West Shore Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Alameda, California.
- Location
- 508 Westline Drive, Alameda, California 94501
- CMS Provider Number
- 056103
- Inspections on file
- 30
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Shore Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain required records of smoke detector sensitivity testing, as no documentation was available to show that testing had been performed within the required timeframe. This deficiency affected all residents and all smoke compartments, with the Maintenance Director unable to provide the necessary records when requested.
Surveyors found that an electrical panel labeled 'Fire Alarm Panel Inside' was obstructed by a desk, boxes, and a backpack in the Director of Staff Development Room, with items placed about one foot from the panel. The Maintenance Director confirmed the desk was recently added for new staff. This obstruction affected 36 residents in one smoke compartment and did not meet NFPA requirements for clear workspace around electrical equipment.
Surveyors found that the emergency preparedness plan did not include strategies for addressing the needs of at-risk or vulnerable residents. During review, the Administrator could not provide the required policy, and the facility did not submit the missing records when given the opportunity. This deficiency affected all residents.
Surveyors found that the facility did not have a policy or procedure in its Emergency Preparedness plan explaining the use of volunteers or other emergency staffing strategies, as required. During document review and interviews, the Administrator was unaware of the missing policy, and the facility did not provide the required documentation when given the opportunity. This deficiency affected all residents.
Surveyors found that the facility did not have required policies and procedures for providing care at an alternate care site under an 1135 waiver. During review and interviews, the Administrator was unaware of the missing policy, and the facility could not provide the necessary documentation for all residents when requested.
Surveyors found that the facility did not have a documented emergency preparedness training and testing program for staff, and the Administrator was unaware of the missing policy. This deficiency affected all residents, as the required records were not provided when requested.
The facility did not participate in a full-scale community-based emergency preparedness exercise within the required timeframe, as confirmed by record review and staff interviews, resulting in noncompliance with federal emergency preparedness regulations for all residents.
Surveyors found that the facility did not provide documentation of the required annual battery charger test and 30-minute discharge test for the Fire Alarm Control Panel, as required by NFPA standards. The Maintenance Director was unable to explain the absence of these records, and no additional documentation was submitted when requested. This deficiency affected all residents in the facility.
The facility failed to provide documentation for a required night shift fire drill during one quarter, as discovered during a review of fire drill records. The Maintenance Director was unable to produce the missing record, and no documentation was submitted by the deadline, affecting all residents in the facility.
The facility did not document discussions about advance directives with three residents, including one who was cognitively intact and two with severe cognitive impairment and complex medical conditions. Medical records and POLST forms lacked evidence that advance directives were addressed or available, and staff interviews confirmed the absence of required documentation.
Two residents with intact cognition reported discomfort and reluctance to use their bathrooms due to old, worn linoleum flooring with black stains and a toilet seat with visible scratch marks. Observations confirmed the unclean and unhomelike conditions, and staff acknowledged the issues but had not fully addressed or reported them.
A resident with dementia and poor cognition repeatedly wandered into other residents' rooms, turned off lights, and took personal items, despite care plan interventions of monitoring and redirection. Staff and other residents reported ongoing incidents, including falls and emotional distress, as the resident continued these behaviors and became agitated when redirected. The facility's interventions were not effective in preventing these occurrences.
A resident's MDS assessment was inaccurately coded to indicate no wandering behavior, despite observations and staff interviews confirming frequent wandering, room entry, and agitation when redirected. The Social Services Director acknowledged the error in coding.
A resident with a history of aggressive behavior and impaired cognition entered another resident's room, ignored requests to leave, and slapped the resident in the face, causing emotional distress and repeated altercations. The incident was witnessed by a roommate and confirmed through interviews and record review, highlighting a failure to protect residents from physical abuse as required by facility policy.
A resident with Alzheimer's and dementia was not adequately protected from physical abuse, resulting in injury after being struck by another resident and experiencing unwanted physical contact in the activity room. Staff interviews, surveillance footage, and medical records confirmed the incidents, and facility policies requiring monitoring and redirection were not effectively followed.
A resident with dementia, morbid obesity, and complete dependence for ADLs was provided incontinence care by a CNA without the required second staff member. Despite being aware of the need for two-person assistance, the CNA proceeded alone, resulting in the resident falling from bed and sustaining fractures to the left arm and leg. The resident was not a candidate for surgery and was discharged to hospice care. Facility records and staff confirmed the resident was at high risk for falls and required two-person assistance, which was not provided.
The facility failed to provide admission agreements to three residents, including one with dementia and another receiving palliative care. The agreements, which outline residents' rights and services, were either delayed or not provided at all, contrary to facility policy.
A facility failed to provide a resident or their representative with written information about the bed-hold policy during a transfer. The resident, with multiple health issues, had a Bed Hold Notification Form that was incomplete, lacking necessary signatures and information. The facility's policy requires written notification prior to transfers, which was not fulfilled in this case.
The facility's patio area was found to be unsafe due to clutter from refrigerator parts, a broken concrete pad, and leaking water hoses creating puddles near resident doors. These conditions posed trip hazards for residents. Interviews with staff confirmed the presence of these hazards and acknowledged the need for removal and proper maintenance.
A resident was discharged without the correct medication instructions, leading to the potential misuse of heparin, a blood thinner. The discharge summary did not include heparin, despite it being part of the active orders. The Nurse Supervisor discharged the resident with heparin without verifying the discharge summary, and the facility policy on medication reconciliation was not followed.
A resident in an LTC facility lost their hearing aids, valued at $2000, and the facility failed to investigate or assist in their replacement. Despite the resident and their family reporting the loss, the facility did not complete the necessary Theft and Loss Report or notify law enforcement as required by policy. The Social Services Director did not take responsibility for the investigation, and the resident's family stated the facility did not respond to requests for assistance.
A resident with severe cognitive impairment did not receive scabies treatment as ordered, as Permethrin cream was washed off two hours after application instead of the prescribed 12 hours. The error was not reported to the physician, and there was no documentation of the incident. Interviews revealed communication lapses among staff, with the CNA unaware of the treatment, leading to the premature washing off of the cream. Facility policies on medication administration and scabies treatment were not adhered to.
A CNA in a LTC facility failed to follow infection control protocols by not performing hand hygiene before feeding a resident with severe cognitive impairment. The CNA did not wash her hands or use sanitizer after handling items in the resident's room and before feeding, despite being aware of the requirement. Facility staff confirmed the expectation for hand hygiene, as outlined in the facility's infection control policy.
A facility failed to follow infection control procedures when a CNA did not wear PPE while providing care to a resident on contact isolation for scabies. Despite clear signage and policy requirements, the CNA assisted the resident without wearing gloves and a gown, as confirmed by staff interviews and a review of the resident's care plan and physician orders.
Failure to Maintain Smoke Detector Sensitivity Testing Records
Penalty
Summary
The facility failed to maintain required records of smoke detector sensitivity testing as mandated by NFPA 101 and NFPA 72 standards. During a record review and interview with the Maintenance Director, surveyors requested documentation showing that smoke detector sensitivity testing had been performed within the last two years. The facility was unable to provide any records of such testing, and the Maintenance Director stated that he believed the vendor had performed the test but would need to contact them for the records. No documentation was provided to the surveyors by the deadline given. This deficiency affected all 120 residents in all four smoke compartments of the facility. The lack of records means there was no evidence that the smoke detectors had been tested for sensitivity as required, which is necessary to ensure their proper functioning in the event of a fire. The surveyors noted that no previous records were available, and the required documentation was not submitted even after an opportunity was given to provide it.
Plan Of Correction
K347-Smoke Detection 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility contracted with a certified vendor who performed smoke detector sensitivity testing on all applicable smoke detectors. The vendor's report confirmed all devices were within operational parameters. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Maintenance Director educated by the Administrator on the requirements and documentation for smoke detector sensitivity testing requirements per NFPA 72: 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review testing schedules monthly to ensure smoke detector sensitivity testing is completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. K 347
Obstructed Electrical Panel in Staff Development Room
Penalty
Summary
A deficiency was identified when surveyors observed that an electrical panel labeled 'Fire Alarm Panel Inside' was obstructed by a desk, boxes, and a backpack in the Director of Staff Development Room. The items were positioned approximately one foot away from the panel, impeding clear access. This situation was noted during a facility tour and confirmed in an interview with the Maintenance Director, who stated that the desk was recently placed due to new staff and had not been there for long. The obstruction of the electrical panel affected 36 out of 120 residents in one of four smoke compartments. The report cites specific requirements from NFPA 101, NFPA 99, and NFPA 70, which mandate that sufficient workspace must be maintained around electrical equipment to allow for safe operation and maintenance. The observed obstruction did not comply with these standards, as it limited the required clear workspace around the panel.
Plan Of Correction
K919- Electrical Equipment - Other 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/07/2025, the desk and boxes obstructing electrical panel "D" in the DSD office were removed, restoring the required 36 inches of clearance. 2. Identification of other residents having the potential to be affected was accomplished by: On (date), the Maintenance Director conducted a facility-wide audit of all electrical panels and determined that no other panels were obstructed. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025 the Maintenance Director was educated by the Administrator on the requirements and documentation for maintaining a 36-inch clearance around all electrical panels in accordance with NFPA 70. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly inspection of all electrical panels to ensure required clearance is maintained. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Emergency Preparedness Plan Lacked Strategies for At-Risk Residents
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that addressed the resident population, specifically the needs of at-risk or vulnerable residents. During a record review and interview with the Maintenance Director and Administrator, it was found that the emergency preparedness plan did not include strategies for addressing the needs of these populations. The Administrator was unable to explain why the relevant policy was missing from the emergency preparedness binder. The deficiency affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the regulatory agency. The lack of documentation and planning for at-risk or vulnerable residents was directly observed during the survey process.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the Emergency Preparedness Plan was revised to include specific strategies addressing the needs of at-risk and vulnerable populations such as residents with cognitive impairments, limited mobility, and complex medical needs. 2. Identification of other residents having the potential to be affected was accomplished by: On 5/12/2025, the Interdisciplinary Team reviewed all resident records to determine which individuals were considered at-risk during an emergency. All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Emergency Plan was updated to include a section for identifying vulnerable residents, and care protocols were developed for each type of identified risk (e.g., evacuation assistance, medication needs). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Missing Emergency Staffing and Volunteer Policy in EP Plan
Penalty
Summary
The facility failed to maintain its Emergency Preparedness (EP) plan by not providing a policy and procedure that explains the use of volunteers or other emergency staffing strategies. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the EP policies and procedures and found that there was no documentation addressing the facility's use of volunteers or integration of state and federally designated health care professionals to address surge needs during an emergency. The Administrator, who had recently started working at the facility, was unaware of the missing policy. This deficiency affected all 120 residents in the facility, as the lack of a documented policy could result in an ineffective emergency preparedness plan. The facility was given an opportunity to submit the missing records, but no records were received by the specified deadline.
Plan Of Correction
E024 - Policies/Procedures: Volunteers and Staffing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/25, the facility developed a written policy outlining procedures for the use of volunteers and alternative staffing during emergencies. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected during emergency staffing shortages or volunteer involvement. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025, the policy was incorporated into the facility's Emergency Preparedness Plan. All department heads were trained on how to implement the policy during an emergency. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. E 024
Missing Emergency Preparedness Policy for 1135 Waiver Alternate Care Site
Penalty
Summary
The facility failed to develop and implement policies and procedures outlining its role in providing care and treatment at an alternate care site under an 1135 waiver, as required by federal regulations. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the Emergency Preparedness policies and procedures. The facility was unable to provide documentation indicating a plan for the provision of care at an alternate location in the event of an emergency requiring activation of an 1135 waiver. The Administrator, who was new to the facility, stated she was not aware that the required policy was missing. The absence of this policy affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the survey agency.
Plan Of Correction
E 026 E026 - Roles Under a Waiver Declared by the Secretary 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/2025, the Emergency Preparedness Plan was updated to include a policy addressing alternate care sites and adjusted staffing/licensure protocols. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected in the event of a federally declared emergency requiring relocation or altered care settings. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The facility incorporated all guidelines into the Emergency Plan and added procedures for continuity of care in alternate locations on (date). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly inspection of the Emergency Plan to ensure waiver protocols are included and current. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Failure to Maintain Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program for staff, as required by federal regulations. During a record review and interview with the Maintenance Director and Administrator, surveyors found that the facility could not provide the policy and procedure related to emergency preparedness training and testing. The Administrator was unaware that the policy was missing and indicated she would need to investigate the reason for its absence. This deficiency affected all 120 residents in the facility, as the lack of a documented and maintained emergency preparedness training and testing program meant that staff were not adequately prepared according to regulatory requirements. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the survey agency.
Plan Of Correction
E036 - Emergency Preparedness Training and Testing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility conducted an Emergency Preparedness training for all staff and completed a tabletop exercise to simulate emergency response procedures. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/09/2025, the facility implemented an annual Emergency Preparedness training and testing calendar and established a system for tracking staff participation. On 05/09/25, the Maintenance Director educated by the Administrator on the requirements and documentation for Emergency Preparedness Training. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of training logs and exercise documentation to ensure all staff are trained and drills are conducted annually. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. 05/15/25 E 036
Failure to Conduct Required Emergency Preparedness Drill
Penalty
Summary
The facility failed to develop and maintain an Emergency Preparedness Training and Testing plan as required by federal regulations. Specifically, the facility did not participate in a full-scale community-based emergency preparedness exercise within the last 12 months. This was confirmed during a record review and interview with the Maintenance Director and Administrator, where no documentation could be provided to show compliance with this requirement. During the review, it was found that the Emergency Preparedness Training program lacked evidence of participation in the mandated exercise. The Administrator confirmed that the facility had not taken part in a full-scale community-based drill, as required by 42 CFR §483.73(d)(2) for long-term care facilities. This deficiency was identified during a survey and affected all 120 residents in the facility at the time. The absence of participation in the required emergency preparedness exercise means that the facility did not meet the federal standard for testing its emergency plan. The surveyors noted that this failure could result in the facility not having adequate planning and preparation in place to protect the health and safety of residents and staff, as directly stated in the report.
Plan Of Correction
E 039 E039 - Emergency Preparedness Testing Requirements 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/25, the facility implemented an emergency preparedness training program for staff. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/09/25, the facility implemented an annual Emergency Preparedness training and testing calendar and established a system for tracking staff participation. On 05/09/25, the Maintenance Director educated by the Administrator on the requirements and documentation for Emergency Preparedness Training. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review the emergency preparedness training program schedule monthly to ensure required drills are completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. --- K345 - Fire Alarm System: Testing and Maintenance 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the facility's licensed fire safety vendor completed the missing annual battery charger test and the 30-minute battery discharge test for the fire alarm control panel. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/08/2025, the Maintenance Director educated by the Administrator on the requirements and documentation for Fire Alarm System: Testing and Maintenance. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Fire Alarm testing log to ensure required testing; including battery charger and discharge tests are scheduled and completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Failure to Maintain and Document Required Fire Alarm System Battery Testing
Penalty
Summary
The facility failed to maintain the Fire Alarm System (FAS) in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During a tour, record review, and interview with the Maintenance Director, surveyors requested documentation of the annual Fire Alarm Control Panel (FACP) battery charger test and the 30-minute battery discharge test for the sealed lead-acid batteries. The facility provided annual and semiannual FAS testing records, but these did not include evidence that the required battery charger test or the 30-minute discharge test had been performed within the last 12 months. The Maintenance Director stated that he believed the vendor had performed the services but could not explain why the tests were not documented in the reports. The facility was given an opportunity to provide the missing records by email, but no additional documentation was received by the deadline. This deficiency affected all 120 residents in all four smoke compartments, as the required testing and documentation for the FACP batteries were not available for review as required by the applicable codes and standards.
Missing Fire Drill Documentation for Night Shift
Penalty
Summary
The facility failed to maintain complete fire drill records as required by NFPA 101, Life Safety Code, 2012 Edition. During a record review and interview with the Maintenance Director, it was found that one of twelve required fire drills was not conducted. Specifically, the facility did not provide documentation for the night shift (NOC) fire drill during the fourth quarter of 2024. The Maintenance Director was unable to produce the missing record at the time of the survey and indicated that he would need to consult with the Administrator to determine if the records had been sent. The surveyors gave the facility an opportunity to submit the missing fire drill documentation by email, but no records were received by the specified deadline. This deficiency affected all 120 residents across four smoke compartments, as the absence of the required fire drill could impact staff familiarity with emergency procedures. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
K712-Fire Drills 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/07/2025, a fire drill was conducted on the NOC shift, which had previously been missed during Q4 of 2024. Documentation was completed and added to the fire drill log. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected by inadequate staff response during an emergency if drills are not routinely conducted on all shifts. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: A fire drill schedule was implemented with quarterly drills planned for all three shifts (day, evening, night). On (date) the Maintenance Director was educated by the Administrator on the requirements and documentation for Fire Drills. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of fire drill documentation to ensure each shift completes a fire drill every quarter. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with the residents and/or their responsible parties. Specifically, for three out of 25 sampled residents, there was no documentation indicating that advance directives were addressed. One resident, who was cognitively intact and admitted with muscle wasting and atrophy, had no record of an advance directive discussion in their file, as shown by the absence of such documentation on their POLST form. Two other residents, both with severe cognitive impairment and diagnoses including depression, adult failure to thrive, and dementia, also lacked documentation of advance directive discussions or availability in their medical records. During interviews and record reviews, the Social Service Director Assistant confirmed that there was no evidence in the records for these residents that advance directives had been discussed with them or their responsible parties. The Director of Nursing was not aware of the facility's policy regarding advance directives. The facility's policy requires inquiry about advance directives upon admission and annual review, with documentation to be prominently displayed in the medical record, but this was not followed for the affected residents.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, as evidenced by observations and resident interviews. In one case, a resident reported discomfort due to the dirty appearance of her bathroom floor, which was visible from her bed. Observation confirmed that the linoleum flooring in her bathroom was old, worn, and discolored with black stains resembling dirt. The resident had intact cognition, as indicated by a BIMS score of 15, and expressed that the condition of the bathroom made her feel uncomfortable. In another case, a resident with intact cognition also expressed reluctance to use her bathroom, describing it as dirty and gross. Observation revealed that the linoleum flooring in her bathroom was similarly old, worn, and discolored with black stains, and the toilet seat and cover had multiple gray and black linear scratch marks. The Housekeeping Supervisor acknowledged the inability to remove the stains despite cleaning efforts and was aware of the toilet seat's condition but had not reported it to Maintenance. The Maintenance Supervisor was unaware of the issue, and both supervisors agreed that the bathrooms did not provide a homelike environment. The facility's policy requires a clean, sanitary, and homelike environment, which was not met in these instances.
Failure to Implement Effective Interventions for Resident with Dementia-Related Wandering
Penalty
Summary
The facility failed to develop and implement adequate person-centered interventions for a resident diagnosed with dementia who exhibited wandering behaviors, including entering other residents' rooms. The resident, who had a BIMS score of 5 indicating poor cognition and a diagnosis of non-Alzheimer's dementia, was observed and reported by staff and other residents to frequently wander the hallways, enter other residents' rooms, turn off lights, and take items belonging to others. The care plan for this resident included monitoring and redirection, but these interventions were not effective in preventing the resident from continuing these behaviors. Multiple incidents were documented where the resident was found in other residents' rooms, sometimes becoming verbally aggressive when asked to leave. Staff interviews confirmed that the resident became agitated when redirected and continued to wander despite interventions. Other residents reported discomfort and distress due to the resident's actions, including invasion of privacy and taking personal items. The resident's behaviors were also noted to have led to falls, including one incident where the resident sustained a bump on the forehead and was diagnosed with a closed fracture of the temporal bone after being found on the floor in the hallway. The facility's records and staff interviews indicated ongoing challenges in managing the resident's wandering and associated behaviors. Despite recognition of the need for more intensive interventions, such as one-on-one monitoring or memory care placement, the existing care plan and implemented strategies were insufficient to prevent the resident from wandering into other residents' rooms and causing distress or injury.
Inaccurate MDS Coding of Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, specifically in section E, which addresses wandering behavior. Observation showed the resident wandering the hallways with a walker and entering other residents' rooms. During interviews, a CNA confirmed that the resident frequently wandered, entered other rooms, turned off lights, and became agitated when redirected. However, a review of the resident's annual MDS assessment indicated that wandering behavior was coded as not exhibited. The Social Services Director, responsible for completing this section of the MDS, acknowledged that the wandering behavior was not coded accurately.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with impaired cognition, schizophrenia, and a history of unpredictable and aggressive behavior entered another resident's room late at night and pulled open the curtain around the bed. The resident whose space was invaded, who had mild cognitive impairment and was able to communicate clearly, screamed and asked the intruding resident to leave. When the resident stood up to ask the other to leave, the aggressive resident slapped her on the left side of the face. This incident was witnessed by a roommate, who confirmed the slap and reported that the event disturbed their sleep. The aggressive resident's care plan documented a pattern of physical behavioral symptoms directed toward others, including previous altercations. Facility records and interviews indicated that the aggressive resident's behavior had previously put others at significant risk for injury. The facility's abuse prevention policy states that residents have the right to be free from physical abuse, but the incident demonstrated a failure to protect a resident from physical abuse by another resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident diagnosed with Alzheimer's disease and dementia from physical abuse by another resident. The resident was found in the hallway with a bleeding and swollen lower lip after being hit by another resident. Multiple staff interviews and a review of surveillance footage confirmed that the resident had entered another resident's room, after which a hand was seen pushing the resident's wheelchair out of the room. The resident reported being hit by a man, and medical documentation confirmed bruising and injury to the mouth and chin. Staff acknowledged that the resident was confused, wandered, and required close monitoring, which was not adequately provided at the time of the incident. Additionally, the same resident was subjected to unwanted physical contact in the activity room when another resident touched her face. Staff present during the incident confirmed the contact, and the resident questioned why she was being touched. Facility policies reviewed indicated a requirement to protect residents from all forms of abuse and to monitor and redirect residents to ensure safety, which was not effectively implemented in these instances.
Failure to Provide Required Two-Person Assistance During Care Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided incontinence care to a resident with significant physical and cognitive impairments without the required assistance of a second staff member. The resident, who had dementia, morbid obesity, osteoarthritis, osteoporosis, and was completely dependent on staff for toileting and bed mobility, required two or more staff for all activities of daily living (ADL) care due to her weight and inability to assist in her own care. Despite being aware of the need for two-person assistance, the CNA attempted to perform care alone after being unable to find help, and did not receive a report from the previous shift or the charge nurse regarding the resident's care needs. During the care, the CNA rolled the resident onto her side and instructed her to hold onto the bed rail. The resident appeared to comply, but when the CNA looked away to retrieve a cleaning wipe, the resident slid off the bed and fell to the floor. The CNA was unable to prevent the fall. Both roommates witnessed the incident and confirmed that the resident always required two or more staff for care and was unable to safely hold onto the bed rail. Following the fall, the resident was assessed by nursing staff and transported to the hospital, where she was found to have sustained fractures to her left arm and left leg. Due to her medical condition, she was not a candidate for surgical repair and was subsequently discharged to hospice care. Facility records and staff interviews confirmed that the resident was at high risk for falls and required two-person assistance for all care, but this protocol was not followed at the time of the incident.
Failure to Provide Admission Agreements
Penalty
Summary
The facility failed to provide a written notice of rights and services prior to or upon admission for three sampled residents. For Resident 1, the admission agreement was provided more than nine months after admission. Resident 1 had multiple diagnoses, including dementia and major depressive disorder, and lacked the capacity to understand healthcare decisions. The Assistant Director of Nursing confirmed that the admission agreement was not provided until much later. For Residents 2 and 3, no admission agreements were provided during their stay. Resident 2, who was receiving palliative care for pancreatic cancer and had Alzheimer's disease, was oriented to the facility but did not receive an admission agreement before passing away shortly after admission. Resident 3, who was self-responsible, was admitted and discharged without receiving an admission agreement. The Medical Records Director confirmed the absence of signed agreements for these residents. The facility's policy required that admission agreements be signed at the time of admission, but this was not adhered to, potentially leaving residents unaware of their rights.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information to a resident or their representative regarding the duration of the state bed-hold policy, reserve bed payments, and conditions for returning to the facility during a transfer to a hospital or therapeutic leave. This deficiency was identified for one of the three sampled residents. The resident, who was admitted in January 2024, had multiple diagnoses including a rib fracture, unspecified dementia with behavioral disturbance, major depressive disorder, hypertension, and chronic pain syndrome. The resident's representative was listed as the responsible party. During a review of the resident's records, it was found that the Bed Hold Notification Form, dated January 31, 2023, was signed by the resident's representative but lacked completion in the section meant to be filled out upon transfer. The facility's policy, last revised in 2017, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to transfers. However, this requirement was not met, as the necessary section of the form was not completed or signed, indicating a failure to ensure the resident or their representative was adequately informed.
Patio Safety Hazards Due to Clutter and Leaking Hoses
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents, staff, and the public in the patio area. Observations revealed that the patio was cluttered with refrigerator parts, a circular concrete pad with broken edges, and two leaking water hoses creating puddles near resident patio doors. These conditions posed potential trip and fall hazards for ambulatory residents using the patio. During an observation, a maintenance worker confirmed that one of the hoses was leaking due to a water faucet not being completely turned off. Interviews with the maintenance worker, Director of Nursing (DON), and Environmental Supervisor (ES) confirmed the presence of these hazards. The maintenance worker acknowledged that the refrigerator parts had been on the patio for more than a day, although the exact duration was unknown. The DON and ES both recognized the refrigerator parts and pooling water as trip hazards, and the ES stated that the broken concrete and refrigerator parts should be removed, and water faucets should be fully turned off after use.
Failure to Provide Correct Discharge Medications
Penalty
Summary
The facility failed to ensure that a resident received the correct medications and instructions upon discharge. The resident, who had been admitted with diagnoses of diabetes mellitus and chronic kidney disease, was discharged without the necessary medication, heparin, which was prescribed to prevent blood clot formation. The discharge summary and instructions did not include heparin, although it was part of the resident's active orders. The Assistant Director of Nurses confirmed that the discharge records did not list heparin as a medication to be administered after discharge. The Nurse Supervisor, who was responsible for the discharge, stated that the night shift had completed the Discharge Medication List, but she was unable to find the Discharge Summary to verify it. Despite this, she discharged the resident with heparin for home use. The facility policy required a reconciliation of pre-placement and post-discharge medications, which was not documented in this case. The resident and a family member confirmed that heparin was sent home, and the resident's doctor later advised against its use. The facility's policy on discharge and transfer of residents was not followed, as there was no documentation of a signed discharge medication list by the resident.
Failure to Assist Resident with Lost Hearing Aids
Penalty
Summary
The facility failed to assist a resident in accessing vision and hearing services by not investigating or replacing the resident's lost hearing aids. The resident, who was admitted in July 2024 with a diagnosis of hypertension, reported the loss of hearing aids valued at $2000. Despite the report, the facility did not complete the Theft and Loss Report, as it lacked essential details such as the name of the person who made the report, the person taking action, and follow-up actions. The Social Services Director (SSD) was informed of the missing hearing aids but did not provide documentation of notifying the police or taking further action. The facility's policy required missing items to be referred to Social Services if not found within 24 to 48 hours, and for law enforcement to be notified if the item's value exceeded $100. However, the SSD stated she was not responsible for investigating the loss, and the Assistant Director of Nursing confirmed the hearing aids were lost while the resident was in the facility. The resident's family reported the facility did not respond to requests for assistance, and the Concern and Grievance Log did not list the missing hearing aids. The facility's failure to adhere to its policy resulted in the resident not having access to necessary hearing aids, impacting their medical and social interactions.
Failure to Administer Scabies Treatment as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of treatment for scabies for a resident, as per the physician's order and instructions. The resident, who had severe cognitive impairment and required substantial assistance for personal care, was prescribed Permethrin 5% cream to be applied from scalp to toe and left on for 12 hours before washing off. However, the cream was washed off only two hours after application, contrary to the physician's order. This error was not reported to the physician, and there was no documentation of the incident in the resident's records. Interviews with facility staff revealed a lack of communication and documentation regarding the treatment. The Corporate Clinical Services Resource acknowledged the error and the need for immediate physician notification, which did not occur. The Licensed Vocational Nurse who applied the cream endorsed the instructions to the next shift, but the Certified Nursing Assistant, unaware of the treatment, gave the resident a shower, washing off the cream prematurely. The facility's policies on medication administration and scabies treatment were not followed, contributing to the deficiency.
Infection Control Protocol Breach During Resident Feeding
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) followed proper infection control protocols while feeding a resident. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia. During an observation, the CNA was seen wheeling the resident into their room and setting up a meal tray without performing hand hygiene. The CNA retrieved a paper towel from the bathroom and placed it on the resident without washing her hands or using hand sanitizer. She then proceeded to feed the resident without cleaning her hands or the resident's hands, acknowledging that she was aware of the requirement to do so to prevent the spread of germs. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD), confirmed that the staff are expected to perform hand hygiene before and after assisting residents with meals and to clean the residents' hands before feeding. The facility's policy on infection control and hand hygiene, revised in August 2014, also mandates the use of alcohol-based hand rub or soap and water before handling food and assisting residents with meals. The failure to adhere to these protocols had the potential to contaminate the resident's food with pathogens.
Failure to Follow Infection Control Procedures for Resident on Contact Isolation
Penalty
Summary
The facility failed to follow infection prevention and control procedures when a Certified Nursing Assistant (CNA) did not wear Personal Protective Equipment (PPE) while providing care to a resident who was on contact isolation due to a confirmed case of scabies. The resident was admitted to the facility with a diagnosis that included scabies and was placed in a single room under contact isolation. Despite clear signage indicating the need for contact precautions, including the use of gloves and gowns, the CNA assisted the resident with meals without wearing the required PPE. This was observed during an interview and concurrent observation, where the CNA admitted to not wearing a gown and gloves without providing a reason for the omission. The facility's policy and procedure for transmission-based precautions clearly stated the need for gloves and gowns when entering the room of a resident on contact isolation. The Director of Nursing (DON) confirmed that staff should wear gowns and gloves when providing Activities of Daily Living (ADLs) care to residents on contact precautions. The failure to adhere to these infection control measures was corroborated by multiple staff interviews and a review of the resident's care plan and physician orders, which all indicated the necessity of contact precautions to prevent the spread of infection.
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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