Victoria Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Costa Mesa, California.
- Location
- 340 Victoria Street, Costa Mesa, California 92627
- CMS Provider Number
- 055237
- Inspections on file
- 31
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Victoria Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident's administration of hydrocodone/APAP 5-325 mg was not accurately documented, with one instance where the MAR showed two tablets given when only one was removed, and another instance where a tablet was removed but not documented as administered. The DON confirmed these documentation errors during record review.
Surveyors found expired food items in the freezer, a damaged and dirty stock pot, dusty and corroded ceiling vents above food storage areas, and meat products with visible dust and stains. Staff were also observed not following hygiene protocols, including a cook not wearing a beard restraint and a dietary aide using a sanitizing solution instead of proper handwashing.
Staff transferred a resident from wheelchair to bed by lifting under the armpits and holding the back of the pants instead of using a gait belt, as confirmed by the Director of Rehab. Additionally, a CNA observed but did not document a new skin break and redness on the resident's toe, and the LVN responsible for wound care was unaware of the change, with no documentation found in the medical record.
Two residents did not receive appropriate catheter care: one was not continuously monitored after a change in condition related to a suprapubic catheter, and another had an indwelling urinary catheter bag observed touching the floor. Staff confirmed these lapses, and documentation did not show required ongoing assessments.
A resident did not receive pain medication according to physician orders, with staff administering hydrocodone-acetaminophen 5-325 mg for severe pain and Tylenol for moderate pain, contrary to the prescribed pain management protocol. Both an LVN and the DON confirmed that the correct medications were not given for the reported pain levels.
A resident with a vascular dialysis catheter in the upper chest was assessed and care planned using interventions intended for other types of dialysis access, such as fistulas or shunts. The care plan and documentation included monitoring for bruit and thrill and other interventions not applicable to the resident's actual access type, as confirmed by nursing staff and the DON.
A resident received a controlled pain medication that was signed out on the narcotic record, but the administration was not documented on the eMAR as required by facility policy. This lapse was confirmed during a review with the DON and was not in line with the facility's procedures for medication administration and record-keeping.
Surveyors observed that a nurse left medications unattended at a resident's bedside multiple times during administration and also left a medication cart unlocked and unattended in a hallway. Additionally, a bubble pack of losartan was found to have a label that did not match the current physician's order, and no change of direction sticker was applied. These actions were not in accordance with facility policies for medication labeling and secure storage.
A resident with moderately impaired cognition was found with Flonase nasal spray at the bedside without a physician's order, assessment, or care plan for self-administration. Facility staff confirmed that required procedures for evaluating and documenting the resident's ability to self-administer medication were not followed, and the medication was accessible in a manner inconsistent with facility policy.
A resident was discharged home without the required MDS discharge assessment being completed and transmitted to CMS. Facility policy requires the MDS nurse to complete and submit all necessary assessments, but review of the medical record and staff interviews confirmed that this was not done for the discharged resident. The DON acknowledged the deficiency.
Two residents receiving nebulizer treatments for COPD were found to have their nebulizer masks stored in bags labeled with their names but not with the date of last change, contrary to facility policy requiring weekly changes and dating. Nursing staff and the DON confirmed the equipment was not dated as required.
Surveyors found that multiple facility trash bins were overfilled and had their lids open, with these conditions confirmed by the Dietary Supervisor. The bins were located in an enclosed area with the door open, contributing to unsanitary conditions.
The facility failed to ensure a complete and accurate medical record for a resident who pulled out their gastrostomy tube (GT) and had it reinserted by a physician. No Change of Condition (COC) report was completed for either event, despite the facility's policy requiring such documentation. The deficiency was confirmed through interviews and medical record reviews with the DON and Medical Records Director.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medication administration for a resident, specifically regarding hydrocodone/APAP 5-325 mg tablets. According to facility policy, when a controlled medication is administered, the licensed nurse must record the date, time, and amount administered on the accountability record, and all medications given must be documented on the Medication Administration Record (MAR). For one resident, the Tab Narcotic and Hypnotic Record showed that on one occasion, one tablet was removed from the supply, but the MAR indicated that two tablets were administered for a pain level of 7. The Director of Nursing (DON) confirmed that the nurse had accidentally signed for two tablets instead of one. On another occasion, the Tab Narcotic and Hypnotic Record showed that one tablet was removed from the supply, but there was no documentation on the MAR to indicate whether the medication was administered. The DON verified that the administration of the controlled medication was not documented as required. These discrepancies were identified through interviews, medical record reviews, and facility document reviews, and were confirmed by the DON during concurrent record review.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, equipment condition, cleanliness, and staff hygiene. Expired food items, including bread, hamburger buns, and English muffins, were found stored in the freezer. A large stock pot was noted to be warped, dented, and had a black substance on its inner top part. Two ceiling vents above the ice machine and freezers were dusty, corroded, and surrounded by peeling paint, with meat products stored underneath these vents observed to be dusty and stained with yellow discoloration. These findings were verified by the Dietary Supervisor and Maintenance Supervisor during the inspection. Additionally, staff were observed not following proper hygiene protocols. One cook was seen working in the kitchen without a beard restraint, and this was confirmed on two separate occasions. A dietary aide was observed placing his hands into a bucket containing sanitizing solution and a dish rag after rinsing dirty dishes, instead of performing hand hygiene at the sink. The aide acknowledged that this was not the correct process for handwashing. These actions and inactions contributed to unsanitary conditions and improper food handling practices in the kitchen.
Improper Transfer Technique and Failure to Document Change in Skin Condition
Penalty
Summary
Staff failed to provide appropriate care and treatment for a resident in two key areas. During a transfer from wheelchair to bed, two CNAs lifted the resident by placing their arms under the resident's armpits and holding the back of the resident's pants, rather than using a gait belt as required. The Director of Rehab confirmed that a gait belt should have been used and that there was no gait belt available in the resident's room at the time of the transfer. The CNAs stated they had been trained by therapy to transfer the resident in this manner, despite facility policy and standard practice. Additionally, a change in the resident's skin condition was not documented as required by facility policy. The resident was found to have a superficial break in the skin and redness on the right big toe. The LVN responsible for wound care was unaware of this change, and the CNA who observed the wound during the resident's morning shower did not document it. Review of the medical record confirmed there was no documentation of the change in skin condition.
Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling urinary catheters, as evidenced by two specific incidents. In the first case, a resident with a suprapubic urinary catheter experienced a change in condition when the catheter was not draining. Although the issue was identified and the resident was sent to the hospital and returned with a new catheter and antibiotics for a UTI, there was no documented evidence that licensed nurses continued to monitor or assess the resident's condition as required by facility policy. Both the LVN and DON confirmed that ongoing monitoring every shift for 72 hours following a change in condition was not performed, which was necessary to observe for complications or infection. In the second case, another resident with an indwelling urinary drainage catheter was observed with the catheter bag touching the floor. This was verified by an LVN, who acknowledged that the catheter bag should not be in contact with the floor. The resident was dependent on staff for activities of daily living and had the catheter in place for wound management. These lapses in catheter care and monitoring were directly observed and confirmed through staff interviews and medical record reviews.
Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for one resident by not administering pain medication according to the physician's orders. The resident had clear physician orders for different pain medications based on the severity of pain, as indicated by a pain scale. Specifically, Tylenol 325 mg was to be given for mild pain, hydrocodone-acetaminophen 5-325 mg for moderate pain, and hydrocodone-acetaminophen 10-325 mg for severe pain. However, medical record review showed that the resident received hydrocodone-acetaminophen 5-325 mg for pain levels of eight, which was outside the prescribed range for that medication, and Tylenol for a pain level of six, which was also not in accordance with the physician's order. Interviews with both an LVN and the DON confirmed that the resident did not receive the correct medication for the reported pain levels and that the physician's orders were not followed. The facility's policy required medications to be administered as prescribed by the attending physician, but this was not adhered to in this case. The resident was documented as having the capacity to understand and make decisions, and the failure to follow the medication orders was verified through both medical record review and staff interviews.
Inaccurate Dialysis Care Planning and Assessment for Resident with Vascular Catheter
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with a vascular dialysis catheter in the right upper chest. The resident's care plan and medical records included interventions and assessments that were not applicable to the type of dialysis access present. Specifically, the care plan and post-dialysis documentation referenced monitoring for bruit and thrill, which are relevant for arteriovenous fistulas or shunts, not for vascular catheters. Additionally, interventions such as not drawing blood or taking blood pressure on the arm with a graft, and checking the fistula daily, were included despite the resident not having these types of access. Interviews with nursing staff, the MDS Coordinator, and the DON confirmed that the care plan and documentation contained inaccurate and inapplicable interventions for the resident's actual dialysis access. The errors were attributed to the use of a care plan library in the electronic health record, where inappropriate interventions may have been selected. The resident's records and care plan were not accurately individualized to reflect the specific type of dialysis access, leading to the potential for inappropriate care.
Failure to Document Controlled Medication Administration on MAR
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its own policies and procedures for one resident. Specifically, the facility's policy required that when a controlled medication is administered, the licensed nurse must immediately document the date and time of administration, the amount administered, and their signature on the accountability record, as well as ensure all current drug and dosage schedules are recorded on the resident's electronic medication administration record (eMAR). For one resident, there was a physician's order for hydrocodone-acetaminophen to be administered as needed for pain. On a specific date and time, one tablet of this controlled medication was dispensed and signed out on the Narcotic and Hypnotic Record. However, review of the resident's July medication administration record (MAR) did not show documentation that the hydrocodone-acetaminophen was administered at the recorded time. This omission was verified during an interview and concurrent medical record review with the Director of Nursing (DON). The lack of documentation on the MAR was not in accordance with the facility's established policies for controlled medication administration and record-keeping.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication management and storage. During a medication administration observation, a nurse was found to have left a tray of prepared medications unattended at a resident's bedside on several occasions while retrieving additional items such as a straw, spoon, and tissue paper. The resident was in bed with a family member present, and the medications, including a nasal spray, were left unsupervised each time the nurse left the bedside. Additionally, the nurse was observed leaving the medication cart unlocked and unattended in the hallway while entering the nurses' station, with non-licensed staff passing by. Further review revealed that the label on a bubble pack of losartan did not match the current physician's order. The label instructed to hold the medication if the systolic blood pressure (SBP) was more than 130 mmHg, while the physician's order specified to hold if SBP was less than 130 mmHg. The nurse confirmed the discrepancy and acknowledged that a change of direction sticker had not been placed on the medication packaging. Facility policies required accurate labeling and secure storage of medications, but these were not followed in the observed instances.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident was observed with a Flonase nasal spray medication at their bedside without a physician's order, assessment, or care plan authorizing self-administration of the medication. The facility's policy requires that residents who wish to self-administer medications must be assessed by the interdisciplinary team, and if deemed appropriate, this must be documented in the resident's chart. Additionally, the policy states that residents should be instructed on proper administration and that medication storage must comply with state and federal requirements. In this case, none of these steps were followed for the resident in question. Medical record review showed that the resident had a BIMS score of 12, indicating moderately impaired cognition. During interviews, both an LVN and the DON confirmed that there was no physician's order for the Flonase, no order to self-administer, no self-administration assessment, and no care plan in place for the medication. The LVN also noted that the medication should not have been at the bedside due to the risk of access by other residents. These findings were verified through observation, interview, and review of facility policy and the resident's medical record.
Failure to Complete and Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) discharge assessment for one nonsampled resident who was discharged home. According to the facility's policies and procedures, the MDS nurse is responsible for scheduling and completing all required assessments, including discharge assessments, and ensuring that encoded, accurate, and complete MDS data are electronically transmitted to the CMS system. Review of the closed medical record for the resident showed that although there was a physician's order for discharge and arrangements for home health services and equipment, there was no evidence that the MDS discharge assessment was completed at the time of discharge. During interviews, the MDS Coordinator confirmed that the discharge assessment should have been completed and submitted to CMS within the required timeframe, and acknowledged that the system used by the facility is designed to track due dates for assessments. The MDS Coordinator verified that the discharge assessment was not completed for the resident, and explained that failure to complete and submit the assessment would result in the resident appearing as still present in the facility and the assessment being marked as missed. The Director of Nursing also acknowledged these findings.
Failure to Change and Date Nebulizer Masks and Bags as Required
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required nebulizer treatments for chronic obstructive pulmonary disease (COPD). During an initial tour, surveyors observed that both residents' nebulizer masks were stored in plastic bags labeled with their names but without any indication of the date the masks or bags were last changed. According to the facility's policy, nebulizer masks, tubing, and storage bags are required to be changed and dated at least every seven days to promote resident safety during oxygen administration. Medical record reviews confirmed that both residents had active physician orders for multiple inhalation medications administered via nebulizer. Interviews with nursing staff and the Director of Nursing (DON) verified that the nebulizer masks and bags were not dated as required, and staff acknowledged this oversight. The failure to date and regularly change the respiratory equipment was not in accordance with the facility's established policies and procedures.
Overflowing Trash Bins and Improper Waste Disposal
Penalty
Summary
Surveyors observed that three out of five facility trash bins were overfilled with trash and had their lids open. These observations were made during the morning hours, with the trash bins located in an enclosed area surrounded by a wooden fence, where the door was found open and at least one bin was visible with the lid open and trash overflowing. During a concurrent interview, the Dietary Supervisor confirmed that the facility's trash bins were overfilled and had their lids open, verifying the unsanitary condition observed by surveyors. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Document Change of Condition
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for one of the sampled residents. Specifically, there was no Change of Condition (COC) report completed when the resident pulled out their gastrostomy tube (GT) and when the GT was reinserted by the physician. This failure was identified during a review of the facility's policies and procedures, which indicated that any change in a resident's condition should be documented in the eInteract Change of Condition. The deficiency was confirmed through interviews and medical record reviews with the Director of Nursing (DON) and the Medical Records Director. The resident in question had severe cognitive impairment and was noted to be agitated during the night, leading to the removal of the GT. The emergent replacement of the GT was performed by a physician, but the medical record did not reflect a COC report for either the removal or the replacement of the GT. The DON acknowledged that a COC report should have been completed for both events. The Medical Records Director further explained that the Licensed Vocational Nurse (LVN) should initiate the COC, and the Registered Nurse (RN) should follow up by contacting the physician and noting new orders, with subsequent monitoring of the resident every shift for 72 hours after the incident.
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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