Windsor The Ridge Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salinas, California.
- Location
- 350 Iris Drive, Salinas, California 93906
- CMS Provider Number
- 555060
- Inspections on file
- 24
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Windsor The Ridge Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of exit-seeking behavior repeatedly left the facility without staff knowledge, despite being identified as at risk for elopement and having interventions such as a wander guard and increased supervision in place. Staff interviews and documentation revealed inconsistencies and lack of clarity in the implementation of monitoring and supervision, leading to multiple incidents where the resident exited the premises undetected.
A resident with essential hypertension did not receive Norvasc as prescribed, as the facility failed to document blood pressure and heart rate checks before administration. Additionally, there was no care plan addressing the resident's hypertension, contrary to facility policies. The DON confirmed these oversights during interviews and record reviews.
The facility failed to follow a physician's order to monitor a resident's inappropriate behavior every shift. Despite the resident's diagnoses of parkinsonism, mood disorder, and mild cognitive impairment, and a care plan that included monitoring for inappropriate touching, there was no documentation of such monitoring from 2/19/24 to 5/6/24. The Director of Nursing confirmed this lapse, which was against the facility's policies for documentation and implementing physician orders.
The facility failed to document the use of bed rail alternatives for 17 residents and did not obtain informed consent for one resident prior to the installation of bed rails. The Director of Staff Development confirmed the use of bed rails for turning and repositioning, but there was no documentation of alternatives being attempted. Additionally, the bed rail consent for one resident was obtained after the bed rails were already in use.
The facility failed to follow the standardized recipe for spinach and did not adhere to residents' dietary preferences, resulting in residents being served food items they disliked. Cook A added red bell peppers to spinach, which was not in the recipe, and two residents were served meals that did not align with their documented dislikes.
The facility failed to follow proper sanitation and food handling practices. A dietary aide did not perform proper hand hygiene after cleaning and handling dirty surfaces, and multiple food items were found in the freezer past their use-by dates. Additionally, a dented can of black beans was improperly stored on the dry storage shelf.
The facility failed to update the fall care plan for a resident with a history of falls and high fall risk due to conditions like Alzheimer's disease and a femur fracture. Despite multiple falls, the interdisciplinary team did not review and revise the care plan after each incident, leading to further falls.
The facility failed to implement its fall management policy for a resident with Alzheimer's disease and a history of falls. The resident did not receive a fall risk assessment upon readmission or after a significant change in condition, and the interdisciplinary team did not develop or implement new interventions after multiple falls. This resulted in subsequent falls and potential for serious injury.
The facility failed to ensure respect and dignity for five residents by not providing privacy sleeves for their indwelling catheter urinary bags. Observations and interviews confirmed that the urinary bags of these residents were visible and uncovered, contrary to the facility's policy on privacy and dignity.
The facility failed to follow policies on self-administration of medication for two residents, resulting in medications being left at the bedside without proper assessments or physician orders. One resident with moderately impaired cognition had antidiarrheal medication at their bedside, and another resident with intact cognition had eye drops at their bedside, both without necessary orders.
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) when their Medicare benefits ended. The Business Office Manager was unaware of the requirement until recently, and the facility's policy was not followed, potentially leading to residents unknowingly assuming financial liability for non-covered services.
The facility failed to accurately complete the MDS for a resident with bipolar disorder, incorrectly marking the PASRR status as 'No' instead of 'Yes'. This error was confirmed by the MDS Coordinator and compromised the facility's ability to provide appropriate care plan interventions.
The facility failed to complete a Level II PASRR for two residents, one with paraplegia, schizophrenia, and morbid obesity, and another who was in isolation due to an infectious disease. The Minimum Data Set Coordinator acknowledged the oversight, and the facility's policy indicated that PASRR should be completed within 24 hours for new admissions.
The facility failed to develop and implement individualized care plans for three residents. One resident with mild depression had no care plan addressing his mood, another resident using oxygen and anticoagulant medication lacked care plans for both, and a third resident using oxygen also had no care plan. Staff confirmed these omissions, which were against the facility's policy.
The facility failed to follow physician's orders for oxygen supplementation for two residents. One resident with chronic respiratory failure and COPD received 2.5 liters per minute instead of the ordered 2 liters, and another resident with respiratory failure and heart failure received 2 liters per minute instead of the ordered 3 liters. LVN confirmed the discrepancies.
The facility failed to ensure that controlled medications were properly reconciled with the corresponding MAR for four residents. Medications were signed out of the CDR but not documented on the MAR, as confirmed through interviews and record reviews with LVNs and the PC.
The facility had an eight percent medication error rate when an LVN failed to administer Zyrtec and MiraLAX to a resident as per the physician's order, due to not checking the next page of the MAR.
The facility failed to label medications appropriately, as observed during a medication cart inspection. An opened bottle of Refresh Tears lubricant eyedrop, Vyzulta 0.024% Ophthalmic Solution, and Brimonidine Tartrate ophthalmic solution were found without open dates. The Pharmacy Consultant confirmed that ophthalmic solutions are good for 28 days after being opened and should be labeled with the resident's name and an open date.
The facility failed to serve food at an appetizing temperature for one test tray food item. The Dietary Manager found that the regular texture Club Spinach had an internal temperature of 125 degrees Fahrenheit, below the required 140 degrees Fahrenheit, after all residents were served the noon meal.
The facility failed to provide physician-prescribed therapeutic diets to four residents. Three residents on a Controlled Carbohydrate Diet were served the wrong dessert, and one resident on a Fortified Diet did not receive the fortified food item. The Dietary Manager confirmed these errors during the noon meal service.
The facility failed to ensure proper infection control practices when a CNA did not perform hand hygiene between assisting multiple residents with meals, and a nasal cannula was improperly stored on the floor in a resident's room. The CNA admitted to not using hand sanitizer due to skin dryness, and an LVN confirmed the improper storage of the nasal cannula.
The facility failed to maintain a safe and comfortable environment for two residents. One resident's bed controller was disconnected for two days, causing discomfort, while another resident's toilet paper holder was broken for three days without being reported or fixed. Staff were either unaware of the issues or did not follow the facility's maintenance reporting procedures.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and supervise a resident with severe cognitive impairment and a known history of exit-seeking behavior. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, alcohol dependence, depression, muscle weakness, and impaired mobility, was assessed as being at risk for elopement. Despite this, the resident was able to leave the facility on multiple occasions without staff knowledge. Documentation showed that the resident's care plan identified the risk and included interventions such as a wander guard device, increased supervision, and ensuring the resident's bedroom screen door was locked. On several occasions, the resident was found outside the facility or attempting to leave, sometimes without the wander guard in place or with the device removed. Staff interviews revealed inconsistencies in the implementation and documentation of increased supervision and 1:1 monitoring. There was also a lack of clarity and evidence regarding how these interventions were carried out. Orders were in place for frequent monitoring and checking the wander guard, but the resident was still able to exit the facility undetected, and staff did not always hear the wander guard alarm or find the device after incidents. The facility's failure to consistently implement and document the required supervision and monitoring interventions, as well as to ensure the effectiveness of the wander guard system, resulted in repeated incidents where the resident left the premises without staff awareness. This lack of adequate supervision and monitoring directly contributed to the deficiency cited in the report.
Failure to Administer Medication According to Physician Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident diagnosed with essential hypertension. The resident was prescribed Norvasc, a hypertension medication, to be administered daily with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. However, from November 1 to November 11, the medication was administered without documented checks of the resident's blood pressure or heart rate, except on November 3 when the resident was noted as sleeping. This oversight was confirmed by the Director of Nursing (DON) during an interview and record review. Additionally, the facility did not have a care plan in place to address the resident's hypertension, which was acknowledged by the DON during a telephone interview. The facility's policies and procedures for administering medications and developing comprehensive care plans were not followed, as they require verification of vital signs before medication administration and the creation of a person-centered care plan to meet the resident's medical needs. The lack of adherence to these policies contributed to the deficiency identified in the care of the resident.
Failure to Monitor Resident's Inappropriate Behavior
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for a resident when it did not follow the physician's order to monitor the resident's inappropriate behavior. The resident, who had diagnoses of parkinsonism, mood disorder, and mild cognitive impairment, was admitted with a care plan that included monitoring for episodes of inappropriate touching towards staff. Despite a physician's order to monitor the resident's inappropriate behaviors every shift, there was no documentation indicating that staff monitored these behaviors from the specified period of 2/19/24 to 5/6/24. During an interview and record review, the Director of Nursing confirmed the absence of documentation for monitoring the resident's inappropriate behavior as ordered. The facility's policies and procedures for accepting, transcribing, and implementing physician orders, as well as for documentation, were reviewed and indicated that all documentation should be completed as required for each resident. However, the facility did not adhere to these policies, resulting in a failure to monitor the resident's behavior as mandated by the physician's order.
Failure to Document Bed Rail Alternatives and Obtain Informed Consent
Penalty
Summary
The facility failed to attempt, offer, and document the use of bed rail alternatives for 17 residents and did not obtain informed consent for one resident prior to the installation of bed rails. During the initial tour observation, it was noted that these residents had upper bed rails elevated and in use. The Director of Staff Development confirmed that the bed rails were used for turning and repositioning. However, there was no documentation indicating that alternatives were attempted or offered for these residents. Additionally, the Medical Record Director confirmed that the bed rail consent for one resident was obtained after the bed rails were already installed and in use. The facility's policy and procedure on side-rail safety, revised in 2012, states that bed rails should only be used to facilitate mobility and that alternatives should be attempted before using side rails as a restraint. The policy also requires a side-rail safety assessment by a licensed nurse or the interdisciplinary team upon admission, when side rails are implemented, and at least quarterly. The administrator confirmed that there was no documentation of bed rail evaluations or the use of alternatives for the 17 residents and that the bed rail consent for one resident was obtained post-installation.
Failure to Follow Recipe and Resident Dietary Preferences
Penalty
Summary
The facility failed to ensure that the recipe for spinach was followed according to the ingredient list and that accurate diets were served according to resident preferences. During an observation, Cook A added cooked red bell peppers to the spinach, which was not listed in the recipe. The Dietary Manager confirmed that red bell peppers were not part of the recipe and acknowledged that the cook was instructed to add them for extra color. This deviation from the standardized recipe was observed during meal preparation for approximately 15 residents. Additionally, the facility did not adhere to residents' dietary preferences. Resident 36, who had a documented dislike for bell peppers, was served spinach with red bell peppers. Similarly, Resident 51, who had a documented dislike for gravy, was served turkey with gravy. The Dietary Manager confirmed that residents' food preferences should always be followed, including their dislikes. The facility's policy and procedure on standardized recipes and resident food preferences were not followed, leading to these deficiencies.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices in the kitchen. Dietary Aide (DA) C was observed cleaning the floor and touching dirty surfaces without performing proper hand hygiene. DA C washed his hands with only water for approximately 15 seconds and then proceeded to unload clean utensils with his bare hands. During an interview, DA C acknowledged that he did not use soap and should have done so before handling clean dishes. This failure to follow hand hygiene protocols was observed during a kitchen inspection and confirmed through an interview with DA C. Additionally, multiple food items were found in the freezer past their use-by dates, including packages of hot dog and hamburger buns. Cook A confirmed that these items should have been discarded. Furthermore, a dented can of black beans was found on the dry storage shelf instead of being placed in the designated box for dented cans. The Dietary Manager (DM) confirmed that the can should not have been on the shelf for use. These observations indicate a failure to adhere to proper food storage and handling practices, which could potentially spread food-borne illnesses to residents.
Failure to Update Fall Care Plan
Penalty
Summary
The facility failed to update the fall care plan for Resident 84, who had a history of falls and was at high risk due to conditions such as a displaced intertrochanteric fracture of the right femur, Alzheimer's disease, and cognitive communication deficit. Despite the resident experiencing multiple falls, the interdisciplinary team did not review and revise the fall risk care plan after each incident. Specifically, after an unwitnessed fall on 2/3/2024 that resulted in hospitalization, there was no documentation of the care plan being updated upon the resident's return. Additionally, after another unwitnessed fall on 2/13/2024 and a witnessed fall on 3/19/2024, the care plan was noted to be updated, but no new fall risk interventions were implemented to prevent further falls. During an interview and record review on 3/28/2024, the Director of Staff Development confirmed that Resident 84's fall risk care plan was not updated following the falls on 2/3/2024 and 3/19/2024. The facility's policy on falls management, revised in 11/2012, mandates that recent falls be reviewed daily by a designated fall team to evaluate the cause and determine additional strategies to prevent recurrence. This policy was not adhered to, resulting in the failure to update and revise the care plan appropriately, leading to subsequent falls for Resident 84.
Failure to Implement Fall Management Policy for Resident
Penalty
Summary
The facility failed to implement its fall management policy and procedure for Resident 84, who had multiple falls. Resident 84, who had diagnoses including a displaced intertrochanteric fracture of the right femur, Alzheimer's disease, and cognitive communication deficit, was readmitted to the facility but did not receive a fall risk assessment upon readmission or after a significant change in condition. Despite having a history of falls and a recent fracture, the interdisciplinary team (IDT) did not develop or implement new interventions after Resident 84's falls on 2/3/2024, 2/13/2024, and 3/19/2024. This lack of action resulted in subsequent falls for Resident 84, who was observed with the bed not in the lowest position and floor mats that could be trip hazards in her room. Licensed vocational nurse K confirmed that fall risk assessments were only done upon admission, and not when there was a significant change in condition. The minimum data set coordinator (MDSC) and the director of staff development (DSD) both confirmed that no fall risk assessments were completed when Resident 84 was readmitted or when there was a significant change in condition. The physical therapist (PT) also confirmed that no post-fall screens were completed after Resident 84's falls, despite the resident being on therapy. The facility's policy on falls management, revised in 2012, indicated that residents should be assessed for fall risk and interventions should be implemented to reduce the risk of falls. The policy also stated that fall risk should be reassessed with each significant change of condition. However, this policy was not followed for Resident 84, leading to multiple falls and the potential for serious injury. The IDT failed to review and update the fall risk care plan and did not implement appropriate new interventions after each fall, as required by the facility's policy.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure respect and dignity for five residents by not providing privacy sleeves for their indwelling catheter urinary bags. Certified Nursing Assistant (CNA) N was observed preparing to empty Resident 94's urinary bag, which was visible from outside the room. Subsequent observations confirmed that Resident 94's urinary bag was not covered with a privacy sleeve. Similarly, Resident 199's urinary bag was visible from outside the room without a privacy sleeve. The Administrator confirmed that urinary bags should be covered with privacy sleeves. Resident 91, who has severe cognitive impairment and multiple medical conditions, was observed on two occasions with an uncovered urinary bag hanging under his wheelchair. During these observations, Resident 91's roommate had visitors in the room, making the uncovered urinary bag visible to them. Resident 3, who has intact cognition and multiple medical diagnoses, was also observed with an uncovered urinary bag that was easily visible to passersby in the hallway. Both a CNA and a Licensed Vocational Nurse (LVN) confirmed that Resident 3's urinary bag was not covered and acknowledged the importance of covering it for privacy. Resident 44 was observed lying in bed with his urinary bag hanging on a portable commode next to his bed, and the bag was not covered. An LVN verified that the urinary bag should be covered even when hanging on the commode. The facility's policy and procedure on privacy and dignity, revised on 10/24/17, indicated that residents' privacy and dignity should always be respected. However, the observations and interviews revealed that this policy was not followed, leading to a deficiency in maintaining residents' dignity and privacy.
Failure to Implement Self-Administration of Medication Policies
Penalty
Summary
The facility failed to implement their policies on self-administration of medication for two residents, leading to medications being left at the bedside without proper assessments or physician orders. Resident 84, who had moderately impaired cognition with a BIMS score of 9, was found with a bottle of antidiarrheal medication at their bedside, which they had brought from home. There was no physician order for this medication, and the resident had not been assessed for the ability to self-administer medications. The registered nurse confirmed the absence of such orders and acknowledged that the medication should not have been at the bedside. Similarly, Resident 3, who had an intact cognition with a BIMS score of 15, was observed with a bottle of eye drop medication on their overbed table. The resident stated they used the eye drops for dry eyes, but there was no physician order for this medication, nor an order allowing the resident to keep it at the bedside. The licensed vocational nurse confirmed the lack of orders and stated that the medication should not have been at the bedside. The facility's policy requires a self-administration assessment and physician order before allowing residents to self-administer medications, which was not followed in these cases.
Failure to Provide SNFABN to Residents
Penalty
Summary
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), which is a financial liability notice. Resident 13 was admitted to the facility and had their stay covered by Medicare until 12/19/23, while Resident 83 had their Medicare benefits from 12/2/23 until 1/12/24. Both residents continued to reside at the facility after their Medicare benefits ended. During an interview, the Business Office Manager (BOM) confirmed that she had never issued an SNFABN before and was unaware of the requirement until she received training on 3/11/24. The Administrator also confirmed that the residents were supposed to receive the SNFABN when their Medicare benefits ended. The facility's policy and procedure, revised in August 2021, indicated that the SNFABN should be delivered with the Notice of Medicare Non-Coverage (NOMNC) to ensure timely delivery when a Part A covered stay ends. However, this procedure was not followed for Residents 13 and 83. The failure to provide the SNFABN could lead to residents unknowingly assuming financial liability for services not covered by Medicare.
Inaccurate MDS Completion for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one of the sampled residents, Resident 63. Resident 63 was admitted with a diagnosis of bipolar disorder, a serious mental illness. The Preadmission Screening and Resident Review (PASRR) for Resident 63 indicated a 'Yes' for having a serious mental illness. However, during a review of Resident 63's MDS, it was found that section A1500, which pertains to the PASRR status, was incorrectly marked as 'No'. The MDS Coordinator confirmed that this section should have been coded as 'Yes'. The facility's policy and procedure for the Resident Assessment Instrument (RAI/MDS) requires that the MDS be completed timely and accurately according to federal guidelines. The failure to accurately assess Resident 63's mental health status compromised the facility's ability to provide appropriate, resident-centered care plan interventions. This discrepancy was identified during an interview and record review with the MDS Coordinator, who acknowledged the error in the MDS documentation.
Failure to Complete Level II PASRR for Two Residents
Penalty
Summary
The facility failed to ensure a Level II PASRR was completed for two residents, which is a federal requirement to ensure individuals with mental disorders and intellectual disabilities are not inappropriately placed in nursing homes for long-term care. Resident 41, who had diagnoses including paraplegia, schizophrenia, and morbid obesity, had a positive Level I PASRR screen completed but did not have a Level II PASRR completed due to being isolated as a health and safety precaution. The Minimum Data Set Coordinator (MDSC) acknowledged that the Level I PASRR was done either on admission or prior to admission and that all PASRR letters were uploaded into the electronic health record. However, the state portal website for PASRR does not trigger if a Level II was not done, leading to the oversight. Similarly, Resident 61, who had a positive Level I PASRR screen, did not have a Level II PASRR completed because they were in isolation due to an infectious disease when the Level II PASRR was scheduled. The MDSC admitted that the Level II PASRR was closed and never followed through to complete a new one. The facility's policy indicated that a PASRR should be completed and submitted online for new admissions within 24 hours, and recommendations from the Determination Letter should be included in the individual's Plan of Care. This failure had the potential to put the residents at risk for not receiving appropriate care and services for their mental health conditions.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for three residents. Resident 74, who was admitted with multiple diagnoses including depression, did not have a care plan addressing his mild depression despite showing signs of sadness and lack of motivation. The Social Service Director confirmed that no mood interventions were implemented after the initial assessment, and no care plan was developed to address Resident 74's mild depression. Resident 3, who was admitted with conditions requiring supplemental oxygen and anticoagulant medication, did not have care plans for either the use of oxygen or the anticoagulant medication. Observations confirmed that Resident 3 was using oxygen, and the MDS Coordinator verified that a care plan for oxygen use was not developed. Additionally, the Director of Staff Development confirmed that Resident 3 was taking Eliquis, an anticoagulant, but no care plan was created to manage its use. Resident 18, who was observed using oxygen, also did not have a care plan for its use. The Interim Director of Nursing confirmed that a care plan should have been developed for Resident 18's oxygen use. The facility's policy and procedure on care plans indicated that comprehensive, person-centered care plans should include measurable objectives and time frames to meet the resident's needs, but this was not followed for the three residents mentioned.
Failure to Follow Physician's Orders for Oxygen Supplementation
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services according to physician's orders for oxygen supplementation. Resident 148, who was admitted with chronic respiratory failure, hypoxia, and COPD, had an order for continuous oxygen administration at 2 liters per minute via nasal cannula. However, observations revealed that Resident 148 was receiving oxygen at 2.5 liters per minute. Licensed Vocational Nurse (LVN) L confirmed the discrepancy and acknowledged that the oxygen administration should follow the physician's order of 2 liters per minute. Similarly, Resident 15, who was admitted with respiratory failure, hypoxia, chronic diastolic heart failure, and unspecified asthma, had an order for continuous oxygen administration at 3 liters per minute via nasal cannula. Observations showed that Resident 15 was receiving oxygen at 2 liters per minute. LVN L confirmed the observation and stated that the oxygen administration should be at 3 liters per minute as ordered by the physician. The facility's policy on oxygen administration emphasizes the importance of verifying the physician's order, including the liter flow rate, which was not adhered to in these cases.
Failure to Reconcile Controlled Medications with MAR
Penalty
Summary
The facility failed to ensure that controlled medications were properly reconciled with the corresponding Medication Administration Records (MAR) for four residents. Specifically, the medications were signed out of the Controlled Drug Record (CDR) but were not documented on the MAR to indicate that the controlled medications were administered to the residents. This discrepancy was identified for four residents who were receiving as-needed controlled medications, including Tramadol and Hydrocodone-Acetaminophen. The failure to document the administration of these medications on the MAR was confirmed through interviews and record reviews with Licensed Vocational Nurses (LVNs) and the Pharmacy Consultant (PC). For Resident 7, a tablet of Tramadol was removed and documented on the CDR but not on the MAR. Similarly, for Resident 37, multiple instances of Hydrocodone-Acetaminophen were documented on the CDR but not on the MAR. Resident 58 also had a tablet of Hydrocodone-Acetaminophen documented on the CDR but not on the MAR. Lastly, for Resident 76, a tablet of Tramadol was documented on the CDR but not on the MAR. The facility's policy and procedure require that controlled medications be documented both on the accountability record and the MAR immediately after administration, which was not followed in these cases.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had an eight percent medication error rate when two medication errors out of 25 opportunities were observed during a medication pass for one resident. During a medication pass observation, a Licensed Vocational Nurse (LVN) was observed preparing and administering ten medications to a resident. However, the LVN failed to administer Zyrtec 10 mg and MiraLAX Oral Powder 17 grams as per the physician's order. The LVN confirmed that she forgot to go to the next page of the Medication Administration Record (MAR), resulting in the omission of these medications. The facility's policy and procedure indicated that medications should be administered in accordance with the written order of the attending physician.
Failure to Label Medications Appropriately
Penalty
Summary
The facility failed to ensure medications were labeled appropriately, as observed during a medication cart inspection. Specifically, an opened bottle of Refresh Tears lubricant eyedrop was found without a resident's name and an open date in medication cart AA. Additionally, an opened bottle of Vyzulta 0.024% Ophthalmic Solution and an opened bottle of Brimonidine Tartrate ophthalmic solution were also found without open dates. These observations were confirmed by a Licensed Vocational Nurse (LVN) during the inspection. During a phone interview with the Pharmacy Consultant (PC), it was confirmed that ophthalmic solutions are good for 28 days after being opened and should be labeled with the resident's name and an open date. The facility's policy and procedure, dated October 2017, also indicated that medications should be labeled in accordance with facility requirements and state and federal laws, with labels permanently affixed to the outside of the prescription container. The failure to label these medications appropriately could lead to the use of medications past their discard date, potentially resulting in unsafe and ineffective treatments for residents.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature for one test tray food item out of seven sampled food items. During an observation, Cook A added cooked red bell peppers to the cooked spinach, completing the cooking process at 11:59 a.m. Later, at 1:20 p.m., the Dietary Manager (DM) tested the internal temperature of seven food items on the sampled test tray after all residents were served the noon meal. One food item, the regular texture Club Spinach, had an internal temperature of 125 degrees Fahrenheit. The DM stated that all hot foods on the tray line should be maintained at 140 degrees Fahrenheit. The facility's policy and procedure indicated that hot foods should be held at 140 degrees Fahrenheit prior to service and that vegetables should be served promptly and not held on the steam table for long periods, with a maximum of one hour prior to serving.
Failure to Provide Physician-Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to provide the physician-prescribed therapeutic diet to four of 96 sampled residents. Three residents who were ordered a Controlled Carbohydrate Diet were served the wrong dessert item, Peach Cobbler Trifle, instead of the prescribed Vanilla Yogurt Mousse. This was observed during the noon meal service, and the Dietary Manager confirmed that the wrong dessert item was served to these residents. The meal tickets for these residents clearly indicated the Controlled Carbohydrate diet order, but the dietary aides did not follow the prescribed diet instructions. Additionally, one resident who was ordered a Fortified Diet did not receive the fortified food item, Super Soup, during the noon meal. The dietary aide failed to add the fortified soup to the resident's tray, and this was confirmed by the Dietary Manager. The meal ticket for this resident indicated the Fortified diet order, but the dietary aides did not comply with the prescribed diet. The facility's policy and procedure for therapeutic diets, which requires daily written instructions and proper training for dietary employees, was not followed in these instances.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented in two specific instances. First, a certified nursing assistant (CNA) did not perform hand hygiene while serving and setting up lunch trays for multiple residents. The CNA was observed assisting one resident with drinking, then immediately assisting another resident without performing hand hygiene in between. This pattern continued as the CNA served lunch trays to other residents without sanitizing hands, despite the facility's policy requiring hand hygiene between patient interactions. The CNA admitted to not using hand sanitizer due to concerns about skin dryness, and the infection control preventionist confirmed that hand hygiene should be performed between resident care activities. Second, a nasal cannula used for oxygen administration was found improperly stored on the floor in a resident's room. The resident was lying in bed with an oxygen concentrator at the bedside, and the nasal cannula tubing was observed on the floor. A licensed vocational nurse (LVN) confirmed the improper storage and acknowledged that the nasal cannula should not be on the floor due to infection control concerns. The facility's policy indicated that oxygen tubing and cannulas should be changed weekly and as needed for excessive soiling, but did not specifically address storage practices.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, and comfortable environment for two residents. Resident 94's bed controller was disconnected, leaving the head of the bed elevated for two days, causing discomfort. The Maintenance Director was aware of the issue but did not replace the bed until the following day. The Occupational Therapist was unaware of the problem until informed by the resident, and the facility's policy on accommodation of needs was not followed, as the resident's comfort was compromised for an extended period. Resident 41's toilet paper holder was broken for three days without being reported or fixed. The Maintenance Director could not find a work order for the issue, and staff members, including a CNA and an LVN, were either unaware of the problem or did not notice it. The facility's policy on work orders was not adhered to, as the broken toilet paper holder remained unfixed despite the process for reporting maintenance issues being in place.
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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