A Grace Sub Acute & Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 1250 S. Winchester Boulevard, San Jose, California 95128
- CMS Provider Number
- 056376
- Inspections on file
- 23
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at A Grace Sub Acute & Skilled Care during CMS and state inspections, most recent first.
The facility did not conduct fire drills at varied times as required, with records showing that drills for both PM and NOC shifts repeatedly occurred at the same times. This issue was confirmed through record review and staff interview, affecting all residents and smoke compartments.
A power strip not meeting required UL standards was found in use at a bedside, resulting in an electrical fire. The device had been brought in by a family member for charging a phone, and the facility could not verify its compliance with safety standards. This deficiency affected multiple residents and a smoke compartment.
A resident with a history of traumatic brain injury and epilepsy did not receive prescribed anti-seizure medications as ordered due to delays in pharmacy delivery. The delays were caused by the need for triplicate prescriptions for controlled substances and a lack of timely delivery authorization for a high-cost medication, with required documentation not provided promptly by the facility and physician. Facility policies requiring timely medication receipt and administration were not followed.
The facility failed to follow professional standards for several residents, including incomplete physician orders for insulin and lorazepam, lack of hypoglycemic protocols, and improper blood pressure monitoring on an arm with an AV fistula. Additionally, a resident on fluid restriction due to renal disease was not monitored for fluid intake and output, contrary to facility policy.
The facility failed to attempt alternatives before using side rails for numerous residents, as observed and documented in their care plans and assessments. Despite having physician orders for side rails for positioning and mobility, there was no evidence of alternative measures being considered. Interviews with the DON confirmed that alternatives were not deemed necessary, contradicting the facility's policy requiring less restrictive interventions to be documented and attempted first.
The facility failed to document the administration of controlled drugs for three residents, leading to unaccounted medications and potential errors. The nursing staff signed out medications from the Controlled Drug Record but did not record their administration on the Medication Administration Record, as required by facility policy. This issue was confirmed by the Minimum Data Set Coordinator.
The facility failed to maintain food safety standards, with undated and expired food items found in storage, and improper sanitization practices observed. Spoiled produce and expired test strips were noted, and a dietary supervisor used a contaminated thermometer without sanitizing it, risking foodborne illness for 44 residents.
The facility failed to follow infection prevention protocols, including dirty oxygen concentrator filters, improper PPE use by a nurse during medication administration to a resident with CP-C.R.E, and incorrect placement of a urinary drainage bag by a CNA, risking infection.
A resident with quadriplegia was not provided with an appropriate call device, relying instead on yelling for assistance. Despite the availability of alternative devices, the resident had not been assessed for a suitable option, contrary to the facility's policy on assistive devices.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, as required by policy. Critical information was missing from the care plans, including therapy services, safety details, completion dates, review dates, and necessary signatures. This was confirmed by interviews with the Nurse Supervisor, MDS Coordinator, and DON, who acknowledged the plans should have been completed within 72 hours.
The CP failed to identify and report medication irregularities for two residents. One resident had an unclear and potentially unsafe insulin order, while another resident with CKD received Calcium Acetate at incorrect times, not aligned with meals, affecting its efficacy. The CP did not address these issues during monthly reviews.
Two residents in the facility were affected by medication mismanagement. One resident received warfarin for an incorrect indication, as the orders specified pulmonary edema instead of the correct condition, pulmonary embolism. Another resident had a lidocaine patch applied continuously without the required 12-hour off period, contrary to the manufacturer's instructions. These errors were confirmed by the DON and a Consultant Pharmacist.
A survey found a medication error rate of 5.56% in an LTC facility. One error involved an LVN not allowing the required interval between puffs of an asthma inhaler for a resident, contrary to facility policy. Another error involved an RN failing to flush a gastrostomy tube with water between medications for a resident, as per policy.
The facility did not adhere to the meal preferences of two residents, as observed during a survey. One resident preferred a cheeseburger daily, which was not provided, and another was served rice despite disliking it. The dietary supervisor confirmed these discrepancies, which were against the facility's policy to honor food preferences.
A resident in a room was unable to reach the call button, which was observed hanging on the wall above the bed, out of reach. The resident confirmed the inability to reach the button, and it remained out of reach during multiple observations until an RN handed it to the resident. The facility's policy indicated that call light devices should be accessible to assist with resident safety and independence.
A facility failed to maintain a safe environment for a resident due to cracked walls near the bathroom door and toilet, which were reported but not fully repaired. The resident, who is cognitively intact, confirmed the facility's awareness of the issue since the previous year. The maintenance director acknowledged that repairs were started but incomplete, contrary to the facility's maintenance policy.
A resident with hemiplegia and muscle weakness experienced a witnessed fall in the facility. Despite being at moderate risk for falls, the facility failed to complete a Morse Fall Scale assessment after the incident, as required by their policy. This deficiency was confirmed through interviews and record reviews.
Failure to Conduct Fire Drills at Varied Times
Penalty
Summary
The facility failed to conduct fire drills at varied times as required by regulation. Record review showed that fire drills for both the PM and NOC shifts were conducted at the same times on multiple occasions within the last 12 months, specifically with PM drills at 4:00 p.m. and NOC drills at 2:30 a.m. This deficiency was identified during a review of fire drill records and confirmed in an interview with the Administrator, who stated that the drills were conducted by the Director of Staff Development. The failure to vary the timing of fire drills affected all 116 residents and all four smoke compartments in the facility.
Plan Of Correction
by the deficient practice. Missing Fire Drill was completed on 12/24/2025 and education was provided to The Maintenance Director and designee. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: The Maintenance Director or designee will maintain Fire drills according to regulation quarterly and be held at different times during the day, with a coded announcement being completed instead of audible alarms. Record keeping of quarterly tests to be gathered in a fire drill binder for reference and evidence of completion and compliance. Any updates necessary will be completed timely and reported to the Safety and QA Committee. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/24/25 K0712
Unapproved Power Strip Causes Electrical Fire at Bedside
Penalty
Summary
A deficiency was identified when a power strip was found in use at a patient bedside location that did not meet the required approval standards. During a facility tour, it was observed that a power strip was located approximately one foot away from a resident's bed on the ground in Resident Room 34. The Maintenance Supervisor confirmed that an electrical fire had occurred at this location in the early morning hours, and the resident occupying the bed reported that the power strip had been brought in by a family member for charging a phone. The facility was unable to verify whether the power strip in question met the necessary UL 1363A or UL 60601-1 standards required for use with patient-care-related electrical equipment in a patient care vicinity. This deficiency affected 47 out of 116 residents and one of four smoke compartments, as noted during the survey. The report does not provide additional details regarding the medical history or condition of the resident at the time of the incident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: A: Power strips and extension cords were immediately removed from the rooms. Both family and resident were notified of power cord safety and the importance of using medical-grade approved cords and safety of surroundings around the power cords. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: A: All residents have the potential to be affected by the deficient practice. Facility-wide audit conducted on 12/08/25 and all other power cords identified were noted and removed. Education was provided on 12/08/25 to the Maintenance Director on appropriate power cords within the facility. Facility-wide audit to be completed weekly for 12 weeks and then PRN as needed. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: A: 1) Resident education on proper equipment usage (i.e., hospital graded extension cords only) 2) Staff In-Serviced on fire safety and prevention in regards to outlets and proper power cord identification—importance of keeping residents' belongings away from outlets and bringing concerns related to storage of belongings to facility leadership team 3) Daily resident room round sheet updated and to be conducted by assigned department managers. Weekly facility rounds will be conducted and every room and common area checked to ensure approved hospital grade extension cords are in place and outlet integrity is compliant by the maintenance supervisor or designee. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: A: Room round sheets will be turned in weekly. The Maintenance Director or designee will complete a facility-wide audit weekly for 12 weeks and report the results of the audit to the Safety Committee and QA meeting for compliance evaluation x4 months and then PRN as needed. Include dates when corrective action will be completed. The corrective action completion dates must be acceptable by the State Agency: Completion date: 12/11/2025
Failure to Provide Timely Pharmacy Services Resulting in Missed Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmacy services to meet the needs of a resident who was readmitted with diagnoses including traumatic brain injury and epilepsy. Upon review, it was found that the resident had physician orders for multiple anti-seizure medications, including Clobazam, Lacosamide, and Zonisamide, all to be administered via gastrostomy tube. However, the medication administration record showed that these medications were not given on several days following the resident's readmission. Progress notes confirmed that the medications were not available at the facility and were pending delivery from the pharmacy. Interviews with facility staff and the consultant pharmacist revealed that delays occurred due to the need for triplicate prescriptions for controlled substances and a lack of timely delivery authorization for a high-cost medication. The pharmacy had requested the necessary documentation and authorizations from both the physician and the facility, but did not receive them in time to ensure the medications were available as ordered. Facility policies required timely receipt and administration of medications, but these were not followed, resulting in the resident not receiving prescribed anti-seizure medications as ordered.
Incomplete Physician Orders and Improper Monitoring in LTC Facility
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for several residents, leading to potential unsafe implementation of medical orders and unmonitored medical conditions. For Residents 25, 35, 93, and 98, there were incomplete physician orders. Resident 93 had an unclear insulin order with an incorrect dosage and no specified frequency or parameters for administration. Resident 35's lorazepam orders lacked dosing frequency, yet the medication was administered multiple times without clarification from the physician. Resident 98's insulin orders referenced a hypoglycemic protocol that was not present in the clinical record, leaving staff without guidance for managing low blood sugar levels. Resident 25 also had insulin orders that referred to non-existent hypoglycemia orders, which were only clarified with the physician shortly before the surveyor's interview. These deficiencies in medication orders and protocols could lead to inappropriate medication administration and inadequate response to residents' medical needs. The facility's policies required medication orders to include dosage, frequency, and clinical conditions, but these were not consistently followed. Additionally, Resident 75, who had an AV fistula for dialysis, had blood pressure readings taken on the arm with the fistula, contrary to care plan instructions and facility policy. This practice could cause injury or bleeding. Furthermore, Resident 75 was on a fluid restriction due to end-stage renal disease, but there was no monitoring of fluid intake and output, which is crucial for dialysis patients. The facility's policy required monitoring of fluid balance, but this was not implemented for Resident 75.
Failure to Attempt Alternatives Before Using Side Rails
Penalty
Summary
The facility failed to offer and/or attempt alternatives before using side rails for 18 of 22 sampled residents and 77 non-sampled residents. This deficiency was identified through observations, interviews, and record reviews. The residents involved had physician orders for side rails for positioning, mobility, or postural support, but there was no documentation that alternatives were considered or attempted prior to their use. The facility's policy required less restrictive interventions to be incorporated into care planning, but this was not followed. During observations, it was noted that residents had side rails or grab bars in use without documented attempts of alternative measures. For instance, Resident 66 had side rails for positioning and mobility, but the care plan and assessments lacked evidence of alternative attempts. Similar findings were noted for other residents, such as Resident 38, Resident 75, and Resident 77, among others. Informed consents for the use of bed rails indicated that alternatives were not attempted, and in some cases, were deemed not appropriate due to the use of specific mattresses like low air loss mattresses. Interviews with the Director of Nursing (DON) revealed that the facility did not consider alternatives necessary, as side rails were used for support, mobility, and positioning. The DON confirmed that most residents had side rails and that the facility used them if deemed beneficial. The facility's policy on the proper use of side rails, revised in 2016, stated that less restrictive interventions should be documented and attempted before considering side rails, but this was not adhered to, leading to the deficiency.
Failure to Document Controlled Drug Administration
Penalty
Summary
The facility failed to ensure accurate accountability and documentation of controlled drug administration for three residents, leading to potential medication errors and drug diversion. During an interview with the Director of Nursing (DON), it was explained that the facility's policy requires nurses to assess residents, review physician orders, sign out medications from the Controlled Drug Record (CDR), administer the medication, document the administration on the Medication Administration Record (MAR), and reassess the resident within one hour. However, discrepancies were found in the records of three residents, indicating that the nursing staff signed out medications from the CDR but failed to document their administration on the MAR. For Resident 39, there were five occasions where diazepam was signed out but not documented on the MAR. Resident 35 had nine instances where lorazepam was signed out without documentation on the MAR. Similarly, Resident 85 had four instances where oxycodone was removed without proper documentation. The Minimum Data Set Coordinator (MDSC) confirmed these findings and acknowledged that the medications were unaccounted for, as the nursing staff did not document the administration as required by the facility's policy.
Food Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several observations in the kitchen. Undated food items, food past their use-by date, and spoiled produce such as bananas with black spots, partially soft tomatoes, and dry green onions were found in the refrigerator and on the shelves. Additionally, a tube of Auto-Chlor test strips, essential for ensuring proper chemical concentration in cleaning solutions, was expired. The dietary supervisor confirmed these findings and acknowledged that expired food should not be on the shelves and should have been discarded. The facility's policies on labeling, dating, and storing produce were not followed, contributing to these deficiencies. Furthermore, during a tray line observation, the dietary supervisor failed to sanitize a contaminated thermometer before using it to check the temperature of lemonade. The thermometer was handled improperly, touching the bin several times before being dipped into the lemonade. This action was contrary to the facility's policy on thermometer use and calibration, which requires cleaning and sanitizing the thermometer before use. These lapses in food safety practices had the potential to cause foodborne illness and cross-contamination, affecting the 44 residents eating at the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention techniques in several instances. Two oxygen concentrators in different rooms were observed with dirty filters, indicating a lack of adherence to the facility's policy for weekly cleaning by the assigned environmental services staff. The Assistant Director of Nursing acknowledged the need for cleaning and checking the policy for frequency, while the Administrator later confirmed the filters had been cleaned. A registered nurse did not follow enhanced barrier precautions while administering medication to a resident who tested positive for CP-C.R.E, a multi-drug resistant organism. Despite clear signage indicating the need for gowns and gloves during high-contact care activities, the nurse entered the resident's room twice without wearing a gown, although gloves and a mask were used. The nurse admitted to the oversight after being shown the precautionary posters. Additionally, a certified nursing assistant placed a urinary drainage bag on a resident's bed during personal care, causing urine to flow back toward the resident. This action was confirmed by the treatment nurse and the infection preventionist, who both stated that the drainage bag should be kept below the bladder to prevent infection. The facility's policy also supports this practice, emphasizing the need to position the drainage bag lower than the bladder at all times.
Failure to Provide Appropriate Call Device for Resident with Quadriplegia
Penalty
Summary
The facility failed to accommodate the needs of a resident with quadriplegia by not providing an appropriate staff call device. The resident, who was admitted with diagnoses including respiratory failure and quadriplegia, was observed with hand splints and a call button placed next to her on the bed. However, due to her condition, she was unable to use the call button effectively and instead had to yell out for assistance. Interviews with staff, including a registered nurse and the maintenance director, revealed that the resident had not been assessed for an appropriate call device, despite the availability of alternative devices that could be activated by other means, such as a head-activated call device. The facility's policy on assistive devices and equipment indicated that call light devices should be appropriate for the resident's condition. Despite this, the resident's needs were not adequately assessed or met, as confirmed by the nurse supervisor and the Director of Nursing. Both acknowledged the availability of other call devices that could be more suitable for the resident's condition, yet no action had been taken to provide such a device. This oversight had the potential to delay necessary care and services for the resident.
Failure to Complete Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents, Resident 66 and Resident 25, as required by their policy. For Resident 66, the baseline care plan was missing critical information such as therapy services, completion date, review date with the resident or representative, and signatures from both staff and the resident or representative. Similarly, Resident 25's baseline care plan lacked details on safety, completion date, review date, and necessary signatures. These omissions were confirmed during interviews with the Nurse Supervisor, MDS Coordinator, and Director of Nursing, who all acknowledged that the baseline care plans should have been completed within 72 hours of admission. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 72 hours to ensure the resident's immediate care needs are met. This includes reviewing healthcare practitioner orders and implementing a plan covering initial goals, physician orders, dietary needs, therapy services, and social services. The policy also requires that a summary of the baseline care plan be provided to the resident and their representative. The failure to adhere to this policy resulted in the potential for residents and their responsible parties to be unaware of the care plan, as evidenced by the incomplete documentation for Residents 66 and 25.
Consultant Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The consultant pharmacist (CP) failed to identify and report medication irregularities during the monthly drug regimen review for two residents. For one resident, an order for Admelog insulin was issued without specifying the frequency or parameters for administration, and the dose was incorrectly set at 3 ml, equating to 300 units, which is excessively high. Despite the order being unclear and potentially unsafe, the CP did not identify or report this irregularity during the monthly reviews since July 2024. For another resident with chronic kidney disease, the CP did not ensure that the medication Calcium Acetate was administered in accordance with the manufacturer's specifications, which require it to be taken with meals. The facility's administration schedule did not align with meal times, resulting in the medication being given at incorrect times on 35 out of 39 occasions. The resident's phosphorous levels were high, indicating the medication was not optimally effective. The CP did not make any recommendations to correct the administration timing after June 2024.
Medication Mismanagement for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, leading to a deficiency in medication management. Resident 35 was administered warfarin, a blood thinner, for an incorrect indication. The resident's clinical record showed a diagnosis of chronic embolism and thrombosis, as well as a saddle embolus of the pulmonary artery with acute cor pulmonale. However, the physician's orders incorrectly indicated that warfarin was prescribed for pulmonary edema, rather than the appropriate condition of pulmonary embolism. This error was confirmed during an interview with the Director of Nursing, who acknowledged the incorrect diagnosis in the warfarin orders. Resident 98 was affected by improper administration of a lidocaine patch, which was not used according to the manufacturer's specifications. The resident's physician's orders specified the application of a lidocaine patch for back pain management, but the patch was applied continuously without the required 12-hour off period. The Licensed Vocational Nurse confirmed the incorrect application schedule, and the Director of Nursing verified that the facility's template for lidocaine patch application was not followed. The Consultant Pharmacist also confirmed the correct usage instructions for the lidocaine patch, highlighting the deviation from proper medication administration practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 5.56% during a survey, with two errors occurring out of 36 opportunities. One error involved a Licensed Vocational Nurse (LVN) administering an asthma medication, Alvesco, to a resident without allowing the recommended 1-2 minute interval between puffs. The LVN was unaware of the need to space out inhalations, which was contrary to the facility's policy and procedures that required a minimum of one minute between inhalations of the same medication. The second error involved a Registered Nurse (RN) administering medications via a gastrostomy tube to another resident. The RN failed to flush the tube with water between administering each of the ten medications, as required by the facility's policy. The policy specified that the tube should be flushed with 10 mL of water between medications and a final flush of 50 mL after the last medication. The RN acknowledged the oversight during an interview, confirming that he did not follow the correct procedure.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals according to the preferences and dislikes of two residents, which was identified during a survey. Resident 55, who was admitted to the facility on an unspecified date, preferred to have a cheeseburger every day, but this preference was not honored during a lunch service observed on October 15, 2024. Similarly, Resident 67, admitted on an unspecified date, was served rice despite her documented dislike for it. These discrepancies were confirmed during an interview with the dietary supervisor, who acknowledged that meals should have been served according to the residents' preferences and dislikes. The facility's 2023 policy on food preferences states that residents' food preferences will be adhered to within reason, and substitutes for disliked foods will be provided from the appropriate food group.
Resident's Call Button Out of Reach
Penalty
Summary
The facility failed to ensure that a resident had access to a staff call device, which is essential for requesting help or in case of an emergency. During multiple observations in Room R3, the call button for bed A was found hanging on the wall above the head of the bed, out of reach of the resident. The resident confirmed that she could not reach the call button and expressed a desire to be able to call for assistance. Despite being observed at different times throughout the day, the call button remained out of reach until a registered nurse noticed the issue and handed the call button to the resident. The facility's policy and procedure on assistive devices and equipment, revised in January 2020, indicated that call light devices should be provided to assist with resident mobility, safety, and independence.
Facility Fails to Repair Cracked Walls in Resident's Bathroom
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for one of the sampled residents due to cracked walls near the bathroom door and at the bottom left side of the toilet in the bathroom. This issue was observed during an interview with the resident, who confirmed that the facility was aware of the damage since the previous year. The resident, who was cognitively intact with a BIMS score of 15, expressed that the walls were damaged and needed repair. During a review of the maintenance log with the maintenance director, it was confirmed that the maintenance staff had started repairs but missed the areas near the bathroom door and the bottom of the toilet. The facility's policy on maintenance service, revised in 2009, indicates that the maintenance department is responsible for maintaining the building in good repair and free from hazards. However, the failure to address the cracked walls in a timely manner represents a deficiency in maintaining a safe environment for residents.
Failure to Complete Morse Fall Scale After Resident Fall
Penalty
Summary
The facility failed to complete a Morse Fall Scale assessment after a witnessed fall involving a resident, which is a requirement according to the facility's policy. The resident, who had diagnoses including hemiplegia, disorientation, and muscle weakness, was admitted on an unspecified date and was identified as being at moderate risk for falls based on a previous Morse Fall Scale assessment. On a specific date, the resident was seen scooting out of bed by a licensed nurse (LN A) and another staff member. Despite attempts to assist, the resident slid onto the ground, which was documented as a witnessed fall. Upon review of the resident's medical record, it was found that there was no documentation of a Morse Fall Scale assessment being completed after the fall. This was confirmed during an interview with another licensed nurse (LN B), who acknowledged that the facility's protocol required a Morse Fall Scale assessment to be completed after each fall. The facility's policy and an undated fall checklist both indicated the necessity of conducting a Morse assessment following a fall, highlighting the deficiency in adhering to established procedures.
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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