Westwood Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 1601 Petersen Avenue, San Jose, California 95129
- CMS Provider Number
- 055750
- Inspections on file
- 44
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Westwood Post Acute during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis after stroke, aphasia, MDD, anxiety, and insomnia had an order for PRN Zolpidem and a care plan for insomnia that included non-pharmacological interventions such as repositioning, snacks/drinks, reassurance, relaxation exercises, and monitoring hours of sleep. Review of nursing progress notes and the MAR for the month showed no documentation that sleep hours were monitored or that the non-pharmacological interventions were provided. During interviews, the IP confirmed the insomnia care plan was not implemented, and the DON stated that ordered monitoring and interventions should have been carried out and documented, contrary to the facility’s comprehensive person-centered care plan policy.
A resident with hemiplegia and hemiparesis, requiring significant assistance with daily activities, was found without access to a functioning call light or alternative call bell at bedside. The resident reported the call light had been nonfunctional for two weeks and no call bell was available, resulting in delays in receiving help. A treatment nurse and the DON confirmed the absence of a call bell, despite facility policy requiring accessible call systems for residents.
A resident with muscle weakness and intact cognition did not receive occupational therapy (OT) services as ordered by a physician, with therapy sessions frequently missed or reduced due to staffing shortages. Therapy records confirmed that the resident received OT less often than prescribed, and facility staff acknowledged the failure to follow the physician's order.
A resident with significant physical impairments was found with unexplained facial and ear bruising. Multiple staff observed the injury, but no cause was determined, and the incident was not reported to required agencies as mandated by the facility's abuse policy. Staff interviews revealed confusion about reporting responsibilities, and the injury was not care planned or externally investigated.
Surveyors observed multiple infection control failures, including improper handling of urinary catheter bags, oxygen tubing, and enteral feeding tubes, as well as lapses in hand hygiene and PPE use between resident care tasks. Staff did not consistently follow isolation precautions, failed to communicate infection status to outside providers, and used incorrect disinfectants on shared equipment. Signage and isolation carts were missing or inadequate, and staff were seen entering isolation rooms without proper PPE or using inappropriate products for hand hygiene.
Staff failed to maintain resident dignity and privacy by not fully drawing a privacy curtain for a cognitively impaired resident who removed her gown, referring to clothing protectors as "bibs" in front of multiple residents, and assisting a resident with eating while standing over her, contrary to facility policy.
Staff did not consistently turn and reposition two immobile residents with existing pressure ulcers, despite care plans and facility policy requiring repositioning at least every two hours. Both residents remained on their backs for extended periods, and staff interviews revealed a lack of adherence to established wound care protocols and insufficient use of pressure-relieving equipment.
Three residents receiving oxygen therapy did not receive safe and appropriate care: two residents had oxygen concentrator filters with significant buildup despite orders and policy for weekly cleaning, and another resident with COPD was given oxygen at a higher rate than ordered, with staff aware of but not following the physician's order.
A resident with osteoarthritis, muscle weakness, and difficulty walking requested assistance via call light to transfer from bed to wheelchair. A CNA entered, turned off the call light, and left without providing help. Interviews and policy review confirmed staff are required to assess and assist residents when the call light is used.
Direct care staffing numbers and nursing staff schedules were not posted or accessible in several hallways, with the DON confirming that this information was only available near the main entrance and not at all nursing stations as required.
Nursing staff failed to consistently document the administration of controlled medications on the MAR after signing them out from the CDR for several residents, and did not obtain required co-signatures from another nurse when wasting controlled substances, resulting in incomplete records for both administration and disposal of these medications.
Multiple residents reported that their meals lacked flavor and that vegetables were overcooked and mushy. During a test tray review, the mashed potatoes were confirmed by dietary staff to lack flavor. These issues were observed in both Regular and Pureed Diet trays, affecting a significant number of residents.
The facility did not provide evening or bedtime snacks to all residents, with staff only offering snacks to those with a physician's order and no system in place for others after kitchen hours. A resident with diabetes did not receive her ordered bedtime snack, and several residents reported never being offered snacks at night, despite the facility's policy requiring routine offering of bedtime snacks.
Surveyors found that food items such as frozen fish and cereals were stored without required labeling for open and use by dates, and a metal container was stacked while still wet. Additionally, pureed food was prepared using a container placed in a wet sink, contrary to best practices and facility policy. These actions did not meet professional standards for food storage and preparation.
A resident with severe cognitive impairment and multiple medical conditions, including a gastrostomy, was using a peek-a-boo mitten as ordered to prevent removal of her feeding tube. However, nursing staff failed to document the use of the mitten and related observations in the resident's weekly summaries over several weeks, despite facility policy requiring complete and accurate documentation of all services and interventions.
Two residents were physically abused by another resident who, in separate unprovoked incidents, struck one resident in the hallway and slapped another in the activities room. Both events were witnessed by CNAs and resulted in minor injuries to the victims, despite the facility's policy to protect residents from abuse.
Two residents had personal care instructions, including clinical details and safety precautions, openly posted in their rooms where they were visible to visitors. Facility staff, including the ADON, LVN, and DON, confirmed that these postings were not in accordance with facility policy, which requires confidential information to be protected and not openly displayed.
A resident admitted with diagnoses including schizotypal disorder and prescribed Trazodone for depression was not accurately identified as having a serious mental illness on the PASARR Level I screening. The screening, completed by hospital staff, incorrectly marked 'no' for both diagnosed mental disorder and psychotropic medication use, despite documentation to the contrary. The MDS director confirmed these discrepancies during review.
A resident with severe cognitive impairment and multiple medical conditions was repeatedly observed partially undressed and exposed in her room, with staff confirming her ongoing behavior of removing her gown. Despite this, no individualized care plan was developed or implemented to address the behavior, and staff interviews confirmed the absence of documented interventions.
A resident with a history of atrial fibrillation and heart failure did not receive scheduled doses of Diltiazem and Carvedilol, and vital signs were not monitored as ordered. There was no documentation explaining the missed medication administration or lack of vital sign checks, despite facility policy requiring such documentation. The DON confirmed these omissions during record review.
A resident with diabetes and one-sided weakness did not receive timely podiatry care despite requesting services and having an order for regular podiatry evaluation. Her toenails were observed to be long, thick, and growing inward, causing pain and concern for infection. Staff confirmed the resident was not seen by the podiatrist as required, and her request for care was not addressed.
A resident receiving vitamin B12 and vitamin D3 supplements for deficiency did not have required laboratory monitoring for vitamin D and B12 levels as ordered by the physician. The absence of these lab results was confirmed by the ADON, indicating inadequate monitoring of the resident's medication regimen.
A resident with complex medical needs was discharged without the necessary home health services, as ordered by the physician. The resident, who required assistance with gastrostomy tube feeding and other therapies, was picked up by a friend of the SSA without a confirmed home health agency. The initial referral was denied, and as of several days post-discharge, no agency was in place, violating the facility's discharge policy.
A resident with complex medical conditions experienced deficiencies in care planning and medication documentation. The baseline care plan for dysphagia and tube feeding was delayed, and the facility failed to provide the prescribed tube feeding formula upon admission. Additionally, a medication administration record was incorrectly initialed by an LVN instead of the RN who administered the IV antibiotic.
A facility failed to provide timely pharmaceutical services, resulting in delayed administration of IV antibiotics for three residents. One resident with multiple diagnoses, including cancer, did not receive Vancomycin on time despite its availability in the emergency kit. Another resident with chronic respiratory failure experienced a delay due to a claimed but undocumented IV access issue. A third resident with osteomyelitis also faced a delay without explanation. Additionally, a nurse used another resident's normal saline to mix Vancomycin, violating facility policy.
A resident with reduced mobility fell during a physical therapy session, sustaining minor injuries. The physical therapist did not report the fall to the nursing staff, relying on the resident's son to inform them. This delay in communication potentially delayed assessment and treatment. Facility policy requires prompt notification of changes in a resident's condition to the physician and responsible representative.
A facility failed to promote respect and dignity for a resident when a social services staff member threatened to call 911 for a 5150 assessment while the resident was advocating for her roommate. The resident, who had a history of multiple medical conditions, felt threatened and called the police herself. The facility's management did not address the issue or clarify the situation with the resident afterward.
A resident with multiple diagnoses was found to have their morning medications left at their bedside, despite the medications being documented as given. The licensed vocational nurse did not observe the resident taking the medications and left the room to attend to another resident. The incident was discovered by a family member and confirmed by a certified nursing assistant.
Failure to Implement and Document Insomnia Care Plan Interventions
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement a comprehensive, person-centered care plan for a resident with insomnia. The resident’s admission record documented multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia, major depressive disorder, anxiety disorder, and insomnia. The resident had a physician’s order for Zolpidem Tartrate 5 mg, to be given by mouth as needed for insomnia for 14 days, with instructions that 1 to 2 tablets could be given as needed. The resident’s care plan for insomnia, initiated on 9/12/2023, included specific non-pharmacological interventions such as repositioning/limb elevation, snacks/drinks, redirection/reassurance/emotional support, deep breathing/relaxation exercises, and monitoring and recording the number of hours of sleep, as well as trying measures like avoiding heavy meals, caffeine, and large fluid intake before sleep and offering milk. Review of the resident’s September 2023 nursing progress notes and MAR showed no documentation that the resident’s hours of sleep were monitored or that the listed non-pharmacological interventions were provided. During an interview and concurrent record review, the infection preventionist nurse confirmed that there was no documentation of sleep monitoring or non-pharmacological interventions and acknowledged that the insomnia care plan had not been implemented. In a separate phone interview, the DON stated that if the care plan directed nurses to monitor hours of sleep and provide non-pharmacological interventions, those interventions should have been implemented and documented in the nurse’s notes or MAR. The facility’s policy on comprehensive person-centered care plans, revised March 2022, required development and implementation of care plans with measurable objectives and timetables to meet residents’ needs, underscoring that the required insomnia care plan interventions for this resident were not carried out or documented.
Failure to Provide Accessible Call Light or Alternative for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident was found without access to a functioning call light or an alternative call bell at bedside. During observation and interview, the resident reported that the call light in her room had not been working for two weeks and that she did not have a call bell available. The resident stated she had to call the front desk for assistance, which resulted in delays. A treatment nurse confirmed the absence of a call bell after searching the resident's bedside area and acknowledged that the call lights in the room were not operational. The Director of Nursing later confirmed that bells were supposed to be provided to all residents in the affected area, and that residents were expected to have a bell at bedside until the call lights were repaired. The resident involved had a history of hemiplegia and hemiparesis, requiring varying levels of assistance with activities of daily living, including being dependent for toileting, lower body dressing, and transfers. The resident was cognitively intact, as indicated by a BIMS score of 15. Facility policy required that call lights or their alternatives be accessible to residents at all times, including when in bed, on the toilet, or in the shower. The failure to provide a call bell or functioning call light was contrary to these policies and procedures.
Failure to Provide Physician-Ordered Occupational Therapy Services
Penalty
Summary
The facility failed to provide occupational therapy (OT) services as ordered by a physician for one resident. The physician's order specified that the resident should receive skilled OT five times per week for eight weeks, including specific therapy modalities. However, therapy records and interviews revealed that the resident received OT only three or four times per week on several occasions, with multiple therapy sessions missing and no documented reasons for the absences. The Director of Rehab and the Assistant Director of Rehab both confirmed that the resident did not consistently receive therapy according to the physician's order. The resident, who was admitted with a diagnosis of muscle weakness and was cognitively intact, reported that therapy sessions were skipped due to insufficient therapy staff. The resident expressed that therapy was beneficial for self-care and that he needed more therapy, but sessions were reduced due to staffing shortages. Facility policy required therapy services to be scheduled in accordance with the resident's treatment plan, but this was not followed in the resident's case.
Failure to Report Injury of Unknown Source as Required by Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy and procedure when it did not report an injury of unknown source for a resident. The resident, who had a history of hemiplegia, hemiparesis following a stroke, dysphagia, and was chronically bedbound, was found with discoloration and swelling on the right side of the face and ear. Multiple staff members, including nurses and the assistant director of nursing, observed the injury but could not determine its cause. The resident was able to communicate but was unaware of how the injury occurred, and there were no documented falls or behavioral incidents that could explain the injury. Despite the facility's policy requiring immediate reporting of injuries of unknown source to state agencies, law enforcement, and the ombudsman, the injury was not reported to any of these authorities. Staff interviews revealed that the incident was discussed internally, with some staff assuming the injury was caused by a feeding pump falling on the resident, although no one witnessed this event and some staff questioned the plausibility of this explanation given the resident's physical limitations. The interdisciplinary team reviewed the case days after the initial discovery, but the possible contributing factors were not documented, and the injury was not care planned. Key staff members, including the DON, ADONs, and the administrator, confirmed that the injury was not reported externally because they believed the cause had been determined or deferred the decision to others. The facility's social services staff was not informed of the incident, and several nurses and CNAs expressed uncertainty about reporting requirements, with some believing it was the administration's responsibility. The facility's policy clearly states that all injuries of unknown source must be reported to the appropriate agencies within 24 hours, but this was not followed in this case.
Widespread Infection Control Failures and Lapses in PPE Use
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed throughout the facility. Staff failed to maintain proper handling of medical equipment, such as allowing a urinary catheter drainage bag to touch the floor and leaving oxygen tubing and enteral feeding tube tips exposed or improperly stored. In several instances, staff did not perform hand hygiene or change personal protective equipment (PPE) between resident care tasks, including when assisting with meals, handling invasive devices, or entering and exiting isolation rooms. There were also failures to don appropriate PPE when entering rooms of residents on contact or COVID-19 precautions, and improper use of disinfectant wipes for hand hygiene was noted. Communication lapses were identified, such as the failure to notify a dialysis center of a resident's isolation status and infection type. Signage and isolation carts for contact precautions were either missing or not clearly visible at room entrances, and PPE was not always readily accessible. Staff were observed entering contact precaution rooms without proper PPE, and in one case, a staff member used hand sanitizer instead of washing hands with soap and water after contact with a resident with C. difficile infection, contrary to CDC guidelines. Additionally, a registered nurse was observed wearing a double mask (N-95 over a surgical mask) when only an N-95 was required, potentially compromising the effectiveness of the respirator. Further deficiencies included improper cleaning and disinfection of shared medical equipment, such as using alcohol wipes instead of the required disinfectant for glucometers, which may not be effective against certain bloodborne pathogens. Staff also failed to ensure that oxygen cannulas not in use were stored properly, and that oxygen tubing was not entangled or lying on the floor. These actions and inactions were directly observed and confirmed through staff interviews and review of facility policies, highlighting widespread non-compliance with established infection control protocols.
Failure to Maintain Resident Dignity and Privacy During Care and Mealtimes
Penalty
Summary
The facility failed to uphold residents' dignity and privacy in several observed instances. One resident with severe cognitive impairment and a history of removing her clothing was found half-naked in bed with her privacy curtain only half drawn, making her visible to others in the room. Staff confirmed that there was no care plan in place to address this behavior, and that the resident should be checked more frequently, especially when family was not present. The facility's policy required staff to treat cognitively impaired residents with dignity and to address the root causes of such behaviors, but this was not followed in this case. Additionally, the Assistant Director of Nursing referred to residents' clothing protectors as "bibs" in front of approximately 15 residents during a mealtime, which was confirmed in an interview. In another instance, a CNA was observed assisting a resident with eating while standing over her, despite facility policy requiring staff to sit while feeding residents to maintain dignity. These actions were observed in the dining room and had the potential to affect the psychosocial well-being of multiple residents present.
Failure to Reposition Bedbound Residents with Pressure Ulcers
Penalty
Summary
Staff failed to provide appropriate pressure ulcer care and prevention for two residents who were immobile and unable to reposition themselves. Multiple observations over two consecutive days showed that both residents remained lying on their backs for extended periods, despite care plans and medical records indicating the need for repositioning every two hours or as needed. Certified Nursing Assistants (CNAs) and other staff did not consistently implement these interventions, and one CNA stated that repositioning was not necessary for one of the residents, contrary to established protocols. Resident 190 had a history of severe medical conditions, including aphasia, chronic respiratory failure, hemiplegia, and a stage 4 pressure ulcer on the sacral/coccyx region, as well as deep tissue damage on the left heel. The resident was non-ambulatory, required extensive assistance with bed mobility, and was cognitively impaired. Despite these needs, observations confirmed that the resident was not turned or repositioned as required, and the wound size remained unchanged over several days. The care plan specifically called for repositioning every two hours, but this was not consistently followed. Resident 546 also had significant medical issues, including pneumonia, respiratory failure, diabetes, and lower extremity embolism and thrombosis. This resident was similarly non-ambulatory, cognitively impaired, and dependent on staff for repositioning. Observations revealed that the resident was left lying on her back for long periods, and staff reported difficulties in repositioning due to lack of appropriate equipment, such as a wedge pillow. The facility's own policy emphasized the importance of frequent repositioning, especially for residents with existing pressure ulcers, but these guidelines were not adhered to in practice.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide proper care and treatment for residents receiving oxygen therapy. Two residents with orders for continuous oxygen via concentrator were observed with thick grayish substance buildup on the filters of their oxygen concentrators, despite physician orders and facility policy requiring weekly cleaning or changing of the filters. The infection preventionist was unsure who was responsible for this task, and the DON stated it should have been done weekly by nurses or central supply staff. Both residents had significant respiratory diagnoses, including acute respiratory failure, hypoxia, pneumonia, and COPD, and were observed in bed on oxygen therapy at the time of the deficiency. Additionally, another resident with a diagnosis of COPD was administered oxygen at a rate of 5 liters per minute, contrary to the physician's order for 2 liters per minute via nasal cannula. The LVN present acknowledged awareness of the correct order but did not adjust the oxygen flow. The resident's care plan also specified that oxygen should be administered as ordered. Facility policy required verification of physician orders prior to oxygen administration, but this was not followed in this instance.
Failure to Assist Resident After Call Light Activation
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to assist a resident who requested help transferring from bed to wheelchair. During observation, the resident, who has diagnoses including primary osteoarthritis of the ankles, feet, and hips, muscle weakness, and difficulty walking, pressed the call light for assistance. The CNA entered the room, turned off the call light, and left without providing any help. The CNA later confirmed in an interview that no assistance was given at that time. Interviews with facility staff, including the case manager and the director of nursing, confirmed that staff are expected to ask residents if they need help before turning off the call light and to address residents' needs whenever the call light is activated. Review of the facility's policy on answering call lights also indicated that staff should respond immediately and fulfill requests within five minutes if possible. The resident's medical record and assessment showed she was cognitively intact but physically limited, further emphasizing her need for assistance.
Failure to Post Daily Nurse Staffing Information at All Nursing Stations
Penalty
Summary
The facility failed to post direct care staffing numbers and the names of nursing staff responsible for resident care in a prominent place at each of the four nursing stations. Observations on multiple hallways revealed that no staff schedule or direct patient care hours were posted or accessible to residents in Hallways 2, 3, 4, and 5. During an interview, the DON confirmed that staffing information was only posted in Hall 1, near the main entrance, and acknowledged that direct daily patient care hours and staffing schedules had never been posted elsewhere in the facility. No specific residents or their medical histories were mentioned in relation to this deficiency.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for several residents. In multiple instances, nursing staff signed out controlled medications from the Controlled Drug Record (CDR) but did not document the administration of these medications on the Medication Administration Record (MAR). This discrepancy was identified for four out of five residents reviewed, with specific examples including missed documentation for oxycodone and hydrocodone/acetaminophen administrations. The Assistant Director of Nursing (ADON) confirmed that these administrations should have been recorded on the MAR, as required by facility policy. Additionally, the facility did not consistently follow its policy for the proper disposal (wasting) of controlled medications. The records showed that wasted medications for several residents were not co-signed by a second nurse, as mandated by the facility's procedures. Specific instances included wasted doses of oxycodone, diazepam, and buprenorphine without the required witness signature. Both the Director of Nursing (DON) and a Registered Nurse (RN) acknowledged that the double signature was missing in these cases and confirmed that the policy requires two signatures for wasted controlled substances. A review of the facility's policies confirmed that staff are required to document medication administration on the MAR and to have two signatures for the wasting of controlled substances. The survey findings demonstrated that these procedures were not consistently followed, resulting in incomplete records for both the administration and disposal of controlled medications.
Unpalatable and Overcooked Food Served to Residents
Penalty
Summary
The facility failed to ensure that food served to residents on a Regular Diet was palatable, as evidenced by multiple observations and resident interviews. During dining observations, one resident refused to eat mashed potatoes, stating they had no flavor and did not taste good. Other residents reported that the food was terrible, lacked flavor, and that vegetables, specifically carrots, were overcooked and mushy. These observations were corroborated by residents who did not finish their meals due to the poor quality of the food. A lunch test tray review conducted with the Dietary Manager, Dietary Director, and Registered Dieticians confirmed that the mashed potatoes served on both Regular and Pureed Diet trays lacked flavor. The facility's ordered diet list indicated that 105 residents were on Regular or Pureed diets. A review of the facility's policy and procedure on Food Preparation stated that food should be prepared to conserve nutritive value, flavor, and appearance, which was not adhered to in these instances.
Failure to Provide Evening and Bedtime Snacks to All Residents
Penalty
Summary
The facility failed to ensure that evening and bedtime snacks were offered to all residents, as required by their own policy and federal regulations. Multiple residents reported during interviews and a Resident Council meeting that they had never received snacks, particularly after the kitchen closed in the evening. Staff interviews confirmed that snacks were only provided to residents with a physician's order, and that there were no snacks available for other residents after kitchen hours. The kitchen closed at 7 p.m. or 9:30 p.m., and there was no system in place for nursing staff to access or provide snacks outside of these hours. Residents expressed that they sometimes wanted snacks at night, but their requests were not accommodated. One resident with diabetes specifically reported not receiving her ordered bedtime snack, despite having a diagnosis that requires careful blood sugar management. The registered dietitians confirmed that snacks were only prepared for residents with physician orders, and that nurses were expected to provide these snacks if requested. However, both nursing and dietary staff indicated that there was no storage or process for providing snacks after kitchen hours, resulting in residents, including those with medical needs, not receiving snacks as ordered or requested. The facility's own policy stated that bedtime snacks should be routinely offered to all residents unless contraindicated, but this was not being followed.
Deficiencies in Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. An opened box of frozen fish was found in the freezer without a use by date, and two opened cereals in the dry pantry were not labeled with open or use by dates. The Dietary Manager confirmed that these items should have been labeled according to facility policy, which requires all food items in storage to be labeled and dated. Additionally, facility guidelines specify that ready-to-eat cereals can be stored for two months after opening, but the lack of labeling made it impossible to determine compliance. Further observations revealed that a metal container was stored while still wet, which was confirmed by the Registered Dietician, who stated that containers must be dry when stacked. During food preparation, a dietary aide placed a metal container in a wet food preparation sink and poured pureed meat into it, rather than using a dry container and scooping the food as per best practice. The Dietary Director acknowledged that the preferred method is to scoop pureed food into a container rather than placing the container in the sink. These actions were not in accordance with the facility's policies and procedures for food preparation and sanitation.
Failure to Document Use of Peek-a-Boo Mitten in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards for one resident who was using a peek-a-boo mitten to prevent removal of a gastrostomy tube. The resident, who had diagnoses including obstructive hydrocephalus, benign neoplasm of the spinal cord, other specified brain disorders, dysphagia, and was receiving care for a gastrostomy, had severe cognitive impairment as indicated by a BIMS score of 0. An order for the use of a peek-a-boo hand mitten was present in the resident's clinical record since admission. Despite the ongoing use of the mitten, the resident's weekly summaries did not document its use or any related observations in multiple entries over several weeks. The DON confirmed that the restraint box should have been checked and relevant behaviors or observations should have been documented, but this was not done. The facility's own policy required that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented objectively, completely, and accurately, which was not followed in this case.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. In the first incident, one resident was observed by a CNA to strike another resident in the face and push her to the floor as they crossed paths in the hallway. The aggressor was described as having a history of anger outbursts and being aggressive toward both staff and other residents, with previous attempts to physically harm staff. The victim sustained redness to the left side of her face as a result of the assault. Documentation and witness interviews confirmed the unprovoked nature of the attack and the aggressor's inability to be easily redirected. In a separate incident, the same resident entered the activities room and, without provocation, slapped another resident multiple times on the head while she was sitting at a table. This event was also witnessed by a CNA, and the victim sustained redness on her forehead. Both incidents were reported to the appropriate authorities and documented in mandated reports and facility investigative records. The facility's policy states a commitment to protecting residents from abuse by anyone, including other residents, but these events demonstrate a failure to uphold that standard.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information for two residents. In one instance, a resident was observed in bed with care instructions posted above the head of the bed, including details such as the need to elevate the head of the bed during feeding and instructions related to left side weakness and repositioning. These instructions were visible to the roommate's visitors. The assistant director of nursing confirmed that the care instructions were still posted and acknowledged that they should have been covered. In another case, a different resident had a care instruction posted above the bed indicating a choking risk and specifying 'no food by mouth.' This information was also visible in the room. A licensed vocational nurse confirmed the observation and stated that the care instruction should not have been posted in that manner. The director of nursing further confirmed that care instructions should be covered when posted. Facility policy reviewed indicated that confidential clinical information, including care needs, should not be openly posted in resident rooms, except for discreet postings for safety reasons.
Inaccurate PASARR Screening for Mental Disorder
Penalty
Summary
The facility failed to ensure that a pre-admission screening and resident review (PASARR) was accurately completed for one resident. The resident was admitted with multiple diagnoses, including acute respiratory failure, influenza, emphysema, and schizotypal disorder. The clinical record showed the resident was prescribed Trazodone for depression and was being monitored for behaviors associated with schizotypal disorder, such as social anxiety and a preference for solitary activities. Despite these documented mental health conditions and the use of psychotropic medication, the PASARR Level I screening indicated negative for serious mental illness, with questions regarding diagnosed mental disorders and psychotropic medication use both marked as "no." During an interview, the MDS director confirmed the resident's diagnoses and medication use, and acknowledged that the PASARR was completed by hospital staff and should have indicated "yes" for those questions. The facility's policy requires all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders per the PASARR process.
Failure to Develop and Implement Care Plan for Resident's Disrobing Behavior
Penalty
Summary
The facility failed to develop and implement an individualized, resident-centered care plan for a resident who exhibited the behavior of pulling off her clothes or facility gown. The resident, who was admitted with diagnoses including obstructive hydrocephalus, benign neoplasm of the spinal cord, other specified brain disorders, dysphagia, and a gastrostomy, had a severe cognitive impairment as indicated by a BIMS score of 0. Multiple observations revealed the resident was frequently found half naked in her bed, with her upper chest exposed, and her privacy curtain only partially drawn, making her visible to others in the room. Interviews with staff, including a CNA, social services, RN, and the DON, confirmed that the resident had a known behavior of stripping off her gown and that there was no care plan in place to address this behavior. Staff acknowledged the need for frequent checks, especially when family was not present, but no formal interventions or strategies had been documented or implemented. Review of facility policy indicated that the interdisciplinary team is responsible for developing comprehensive, person-centered care plans, but this process was not followed for the resident's specific behavioral needs.
Failure to Administer Medications and Monitor Vital Signs per Physician Orders
Penalty
Summary
A resident with diagnoses of paroxysmal atrial fibrillation and acute on chronic combined systolic and diastolic heart failure did not receive treatment and care in accordance with professional standards of practice. Physician orders required administration of Diltiazem and Carvedilol for hypertension, with specific parameters to hold the medications if systolic blood pressure was less than 100 or pulse was less than 60. The resident's medical record showed that Carvedilol was last administered at 9 a.m. and Diltiazem at 1 p.m. on the day prior to the resident being found unresponsive. Blood pressure was last checked at 11:09 a.m. and pulse at 6 p.m., with the pulse noted to be elevated at 103 beats per minute. There was no documentation explaining why the afternoon doses of Carvedilol and Diltiazem were not given, nor why vital signs were not checked in the afternoon. The Director of Nursing confirmed during interview and record review that the lack of documentation for missed medication administration and vital sign monitoring was not in accordance with facility policy. Facility policies required that vital signs be obtained as appropriate and that all medications administered, as well as procedures and treatments, be documented in the resident's medical record, including reasons for refusal or omission. The failure to follow these protocols resulted in a deficiency related to providing treatment and care according to orders and professional standards.
Failure to Provide Timely Podiatry Services for a Resident with Diabetes and Mobility Impairments
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including hemiplegia, hemiparesis, and diabetes, did not receive necessary podiatry services as ordered. The resident's clinical records indicated an order for podiatry evaluation, treatment, and follow-up every 61 days and as needed. Despite the resident's request for podiatry services, her toenails were observed to be long, thick, and growing inward, causing her pain and concern for potential ingrown toenails or infection. The resident reported that although she was shown documentation stating she had been seen by the podiatrist, she was not actually seen, and her toenails remained untreated. Interviews with staff confirmed that the resident's request for podiatry services was documented, but she was not scheduled or seen during the most recent podiatry visit. Observations by both staff and surveyors confirmed the resident's toenails were not trimmed and did not appear to have been recently cared for by a podiatrist. The facility's policy requires referral to qualified professionals for residents with medical conditions associated with foot complications, but this was not followed in the resident's case.
Failure to Monitor Vitamin Supplement Levels as Ordered
Penalty
Summary
A resident with a history of B group vitamin deficiency and falls was admitted and prescribed daily cyanocobalamin (vitamin B12) and vitamin D3 supplements. The physician's orders included routine monitoring of vitamin D levels every six months and ongoing administration of vitamin B12 for deficiency. However, a review of the clinical record revealed that no vitamin D laboratory results were available for the specified monitoring periods, and no vitamin B12 level had been drawn since the initiation of the order over two years prior. During an interview and record review, the Assistant Director of Nursing confirmed the absence of required vitamin D and B12 laboratory results, despite efforts to locate them. The facility's policy required staff and physicians to evaluate the effectiveness and effects of medications, but this was not followed, as evidenced by the lack of laboratory monitoring for the resident's prescribed supplements. This resulted in inadequate monitoring related to medication management for the resident.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was discharged without the necessary home health services as ordered by the physician. The resident, who had a history of hearing loss, a gastrostomy, and malignant neoplasm of the larynx, was discharged on January 1, 2025, without an established home health agency to provide the required physical therapy, occupational therapy, speech therapy, registered nurse services, and durable medical equipment. The resident was picked up by a friend of the Social Services Assistant (SSA) in a private car, and it was noted that the resident's home was cluttered and that the resident required assistance with feeding through the gastrostomy tube. The SSA admitted that the referral to the home health agency was not confirmed before the resident's discharge, and the initial referral was denied by the agency due to the lack of speech therapy services. As of January 6, 2025, the resident still did not have a home health agency in place. The facility's policy required that a post-discharge plan be developed, including arrangements for follow-up care and services, but this was not provided. The Director of Nursing confirmed that the physician's discharge orders must be followed, indicating a failure in adhering to the established discharge procedures.
Deficiencies in Care Planning and Medication Documentation
Penalty
Summary
The facility failed to provide services according to professional standards for a resident with multiple complex medical conditions, including malignant neoplasm of the esophagus, secondary malignant neoplasm of unspecified lung, liver, intrahepatic bile duct, and digestive organs, severe protein-calorie malnutrition, dysphagia, and gastrostomy status. The baseline care plan for the resident's dysphagia and tube feeding was not developed in a timely manner, being completed five days after admission instead of within the required 48 hours. This delay was confirmed by the registered dietitian and social worker involved in the care planning process. Additionally, upon the resident's admission, the facility did not have the prescribed tube feeding formula in stock. The resident's family member had to obtain the formula from the hospital, and the facility staff failed to notify the dietitian or the attending physician to obtain an alternative formula. The new tube feeding formula was only initiated five days after admission, which was confirmed by the director of nursing and assistant director of nursing. Furthermore, there was an issue with medication administration documentation. A licensed vocational nurse incorrectly initialed the medication administration record for an IV antibiotic administered by a registered nurse. This error was acknowledged by the director of nursing and assistant director of nursing, who confirmed that the registered nurse should have documented the administration. The facility's policy requires the individual administering the medication to document it in the resident's medical record.
Delayed Administration of IV Antibiotics and Medication Errors
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of three residents, resulting in delayed administration of intravenous (IV) antibiotics. Resident 1, who was admitted with multiple diagnoses including malignant neoplasm of the esophagus and severe protein-calorie malnutrition, did not receive the ordered Vancomycin at the scheduled times. The first dose was administered late on the evening of 7/11/2024, and the second dose was delayed until the afternoon of 7/12/2024. Despite having Vancomycin available in the emergency kit, the medication was not administered on time, as confirmed by the licensed vocational nurse and the director of nursing. Resident 2, diagnosed with chronic respiratory failure and infections including MRSA, also experienced a delay in receiving Vancomycin. The medication was scheduled for 8:00 p.m. on 12/21/2024 but was not administered until 10:51 p.m. The registered nurse responsible for Resident 2's care cited a clogged IV access as the reason for the delay, but there was no documentation to support this claim, and no PICC line was inserted as stated. Resident 3, with a history of chronic osteomyelitis and MRSA infection, was scheduled to receive Vancomycin at 9:00 p.m. on 12/9/2024, but the medication was not given until 1:36 a.m. the following day. There was no documentation explaining the delay. Additionally, a nurse used another resident's normal saline to mix Vancomycin for Resident 1, which was confirmed by the assistant director of nursing. This action was against the facility's policy, which requires using the emergency kit for such needs and verifying medication labels three times to ensure the correct resident receives the correct medication.
Failure to Notify Physician of Resident Fall During Physical Therapy
Penalty
Summary
The facility failed to promptly notify the physician when a resident fell during a physical therapy session and sustained minor injuries. The incident involved a resident who was admitted with diagnoses including oral surgical aftercare, cancer, and reduced mobility. During a physical therapy session, the resident fell outside the facility, resulting in small excoriations on both knees. The physical therapist did not report the fall to the nursing staff, as the resident's son had already informed them. This delay in communication had the potential to result in a delay of assessment and possible treatment. Interviews with facility staff revealed that the physical therapist did not consider the fall a reportable event and therefore did not notify the charge nurse. The Director of Rehab and the Assistant Director of Nursing confirmed that the therapist should have reported the fall immediately to the nursing staff. The facility's policy requires prompt notification of changes in a resident's condition to the physician and responsible representative. The failure to adhere to this policy led to a delay in assessing and treating the resident's injuries.
Failure to Promote Respect and Dignity for Resident
Penalty
Summary
The facility failed to promote respect and dignity for a resident when a social services staff member threatened to call 911 for a 5150 assessment. The incident occurred when the resident was advocating for her roommate, who was experiencing a fever. The social services staff member's threat made the resident feel threatened and led her to call the police herself. The facility's management did not address the issue or clarify the situation with the resident afterward. Interviews with other staff members confirmed that the resident was cognitively intact and had no history of being a danger to herself or others. The resident had a history of type 1 diabetes, major depression disorder, anxiety disorder, pancreatic cancer, and the absence of both upper limbs below elbows and both legs above knees. The social services staff member involved was not the resident's assigned social services staff and had been directed not to communicate with the resident. The facility's policy and procedure on resident rights emphasized treating all residents with kindness, respect, and dignity, which was not upheld in this situation.
Failure to Ensure Medication Administration Compliance
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice when a licensed nurse did not observe a resident taking their medications. The resident, who had multiple diagnoses including fractures, hypertension, hyperlipidemia, and atrial fibrillation, was found to have their morning medications left at their bedside. The medications were documented as given in the Medication Administration Record (MAR), but the nurse did not verify that the resident had actually taken them before attending to another resident. The incident was discovered when a family member notified the Case Manager about the medications found at the resident's bedside. A certified nursing assistant confirmed seeing the pills but did not report it to anyone. The licensed vocational nurse later acknowledged that he had documented the medications as given without observing the resident taking them. He admitted that he should have ensured the resident took the medications and reported the incident to the physician and the Director of Nursing (DON). The DON confirmed that the nurse had left the room during the medication administration process and had documented the medications as given. The facility's policy on administering medications requires that medications be administered within one hour of their prescribed time and that any discrepancies be reported. The nurse was re-educated on the proper procedures for medication administration and observation to ensure compliance with professional standards of practice.
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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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