, instructing individuals to use another exit. In interviews, the maintenance director confirmed the door was only to be used during emergencies and that staff were aware an alarm would sound if it was opened. The DON also confirmed the door was intended for emergency use only but acknowledged that some staff used this door to enter and exit the facility during non-emergencies, despite the loud alarm it produced. Review of the facility’s “Homelike Environment” policy indicated the facility was to maximize characteristics of a personalized, homelike setting, including maintaining comfortable sound levels, which conflicted with staff’s non-emergency use of the alarmed door. No specific resident medical histories or conditions were described in the report, but the door in question was located next to a resident room, and the deficiency centered on the impact of the alarm noise on maintaining comfortable sound levels as required by the facility’s homelike environment policy.
Emergency Exit Door Alarm Turned Off by Staff
Penalty
Summary
Facility staff failed to ensure an emergency exit door alarm was functioning to keep the environment as free of accident hazards as possible. An emergency exit door located next to a resident room had signage stating it was for emergency use only and that an alarm would sound if opened, and another sign instructing individuals not to open the door because the alarm was on and to use another exit. During an observation, the DON opened this emergency exit door and no alarm sounded. In interviews, the MD confirmed the door was intended for emergency use only and that the alarm should sound when opened, and later explained that social services staff had turned off the alarm so they could hold a conference outside, despite staff not being permitted to turn off the emergency door alarm and the expectation that it remain on at all times. No specific residents, medical histories, or conditions were described in the report, and the deficiency centered on the non-functioning emergency door alarm and staff actions that led to it being turned off.
Failure to Arrange Physician-Ordered Referrals
Penalty
Summary
The facility failed to follow its own policies and procedures to ensure that physician orders for referrals were carried out for a resident. Specifically, a resident with chronic pain syndrome and rheumatoid arthritis had physician orders for a retinal screening and a rheumatology consult. These orders were documented in the clinical record, but there was no evidence that the referrals were arranged or that the resident was seen for these consultations. During interviews and record reviews, the social service assistant confirmed that she was responsible for arranging the consults and transportation but had missed the consult orders. The assistant director of nursing also confirmed that the physician orders for the consults were not carried out as required. The facility's policy stated that social services should coordinate and document physician-ordered referrals and arrange transportation, but this was not done for the resident in question.
Failure to Provide Ordered Consultations and Nail Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident with multiple diagnoses, including major depressive disorder, schizophrenia, adult failure to thrive, and a need for assistance with personal care. The resident required partial to maximal assistance with personal hygiene, bathing, and toileting. Observations revealed that the resident had long fingernails on several digits, with overgrowth of skin and dryness around the nails. The assistant director of nursing confirmed that the resident's fingernails were long and needed trimming, and facility policy indicated that proper nail care is necessary to prevent skin problems. Additionally, the facility did not follow through on physician orders for psychiatric and dermatology consultations for the resident. Although orders for these consults were documented, interviews with staff, including an LVN, the social service assistant, and the director of nursing, confirmed that there was no evidence the consultations had been completed or documented in the resident's clinical record. The staff acknowledged that the orders should have been followed and arrangements made for the resident to be seen by the appropriate specialists.
Failure to Document Vancomycin Administration
Penalty
Summary
The facility failed to ensure that physician orders were carried out or documented as written for a resident, resulting in a deficiency. Specifically, three doses of intravenous vancomycin, an antibiotic, were not documented on three separate days for a resident who was admitted with functional quadriplegia, aphasia, and osteomyelitis of the sacrum. The physician had ordered vancomycin to be administered three times a day for sepsis, but the medication administration record (MAR) showed missing documentation for specific dates and times. During an interview and concurrent record review, the Director of Nursing (DON) confirmed the missing documentation and stated that if a dose of medication is missed, the nurse should notify the provider and document it in a progress note. The facility's policy on administering medications requires that medications be administered in accordance with prescriber orders and that the administration details be recorded in the resident's medical record. The lack of documentation for the vancomycin doses indicates a failure to adhere to this policy.
Failure to Implement Physician's Order for Medication Dosage
Penalty
Summary
The facility failed to implement a physician's order in a timely manner for a resident diagnosed with hypothyroidism. The resident was admitted with a prescription for levothyroxine sodium 50 mcg daily. On a subsequent tele-visit with an endocrine clinic, the physician ordered an increase in the dosage to 150 mcg daily. However, the facility did not adjust the medication dosage as per the new order until several months later. The resident continued to receive the initial dosage of 50 mcg until it was slightly increased to 75 mcg, but the prescribed 150 mcg was not administered until much later. This delay in implementing the physician's order was confirmed by a licensed nurse during an interview and record review. The facility's policy mandates that medications be administered according to the prescriber's orders, which was not adhered to in this case.
Inappropriate Insulin Administration and Lack of Communication
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality and facility policies for a resident who was diagnosed with diabetes and received insulin orders without documented evidence supporting the diagnosis. The resident, who had a history of aphasia following a stroke and a urinary tract infection, was admitted without a diabetes diagnosis. Despite this, insulin orders were made by a covering physician without documented laboratory results or symptoms meeting the diagnostic criteria for diabetes as per the American Diabetes Association guidelines. The resident's A1c levels were within normal range, and there was no evidence of high blood sugar readings prior to the administration of insulin. The insulin orders were entered into the system by a registered nurse based on a phone endorsement from another nurse, but neither could provide evidence of the high blood sugar reading that supposedly justified the insulin prescription. The attending physician, who was on leave at the time, confirmed that there was no documented reason for the insulin orders and that the resident was not on any medications that could have caused elevated blood sugar levels. The facility's policy required physicians to document relevant tasks and review the resident's care program, which was not adhered to in this case. Additionally, the facility failed to inform the resident's responsible party about the new insulin orders, as required by their policy on resident rights and changes in condition. The responsible party was not notified of the insulin treatment and only discovered it after noticing the resident's lethargy and questioning the staff. The lack of communication and documentation regarding the insulin orders and the resident's condition change violated the facility's policies and the resident's rights.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in three out of six medication carts. Discontinued medications for three residents were not removed from active stock. Specifically, a multi-dose vial of insulin lispro belonging to a resident who was discharged over a month ago was found in Medication Cart 3A. Similarly, a Humulin N vial for another resident and a Lantus vial for a third resident, both of whom were no longer in the facility, were found in Medication Cart 1A. The Licensed Vocational Nurses (LVNs) responsible for these carts acknowledged that these medications should have been removed. Additionally, an insulin glargine-yfgn pen was found in Station 4 Medication Cart without any patient-specific labeling or an open date. The LVN responsible for this cart was unable to identify the pen's owner or when it was opened. According to the manufacturer's prescribing information, such pens should be discarded 28 days after opening. The Director of Nursing confirmed that medications belonging to discharged residents should be removed to prevent errors, and insulin pens should be labeled with the resident's name and open date. The facility's policy on medication labeling and storage was not adhered to, contributing to these deficiencies.
Incomplete Medical Record for Resident with Coccyx Wound
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was admitted with a coccyx wound. Upon admission, the resident had non-blanchable redness with open skin on the coccyx, but the facility did not document obtaining a physician's order for wound treatment until eight days later. Additionally, the facility did not document any treatments for the coccyx wound until eight days after admission, and there was a lack of documentation for weekly wound assessments during the first week after admission. Interviews with the wound treatment nurse and the assistant director of nursing confirmed these documentation gaps. The facility's policies require that wound treatments be documented in the treatment administration record and that weekly wound assessments be recorded in the medical record. However, these protocols were not followed, as evidenced by the absence of documentation for the initial wound treatment order, the delay in recording wound treatments, and the missing weekly wound assessment for the first week after admission.
Failure to Follow Physician's Orders for Steroid Tapering
Penalty
Summary
The facility failed to follow physician's orders for a resident's steroid tapering regimen, resulting in the resident receiving incorrect dosages of prednisone. The resident, who was admitted with multiple diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, pulmonary hypertension, bronchiectasis, and bacterial pneumonia, was prescribed a tapering dosage of prednisone to reduce inflammation. However, the facility administered a higher dosage than prescribed for six days and missed one dose entirely. Specifically, the resident received 55 mg of prednisone daily from September 4 to September 9, instead of the prescribed 25 mg, and did not receive any prednisone on September 11. The discrepancy arose from a failure to discontinue the previous order of 30 mg of prednisone when the new tapering order was issued. Licensed nurses administered both the old and new dosages concurrently, leading to the excessive dosage. The facility's policy on physician orders requires that any ambiguities or concerns be clarified with the ordering physician before execution, but this was not done. The Director of Nursing confirmed the errors and acknowledged that the orders should have been clarified with the physician, as the specific dates in the order did not align with the intended tapering schedule.
Failure to Administer Prescribed Respiratory Therapy
Penalty
Summary
The facility failed to ensure that respiratory therapy (RT) treatment orders were carried out as prescribed for six residents, potentially impacting their physical well-being. Residents 3, 5, 6, 7, 8, and 9 did not receive the ordered five times daily chest physiotherapy, which is crucial for optimizing their respiratory function. The deficiency was identified through interviews and record reviews, revealing that the residents received RT less frequently than ordered, with some receiving it only two or three times a day. Resident 5, with a history of COVID-19, was supposed to receive chest physiotherapy five times daily but only received it two to three times on several days. Similarly, Resident 6, who had respiratory disorders, was scheduled for five daily treatments but received only one to three treatments on various days. Resident 3, diagnosed with bronchiectasis, also did not receive the prescribed five daily treatments, with some days showing no treatment at all. The deficiency was further confirmed through interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD), who acknowledged the failure to administer the treatments as ordered. The respiratory therapist noted the challenge of providing five daily treatments, indicating that three times a day was more feasible. The facility lacked a policy addressing the implementation of physician's orders for treatments, contributing to the inconsistency in administering RT as prescribed.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications in two of its medication rooms. During an inspection, it was observed that the medication room containing the facility's automated dispensing unit (ADU) was left unlocked when not in use, allowing potential unauthorized access to medications. Additionally, expired medications were found in the medication refrigerators in two different stations. Specifically, an expired eye drop solution for a resident and an expired multi-dose tuberculin solution vial were identified, both of which had not been removed from the storage. Furthermore, the facility did not consistently monitor the temperature of a medication refrigerator as per the guidelines. The temperature log for November 2024 showed that the temperature was not recorded ten times within the month, indicating a lack of adherence to the policy of monitoring and recording refrigerator temperatures twice daily. This oversight could lead to ineffective medications or loss of drug potency due to unmonitored temperatures.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to ensure that staff immediately reported an incident of suspected abuse involving a resident. According to the facility's policy, any suspected abuse must be reported immediately to the Director of Nursing Services or, in their absence, to the Nurse Supervisor on duty. However, a Licensed Vocational Nurse (LVN) documented an incident in the progress notes where a resident's spouse was heard speaking aggressively to the resident over the phone, but there was no indication that the LVN reported this suspected abuse to the appropriate authorities. The resident involved had a medical history that included severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. The resident was admitted to the facility with conditions such as dysphasia following a stroke, schizophrenia, parkinsonism, major depressive disorder, and anxiety disorder. Despite the facility's policy requiring immediate reporting of suspected abuse, both the Administrator and Director of Nursing were unaware of the incident until it was brought to their attention during the survey. This lack of communication and failure to follow protocol led to the deficiency noted in the report.
Failure to Resubmit and Accurately Complete PASARR Screenings
Penalty
Summary
The facility failed to resubmit a new Level I Preadmission Screening and Resident Review (PASARR) for a resident who was admitted on 05/14/2024 with a medical history of bipolar disorder, major depressive disorder, and anxiety disorder. The resident's initial PASARR was negative due to an exempted hospital discharge, which required a new Level I Screening if the resident remained in the facility longer than 30 days. Interviews with the Director of Nursing (DON), Marketing Director, and Administrator revealed that the facility did not complete the necessary screening on the 31st day, as expected. Another resident was admitted on 03/15/2024 with a medical history that included unspecified moderate dementia, anxiety disorder, and unspecified psychosis. The PASARR Level 1 Screening for this resident inaccurately indicated no serious diagnosed mental disorder, omitting the diagnosis of psychosis. Interviews with the Social Services Director, DON, and Marketing Director highlighted that the responsibility for ensuring the accuracy of PASARRs lay with the nursing department and admission team. The omission of the psychosis diagnosis was not caught, despite the resident being on antipsychotic medication. The Administrator confirmed that the admission team was responsible for reviewing PASARRs and involving the clinical team if inconsistencies were found. The medical records staff was tasked with auditing charts to ensure PASARR presence and to identify any clinical changes that might warrant a Level II evaluation. However, the facility failed to capture the psychiatric diagnosis and medication for the second resident, leading to an inaccurate PASARR.
Failure to Obtain Treatment Orders for Resident's Laceration
Penalty
Summary
The facility failed to obtain treatment orders for a laceration on a resident's forehead, which was identified during a review of non-pressure related skin integrity issues. The resident, who had a history of severe cognitive impairment and was at risk for falls, sustained a fall resulting in an open cut with active bleeding. The licensed vocational nurse (LVN) cleaned the wound, applied adhesive strips, and sent the resident to the hospital for further treatment. Upon the resident's return, no new treatment orders were provided, and the facility did not document any orders for the assessment or treatment of the wound. Interviews with staff revealed that the lack of treatment orders was not in compliance with the facility's wound care policy, which required a physician's order for wound care procedures. The Director of Nursing and the Administrator both acknowledged that treatment orders should have been written for the resident's wound care. Observations confirmed that the resident had a bandage on their forehead, but there were no documented orders for the adhesive strips or dressing applied to the wound.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy during wound care treatment for a resident with a pressure ulcer. The policy mandates the use of gowns and gloves during high-contact resident care activities, including wound care, to prevent the transmission of multi-drug-resistant organisms (MDROs). However, during an observation, staff members, including a Licensed Vocational Nurse and an Infection Control Preventionist, did not wear gowns while performing wound care on a resident with a pressure ulcer, despite wearing surgical masks and gloves. The resident involved had a medical history of congestive heart failure and required assistance with personal care. The resident was admitted with a stage I pressure injury and was receiving care for it. The facility's policy clearly indicated that residents with chronic wounds should be placed on EBP, which includes the use of gowns and gloves. Interviews with the Infection Control Preventionist and the Director of Nursing confirmed that the resident should have been on EBP, highlighting a lapse in following the facility's infection prevention protocols.
Room Capacity Exceeded in LTC Facility
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to four, as evidenced by room [ROOM NUMBER] accommodating five residents. This deficiency was identified through interviews and document reviews. A memorandum dated 11/15/2021 confirmed that room [ROOM NUMBER] had five beds. During the entrance conference, the Director of Nursing acknowledged the presence of a room housing more than four residents. Both the Maintenance Director and the Administrator confirmed the existence of this room. The Administrator mentioned that the facility had been receiving a yearly waiver for this room and had not received any concerns regarding the number of residents it housed.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident in 16 out of 62 resident rooms. The Client Accommodations Analysis, dated January 1, 2023, revealed that several rooms had less than the required square footage, with measurements ranging from 70 to 76 square feet per resident. This deficiency was confirmed through interviews and document reviews conducted by the surveyors. During interviews, the Maintenance Director acknowledged that the facility had between 10 to 20 rooms that did not meet the minimum standard. Despite this, staff members, including a Licensed Vocational Nurse, a Certified Nursing Assistant, and the Director of Nursing, reported no impact on their ability to provide care due to the smaller room sizes. Additionally, the Administrator mentioned that the facility annually received a waiver for rooms with less than 80 square feet per resident and had not received any complaints regarding room size.
Failure to Document Scheduled Treatments for Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for 13 of 28 sampled residents. This deficiency was identified through interviews, observations, and record reviews, revealing that there were multiple days where there was no documentation of scheduled treatments being administered. The lack of documentation was noted across various treatments, including topical creams and ointments for conditions such as rashes, itchiness, and wound healing, as well as the application of heel protectors for skin breakdown prevention. For instance, Resident 1 had a physician's order for a topical cream to be applied every shift, yet there were 15 days in August 2024 without documentation of this treatment. Similarly, Resident 2 had orders for hydrocortisone cream and nystatin powder, with 5 and 12 days respectively lacking documentation of administration. Resident 3 also reported that staff did not apply the prescribed lotion to his face in the evenings, with 12 days missing documentation. These instances were corroborated by interviews with the residents, who were cognitively intact and able to confirm the lapses in their care. The facility's policy and procedure on charting and documentation, as well as the job description for LPNs, emphasize the importance of documenting all services provided to residents. However, the assistant director of nursing confirmed that there were multiple days where treatments were not documented as administered. This failure to document treatments as ordered was consistent across several residents, indicating a systemic issue within the facility's care and documentation practices.
Failure to Document Chest Percussion Therapy
Penalty
Summary
The facility failed to provide chest percussion therapy as ordered for three residents, which was identified through interviews and record reviews. Resident 1, diagnosed with pulmonary fibrosis and emphysema, had a physician's order for chest percussion therapy four times daily. However, documentation for the therapy at 2:00 p.m. and 8:00 p.m. was missing from 8/3/24 to 8/11/24. Similarly, Resident 2, with pulmonary edema, had an order for therapy five times daily, but records for the 5:00 p.m. and 8:00 p.m. sessions were left blank during the same period. Resident 3, suffering from chronic respiratory failure, also had an order for therapy five times daily. Documentation was missing for the 5:00 p.m. and 8:00 p.m. sessions from 8/1/24 to 8/11/24, and all sessions on 8/2/24 were undocumented. During an interview, a licensed nurse confirmed the absence of documentation and verified that there was no record of the residents refusing treatment. The facility's policy mandates that all services provided must be documented, including the date and time of treatment or any refusal by the resident.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a change in condition and a new medication order for one of the residents. The resident, who had a designated RP, experienced elevated blood pressure, and the physician ordered hydralazine to manage this condition. However, there was no documentation indicating that the RP was informed of the elevated blood pressure and the new medication order. During an interview and record review, a licensed nurse confirmed the absence of documentation regarding the notification to the RP. The facility's policy mandates prompt notification of the resident, attending physician, and resident representative about changes in the resident's medical condition. Despite this policy, the facility did not adhere to the requirement, leading to the deficiency.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for one of the sampled residents, which compromised the ability to develop and implement necessary interventions. The clinical record of a resident, who was admitted with diagnoses including abnormal posture and difficulty in walking, indicated an unwitnessed fall occurred in the facility. During an interview and record review, a licensed nurse confirmed that the fall should have been coded on the resident's MDS. However, the MDS section J1800 was incorrectly coded as 'No', indicating no fall occurred during the specified time frame, when it should have been coded 'Yes'. This error was confirmed by the licensed nurse, who acknowledged the discrepancy in the MDS coding.
Inaccurate Documentation in Resident's Clinical Record
Penalty
Summary
The facility failed to accurately document in the clinical record for a resident when the resident's clinical record contained progress notes pertaining to a different, unknown resident. This issue was identified during a review of the resident's clinical record, which indicated that the resident was admitted with diagnoses including abnormal posture and difficulty in walking. The resident experienced an unwitnessed fall and was transported to an acute hospital, never returning to the facility. Despite this, late entries were made in the resident's clinical record for dates after the resident had been transferred, indicating the resident was still present and being monitored at the facility. During interviews, it was acknowledged by the involved licensed nurse that the late entries were mistakenly documented in the wrong resident's clinical record. The nurse admitted that the notes were intended for another resident but could not provide the correct resident's name. The facility's policy requires maintaining complete and accurately documented clinical records for each resident, which was not adhered to in this instance, potentially compromising the facility's ability to monitor and implement interventions for the correct resident.
Inaccurate MDS Completion for Resident Fall
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for a resident, which compromised the ability to develop and implement necessary interventions. The resident, who had multiple diagnoses including sepsis, diabetes, respiratory failure, muscle weakness, and difficulty in walking, experienced an unwitnessed fall in the facility. During a review, it was confirmed that the fall was not properly coded in the MDS, as section J1800 was incorrectly marked as 'No' instead of 'Yes', indicating that the resident did not fall during the specified time frame. This error was acknowledged by the MDS nurse during an interview and record review.
Failure to Document Weekly Evaluations and Summaries
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents. For one resident, there was no documentation of weekly Skin & Wound Evaluations after an initial evaluation was completed, despite the resident having a skin condition that required treatment with Clotrimazole Cream. The facility's policy required weekly evaluations for residents with skin conditions, but this was not adhered to, as confirmed by a licensed nurse during an interview and record review. Additionally, the facility did not consistently complete the Nursing Weekly Summary for two residents. The summaries, which are meant to document various aspects of a resident's condition, were not completed after specific dates for both residents. This lack of documentation was acknowledged by a licensed nurse, who confirmed that the summaries should be completed weekly according to the facility's policy. The absence of these assessments potentially compromised the facility's ability to identify and address the residents' needs effectively.
Inaccurate Elopement Risk Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Elopement Risk Observation/Assessment for two residents, compromising its ability to identify those at risk for elopement and implement necessary interventions. Resident 1, who was admitted with a diagnosis of subarachnoid hemorrhage, had a physician's order for Seroquel, a psychotropic medication. However, the assessment incorrectly indicated that Resident 1 was not on any psychotropic medications, resulting in an inaccurate elopement risk score. This oversight was confirmed during an interview with a licensed nurse, who acknowledged the error. Subsequently, Resident 1 was reported missing from the facility and was later returned safely by the local police. Similarly, Resident 2, admitted with conditions including trigeminal neuralgia and osteoporosis, had a physician's order for Trazodone, another psychotropic medication. The assessment for Resident 2 also failed to recognize the presence of psychotropic medication, leading to an incorrect elopement risk score. This error was confirmed by the same licensed nurse during a record review. The facility's policy on wandering and elopements emphasizes the importance of identifying residents at risk and maintaining accurate clinical records, which was not adhered to in these cases.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman office was notified of a hospital transfer for one of the sampled residents. Resident 2, who was admitted with a diagnosis of metabolic encephalopathy, exhibited increased confusion and refused medication, leading to a doctor's order for hospital transfer. Despite the facility's policy requiring notification to the Ombudsman office, there was no documentation or fax confirmation that this notification occurred for Resident 2's transfer on the specified date. Interviews with social services staff and the Ombudsman office confirmed the lack of notification. Social services staff indicated that notifications should be sent weekly via fax, with a confirmation sheet to verify the transmission. However, the fax confirmation sheet for Resident 2 was missing, and the Ombudsman office confirmed they did not receive any notification for Resident 2's transfer during the relevant period. This oversight was contrary to the facility's policy, which mandates that a copy of the transfer notice be sent to the Ombudsman office.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident received medication as ordered, which had the potential to compromise the resident's health and well-being. The resident, who was admitted with a diagnosis of alcohol dependence, had a physician order for Zenpep to be taken with meals. However, from 9/21/23 to 9/24/23, the medication administration record indicated that ten scheduled doses of Zenpep were not administered because the medication was unavailable. Licensed nurses documented the absence of the medication but did not follow up with the pharmacy until 9/24/23, resulting in multiple missed doses. During an interview, a registered nurse confirmed that the facility did not follow up with the pharmacy in a timely manner, which could have prevented the missed doses. The facility's policy on administering medications states that medications should be administered in a safe and timely manner, as prescribed. The failure to adhere to this policy led to the resident missing critical doses of their prescribed medication.
Failure to Provide Food According to Standing Orders
Penalty
Summary
The facility failed to provide food in accordance with Standing Orders for one of four sampled residents. Resident 1, who had diagnoses including diabetes, anemia, and hyperlipidemia, did not receive all the food items listed on his lunch tray slip dated 4/30/24. Specifically, his lunch tray was missing soup and a second serving of milk. During an observation and interview, LVN E acknowledged the missing items and requested LVN G to retrieve them. Dietary staff C confirmed that the Standing Orders on the lunch tray slip, which reflected Resident 1's preferences, should have been provided.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as observed during a survey. Staff members were seen wearing face masks improperly, with their noses uncovered, while in resident care areas. This was noted in the rehabilitation gym and in resident rooms, where residents were either improperly masked or not masked at all. Interviews with staff confirmed that there was an awareness of the mask-wearing policy, but it was not consistently followed. The facility's policy and local public health guidelines both require face masks to cover the nose and mouth, especially during the Winter Respiratory Virus Period from November 1 through March 31. Additionally, the facility did not ensure that a family member of a resident was screened for COVID-19 before entering the facility. The family member was allowed to enter and move through the facility without documentation of a temperature check or symptom screening. Interviews with staff revealed that the screening process was not followed, and a review of the Visitors Screening Log confirmed the absence of the required documentation. This lapse in protocol could potentially lead to the spread of infection within the facility.
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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