Walnut Creek Skilled Nursing & Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Walnut Creek, California.
- Location
- 1224 Rossmoor Parkway, Walnut Creek, California 94595
- CMS Provider Number
- 056327
- Inspections on file
- 35
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Walnut Creek Skilled Nursing & Rehabilitation Cent during CMS and state inspections, most recent first.
A resident with quadriplegia, moderate cognitive impairment, and complete dependence on staff for feeding had a visible timer placed on the overbed table to track the duration of feeding and repositioning care. The DON reported that, after IDT discussion about the time staff spent providing care, the team decided to use the timer so the resident could see how long CNAs were with him. The resident stated that no one asked for permission or consent before placing the timer, that it made him feel rushed, and that he worried about choking if he ate too fast. A UM reported obtaining verbal permission before placing the timer but could not produce any documentation of the resident’s agreement, despite a facility policy requiring residents be treated with dignity, respect, and self-determination.
A dependent resident with traumatic brain injury, dysphagia, and moderate cognitive impairment, receiving GT feeding and fully dependent on staff for ADLs, was observed with an oily face, visible dry white matter in the mouth and on the teeth, and crust-like material between the eyelids. An LVN acknowledged the need for suction-based oral care, and a CNA noted the need for face washing and shaving, while the Infection Preventionist stated the eyes required cleaning. The UM reported that oral and personal hygiene should be provided at least twice daily and as needed, consistent with facility policy requiring assistance to maintain grooming and personal and oral hygiene for dependent residents.
A resident with CKD stage 3, gait and mobility issues, depression, and prior TIA, admitted under Kaiser Medicare coverage, had an unsigned NOMNC indicating an end to covered services and a planned discharge. After the resident experienced oxygen desaturation, was sent to the ED, and returned for further observation and treatment, the facility placed the discharge on hold but changed the payer status to private pay based on the unsigned NOMNC, without obtaining updated authorization from Kaiser or a new NOMNC. The Business Office did not secure required authorization or a Financial Responsibility Form and instead billed the resident’s representative for several days of room and board and sent multiple collection letters, despite remaining Medicare days and facility policies and contract terms requiring proper notice and documentation for non-covered services.
A resident with CKD stage 3, gait and mobility issues, depression, and a history of TIA experienced a change in payer source from Medicare to private pay without proper financial notification. The facility relied on an unsigned NOMNC to end Medicare coverage and convert the stay to private pay, but there was no resident or representative signature, no attestation, and no documented notice of private pay costs. The business office manager confirmed that private payment was required from the effective date of the payer change until discharge based on this unsigned NOMNC. Review of the Kaiser contract and facility policy showed that residents must be notified in advance and sign appropriate financial responsibility documents for non-covered services, and must receive notices detailing covered and non-covered services and charges, which did not occur in this case.
Several residents with complex medical needs were found to have mattresses with visible grime, stains, and dried matter, despite facility policies requiring daily cleaning and infection control. Staff interviews revealed inconsistent cleaning practices and discomfort cleaning around medical equipment, leading to unsanitary conditions that were noticed by at least one cognitively intact resident.
Two residents were routinely administered pain medications, including Norco and acetaminophen, without documented evidence of pain or clarification of physician orders. Nursing staff provided these medications on a scheduled basis even when pain assessments indicated no pain, and the DON confirmed that orders should have been clarified with the physician. This resulted in unnecessary drug administration without adequate clinical justification.
A staff member was observed handling ready-to-eat food with the same gloved hand used to touch oven and steamer handles, without changing gloves between tasks. This practice was inconsistent with the facility's policy, which requires gloves to be changed after each use and food to be handled with clean utensils to prevent manual contact.
Two residents who required staff assistance with ADLs, including nail care, were observed with long fingernails despite care plans and facility policies mandating regular grooming. Staff acknowledged the issue but did not ensure timely nail trimming, and both residents remained with untrimmed nails, contrary to established procedures for hygiene and infection prevention.
The facility did not consistently provide the ordered frequency of Restorative Nursing Assistant (RNA) services for range of motion (ROM) to three residents with significant mobility limitations, including those with hemiplegia, hemiparesis, and contractures. Despite physician orders and care plans specifying RNA interventions three times weekly, documentation and staff interviews confirmed that only one or two sessions were provided per week due to staffing reassignments.
Two residents with depression expressed suicidal ideation, but staff did not implement required safety measures such as one-on-one monitoring or removal of potentially harmful objects. One resident reported suicidal thoughts without subsequent care plan updates or increased supervision, while another was found with a wrist injury that was not investigated for self-harm. Both residents continued to have access to hazardous items in their rooms, and staff responses did not align with facility policy for managing suicide threats.
Staff failed to wear required PPE while providing care to two residents on Enhanced Barrier Precautions, including one resident with quadriplegia and ventilator dependence. Despite posted signage and facility policy, a respiratory therapist and a CNA did not use gowns or gloves during high-contact care activities, while the Infection Preventionist and DON confirmed this was a breach of infection control protocol.
A resident's personal belongings, including a transfer sling and orthopedic shoes, were repeatedly lost or mishandled by staff, causing distress to the resident's family and lack of reimbursement documentation. In a separate incident, another resident with incontinence and chronic health conditions was found to have wet towels placed inside their disposable brief by a CNA, leading to emotional distress and a violation of care protocols.
A resident's representative was not promptly notified when the resident experienced vomiting, despite being listed as the emergency contact and representative. The representative only learned of the situation after the resident's condition worsened and required hospital transfer for fever and weakness. Facility records confirmed the lack of timely notification.
A resident dependent on staff for all care, with multiple medical conditions including dementia and Tourette syndrome, was transferred from a shower chair to their room using a mechanical lift. During the transfer, the resident's genitals were exposed and visible from the hallway, as staff were unable to fully cover them with linens and did not use a privacy curtain. The transfer was performed in the hallway due to space constraints in the room, and the resident was loudly vocalizing, drawing attention from others.
A resident with multiple complex conditions, including hypotension and quadriplegia, did not receive prescribed doses of Midodrine HCL on several occasions when nursing staff incorrectly held the medication at a systolic blood pressure of 140, despite physician orders to hold only for SBP greater than 140. Staff did not notify the physician or document the reason for withholding the medication as required.
A resident with quadriplegia and hypotension did not receive prescribed Midodrine HCL on several occasions when their systolic blood pressure was at the threshold specified in the physician's order. Nursing staff held the medication without proper notification or documentation, and the medication was not administered as required, contrary to facility policy.
A resident experienced emotional distress when an RN administered medications despite the resident's refusal to receive care from that nurse. The resident, with a history of refusing new staff due to ALS and anxiety, requested a different nurse, but the RN proceeded, citing other nurses were busy. The facility lacked a specific policy on residents' rights to refuse staff, relying on standard healthcare principles.
A resident with multiple sclerosis was confined to bed for two days due to the unavailability of a Mechanical Lifting Device (MLD) sling needed for transfers. Interviews with CNAs and the administrator confirmed a shortage of slings, affecting multiple residents. The facility's policy on safe lifting and movement was not followed, compromising the resident's ability to leave her bed.
A resident admitted with thoracic fusion and chronic pain did not receive prescribed Oxycodone for 13 hours, leading to severe pain and feelings of neglect. Staff interviews revealed medication was unavailable due to prescription issues, and alternative pain management measures were not documented. The facility's policy on pain management was not followed.
A resident with a FULL CODE status did not receive immediate chest compressions when found unresponsive, leading to a delay in emergency basic life support. Despite the presence of multiple staff members, chest compressions were not initiated until additional staff arrived. The resident was pronounced deceased 42 minutes after being found with no pulse.
The facility failed to re-train a CNA accused of abuse before allowing her to return to work, as required by their policy. The CNA, who had an incident with a resident with multiple diagnoses, returned to work without completing the necessary abuse training, potentially exposing residents to harm.
The facility failed to protect a resident from potential abuse when a CNA, who was the alleged abuser, continued to work in resident care areas after an abuse allegation was reported. Despite the resident's request for another CNA, the alleged abuser continued to care for other residents until the end of the shift, contrary to the facility's policy.
Use of Timer During Care Undermining Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to honor a resident’s right to dignity and respect when staff placed a visible timer on the resident’s overbed table to indicate the duration of feeding and repositioning care. The resident, who had quadriplegia and was completely dependent on staff for meals, had a BIMS score of 12, indicating moderate cognitive impairment. During observation, a small white rectangular timer with visible red markings was seen on the resident’s overbed table. The resident reported that the DON had put the timer there about two months earlier, that no one had asked for his permission or consent before placing it in front of him, and that staff last used the timer about a month prior. The resident stated that the timer made him feel rushed and worried that eating too fast could cause choking. In interviews, CNA 1 confirmed awareness of the timer in the resident’s room. The DON stated that the resident required two CNAs for one to two hours or longer to provide care and had complained that CNAs did not spend enough time with him. The DON reported that, after discussion with the IDT, the team decided to place a timer in the resident’s room to make the resident aware of the amount of time CNAs were spending with him. The Unit Manager stated he placed the timer in the room after speaking with the resident and obtaining verbal permission, but he was unable to locate any documentation of the resident’s agreement or consent. The facility’s Resident Rights policy stated that employees shall treat all residents with kindness, respect, and dignity, and that residents have rights to a dignified existence, to be treated with respect, kindness, and dignity, and to self-determination.
Failure to Provide Adequate ADL and Oral Hygiene Care for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary ADL care, including grooming and personal and oral hygiene, for a dependent resident who required staff assistance. The resident had a traumatic brain injury, dysphagia, and a BIMS score of 8 indicating moderate cognitive impairment, and was dependent on staff for ADLs such as oral and personal hygiene per the MDS. During observation, the resident was in bed receiving GT feeding with an oily-appearing face and pale, white dry matter noted between the upper roof of the mouth and tongue and between the upper and lower teeth. The LVN present acknowledged that the resident required oral care and stated that the resident’s oral care involved suctioning, which was the responsibility of licensed nursing staff. Additional observations throughout the same day showed that the resident’s basic hygiene needs remained unmet. A CNA stated that the resident’s face needed to be washed and shaved, and later, in the presence of the Infection Preventionist, crust-like matter was observed stuck between the resident’s left upper and lower eyelids, and the Infection Preventionist stated the resident’s eyes needed to be cleaned. The Unit Manager later stated that oral and personal hygiene should be provided at least twice daily and as needed, and that both licensed staff and CNAs were responsible for ensuring residents received proper ADL care. The facility’s policy on ADL care for dependent residents indicated that residents unable to carry out ADLs should receive necessary services to maintain grooming and personal and oral hygiene.
Improper Private-Pay Billing for Medicare-Covered Stay Extension
Penalty
Summary
The deficiency involves the facility’s failure to limit charges against a resident’s personal funds for services covered by Medicare. A resident was admitted with chronic kidney disease stage 3, gait and mobility abnormalities, depression, and a history of transient ischemic attack, and had full Medicare coverage for 100 days through Kaiser upon admission. A NOMNC dated 3/17/23 indicated Medicare-covered services would end on 3/20/23 with discharge planned for 3/21/23, but this NOMNC was unsigned and lacked attestation. Despite this, the facility treated the NOMNC as effective and changed the resident’s payer status to private pay effective 3/21/23, based on the unsigned NOMNC and without providing the resident or resident representative with a notice of private pay costs. On 3/20/23, the resident experienced oxygen desaturation, was transferred to the hospital, and then returned to the facility early on 3/21/23. Progress notes showed that the discharge to a board and care was placed on hold for observation after the emergency room visit, and the attending physician ordered STAT labs and a chest x-ray, followed by continued monitoring and a later plan for discharge with home health and PCP follow-up. The resident ultimately remained in the facility and was discharged to a board and care on 3/24/23. During this extended stay, the Admissions Coordinator stated that if a resident returns from the hospital with remaining Medicare days, coverage should continue automatically, and acknowledged uncertainty about what happened with this resident’s coverage, as Medicare days were still remaining when the NOMNC was issued. The Business Office Manager and Traveling Business Office Manager reported that the facility did not request authorization from Kaiser for the resident’s continued stay after the hospital return and did not obtain an updated NOMNC with a new discharge date. Kaiser’s referral message on 3/21/23 documented a discharge date of 3/21/23 with 3/20/23 as the last covered day, and there was no documented authorization request by the facility. Relying on the unsigned NOMNC and without a Financial Responsibility Form or prior notification of non-covered services as required by the facility’s contract with Kaiser and its own policy on notice of covered and non-covered services, the facility billed the resident’s representative for three days of room and board and generated multiple collection letters before Kaiser ultimately paid the facility. This resulted in unnecessary billing, inconvenience, and potential emotional distress to the resident’s representative.
Failure to Provide Required Financial Liability Notice When Payer Source Changed
Penalty
Summary
The facility failed to notify a resident and/or the resident’s representative of potential financial liability when the payer source changed from Medicare to private pay. The resident was admitted with chronic kidney disease stage 3, gait and mobility abnormalities, depression, and a history of transient ischemic attack, and the admission record identified the resident’s representative as the guarantor. The case manager stated the resident had full Medicare coverage for 100 days upon admission and that a Notice of Medicare Non-Coverage (NOMNC) dated 3/17/23 indicated Medicare-covered services would end on 3/20/23, with discharge scheduled for 3/21/23. However, the NOMNC was unsigned and lacked attestation. A plan of care note documented that the Kaiser case manager emailed the NOMNC to the facility case manager, stating the resident was to be discharged to a board and care, and that the facility case manager would follow up the next day. The business office manager reported that the resident’s payer changed effective 3/21/23, requiring private payment from that date until discharge due to lack of secondary insurance, and that this change was based on the unsigned NOMNC. The business office manager acknowledged that the NOMNC should have been signed by the resident and that a notice of private pay costs should have been provided, but neither occurred. The medical records assistant confirmed there was no signed NOMNC in the chart and no documentation that a private pay cost notice was issued. Review of the facility’s contract with Kaiser showed that residents may be billed for non-covered or unauthorized services only if notified beforehand and if a Financial Responsibility Form is signed, and otherwise the facility cannot charge more than the resident’s cost share. The facility’s policy on Notice of Covered and Non-Covered Services required that residents receive a notice detailing covered and non-covered services and associated charges upon admission and periodically throughout their stay, but this was not documented for this resident at the time of the payer change.
Failure to Maintain Clean and Sanitary Mattresses for Multiple Residents
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment for five residents, as evidenced by the presence of whitish grime, stains, and dried matter on their mattresses. Observations revealed that mattresses used by residents with significant medical needs, such as tracheostomies, tube feedings, and ventilator support, were visibly soiled. For example, one resident's mattress had whitish grime on the bottom left portion, while another's had whitish stains and dust-like powder on multiple areas. Additional mattresses were noted to have yellowish dried matter, brownish drip-like stains, and powder-like grime. Interviews with staff, including a CNA and the housekeeping supervisor, confirmed that both nursing and housekeeping staff were responsible for cleaning and sanitizing mattresses after care or spills. However, there was a lack of immediate cleaning following spills, and some staff expressed discomfort cleaning around medical equipment, leading to unaddressed stains and grime. One resident, who was cognitively intact, reported that her mattress was dirty and that no one had come to clean it, expressing a preference for a clean mattress. Record reviews indicated that the facility had policies in place requiring daily cleaning of patient rooms and emphasized the importance of infection control and maintaining a homelike environment. Despite these policies, the observed conditions and staff interviews demonstrated that cleaning and sanitizing practices were not consistently followed, resulting in unsanitary mattresses for multiple residents with complex medical conditions.
Routine Administration of Pain Medications Without Indication or Physician Clarification
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications, specifically pain medications, which were administered routinely without adequate indications or clarification of physician orders. For one resident with end stage renal disease and a BIMS score indicating cognitive intactness, Norco (hydrocodone-acetaminophen) and Tylenol Extra Strength were ordered and administered on a scheduled basis for pain, despite the resident consistently reporting a pain level of 0. Nursing staff confirmed that these medications were given as scheduled, regardless of the resident's reported pain level, and acknowledged that the resident did not have a chronic pain diagnosis. The Director of Nursing stated that nurses should have assessed for pain before administering these medications and should have clarified the orders with the physician. Another resident, diagnosed with a persistent vegetative state and non-verbal, was also administered acetaminophen routinely via g-tube for pain management, with scheduled doses given twice daily. The medication administration records showed that the pain level was documented as 0 most of the time. Nursing staff confirmed that the medication was given routinely, and the Director of Nursing again stated that the orders should have been clarified with the physician. In both cases, the facility's practice resulted in the regular administration of pain medications without documented evidence of pain or appropriate clinical justification, and without clarification of the physician's intent for routine versus as-needed administration. This practice was observed through medication administration records, staff interviews, and direct observation, and was acknowledged by both nursing staff and facility leadership as not aligned with proper medication management protocols.
Improper Glove Use During Food Preparation
Penalty
Summary
A facility staff member was observed preparing and serving food while wearing disposable gloves that were used to both handle ready-to-eat food and touch oven and steamer handles without changing gloves. The staff member scooped food from trays, placed items on plates, and at times pushed food toward the center of the plate with the same gloved hand that had been used to open and close kitchen equipment. This practice was witnessed during a trayline observation and confirmed by the kitchen manager, who acknowledged the issue. The facility's policy and procedure on food preparation and handling, last updated in 2023, specifies that bare hands should never touch ready-to-eat food and that disposable gloves are single-use items to be discarded after each use, with food to be handled using clean utensils to avoid manual contact.
Failure to Provide Necessary Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents who were unable to perform self-care, specifically in the area of grooming and personal hygiene related to fingernail care. Both residents had documented needs for staff assistance with ADLs, including nail care, as outlined in their care plans. Despite these interventions, observations revealed that both residents had long fingernails, and staff acknowledged the issue but did not ensure the nails were trimmed in a timely manner. Resident 60 was admitted with hemiplegia and hemiparesis following a cerebral infarction, resulting in dependence on staff for self-care. The care plan for this resident included checking and trimming nails on bath days as necessary. However, during observations, Resident 60 was found with long fingernails while being dependent on a ventilator and feeding tube. Staff interviews confirmed awareness of the long nails but cited the absence of nail clippers as a reason for not addressing the issue. Resident 142, admitted with diagnoses including malignant neoplasm of the tongue and systemic lupus erythematosus, also required assistance with personal care and had moderate cognitive impairment. Observations and interviews indicated that this resident had long fingernails and expressed a preference for shorter nails, but staff had not offered to trim them. Facility policies and procedures reviewed emphasized the importance of regular nail care for hygiene and infection prevention, and staff interviews confirmed their responsibility for maintaining residents' fingernails, yet the necessary care was not provided.
Failure to Provide Ordered Range of Motion Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decline in range of motion for three residents who required Restorative Nursing Assistant (RNA) services as indicated in their physician orders and care plans. Specifically, one resident with hemiplegia and hemiparesis following a cerebral infarction, and another resident in a persistent vegetative state with contractures, both had active physician orders and care plans for RNA programs three times a week for upper and lower extremities. However, documentation and staff interviews revealed that these residents only received one or two sessions per week instead of the prescribed three sessions. Observations confirmed that both residents were dependent on ventilators and feeding tubes, with one resident exhibiting stiffness in the upper extremities. The RNA responsible for providing these services stated that she was unable to consistently deliver the RNA program due to being reassigned as a CNA during staff shortages. Facility policy required verification of physician orders and review of care plans for range of motion exercises, but these were not consistently followed, resulting in a failure to provide the ordered frequency of care.
Failure to Provide Immediate Behavioral Health Interventions for Residents Expressing Suicidal Ideation
Penalty
Summary
The facility failed to provide immediate and necessary behavioral health care and services for two residents who expressed suicidal ideation. One resident, with a diagnosis of depression and a recent significant weight loss, reported feeling suicidal to a nurse, but there was no evidence of one-on-one monitoring, removal of potentially harmful objects, or an updated care plan addressing suicidal ideation. Staff interviews revealed that after the resident expressed suicidal thoughts, the information was reported to the unit manager, but no further immediate safety measures were implemented, and the care plan did not reflect the resident's current mental health needs. Another resident, also diagnosed with depression and previously observed holding scissors to his wrist while expressing a desire to die, was later found with a skin tear on his wrist. Although the physician was notified and treatment was provided, there was no documentation that staff investigated the cause of the injury. The resident continued to express emotional instability and thoughts of self-harm, and staff responses were limited to reassurance and email notifications, without evidence of increased monitoring or environmental safety checks. The social services team was not consistently informed of the resident's behaviors, and the director of nursing was unaware of the ongoing issues. Observations showed that both residents had access to potentially harmful items in their rooms, such as gait belts, electrical cords, and plastic bags, despite their expressed suicidal ideation. Facility policy required staff to take suicide threats seriously, remain with the resident, and notify appropriate personnel, but these procedures were not consistently followed. The lack of immediate action and investigation into self-harm incidents demonstrated a failure to ensure resident safety and provide necessary behavioral health interventions.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for two of three sampled residents when staff did not wear appropriate Personal Protective Equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). Specifically, one respiratory therapist did not wear a gown while performing oral suctioning for a resident with quadriplegia and ventilator dependence, despite an EBP sign posted on the door. The therapist initially stated that PPE was not necessary for this care, but later acknowledged that proper PPE should have been used to prevent contamination and transmission of secretions and bodily fluids. In another instance, a certified nursing assistant provided care to a resident under EBP without wearing any PPE, while the resident's family member did wear PPE. The CNA confirmed awareness that PPE was required in EBP rooms but did not comply during the observed care activity. Both residents were located in the subacute unit, where all residents were reportedly under EBP due to the risk of multidrug-resistant organisms (MDROs). Interviews with the Infection Preventionist and the Director of Nursing confirmed that EBP signage was posted for staff compliance and that not wearing PPE in these rooms posed a risk of spreading infection. Facility policy required the use of gown and gloves during high-contact resident care activities, such as device care or use, which includes tracheostomy and ventilator care. The observed failures represented a break in the facility's infection control protocol.
Failure to Safeguard Resident Belongings and Provide Dignified Incontinence Care
Penalty
Summary
The facility failed to respect and safeguard the personal belongings of a resident with a history of intracranial injury. The resident's family reported that a personally purchased and labeled transfer sling had been missing for over two months, and a wheelchair, also labeled, had previously gone missing but was later found in another unit. Additionally, a pair of black orthopedic shoes intended to prevent foot deformities was lost for about three months, requiring the family to purchase a replacement. Despite the family providing receipts for reimbursement, there was no documentation that reimbursement occurred, and the family expressed emotional distress and frustration over the repeated loss and mishandling of the resident's belongings. Another deficiency involved the failure to treat a resident with respect and dignity during incontinence care. A resident with chronic kidney disease, heart failure, and incontinence, who was cognitively intact and dependent on staff for personal care, reported that a CNA placed two rolled towels inside their disposable brief. The resident and their representative both stated this caused significant emotional distress. Upon investigation, another CNA confirmed finding the wet towels during a shift change after the resident complained of discomfort. The CNA responsible admitted to placing towels and sometimes paper towels in the resident's brief in an attempt to keep the resident dry, as the resident frequently requested to be kept dry. The care plan for the resident indicated a risk for incontinence-associated dermatitis and directed staff to provide perineal care and regular toileting, but did not include the use of towels or other absorbent materials inside briefs. The unit manager confirmed that such practices were inappropriate and not permitted.
Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify the resident's representative (RR 2) when the resident experienced vomiting early in the morning. The resident, who had a history of senile degeneration of the brain and major depressive disorder, was later transferred to the hospital the same day after developing a high fever and weakness. Documentation showed that the physician was notified of the vomiting, but there was no record that RR 2 was informed at that time. Notification to RR 2 only occurred later in the day when the resident's condition had worsened. Interviews with RR 2 confirmed that she was not made aware of the vomiting episode until after the resident's condition had deteriorated. Facility staff, including the Assistant Director of Nursing and Unit Manager, acknowledged that RR 2 was listed as the resident's representative and emergency contact and should have been notified of the change in condition. Clinical records and interviews confirmed the lack of timely notification to the resident's representative regarding the initial change in condition.
Failure to Maintain Resident Privacy During Transfer
Penalty
Summary
Staff failed to ensure privacy for a resident with vascular dementia, Tourette syndrome, seizures, and an intracranial injury, who was dependent on staff for all care needs. During a transfer from a shower chair to the resident's room using a mechanical lift, the resident was covered with linens but did not have clothes underneath. Despite attempts to cover the resident, the scrotum remained visible, and the resident's genitals were exposed and viewable from the hallway. The transfer was conducted without the use of a privacy curtain, and the resident was loudly and repeatedly yelling an expletive, which drew additional attention from others in the hallway. Staff interviews revealed that the transfer could not be performed inside the resident's room due to space limitations, requiring all transfers to be conducted in the hallway. The care plan indicated the need for a mechanical lift with two-person assistance for transfers. Facility policy stated that residents have the right to privacy and confidentiality, and the DON confirmed that it was not acceptable for a resident's genitals to be visible in the hallway.
Failure to Administer Medication as Ordered for Resident with Hypotension
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. Specifically, the resident, who had diagnoses including cervical spinal cord injury, quadriplegia, hypotension, autonomic nervous system disorder, generalized muscle weakness, and depression, did not receive prescribed doses of Midodrine HCL on three occasions. The physician's order specified that Midodrine should be held only if the resident's systolic blood pressure (SBP) was greater than 140. However, the medication was held and not administered when the SBP was exactly 140, which did not meet the criteria for withholding the medication according to the order. Record reviews and staff interviews confirmed that the medication was not given on these occasions, and the staff used a code indicating 'No Med Required - Outside of Parameter' on the Medication Administration Record (MAR). The unit supervisor and administrator both stated that the physician's order was to hold the medication only for SBP greater than 140, and that the nurse should have administered the medication when the SBP was 140. The nurse involved acknowledged that the process required physician notification if the medication was held, but this was not documented in the resident's progress notes.
Failure to Administer Ordered Medication for Hypotension
Penalty
Summary
A deficiency occurred when a resident with a history of cervical spinal cord injury, quadriplegia, hypotension, autonomic nervous system disorder, muscle weakness, and depression did not receive Midodrine HCL as ordered by the physician on multiple occasions. The medication, prescribed to manage low blood pressure, was scheduled to be administered via G-tube every 8 hours and held only if the resident's systolic blood pressure (SBP) was greater than 140. On three separate dates, the medication was not given when the resident's SBP was exactly 140, which did not meet the physician's criteria for holding the medication. The Medication Administration Record (MAR) documented that the medication was held due to being 'outside of parameter,' and the code used indicated 'No Med Required.' Interviews with facility staff revealed that the expectation was to administer the medication unless the SBP exceeded 140, and that the nurse should have notified the physician and documented the reason if the medication was held. The resident and responsible party confirmed that the medication was not administered as scheduled, and that a different nurse, not the primary charge nurse, was involved in medication administration on at least one occasion. The facility's policy required medications to be administered as prescribed, but this was not followed, resulting in the resident not receiving the ordered treatment for hypotension.
Resident's Right to Choose Healthcare Provider Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose their healthcare provider, resulting in emotional distress for the resident. The incident involved a registered nurse (RN1) who administered medications to a resident despite the resident's explicit refusal to receive care from RN1. The resident, who had a history of refusing care from new staff due to multiple medical issues including ALS and anxiety, expressed a preference for another nurse. Despite this, RN1 proceeded with the medication administration, citing that other nurses were busy and did not inform the Sub-Acute Manager (SAM) to switch the assignment. The resident, who had an intact cognitive status as indicated by a BIMS score of 15, reported feeling distressed and unable to sleep following the incident. The resident described RN1 as rude and unprofessional and had requested SAM to be called to switch the assignment. However, RN1 did not comply with this request, leading to the resident's emotional distress. The facility's administrator acknowledged that RN1 should have respected the resident's choice and noted that there were enough nurses available to accommodate the resident's request. The facility lacked a specific policy regarding a resident's right to refuse a staff member, relying instead on the basic healthcare principle that residents have the right to refuse care from specific staff.
Resident Confined to Bed Due to Lack of MLD Sling
Penalty
Summary
The facility failed to meet the needs of a resident who required a Mechanical Lifting Device (MLD) sling for transfers, resulting in the resident being confined to bed for two days. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have enough slings available. The resident, who has multiple sclerosis and impairments in both upper and lower extremities, expressed dissatisfaction with being unable to leave her bed due to the lack of a sling. Interviews with Certified Nurse Assistants (CNAs) confirmed the shortage of slings, which affected multiple residents, including the one in question. The facility's administrator acknowledged the issue, stating that all residents needing slings should have access to them. The facility's policy on safe lifting and movement, revised in July 2017, emphasizes the use of appropriate techniques and devices to ensure resident safety, dignity, and comfort, which was not adhered to in this instance.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to manage pain for a resident who was admitted with a diagnosis of thoracic fusion and chronic pain. Upon admission, the resident was cognitively intact and had a physician's order for Oxycodone 5 mg every 6 hours as needed for moderate to severe pain. Despite this, the resident did not receive the prescribed pain medication for 13 hours after admission, resulting in severe pain and feelings of neglect. The resident's pain was initially assessed at a level of four, but no further pain management was documented that night. Interviews with staff revealed that the medication was unavailable due to prescription issues, and alternative pain management measures such as Tylenol and ice packs were reportedly given but not documented. The charge nurse could not recall administering any pain medication, and the Director of Nursing confirmed the lack of documentation and stated that the resident's pain should have been addressed. The facility's policy on pain assessment and management emphasizes the importance of recognizing and managing pain, which was not adhered to in this case.
Failure to Provide Timely CPR
Penalty
Summary
The facility failed to provide emergency basic life support, including CPR, to a resident who was found with no pulse and no spontaneous respiration. The resident, who had diagnoses including anoxic brain damage, dependence on respirator status, and chronic respiratory failure, was admitted with a Physician Orders for Life Sustaining Treatment (POLST) form indicating to attempt resuscitation/CPR and a code status of FULL CODE. Despite these directives, the resident did not receive immediate chest compressions when found unresponsive, leading to a delay in the provision of emergency basic life support. On the morning of the incident, a Licensed Vocational Nurse (LVN) was called to the resident's room by a Certified Nursing Assistant (CNA) and found a Respiratory Therapist (RT) bagging the resident, who had already turned blue. The LVN called a code and instructed another staff member to call 911 while grabbing the crash cart. Despite the presence of multiple staff members, including two RTs, chest compressions were not immediately initiated. It was only after additional staff arrived that chest compressions were started. The resident was pronounced deceased by emergency personnel 42 minutes after being found with no pulse. Interviews with the involved staff revealed confusion and a lack of immediate action in initiating CPR. The RTs and LVN provided inconsistent accounts of the sequence of events and the actions taken. Documentation in the resident's clinical record was found to be incomplete and did not include all important details about the incident. The facility's policy and procedure for CPR and Basic Life Support were not followed, contributing to the delay in providing life-saving measures to the resident.
Failure to Re-train Staff Accused of Abuse Before Returning to Work
Penalty
Summary
The facility failed to develop and implement written policies and procedures that included re-training and re-education of staff accused of abuse before returning to work with residents. This deficiency was identified during a review of Resident 8's case, who had multiple diagnoses including Alzheimer's disease, depressive disorder, type 2 diabetes mellitus, hemiplegia, and hemiparesis following a stroke. On a specific date, a CNA entered Resident 8's room and found feces on the floor, which led to an interaction where the resident felt the CNA was upset. The CNA was given in-service training and a suspension letter but refused to sign them and later returned to work without completing the required abuse training. Interviews with the DON, Administrator, CNA, LVN, and DSD revealed that the CNA did not receive the mandated one-on-one abuse training before returning to work. The facility's policy required all employees to attend resident rights and abuse prevention program in-service training sessions before having any resident contact. However, the policy did not explicitly state the need for re-training staff before returning to work after an alleged abuse incident. This oversight led to the CNA being scheduled to work without the necessary re-training, potentially exposing vulnerable residents to abuse.
Failure to Protect Resident from Alleged Abuser
Penalty
Summary
The facility failed to ensure Resident 8 was protected from further potential abuse when CNA 7, who was the alleged abuser, continued to work in resident care areas after an abuse allegation was reported. Resident 8, who has Alzheimer's disease, depressive disorder, type 2 diabetes mellitus, and hemiplegia and hemiparesis following a stroke, was very upset that CNA 7 was yelling and not very nice. Despite Resident 8's request for another CNA, CNA 7 continued to work in the same assignment and had access to Resident 8 and other residents. Interviews and record reviews revealed that CNA 7 was not immediately reassigned to duties that did not involve resident contact, as per the facility's policy and procedure. CNA 7 continued to care for nine other residents and answered their call lights until the end of the shift. The facility managers did not send CNA 7 home before the shift ended because they wanted to talk to her. This failure had the potential to result in retaliation and further occurrences of abuse.
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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