Alta Healthcare Center Of Camarillo
Inspection history, citations, penalties and survey trends for this long-term care facility in Camarillo, California.
- Location
- 6000 Santa Rosa Road, Camarillo, California 93012
- CMS Provider Number
- 555876
- Inspections on file
- 34
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Alta Healthcare Center Of Camarillo during CMS and state inspections, most recent first.
Two residents experienced significant delays in staff response to their call lights, with reported wait times of up to 45 minutes. Observations confirmed that staff did not respond promptly even when alerted by the call light system, and interviews with staff and administration acknowledged that such delays were not in line with facility policy.
Two residents did not have comprehensive care plans addressing their specific needs: one with multiple wounds, including pressure injuries and a traumatic leg wound, and another with bilateral bedrails in use since admission. Despite documentation of these conditions and interventions in medical records, no care plans were created as required by facility policy, a deficiency confirmed by the MDS coordinator, DON, and other staff.
A resident with psychosis and dementia was provided with bilateral bedrails without a documented assessment for risk of entrapment, as required by facility policy. Staff confirmed the absence of the assessment, and the bedrails had been in use since admission, with only staff able to operate them.
A resident with chronic pain and a history of spinal surgeries had orders for both Tylenol and Hydrocodone-acetaminophen written for the same pain level range, which was confirmed by nursing staff to be potentially confusing and could result in duplicate medication administration. The DON acknowledged the error and that the physician was not contacted to clarify the orders, contrary to facility policy.
A resident who required supplemental O2 and nebulizer treatments had both nasal cannula and nebulizer air tubing in use that were not labeled or dated, preventing staff from determining when the equipment should be replaced. An LN confirmed the missing information, which was not in accordance with facility policy requiring regular changes of such equipment.
A facility failed to develop a care plan for a resident with a suprapubic catheter within 48 hours of admission, as required by policy. The resident was admitted with conditions including septic shock and a suprapubic abscess. Despite these conditions, the baseline care plan did not include instructions for managing the catheter, confirmed by both the Treatment Nurse and the DON.
A facility failed to create an individualized care plan for a resident with a stage 4 pressure ulcer on the sacrum. The care plan included general interventions like a low air loss mattress and wound monitoring but was not person-centered. Interviews with staff confirmed the plan did not meet the resident's specific needs, despite the resident's history of septic shock and a triggered care area assessment for the ulcer.
A facility failed to report a resident's injuries of unknown origin to the State Agency and Ombudsman in a timely manner. The injuries were first noticed by the DSD and later confirmed by the Treatment Nurse, but were not reported until six days later. The resident's family had also brought the injuries to the facility's attention. The facility's policy requires timely reporting of such incidents, which was not adhered to in this case.
A resident was found with unreported injuries of unknown origin, including skin discoloration and an abrasion, which were discovered by the family. The facility staff were unaware of these injuries until informed by the family, and there was no documentation or reporting of the injuries as required by the facility's policies. This oversight indicated a deficiency in the facility's abuse prevention and reporting procedures.
The facility failed to maintain an effective infection prevention and control program, including cluttered hand washing areas, improper disposal of contaminated briefs, contamination of medication preparation areas, and improper handling of dirty laundry. These actions risked spreading harmful microorganisms.
The facility failed to ensure proper food storage, maintain an appropriate air gap for the dish machine drain, and follow high temperature dish machine guidelines. Raw ground hamburger was stored above pork cutlets, cooked pasta was not documented on the cool down log, and the dish machine's wash and rinse temperatures were below required levels.
A facility failed to develop and implement a care plan for a resident using a foley catheter. The catheter bag was found on the floor, and there was no doctor order or care plan in the resident's electronic medical record. The Infection Preventionist confirmed the oversight.
A resident's foley catheter bag was found on the floor, and there was no doctor order or care plan for the catheter. The facility's policy for catheter care was not followed, as confirmed by the Infection Preventionist.
The facility failed to document the quantity consumed of nutritional supplements for two residents, impacting the accuracy of nutrition assessments and the ability to monitor the effectiveness of interventions. Staff were not trained to document the quantity consumed, and supplements were often recorded as part of the overall meal intake without differentiation.
The facility failed to discard expired items in the medication storage room and treatment cart, and did not maintain proper temperature controls for medications and biologicals. Observations revealed expired items in a First Aid Kit and opened single-use items in the treatment cart. Additionally, the medication storage room and refrigerator temperatures were consistently out of the acceptable range.
The facility failed to implement its policy for foods brought in by family or visitors, as staff were unaware of the policy and there was no clear guidance on designated refrigerated storage. Interviews revealed a lack of training and contradictory practices regarding the storage of outside food.
The facility failed to maintain the confidentiality of resident medical records when the Discharge Summary (DS) of one resident was found attached to the DS of another resident. The Director of Nursing (DON) confirmed that the DS of the unsampled resident was mistakenly scanned into the clinical record of the sampled resident, violating the facility's policy on maintaining confidentiality of protected health information.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights for two of three sampled residents. One resident reported that it often took up to 45 minutes for staff to respond to her call light, which was her only means of communicating needs while in bed. During an observation, the call light was activated in her room and no staff responded for 15 minutes, despite six staff members being present at the nurse's station and visibly able to see the call light indicator. Staff interviews confirmed that the call light system alerts staff via monitors and hallway lights, and that they are expected to respond immediately. Another resident stated that staff did not answer call lights in a timely manner, sometimes waiting up to 45 minutes for a response. On one occasion, the resident had to physically approach staff at the nurse's station after receiving no response, and was told all nurses were on break. The facility's policy requires call lights to be answered within a reasonable time, which the administrator defined as within 3 to 10 minutes. The administrator agreed that response times of 30 to 45 minutes were not reasonable.
Failure to Develop and Implement Comprehensive Care Plans for Wound Management and Bedrail Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to wound care and the use of bedrails. For one resident, multiple wounds were identified upon admission, including a left heel deep tissue injury, a stage 2 sacral pressure injury, a right anterior leg traumatic wound, and a right heel skin fissure, along with skin discoloration on both upper and lower extremities. Despite these findings being documented in the resident's admission records, physician orders, and treatment administration records, there was no corresponding care plan addressing these wounds. The absence of a care plan was confirmed by both the MDS coordinator and the Director of Nursing during record reviews and interviews. Another resident was observed to have bilateral bedrails in use while in bed, a fact confirmed by staff and present since admission. However, there was no care plan in place to address the use of bedrails for this resident. This omission was acknowledged by both the Registered Nursing Supervisor and the Director of Nursing during interviews and record reviews. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, based on a thorough assessment and within seven days of the required comprehensive assessment. The lack of care plans for both wound management and bedrail use meant that the residents' specific care needs were not formally addressed or coordinated as required by facility policy. These failures were identified through direct observation, record review, and staff interviews, and were acknowledged by facility leadership.
Failure to Assess Entrapment Risk Prior to Bedrail Use
Penalty
Summary
The facility failed to assess the risk of entrapment prior to the use of bilateral bedrails for a resident who was admitted with diagnoses including unspecified psychosis, dementia with behavioral disturbance, and a need for assistance with personal care. During an observation, the resident's bed was found with small bilateral bedrails in the raised position. Record review and interviews with the registered nursing supervisor and the director of nursing confirmed that there was no completed assessment for risk of entrapment in the resident's health record. Further interviews revealed that the resident had the bedrails in place since admission, and only staff could operate the rails due to a locking mechanism. Review of the facility's policy indicated that an assessment for risk of entrapment should be completed when side rails are used for mobility or transfer. The lack of this assessment constituted a failure to follow facility policy and ensure resident safety regarding bedrail use.
Failure to Clarify Pain Medication Orders for a Resident
Penalty
Summary
The facility failed to ensure that pain medication orders for a resident with chronic back and leg pain were properly clarified with the physician regarding the appropriate pain level parameters for each medication. The resident, who had a history of multiple spinal surgeries and was diagnosed with spondylolisthesis and other musculoskeletal conditions, was observed to be alert and oriented while reporting ongoing pain. A review of the resident's Medication Administration Record revealed that both Tylenol and Hydrocodone-acetaminophen were ordered for the same pain level range (4-6), which could cause confusion for nursing staff regarding which medication to administer. A licensed nurse confirmed that the identical pain level parameters for both medications could lead to uncertainty in pain management. The Director of Nursing acknowledged that the orders were written in error and, without clarification from the physician, there was potential for the resident to receive duplicate medications. The facility's policy requires contacting the physician in the event of medication discrepancies, but this was not done in this case.
Failure to Label and Date Oxygen and Nebulizer Tubing
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident who was dependent on supplemental oxygen and nebulizer treatments. During an observation and interview, it was found that the resident's nasal cannula and nebulizer air tubing were not labeled or dated, making it impossible to determine when the equipment should be replaced. A licensed nurse confirmed the absence of labeling and dating on the tubing. Review of the facility's policy indicated that oxygen tubing and masks or cannulas should be changed weekly, and nebulizer tubing and delivery devices should be changed every 72 hours or as needed if soiled or contaminated. The lack of labeling and dating on the tubing was inconsistent with the facility's established procedures.
Failure to Develop Care Plan for Suprapubic Catheter
Penalty
Summary
The facility failed to develop a care plan for a resident with a suprapubic catheter within 48 hours of admission, as required by their policy. The resident was admitted with serious conditions including septic shock, a suprapubic abscess, a urinary tract infection, and a pressure ulcer. Despite these conditions, the baseline care plan did not include instructions for managing the suprapubic catheter, which was confirmed by both the Treatment Nurse and the Director of Nursing. The facility's policy mandates that a baseline care plan be developed to address the immediate health and safety needs of residents within 48 hours of admission. This plan should include necessary healthcare information such as physician's orders and therapy services. However, the care plan for the resident in question did not include any information regarding the management of the suprapubic catheter, which was a critical aspect of the resident's care needs.
Failure to Individualize Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to complete an individualized care plan for a resident with a stage 4 pressure ulcer on the sacrum. The baseline care plan, which should have been developed within forty-eight hours of admission, was not person-centered and did not reflect the resident's specific needs for the sacral wound. The care plan included interventions such as the use of a low air loss mattress, wound treatment, and monitoring for infection, but it was not customized to the resident's condition. During interviews, the treatment nurse and the Director of Nursing acknowledged that the care plan was not individualized according to the resident's needs. The resident had a history of septic shock and a pressure ulcer, and the Minimum Data Set had triggered a care area assessment for the pressure ulcer. Despite these indicators, the care plan lacked the necessary person-centered approach, potentially leaving the resident's health, safety, and care needs unmet if their condition changed.
Delayed Reporting of Resident Injuries
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident to the State Agency and the Ombudsman in a timely manner. On May 8, the Director of Staff Development (DSD) noticed a skin abrasion on the resident's shoulder, cleaned it, and reported it during a morning clinical meeting. The Director of Nursing (DON) then delegated a skin check to the Treatment Nurse, who noted the abrasion and additional skin discoloration on the resident's chin. However, the facility did not report these injuries until May 14, six days after they were initially observed. The resident's family noticed the injuries on May 9 and informed the facility, but the facility still delayed reporting the incident. The facility's policy requires reporting any injury of unknown origin within 2 hours if it involves abuse or results in serious bodily injury, or within 24 hours if it does not. The resident had a medical history including acute post-hemorrhagic anemia, gastrointestinal bleeding, and other conditions. The facility's delay in reporting the injuries was acknowledged by the Administrator, who admitted the report should have been made sooner.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its Abuse/Injuries of Unknown Origin policies and procedures when a resident was found with unreported injuries of unknown origin. The resident was observed with skin discoloration under the chin and on the left cheek, as well as an abrasion on the right shoulder. These injuries were discovered by the resident's responsible party and family, who were not notified of any incidents or falls that could have caused the injuries. The facility staff, including the administrator and Director of Nursing, were unaware of the injuries until they were brought to their attention by the family. The resident, who was admitted with multiple medical conditions including acute post-hemorrhagic anemia, gastrointestinal bleeding, and unspecified dementia, was noted to have intact skin upon admission. However, the facility's documentation did not reflect any changes in the resident's skin condition or any incidents that could have led to the injuries. The Director of Nursing and other staff members were unable to provide documentation or explanations for the injuries, indicating a lack of proper monitoring and reporting. The facility's policies require that any injury of unknown origin be reported to the appropriate authorities within a specified timeframe. However, in this case, the facility did not adhere to these policies, as there was no documentation of the injuries being reported or investigated. This oversight placed the resident at risk for further harm and highlighted a deficiency in the facility's abuse prevention and reporting procedures.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in several instances. In one case, a hand washing sink area in a resident's room requiring transmission-based precautions for C-DIFF was cluttered with a pink wash basin, preventing staff from washing their hands before exiting the room. The resident confirmed that staff did not wash their hands before leaving. The Infection Preventionist acknowledged the issue but cited limited storage space as a reason for the cluttered sink area. Additionally, C-DIFF contaminated briefs were improperly discarded in the same trash can used for doffing PPE, and the Infection Preventionist was observed compacting the trash with unprotected hands, further risking contamination. Another deficiency was observed with the medication cart, where a personal jacket, supply bag, and BP cuff were stored on the clean medication preparation area, contaminating it. A licensed nurse was seen placing a BP cuff from a contact isolation room on the clean PPE supply cart for cleaning, which was not in line with proper infection control practices. The facility's policy indicated that non-critical resident-care equipment should be dedicated to a single resident when transmission-based precautions are in effect, but this was not followed. Additional issues included an overflowing medication cart trash, expired water management test kits, and improper transportation of dirty laundry through the clean laundry area. The Director of Maintenance admitted awareness of the expired test kits but had not yet replaced them. A laundry worker was observed transporting dirty laundry through the clean laundry room, contrary to the facility's policy on handling soiled laundry. These failures collectively had the potential to spread harmful microorganisms to staff, residents, and visitors.
Food Safety and Equipment Compliance Issues
Penalty
Summary
The facility failed to ensure proper food storage in accordance with professional standards of food service safety. During an observation, a box of raw ground hamburger was found stored above pork cutlets in the walk-in refrigerator, contrary to the facility's policy and procedure which indicated that whole cuts of meat should be stored above ground meat. The Food Service Director (FSD) confirmed the improper storage and acknowledged the posted guidelines for proper food storage order were not followed. Additionally, cooked pasta, a Time-Temperature Control for Safety (TCS) food, was found in the walk-in refrigerator without documentation of the cool down process on the cool down log, as required by the facility's policy. The FSD and Kitchen Supervisor verified the omission and confirmed the pasta was intended for resident meals in both assisted living and skilled nursing sections of the facility. The facility's policy required recording food temperature every hour during the cooling process, which was not adhered to in this instance. The facility also failed to maintain an appropriate air gap between the dish machine drain and the floor sink drain to prevent contaminated water from backing up into the dish machine. Observations revealed that the black plastic pipe used for drainage extended below the flood level rim of the floor sink drain, and the copper pipe was zip-tied to the black plastic pipe but not utilized for drainage. The Director of Maintenance (DOM) and FSD confirmed the lack of an appropriate air gap, which did not meet FDA food code guidelines requiring a one-inch air gap above the floor sink drain rim. An email communication with the Department of Health Care Access and Information (HCAI) also confirmed the requirement for an air gap and the prohibition of plastic pipes for drainage. Furthermore, the facility did not follow the high temperature dish machine (HTDM) manufacturer guidelines. The HTDM was observed to have wash and rinse temperatures below the required levels, with the wash temperature reaching only 138 degrees Fahrenheit and the rinse temperature reaching 158 degrees Fahrenheit, whereas the manufacturer's guidelines required a minimum wash temperature of 155 degrees Fahrenheit and a rinse temperature of 180 degrees Fahrenheit. The facility's policy mandated recording dish machine temperatures every shift and reporting any deviations to the Director of Food and Nutrition Services, but the Dishmachine Temp Log indicated multiple instances of temperatures below the required levels without appropriate action being taken. The FSD and Kitchen Manager confirmed the non-compliance with the manufacturer's guidelines and the facility's policy.
Failure to Develop and Implement Care Plan for Foley Catheter Use
Penalty
Summary
The facility failed to ensure that a care plan was developed and implemented for a resident using a foley catheter. During an observation, a foley catheter bag was found on the floor next to the resident's bed. Further review of the resident's electronic medical record revealed no doctor order or care plan for the foley catheter. The Infection Preventionist confirmed that the resident was not on the list of those with a foley catheter and acknowledged the presence of the catheter during a subsequent observation. The facility's policy requires the Care Planning/Interdisciplinary Team to develop an individualized comprehensive care plan for each resident, which was not done in this case.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate care and services to manage an indwelling catheter. During an observation, a foley catheter bag was found laying on the floor next to the resident's bed. The Infection Preventionist (IP) confirmed that there was no doctor order or care plan for the foley catheter in the resident's electronic medical record, and the resident was not listed as having a foley catheter. The facility's policy and procedure for catheter care, which includes keeping the catheter and tubing off the floor and ensuring the drainage bag is positioned lower than the bladder, was not followed.
Failure to Document Nutritional Supplement Consumption
Penalty
Summary
The facility failed to consistently document the quantity consumed of nutritional supplements for two residents, which impacted the accuracy of nutrition assessments and the ability to monitor the effectiveness of interventions. Resident 30, who was readmitted with severe protein-calorie malnutrition and a significant weight loss, had specific nutritional supplements ordered to meet their dietary needs. However, the staff did not document the quantity of these supplements consumed, and the supplements were not always offered or consumed as prescribed. The Restorative Nurse Assistant (RNA) and Licensed Nurse (LN) confirmed that they were not trained to document the quantity of nutritional supplements consumed, and the supplements were often recorded as part of the overall meal intake without differentiation. Resident 143, who appeared thin and was recommended nutritional supplements to meet their energy needs, also had issues with documentation. The Medication Administration Record (MAR) indicated that the supplements were administered, but there was no documentation of the quantity consumed. The Clinical Registered Dietitian (CRD) and other staff members confirmed that the lack of consistent and accurate documentation impeded the ability to monitor the effectiveness of the nutritional interventions. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Food Service Director (FSD) revealed that there was no system in place to quantify the consumption of nutritional supplements separately from the overall meal intake. The facility's policy and procedure on nutritional assessment required the dietitian to identify whether the resident's current intake met their nutritional needs, but the lack of proper documentation hindered this process. The staff had not received formal training on documenting the intake quantity of nutritional supplements, leading to inconsistencies and potential delays in revising interventions to meet the residents' nutritional needs.
Expired Items and Improper Temperature Controls in Medication Storage
Penalty
Summary
The facility failed to ensure that expired items in the medication storage room and treatment cart were discarded and not readily available for staff use. During an observation and interview, a sealed First Aid Kit (FAK) was found without a visible expiration date label, and upon opening, it was revealed to have expired in 2022. Additionally, the treatment cart contained opened, single-use items and steri-strips that should have been discarded. The facility's policies and procedures indicated that outdated or deteriorated medications should be immediately removed from stock, which was not followed in this instance. The facility also failed to maintain proper temperature controls for medications and biologicals stored in locked compartments. Observations revealed that the room temperature in the medication storage room was consistently out of the acceptable range, with readings of 78 and 79 degrees Fahrenheit, and the refrigerator temperature readings were 58 and 48 degrees Fahrenheit, both out of the required range. The facility's policies and procedures specified that medications requiring refrigeration should be kept between 36 and 46 degrees Fahrenheit, which was not adhered to, as evidenced by the temperature logs and staff interviews.
Failure to Implement Policy for Foods Brought by Family/Visitors
Penalty
Summary
The facility failed to ensure the implementation of its policy and procedure for foods brought in by family or visitors. Staff members were unaware of the policy, and there was no clear guidance on the location of a designated refrigerated area for storing such foods. During interviews, a Certified Nursing Assistant (CNA) stated that they did not know if family could bring in food to be stored for a resident and had not received training on this matter. Another CNA mentioned that the Food Service Director (FSD) checks the food first, and it gets stored in the kitchen. However, the FSD contradicted this by stating that the facility does not store outside food for residents. The Director of Marketing (DMK) confirmed that families sign the policy on admission, but staff are not educated on it. The Director of Staff Development (DSD) also confirmed that there is no formal training on foods brought from home. The facility's policy, dated 11/2017, indicated that food brought by family or visitors should be labeled and stored in a manner distinguishable from facility-prepared food, with perishable foods stored in resealable containers with tightly fitting lids in a refrigerator. The containers should be labeled with the resident's name, the item, and the use-by date. The lack of staff awareness and training on this policy led to the deficiency, potentially denying residents, family, and visitors their right to store outside food safely for later consumption.
Breach of Resident Confidentiality in Medical Records
Penalty
Summary
The facility failed to ensure resident medical records were kept confidential when the Discharge Summary (DS) of one unsampled resident was found attached to the DS of one sampled resident. This breach occurred during a review of the clinical record of the sampled resident, where a document titled Discharge Summary under the unsampled resident's name was found attached to the sampled resident's DS. During a concurrent interview and record review with the Director of Nursing (DON), it was confirmed that the DS of the unsampled resident was mistakenly scanned into the clinical record of the sampled resident. The facility's policy and procedure on the release of information indicated that the confidentiality of each resident's personal and protected health information must be maintained, which was not adhered to in this instance.
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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