Advanced Health Care Of Sacramento
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 1411 Expo Parkway, Sacramento, California 95815
- CMS Provider Number
- 555913
- Inspections on file
- 21
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Advanced Health Care Of Sacramento during CMS and state inspections, most recent first.
Kitchen staff were unable to properly calibrate food thermometers during meal service, with repeated failed attempts and inconsistent readings. Staff lacked knowledge of the correct calibration procedure, could not provide relevant policy guidance, and had no record of adequate training or regular calibration documentation, as required by facility policy.
A resident was given escitalopram, an antidepressant, without a documented diagnosis of depression or observed behavioral symptoms to justify its use. The resident's assessments and medical records indicated no depression, and staff interviews confirmed the absence of depressive symptoms or target behaviors. Despite this, the medication was continued, and the facility could not provide a policy on unnecessary medications.
Surveyors found that a medication refrigerator containing lorazepam and a medication cart were both left unlocked and unattended. Facility staff, including the DON and licensed nurses, confirmed these items should have been locked when not in use, as required by facility policy for medication and controlled substance security.
Kitchen waste fat was found uncovered in a silver pot on the floor near a garbage can, and an outdoor grease receptacle bin was repeatedly observed with its lid open and grease residue present. The Certified Dietary Manager confirmed the grease was from the kitchen stove's grease trap and that staff had not received training on proper disposal or pest avoidance. Facility policy required tight-fitting lids and sanitary maintenance, which was not followed.
A resident with cognitive and cardiac conditions eloped from the facility due to inadequate supervision. The individual was later found at a nearby restaurant after being reported missing, and was returned to the facility for medical assessment. The incident occurred despite the resident's dietary restrictions and the facility's policy requiring a safe environment.
The facility failed to safely store food for two residents, as food was found in room refrigerators labeled as coolers, which were not monitored for safe food temperatures. Interviews revealed inconsistencies in staff understanding and enforcement of food storage policies. The DON confirmed that room refrigerators were meant only for beverages, and any outside food should be stored in the gym refrigerator. However, some staff were unaware of these guidelines, leading to improper food storage and a potential risk of food-borne illness.
A resident's responsible party was not provided with a written notice of bed-hold when the resident was transferred to a hospital. Despite the facility's policy requiring notification, the responsible party was not informed about the bed-hold options, as confirmed by interviews with the Director of Nursing and the Admission Coordinator.
The facility failed to develop and update person-centered care plans for several residents, affecting their ability to address medical and psychosocial needs. This included missing care plans for antibiotics, psychotropic medications, and PICC line management, as well as inaccuracies in nutrition interventions. The facility's policy requires care plans to be updated as needed, which was not followed.
Nursing staff failed to follow professional standards in medication administration and IV management for four residents. A resident did not have their heart rate or blood pressure checked before receiving digoxin and midodrine. Another resident received Lovenox injections without proper site rotation. Additionally, a resident's PICC line was not monitored or had its dressing changed as required, and another resident's port-a-cath was not flushed due to missing physician orders.
A facility failed to accurately document the administration of controlled medications for a resident, leading to potential misuse. The DON confirmed discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR) for hydrocodone/acetaminophen, with late or missing entries. This failure to follow policy could result in harm if doses were administered without proper documentation.
A LTC facility was found to have an 18.18% medication error rate during a medication pass observation. Errors included administering medications on an empty stomach, failing to rotate injection sites, and not providing prescribed medications due to unavailability. These actions were contrary to physician's orders and manufacturer's specifications, affecting the therapeutic effect of the medications for two residents.
A resident received expired doses of insulin lispro and insulin glargine due to the failure of nursing staff to check expiration dates before administration. The facility's policies require expired medications to be discarded and replaced, but these procedures were not followed, resulting in the administration of ineffective insulin.
The facility failed to properly store and label medications, including tubersol, insulin, and inhalers, as observed during inspections of medication carts. Medications were found stored at incorrect temperatures, missing opened dates, and some were expired. Interviews confirmed these practices could risk resident safety, as facility policies on medication storage and labeling were not adhered to.
A facility failed to maintain effective infection control practices during medication administration. An LPN did not perform hand hygiene before or after glove use and did not disinfect a pill cutter after use, contrary to facility policy. These actions increased the risk of infection spread among 39 residents.
A resident experienced skin irritation and discomfort after a Licensed Nurse applied Bengay instead of the prescribed Voltaren Arthritis Pain gel. The nurse, who was busy and running behind, failed to verify the medication before application. The resident, who was cognitively intact, reported the burning sensation immediately. The Director of Nursing confirmed the error and lack of documentation, highlighting a failure to follow the facility's medication administration policy.
A resident with a history of amputation and diabetes did not receive prescribed wound care for their left heel and toe, despite documentation indicating otherwise. The DON confirmed the treatments were not completed, and a wound nurse noted unchanged bandages, highlighting a failure to follow physician orders.
A resident with a history of amputation and diabetes had worsening wounds due to a Licensed Nurse falsely documenting wound care as completed. The Director of Nursing confirmed the treatments were not performed, and a Wound Nurse observed unchanged bandages, indicating the care was not provided as ordered.
The facility failed to secure medications when a medication cart was found unlocked and unattended, with multiple people walking by. The ADON confirmed the cart was unlocked and should have been secured to prevent unauthorized access. The DON expected all medication carts to be locked when unattended, as per the facility's policy.
A resident with multiple health conditions, including heart failure and chronic kidney disease, was on a physician-ordered 1500 ml per day fluid restriction. Despite this, the resident was found with a water pitcher in their room, which they had been consuming. Staff interviews revealed a lack of communication and adherence to the fluid restriction policy, as the CNA was unaware of the specific order and did not measure the water provided. The DON confirmed the failure to follow the physician's order and the absence of necessary signage in the resident's room.
Failure to Ensure Proper Thermometer Calibration and Staff Training in Food Safety
Penalty
Summary
The facility failed to ensure that food preparation was conducted in accordance with professional standards for food service safety. During a lunch tray line observation, kitchen staff, including the lead cook and certified dietary manager, were unable to properly demonstrate or verbalize the correct procedure for calibrating food thermometers. Multiple attempts to calibrate digital thermometers using the ice bath method resulted in inconsistent and inaccurate readings, with staff unable to achieve the required 32°F reading. Staff also could not provide a relevant policy for reference during the observation and acknowledged their inability to properly calibrate thermometers. Further review revealed a lack of documented staff education or in-service training on thermometer calibration, with only two sporadic entries on an emergency calibration log and no ongoing monthly temperature data. The facility's written policy required monthly calibration using the ice point method, specifying a 30-second wait time for an accurate reading, which staff did not follow. Both the certified dietary manager and registered dietician confirmed the absence of adequate staff training and documentation related to thermometer calibration, as well as the expectation that staff should be knowledgeable about proper food temperature controls.
Administration of Antidepressant Without Justified Diagnosis or Symptoms
Penalty
Summary
A deficiency occurred when a resident was administered an antidepressant medication, escitalopram, without a corresponding medical diagnosis or documented behavioral symptoms to justify its use. The resident was admitted with a diagnosis of anxiety disorder, but there was no diagnosis of depression documented in the Minimum Data Set (MDS), physician progress notes, or the problem list. The MDS assessment indicated no symptoms or behaviors of depression, and the depression screening was negative. Despite this, a physician's order was written for escitalopram with the indication of depression, citing 'verbalized sadness' as the target behavior, but the Treatment Administration History Record showed that this behavior did not occur during the review period. Further review of the Medication Regimen Review raised concerns about the lack of a documented indication for escitalopram, noting that depression was not listed in the resident's problem list and the history and physical stated the depression screening was negative. Interviews with facility staff, including the MDS Coordinator, a licensed nurse, and the DON, confirmed that the resident did not have a diagnosis of depression and that no target behaviors were observed or documented. The facility's policy on comprehensive care planning was reviewed, but a policy on unnecessary medications was requested and not provided.
Failure to Securely Store Medications and Controlled Substances
Penalty
Summary
Surveyors observed that the facility failed to ensure the secure storage of medications and controlled substances. During an inspection of the medication storage room, the refrigerator containing lorazepam, a controlled substance, was found unlocked and unattended, despite facility policy requiring such items to be double-locked and accessible only to authorized personnel. The Director of Staff Development and the Director of Nursing both confirmed that the refrigerator should have been locked when not in active use to prevent unauthorized access. Additionally, a medication cart was found unlocked and unattended. Licensed nurses present at the time acknowledged that the cart should have been locked when not attended, in accordance with facility policy. Review of the facility's medication storage policy confirmed that all drugs and biologicals must be stored in locked compartments, with controlled substances under double lock, and that medication rooms and carts must be locked or attended by authorized staff.
Improper Disposal and Storage of Kitchen Grease and Refuse
Penalty
Summary
The facility failed to maintain sanitary conditions in both indoor and outdoor refuse areas, as observed during multiple kitchen tours. In the Receiving Room, a one-gallon uncovered silver pot, half-filled with thick yellow liquid from the kitchen stove's grease trap, was found on the floor near a garbage can. Additionally, outside dumpsters were found with their doors open, and a green rigid plastic receptacle bin was observed with its lid open. Large amounts of old, dried, and wet yellow grease and food particles were adhered to the grated opening of the bin. On a subsequent observation, the same bin was again found with its lid open, and the silver pot was turned upside down over the grated opening. During interviews, the Certified Dietary Manager (CDM) confirmed that the silver pot was used to collect grease from the kitchen and was stored in the Receiving Room for convenience before being disposed of in the outside receptacle. The CDM acknowledged that staff had not received in-service training related to grease or garbage disposal or pest avoidance, and there was uncertainty regarding the facility's garbage/refuse disposal policy. The facility's policy and procedure required containers to have tight-fitting lids and to be maintained in a sanitary manner, which was not followed in these instances.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of a resident who eloped from the building. The resident, who had diagnoses including toxic encephalopathy and congestive heart failure, was admitted with a diet order for pureed texture and mildly thick liquids. On the day of the incident, a CNA notified a nurse that the resident was missing. A thorough search of the resident's room, the building, and staff rooms was conducted, but the resident could not be located. Facility management reviewed surveillance cameras and confirmed that the resident had left the building and was seen heading east. The resident was later found inside a local restaurant approximately 0.4 miles from the facility by the Administrator in Training. The restaurant staff had contacted emergency services due to the resident appearing confused. Upon return to the facility, the resident was medically assessed, including for aspiration risk due to consumption of non-thickened liquids. The Director of Nursing confirmed that the resident was not their own responsible party and reiterated the resident's dietary restrictions. The facility's policy states that residents have the right to a safe environment, but the lack of adequate supervision allowed the resident to leave the premises unsupervised.
Improper Food Storage in Resident Room Refrigerators
Penalty
Summary
The facility failed to safely store food for two residents, as food was found in room refrigerators labeled as coolers, which were not monitored for safe food temperatures. Resident 2, admitted with multiple diagnoses including metabolic encephalopathy and hemiplegia, had an open cup of applesauce and a container of chocolate pudding in their room refrigerator. Similarly, Resident 5, who had undergone orthopedic aftercare following an amputation and had other health issues, had a container of fruit salad in their room refrigerator. Both refrigerators had signs indicating they were for drinks only, and no food storage was permitted. Interviews with staff revealed inconsistencies in the understanding and enforcement of food storage policies. A CNA mentioned that room refrigerators were not used for outside food except for protein shakes, and snacks were to be discarded after one day if opened. However, the housekeeper stated that she did not discard items unless the resident was discharged. The DON confirmed that room refrigerators were meant only for beverages and that any outside food should be stored in the gym refrigerator, which was monitored for temperature. Despite this, some staff, including LN 2 and LN 3, were unaware of these guidelines and believed snacks could be stored in room refrigerators. The facility's policies on food storage and handling from outside sources were not effectively implemented. The policy indicated that food should be stored at appropriate temperatures to prevent contamination, and food from outside sources should be monitored and stored correctly. However, there was no policy for monitoring room refrigerator temperatures, as they were not intended for food storage. This lack of monitoring and enforcement of food storage policies led to the deficiency, as food was improperly stored in room refrigerators, posing a risk of food-borne illness to residents.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide a written notice of bed-hold to a resident's responsible party (RP) at the time of the resident's transfer to a hospital. This deficiency was identified for one of the three sampled residents. The resident, who was admitted to the facility with hypertensive heart disease and generalized weakness, was transferred to the hospital due to low oxygen levels. Despite the transfer, there was no documented evidence that the resident's RP was informed in writing about the bed-hold policy, which is a requirement according to the facility's policy. Interviews with the resident's RP and facility staff, including the Director of Nursing (DON) and the Admission Coordinator (AC), confirmed that the RP did not receive any written notice or information regarding the bed-hold options. The AC, who was responsible for notifying residents or their RPs about bed-hold notices, admitted that the RP was neither called nor offered a bed-hold. The facility's policy mandates that the RP should be notified about the bed-hold option when a resident is transferred to acute care, but this procedure was not followed in this case.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, which compromised their ability to meet the residents' medical, physical, mental, and psychosocial needs. For Resident 32, despite being prescribed Augmentin for a urinary tract infection, there was no care plan developed to monitor the effectiveness of the antibiotic or any potential adverse side effects. This was confirmed by the Minimum Data Set Nurse during a record review. Resident 22's care plan lacked interventions for the management of a PICC line and the use of psychotropic medication, despite having orders for both. Similarly, Resident 186's care plan inaccurately included interventions for tube feedings and IV fluids, which were not part of the resident's treatment. Resident 189's care plan also failed to include necessary interventions for a PICC line, while incorrectly listing tube feedings and IV fluids. Resident 191's care plan did not incorporate the use of multiple psychotropic medications prescribed for schizophrenia and depression. Additionally, Resident 1's comprehensive care plan did not reflect the prescribed Alzheimer's medication, rivastigmine, despite its inclusion in the physician's orders. The Director of Nursing confirmed the omission of this medication from the care plan. The facility's policy mandates that care plans be updated as needed, reflecting changes in conditions, goals, and interventions, which was not adhered to in these cases.
Medication and IV Management Deficiencies
Penalty
Summary
Nursing staff at the facility failed to adhere to professional standards of quality in the administration of medications and management of intravenous lines for four residents. For Resident 26, the nursing staff did not check the heart rate or blood pressure before administering digoxin and midodrine, despite physician orders specifying these parameters. This oversight occurred during a medication pass observation, where the licensed nurse acknowledged the failure to perform the necessary checks. Resident 392 received Lovenox injections without proper site rotation, contrary to the manufacturer's specifications. The nurse administered the injection in the same location on consecutive days, which could lead to bruising or scar tissue formation. The Director of Nursing confirmed that site rotation is essential to prevent these issues and ensure proper medication absorption. For Resident 22, the nursing staff did not obtain necessary physician orders for monitoring and changing the dressing of a PICC line, which is crucial for preventing infection. Similarly, Resident 537's port-a-cath was not flushed as required, and there was no physician order for this procedure. The facility's policy mandates daily flushing of accessed ports, but this was not documented or performed, as confirmed by the nursing staff and the Director of Nursing.
Inaccurate Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accounting of controlled substance medications for a resident, leading to potential misuse or abuse. The Director of Nursing (DON) confirmed that the expectation was for nurses to sign out controlled medications from the Controlled Drug Record (CDR) and document their administration on the Medication Administration Record (MAR). However, discrepancies were found in the records for a resident prescribed hydrocodone/acetaminophen for pain management. On multiple occasions, the CDR indicated that doses were removed from the medication cart, but the MAR either showed late documentation or no documentation at all, indicating a lack of accurate record-keeping by the nursing staff. The specific instances of inaccurate documentation included late entries for doses administered and missing entries for doses removed from the cart. For example, on one occasion, a dose was removed at 1 a.m., but the MAR was not updated until over four hours later. Similarly, another dose was removed at 7:57 p.m., but the MAR was updated over three hours later. The DON acknowledged these inaccuracies and stated that the failure to document at the time of administration could result in harm to the resident if another dose was given without knowledge of the previous administration. The facility's policy required immediate documentation after medication administration, which was not followed in these instances.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have an 18.18% medication error rate during a medication pass observation, which is significantly higher than the acceptable threshold of 5%. The errors involved two residents, with multiple instances of medications not being administered according to the prescriber's orders or manufacturer's specifications. For Resident 26, a licensed nurse (LN 1) administered Macrobid and potassium chloride on an empty stomach, contrary to the requirement to give these medications with food to improve absorption and reduce adverse effects. Additionally, LN 1 failed to remove a lidocaine patch after 12 hours as per the physician's order, risking lidocaine toxicity. For Resident 392, LN 1 administered Lovenox injections in the same site on consecutive days, contrary to the requirement to rotate injection sites to prevent bruising and scar tissue formation. Furthermore, LN 1 did not administer Trelegy Ellipta and Metamucil as they were not available in the medication cart, despite physician's orders for these medications. The Director of Nursing (DON) confirmed that nursing staff were expected to follow the provider's instructions and manufacturer's specifications when administering medications. The report highlights the failure of the nursing staff to adhere to medication administration protocols, which resulted in residents not receiving the full therapeutic effect of their medications. The DON and Pharmacy Consultant emphasized the importance of following special instructions and rotating injection sites to ensure proper medication absorption and prevent adverse effects. The facility's policy and procedure on medication orders also stressed the need for clear and complete orders, which were not followed in these instances.
Expired Insulin Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they administered expired insulin to one of the sampled residents. During an inspection of a medication cart, it was discovered that insulin lispro and insulin glargine vials for a resident were past their expiration dates. The Licensed Nurse confirmed that the insulins had expired, and a review of the resident's medical record showed that the resident received seven doses of expired insulin lispro and four doses of expired insulin glargine over several days. The Director of Nursing stated that nursing staff are expected to check expiration dates before administering medications, and confirmed that expired insulin would not be effective in controlling blood sugar. The facility's policy and procedure documents also indicated that expired medications should be discarded immediately and replaced. However, these procedures were not followed, leading to the administration of expired insulin to the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed during an inspection of medication carts. On Medication Cart 2, a vial of tubersol was found stored outside the refrigerator, contrary to the manufacturer's instructions, which require refrigeration to maintain effectiveness. Additionally, an Evencare G3 vial of test strips was missing an opened date, and two vials of insulin were not discarded after the recommended 28 days. A Breo Ellipta inhaler was also found without an opened date, and several expired medications, including tubersol and Pepto Bismol, were identified. On Medication Cart 3, similar issues were observed, including an Evencare G3 vial of test strips without an opened date and expired control solutions. An Arnuity Ellipta inhaler and a vial of Rocklatan eye drops were found open and unlabeled with opened dates. An albuterol inhaler was found without a pharmacy label or patient name, only marked with a room number, which is inadequate for proper identification. An expired bottle of acetaminophen was also noted. Interviews with the Director of Nursing and the facility's Pharmacy Consultant confirmed that these practices could place residents at risk if expired medications were administered. The facility's policies and procedures require multi-dose vials to be dated upon opening and discarded within specified timeframes, and medications requiring refrigeration to be stored accordingly. However, these protocols were not followed, leading to the deficiencies noted in the report.
Infection Control Lapses in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Licensed Nurse 1 (LN 1) during medication preparation and administration. LN 1 was observed not performing hand hygiene before or after donning gloves while administering medications to two residents. This practice was contrary to the facility's policy, which requires hand hygiene before and after glove use. Interviews with LN 1, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that hand hygiene was expected between residents, before treatment, and before and after glove use. The failure to adhere to these protocols increased the risk of infection spread among residents, visitors, and staff. Additionally, LN 1 did not sanitize or disinfect the pill cutter after use, merely wiping it with a gloved hand before using it again. This action was against the facility's policy, which mandates that equipment for medication administration be thoroughly cleaned and properly stored after each use. The IP and DON both acknowledged that the pill cutter should have been disinfected after each use to prevent potential harm from medication residue. These lapses in infection control practices placed 39 residents at increased risk of infections.
Medication Administration Error Leads to Resident Discomfort
Penalty
Summary
The facility failed to provide care in accordance with professional standards when a resident did not receive the prescribed medication, Voltaren Arthritis Pain gel, as ordered by the physician. Instead, a Licensed Nurse (LN) applied Bengay Extra Strength, which was not prescribed for the resident. This error occurred when the LN, who was reportedly busy and running behind, grabbed the wrong cream from the cart without verifying it against the resident's medication order. The resident immediately experienced a burning sensation and reported the issue to the LN, who admitted to not checking the medication properly. The resident, who was cognitively intact and able to communicate effectively, suffered from skin irritation, redness, and sensitivity in the areas where the Bengay was applied. The Director of Nursing (DON) confirmed that there was no medical order for Bengay for this resident and that the application of the wrong medication was not documented in the resident's medical record or the facility's documents. The facility's policy on medication administration, which requires verification of the right patient, drug, dose, dosage form, route, and time, was not followed, leading to this deficiency.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident, resulting in a deficiency related to wound care. The resident, who was admitted with diagnoses including orthopedic aftercare following a right below-knee amputation and diabetes with a foot ulcer, had specific physician orders for wound care on the left lateral heel and left first toe. These orders included cleansing with normal saline, applying a skin protectant barrier, and covering with a foam dressing for the heel, and cleansing with normal saline and painting with betadine for the toe. The orders specified that these treatments should be performed daily and monitored for signs of infection. Despite documentation by a licensed nurse indicating that the treatments were completed on two specific days, an interview with the Director of Nursing confirmed that the treatments were not actually performed on those days. Additionally, a wound nurse reported that the bandages he applied on a previous day remained unchanged when he returned to work, indicating that the treatments had not been conducted as documented. This failure to provide the ordered wound care had the potential to worsen the resident's wounds, as noted in the progress notes when the resident was sent back to the hospital for treatment.
False Documentation of Wound Care in LTC Facility
Penalty
Summary
The facility failed to ensure accurate clinical records for a resident when a Licensed Nurse (LN 1) falsely documented that she completed the ordered wound care. This deficiency was identified during an investigation into allegations of wound care not being provided as ordered and falsely documented as completed. The resident, who was admitted with diagnoses including orthopedic aftercare following a right below-knee amputation and diabetes with a foot ulcer, had a worsening wound condition that required hospital treatment. Physician orders specified daily wound care for the resident's left lateral heel and left first toe, which included cleansing, applying skin protectant, and monitoring for signs of infection. Despite these orders, LN 1 documented that she completed the wound treatments on two specific dates, although the Director of Nursing confirmed that the treatments were not performed. A Wound Nurse, who was responsible for the resident's wound care on a prior date, noted that the bandages with his initials remained unchanged when he returned to work, indicating that the treatments had not been done. The facility's policy and procedure for patient care required that treatments be delivered as ordered and documented accurately in the medical record at the time of occurrence.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the security of medications for a census of 38 residents when a medication cart was found unlocked and unattended. During an observation on June 7, 2024, at 11:05 a.m., the medication cart was positioned against the wall between two resident rooms, left unattended and unlocked, with multiple people passing by. This was confirmed during a concurrent observation and interview with the Assistant Director of Nursing (ADON) at 11:25 a.m., who acknowledged that the cart containing prescription medications was unlocked and stated that it should have been locked to prevent unauthorized access. Further confirmation came from an interview with the Director of Nursing (DON) at 1:10 p.m. on the same day, who expressed the expectation that all medication carts with prescribed medications should be locked when unattended for safety reasons. A review of the facility's policy titled 'Medication-Storage,' dated September 28, 2022, indicated that medication rooms, carts, and supplies are to be locked or attended by authorized personnel.
Failure to Adhere to Fluid Restriction Orders
Penalty
Summary
The facility failed to adhere to professional standards of care for a resident who was on a physician-ordered fluid restriction. The resident, admitted with multiple diagnoses including coronary artery bypass grafting, hypertensive heart, and chronic kidney disease with heart failure, was ordered a 1500 ml per day fluid restriction. Despite this, the resident was found with a water pitcher and a cup filled with clear liquid in his room, which he had been consuming. This was contrary to the facility's policy that patients on fluid restrictions should not have water pitchers in their rooms. Interviews with staff revealed a lack of communication and adherence to the fluid restriction order. A registered nurse confirmed the presence of the water pitcher and acknowledged that the fluid intake documentation would be inaccurate due to the unmeasured liquids. The certified nursing assistant admitted to bringing the water pitcher into the room without measuring the water, and was unaware of the specific fluid restriction order. The director of nursing confirmed that the fluid restriction was not followed as per the physician's order and that the room lacked the necessary signage to indicate the restriction. The facility's policy on fluid restrictions was not followed, as evidenced by the presence of unmeasured fluids at the resident's bedside and the lack of proper communication among staff. The policy stated that no water should be provided at the bedside unless calculated into the daily total fluid restriction, and that both nursing and dietary departments were responsible for documenting fluid intake. The failure to follow these procedures resulted in a deficiency in meeting the professional standards of care for the resident.
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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