Auburn Oaks Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 3400 Bell Road, Auburn, California 95603
- CMS Provider Number
- 555219
- Inspections on file
- 43
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Auburn Oaks Care Center during CMS and state inspections, most recent first.
A resident with moderate dementia, PTSD, and a history of unsafe wandering was able to leave the facility unsupervised after the removal of a previously ordered wander guard and the resolution of elopement risk in the care plan. The resident was found outside by a family member, and staff were unaware of the absence until notified. The care plan did not reflect the resident's ongoing elopement risk at the time of the incident.
A resident with cognitive impairment and physical limitations was not protected from abuse when another cognitively impaired resident became physically aggressive during a meal, pushing the first resident's plate onto her chest and lap. The incident was witnessed by CNAs and resulted in emotional distress for the affected resident.
A resident sustained injuries during a transfer from bed to shower chair due to improper use of a Hoyer lift by two CNAs. The resident, who required assistance for transfers and was at high risk for falls, fell when the lift tipped over due to incorrect maneuvering and lack of stability. This resulted in a right ankle sprain and back pain, causing the resident to fear future transfers.
A resident with a right ankle sprain was not properly monitored for the use of a postoperative boot, as there were no physician orders or care plans in place. Despite the resident's high fall risk and moderate cognitive impairment, the facility failed to document or evaluate the boot's use, which was confirmed by the ADON and DOR.
Two LVNs at a facility pronounced a resident deceased, which violated the facility's policy and state law as only a physician or RN is authorized to do so. The resident, on hospice care for COPD, was found unresponsive with no signs of life. Interviews confirmed the LVNs acted outside their scope of practice, potentially jeopardizing resident safety.
A resident with cognitive impairments was physically abused by another resident, resulting in a scratch on her face and feelings of unsafety. The incident occurred after a verbal exchange when one resident accidentally bumped into the other's foot, leading to a physical altercation. The facility's policies on abuse prevention and resident-to-resident altercations were not effectively implemented, resulting in a failure to protect the resident from abuse.
A resident was mistakenly given another resident's medications upon discharge, breaching confidentiality. The error occurred because medications for both residents were stored in the same drawer, and staff failed to verify the medications properly. The facility's policy on confidentiality was not followed, and the breach was not reported to the state or the affected resident's family.
A resident was discharged with another resident's medications due to a mix-up by the nursing staff. The error occurred when medications were pulled from a shared drawer without proper verification. The facility's policy for reviewing discharge instructions and medications was not adequately followed, leading to the resident leaving with incorrect medications.
The facility did not complete annual performance evaluations for three CNAs, as required by policy, increasing the risk of poor-quality care. The DSD admitted to not conducting evaluations for 2023-2024, and the DON and ADM confirmed the oversight. These evaluations are crucial for identifying areas for improvement and assessing CNA competency.
The facility failed to properly manage medications and oxygen for several residents, leading to potential health risks. Medications were left unlabeled and undated at the bedside, and oxygen equipment was not maintained or monitored as required. These deficiencies were confirmed by nursing staff, highlighting a lack of adherence to professional standards.
The facility failed to document controlled substance medications accurately for four residents, with discrepancies between the MAR and CDR. Additionally, an opened antibiotic e-kit was not replaced within the required timeframe, risking medication availability. Interviews confirmed the expectation for accurate documentation and timely e-kit replacement, as per facility policy.
A facility failed to document clinical rationale when disagreeing with pharmacy consultant recommendations for a resident's medication regimen. The resident, with multiple diagnoses including Huntington's disease and depression, was on a complex medication regimen. The pharmacy consultant identified potential risks, but the provider disagreed with recommendations without documenting reasons. The facility lacked a policy for reviewing pharmacy consultant reports.
The facility failed to properly store and label medications, leading to expired and improperly stored medications being available for use. Inspections revealed expired medications, loose tablets, and improper storage of medications requiring different administration routes. The DON confirmed the need for separate storage and proper labeling, as per facility policies.
The facility failed to follow professional standards for food service safety, affecting 95 residents. Observations revealed improper food labeling, expired items not discarded, and poor storage conditions for produce and utensils. The RD confirmed these issues, which contradict the facility's policies and FDA guidelines.
The facility failed to maintain proper infection control by not labeling, dating, or changing respiratory equipment weekly for several residents, increasing the risk of respiratory infections. Staff confirmed lapses in following policies for managing oxygen therapy equipment, which were not consistently adhered to, posing potential infection risks.
A facility failed to accurately code the MDS for a resident, indicating discharge to a hospital instead of home, despite documentation showing the correct discharge destination. The MDS Coordinator confirmed the error, and the DON emphasized the need for accurate MDS coding. The resident had multiple diagnoses, including heart failure and difficulty walking.
The facility failed to develop or implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with pulmonary edema had no care plan for a respiratory treatment, while another with asthma had expired respiratory equipment and an empty oxygen tank. A third resident with lung cancer received oxygen therapy at a higher rate than prescribed, and their oxygen saturation levels were not monitored. These oversights resulted in care plans not being followed.
The facility failed to assist four residents with activities of daily living, leading to deficiencies in personal hygiene and nutrition. A resident with Huntington's Disease and another with cognitive impairment had long, unclean fingernails despite needing assistance. Another resident with dementia also had unclean nails. Additionally, a resident with spinal stenosis and dysphagia did not receive the required one-to-one assistance during meals, as confirmed by staff and care plans.
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. A resident with lung cancer and COPD received oxygen at a higher rate than prescribed, and monitoring was inconsistent. Another resident with diabetes received insulin despite blood sugar levels being below the ordered threshold. Staff confirmed these discrepancies, highlighting a failure to follow medical orders.
The facility failed to ensure safe water temperatures in resident bathrooms, with four bathrooms having water temperatures exceeding 120 degrees Fahrenheit. Staff confirmed the excessive heat, and residents expressed fear of burns. The facility's policy requires water temperatures to be between 105 and 120 degrees Fahrenheit, but this was not adhered to, posing a risk of scalds or burns.
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional risks. A resident with severe memory impairment was served a regular sandwich instead of a meal that met her dietary needs. Another resident expressed dissatisfaction with being served pasta despite disliking it, and a third resident repeatedly received meals with sauces despite expressing a dislike for them. A fourth resident was served a sandwich for lunch, which did not align with her expectations or preferences.
A resident with a history of UTIs was prescribed Cephalexin without a stop date, contrary to the facility's antibiotic stewardship policy. Staff interviews revealed a lack of clarity and monitoring for the antibiotic's necessity and duration, with no specific orders to monitor for UTIs.
A resident, who was cognitively intact and required assistance with toileting, experienced verbal abuse from a CNA who used profanity and refused to help. The incident was witnessed by another resident and staff, who confirmed the CNA's aggressive behavior. The facility's policies on resident rights and abuse prevention were not followed, leading to a deficiency in care standards.
A resident with chronic conditions self-administered multiple non-prescription supplements and vitamins without evaluation or monitoring by health professionals. The facility's policy required an IDT evaluation for safe self-administration, but no such evaluation was conducted. This oversight led to the resident taking duplicate medications and supplements without professional oversight, raising safety concerns.
Failure to Prevent Elopement for Resident with Dementia and PTSD
Penalty
Summary
A resident with moderate dementia, PTSD, and difficulty walking was admitted to the facility and identified as being at risk for elopement, as documented in the resident's Elopement and Wandering Risk Assessment. The assessment indicated the need for a wander alarm device, and a physician's order for a wander guard was in place. However, the wander guard order was discontinued and the device was removed several months prior to the incident. The resident's care plan was also revised to indicate that the elopement risk and need for a wander guard were resolved, despite the resident's ongoing cognitive impairments and history of unsafe wandering. On the date of the incident, the resident left the facility unsupervised and was found by a family member walking down the street and standing at a traffic light intersection. Facility staff were unaware of the resident's absence until notified by the family member. Upon review, the care plan did not reflect the resident's elopement risk during the period leading up to the incident, and staff confirmed that the resident's elopement was a safety issue due to his dementia and PTSD. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety, which was not followed in this case.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of hemiplegia, dementia, and anxiety disorder was not protected from abuse by another resident. The incident took place in the dining room, where three CNAs were present. During the meal, another resident with severely impaired cognition due to metabolic encephalopathy and Alzheimer's disease became physically aggressive, pushing the first resident's plate onto her chest and lap. The affected resident reported feeling upset by the incident. Staff interviews confirmed that the altercation was witnessed, and the facility's policy states that residents must be protected from abuse by anyone, including other residents. Despite this, the event resulted in a failure to ensure the resident's right to be free from abuse, as required by federal regulations.
Plan Of Correction
Residents were separated immediately at the time of the incident and Resident 21 was removed from the dining room. All residents who have an altercation have the potential to be affected by the same deficient practice. Any residents who have an altercation will be separated immediately and reported accordingly. DSD in-serviced staff on 07/08/25 on Abuse Policy and ways to prevent altercations. DSD to observe the behavior of Resident 12 in the dining room weekly x 4 weeks, monthly x 1 month to ensure no altercations occur and residents feel safe. Any findings out of compliance will be brought to the attention of the Administrator and addressed immediately. All findings will be reported to the QA Committee. Corrective action will be achieved and sustained by 07/24/2025.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to provide safe supervision and assistance during a transfer for a resident, resulting in an accident. The incident occurred when two CNAs were transferring a resident from bed to a shower chair using a Hoyer lift. The CNAs did not follow the proper maneuvering and operation procedures for the lift, leading to the lift tipping over and the resident falling to the ground. This resulted in the resident sustaining a right ankle sprain, back pain, and developing a fear of being moved out of bed using a lift. The resident involved in the incident had been admitted to the facility with diagnoses including morbid obesity, muscle weakness, fibromyalgia, and difficulty walking. The resident's Minimum Data Set indicated moderate cognitive impairment and a dependency on staff for toileting hygiene, transfers, and showering, requiring the assistance of two or more staff members. The resident was also assessed as being at high risk for falls, with a care plan in place to minimize fall risks, including a recommendation for a room change to accommodate a bariatric bed and ease the maneuvering of the Hoyer lift. During the transfer, CNA 1 improperly maneuvered the lift by moving it sideways instead of pivoting it, and CNA 2 was positioned away from the lift, failing to provide adequate support. The lift's legs were not opened or extended, compromising its stability, and the brakes were not used correctly. As a result, the lift tipped over, causing the resident to fall and the lift to land on the resident's right ankle. The incident was compounded by the CNAs not adhering to the facility's policy and procedure for using mechanical lifts, which emphasized the importance of stability and proper handling to prevent accidents.
Failure to Monitor Postoperative Boot Use
Penalty
Summary
The facility failed to provide necessary care and services for a resident who was using a postoperative boot following a fall that resulted in a right ankle sprain. The resident, who was admitted with conditions including morbid obesity, muscle weakness, fibromyalgia, and difficulty walking, was at high risk for falls and had moderate cognitive impairment. After a fall, the resident was diagnosed with a possible avulsion fracture and was discharged from the hospital with a postoperative boot and pain medication. However, the facility did not monitor or evaluate the use of the boot, as there were no physician orders, treatment notes, or care plans in place for its use. During observations and interviews, it was confirmed that the resident was wearing the boot, but there was no documentation or monitoring for skin integrity and circulation, which are essential when using such devices. The Assistant Director of Nursing (ADON) and the Director of Rehabilitation (DOR) acknowledged the lack of orders and care plans for the boot. The facility's policy on safety and supervision of residents emphasizes the need for implementing, documenting, and evaluating interventions, which was not adhered to in this case.
Improper Pronouncement of Death by LVNs
Penalty
Summary
The facility failed to adhere to its policy regarding the pronouncement of death, resulting in a violation of professional standards of quality. Two Licensed Vocational Nurses (LVNs) pronounced a resident deceased, which is outside their scope of practice according to the facility's policy and state law. The resident, who was on hospice care for Chronic Obstructive Pulmonary Disease (COPD), was found unresponsive in bed with no signs of life. The LVNs documented the absence of a pulse and respiratory effort, and subsequently declared the time of death. Interviews with the Registered Nurse (RN), Hospice Clinical Consultant (HCC), and Director of Nursing (DON) confirmed that only a physician or RN is authorized to pronounce death, especially for residents on hospice care. The facility's policy titled "Death of a Resident" explicitly states that a resident may only be declared dead by a licensed physician or RN with physician authorization. The DON verified that the LVNs acted outside their scope of practice, which could potentially jeopardize resident health and safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident grabbed her hands, resulting in a scratch on her face and feelings of unsafety. The incident involved two residents with cognitive impairments. Resident 1, who has a history of cerebral infarction and schizophrenia, was sitting in her wheelchair when Resident 2, diagnosed with postconcussional syndrome and mild cognitive impairment, accidentally bumped into her foot. This led to Resident 1 grabbing Resident 2's wrists and scratching her face. The incident was witnessed by a CNA and a Licensed Nurse (LN 1), who were at the nursing station when they heard yelling from the residents' room. The CNA reached the room first and observed Resident 1 grabbing Resident 2's hands after a verbal exchange. LN 1 intervened by pulling Resident 2's wheelchair back. Both residents had a history of memory problems, and Resident 1 was known for behaviors such as yelling and repetitiveness. The facility's policy on abuse prevention and resident-to-resident altercations emphasizes the need to protect residents from abuse, including physical abuse by other residents. The policy outlines that all altercations should be investigated and reported to the nursing supervisor, director of nursing services, and the administrator. However, the incident highlights a failure in preventing resident-to-resident abuse, as Resident 2 sustained a physical injury and felt unsafe in her room.
Confidentiality Breach Due to Medication Mix-Up
Penalty
Summary
The facility failed to maintain confidentiality for one of its residents when medications belonging to another resident were mistakenly given to an unauthorized recipient. Resident 1, who was admitted with orthopedic aftercare and spinal stenosis, was discharged with medications that included those belonging to Resident 2, who had been admitted with hemiplegia and hemiparesis following a stroke. This error occurred because the medications for both residents were stored in the same drawer, and during the discharge process, Resident 2's medications were inadvertently included with Resident 1's. The error was discovered when Resident 1's family member noticed the mistake after leaving the facility. Interviews with the Director of Nursing (DON) and several Licensed Nurses (LNs) revealed that the medication cart nurse and desk nurse did not adequately verify the medications before discharge. The medication cart nurse mistakenly pulled medications from the wrong drawer, and the desk nurse failed to thoroughly check the contents of the medication bag, leading to the breach of confidentiality. The DON acknowledged the mistake and noted that the confidentiality breach was not reported to the state, and the family of Resident 2 was not informed of the incident. The facility's policy on confidentiality and resident rights emphasizes the protection of personal and medical records, but the policy was not followed in this instance. The facility's failure to adhere to its own procedures resulted in the unauthorized release of Resident 2's confidential information.
Resident Discharged with Wrong Medications
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, who was discharged with another resident's medications. This incident involved two residents, one of whom was discharged with medications belonging to their roommate. The discharged resident had been admitted with orthopedic aftercare needs and was cognitively intact, while the roommate had been admitted with conditions related to a stroke. The error occurred when the medication cart nurse mistakenly pulled the roommate's medications instead of the discharged resident's. The desk nurse briefly reviewed the medications but failed to notice the error, resulting in the wrong medications being sent home with the resident. The facility's Director of Nursing acknowledged the mistake and noted that the medications were not properly verified before discharge. Interviews with staff revealed that the medications for both residents were stored in the same drawer without proper separation, leading to the mix-up. The staff involved admitted to not thoroughly checking the medications before discharge, and the error was only discovered after the resident had left the facility. The facility's policy required that discharge instructions and medications be reviewed with the resident or responsible party, which was not adequately followed in this case.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled certified nursing assistants (CNAs) in a facility with a census of 95. During interviews and record reviews, it was found that CNAs hired on various dates had no documented evidence of annual performance evaluations being conducted. The Director of Staffing Development (DSD) admitted to not completing any performance evaluations for the year 2023 to 2024. The Director of Nursing (DON) and the Administrator (ADM) confirmed the absence of these evaluations, which are intended to identify areas for improvement in resident care and assess the competency of CNAs. The facility's policy requires that job performance be reviewed and evaluated at least annually, but this was not adhered to, increasing the risk of residents receiving poor-quality care.
Medication and Oxygen Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications and ointments were properly managed and stored for several residents, leading to potential health risks. For Resident 143, medications and ointments were left on the nightstand, unlabeled and undated, which the resident did not recognize. This was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), who acknowledged that the medications should not have been left there and were not properly labeled. Resident 144 experienced a similar issue, with medications and hazardous liquids left at the bedside. A medication labeled for another resident was found in Resident 144's room, along with an unlabeled container of mentholatum ointment and a large plastic container of mouthwash. The CNA and LN confirmed that these items should not have been at the bedside and that medications from home should be checked in with a nurse and stored properly. For Resident 36, a medication was not administered completely and was left at the bedside, and an oxygen tank was found empty while in use. The nasal cannula and other equipment were not dated or changed as required, leading to potential infection risks. Additionally, Resident 85's oxygen saturation levels were not monitored as ordered, and the oxygen was administered at an incorrect rate. These failures were confirmed by the nursing staff, who acknowledged the importance of following physician orders and the potential for respiratory distress if not adhered to.
Deficiencies in Controlled Medication Documentation and E-Kit Replacement
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substance medications for four residents. For Resident 3, a hydrocodone/acetaminophen tablet was removed but not documented on the medication administration record (MAR). Resident 22 received tramadol, but its removal was not recorded on the Controlled Drug Record (CDR). Resident 75 had lorazepam removed, but the administration was not documented on the MAR. For Resident 78, multiple administrations of hydrocodone/acetaminophen were recorded on the MAR, but their removal was not documented on the CDR. Interviews with Licensed Nurse 2 and the Director of Nursing confirmed the expectation that both the CDR and MAR should reflect the administration and removal of controlled medications, as per the facility's policy. Additionally, the facility did not replace an opened antibiotic emergency kit (e-kit) in a timely manner. The e-kit, identified with a red plastic tie indicating it had been opened, contained logs showing medications were removed on several dates. The Assistant Director of Nursing confirmed that nursing staff were expected to request a replacement e-kit immediately after it was opened to ensure availability of medications. The facility's policy stated that opened kits should be replaced within 72 hours, which was not adhered to in this instance.
Failure to Document Clinical Rationale for Medication Decisions
Penalty
Summary
The facility failed to implement a process to ensure that clinical rationale was documented when no changes were made to medications in response to identified irregularities and recommendations by the pharmacy consultant (PC) for a resident. The resident, who was admitted with multiple diagnoses including Huntington's disease, anxiety, insomnia, dementia, high blood pressure, depression, and repeated falls, was on a complex medication regimen. The PC's monthly drug regimen reviews (MRR) identified potential medication-related problems, such as increased risk of central nervous system depression, serotonin syndrome, neuroleptic malignant syndrome, and extrapyramidal symptoms due to the combination of medications prescribed. Despite these identified risks, the provider disagreed with the PC's recommendations to evaluate and possibly adjust the medication regimen, including the dosing of lamotrigine ER and the use of two antidepressants, without documenting the clinical rationale for these decisions. The Director of Nursing (DON) confirmed that the provider marked disagreement with the PC's recommendations on the MRRs but did not provide the necessary clinical rationale. Additionally, the facility was unable to provide a policy and procedure (P&P) addressing the process for reviewing and acting upon the PC's MRRs when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled according to professional standards and the facility's policies and procedures. During an inspection, expired medications, including Skintegrity Hydrogel and EvenCare G3 blood glucose test strips, were found in the Central Supply. Additionally, an open vial of Assure Platinum blood glucose test strips was identified without an open date label, and loose tablets were found in medication carts. Partially used bottles of sterile normal saline and acetic acid irrigation, which are intended for single use, were not discarded after opening, contrary to the manufacturer's instructions. Further inspections revealed that medications requiring different routes of administration were improperly stored together, such as injectable medications and topical patches being stored with oral medications. The Director of Nursing confirmed that medications should have been stored separately based on their administration routes and that all medications provided by the pharmacy should have been labeled with the resident's name. The facility's policies emphasized the importance of maintaining medication storage areas in a clean, safe, and orderly manner, which was not adhered to, leading to the potential for unsafe medication administration and misuse.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 95 residents who received facility-prepared foods. During an initial kitchen tour, it was observed that proper food labeling was not followed. Items such as coconut flakes, diced onions, and cut celery sticks were found without proper labels indicating the opened or used-by dates. The Registered Dietitian (RD) confirmed these observations and acknowledged that the staff is expected to label food items correctly as per the facility's policy and procedure. Additionally, expired food items were not discarded as required. Expired items such as oat milk, salad dressing packets, chocolate baking chips, pie crust, and soy milk were found in various storage areas. The RD confirmed these findings and stated that expired items should have been discarded immediately. The facility's policy mandates that no food should be kept beyond its expiration date, aligning with the U.S. Food and Drug Administration (FDA) guidelines. The facility also failed to maintain proper storage conditions for produce and utensils. A box of undated bananas with discoloration and leaking fluids was found in the walk-in refrigerator, which the RD and Dietary Manager confirmed should not be served to residents. Furthermore, several wet steam table pans were found stacked in the clean storage area, contrary to the facility's policy and FDA guidelines that require items to be air-dried before storage to prevent microorganism growth.
Inadequate Infection Control in Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper management of respiratory equipment for four residents. Resident 148 had a hand-held nebulizer and a nasal cannula that were unlabeled and undated, with a nebulizer bag that was dated more than a week prior. Resident 36 had an unlabeled and undated nasal cannula and nebulizer machine, with a disconnected nebulizer chamber and an undated oxygen mask, some of which were touching the floor. These items were not changed weekly as required, increasing the risk of respiratory infections. Resident 1's oxygen tubing and face mask were not labeled or dated, contrary to the facility's policy of weekly changes to prevent infections. The care plan for Resident 1 highlighted the risk of infection due to the use of muscle relaxants and a history of COVID-19, yet the necessary precautions were not followed. Similarly, Resident 3's oxygen tubing and face mask were not labeled or dated, and the antimicrobial bag was expired. The physician orders for Resident 3 specified weekly changes of oxygen equipment, which were not adhered to, posing a risk of infection. Interviews with staff, including CNAs and the Director of Nursing, confirmed the lapses in following the facility's policies for infection control. The facility's policies required that oxygen therapy equipment be labeled, dated, and changed weekly, with storage in antimicrobial bags changed monthly. These procedures were not consistently followed, leading to potential risks of respiratory infections among the residents.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the current condition of a resident, identified as Resident 92. The deficiency occurred when the discharge MDS inaccurately indicated that the resident was discharged to a short-term general hospital, despite documentation in the resident's Physician Orders, Nurse's Note, and Nurse Practitioner Note indicating that the resident was discharged to home. This discrepancy was confirmed during a record review and interview with the MDS Coordinator, who acknowledged the error and stated that the MDS should have been coded correctly. Resident 92 was admitted to the facility with multiple diagnoses, including heart failure and difficulty in walking. The facility's policy and procedure on resident assessments, which are federally mandated, require that discharge assessments be accurate and conducted by the interdisciplinary team. The Director of Nursing emphasized the expectation for MDS coding to be accurate. The inaccurate MDS submission to CMS resulted from a failure to adhere to these policies, as evidenced by the incorrect discharge status recorded in the MDS.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident 148, who was admitted with pulmonary edema, muscle weakness, and swallowing difficulty, had a physician's order for a respiratory treatment using Ipratropium-Albuterol Solution. However, there was no care plan developed for this treatment, and the resident was unaware of the purpose of the nebulizer treatment, indicating a lack of communication and documentation. Resident 36, admitted with asthma exacerbation and respiratory failure with hypoxia, had care plans that were not implemented. Observations revealed expired and undated respiratory equipment, such as nasal cannulas and nebulizer masks, which were not replaced as required. Additionally, the resident's oxygen tank was found empty, and staff failed to monitor and replace it, leading to the resident experiencing shortness of breath. These oversights in equipment management and monitoring contributed to the failure in implementing the care plan. Resident 85, diagnosed with lung cancer, pulmonary fibrosis, and COPD, received oxygen therapy at a higher rate than prescribed. The care plan indicated oxygen should be administered at 3L/min, but observations showed it was consistently given at 4L/min. Furthermore, the resident's oxygen saturation levels were not monitored as ordered, and the staff did not adhere to the care plan interventions. These actions and inactions resulted in the care plan not being followed, potentially affecting the resident's health outcomes.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, leading to deficiencies in personal hygiene and nutrition. Resident 83, who has Huntington's Disease, was observed with long fingernails and a thick dark substance underneath them, despite requiring partial/moderate assistance for personal hygiene. Similarly, Resident 44, with cognitive impairment and muscle weakness, had long fingernails with chipped nail polish and a dark substance underneath, even though they needed substantial/maximum assistance with personal hygiene. Resident 20, diagnosed with dementia and lack of coordination, also had long fingernails with a dark substance underneath, despite requiring partial/moderate assistance for personal hygiene. Staff interviews confirmed the lack of nail care and the importance of maintaining clean nails to prevent cross-contamination and bacterial growth. Additionally, the facility failed to provide one-to-one assistance during meals for Resident 29, who has spinal stenosis, dysphagia, and dementia. Despite the care plan indicating the need for one-to-one assistance and encouragement during meals, Resident 29 did not receive the required assistance during a dining observation. The Registered Dietitian and Director of Nursing confirmed the need for one-to-one assistance, as outlined in the resident's care plan and meal ticket. The facility's policies on ADL and nail care emphasize the necessity of providing services to maintain good nutrition, grooming, and personal hygiene, which were not adhered to in these cases.
Failure to Follow Physician's Orders for Oxygen and Insulin Administration
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. Resident 85, who was diagnosed with lung cancer, pulmonary fibrosis, and COPD, was prescribed oxygen therapy at 3 liters per minute to maintain oxygen saturation levels above 90%, with monitoring every shift. However, observations revealed that the resident was receiving oxygen at 4 liters per minute, and the oxygen saturation levels were not consistently monitored as ordered, with some days having only one or two checks instead of every shift. Licensed nurses confirmed the discrepancies in oxygen administration and monitoring. Resident 71, who was readmitted with a diagnosis of diabetes, had a physician's order for Insulin Glargine to be administered with specific parameters: 25 units to be injected unless blood sugar was below 151. Despite this, the medication was administered on two occasions when the resident's blood sugar levels were below the specified threshold, at 110 and 136, respectively. The Director of Nursing confirmed that the insulin was given outside the ordered parameters, and a licensed nurse acknowledged the importance of adhering to insulin orders to prevent rapid drops in blood sugar levels.
Excessive Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the water temperatures in four out of ten residents' bathrooms exceeding 120 degrees Fahrenheit. During observations and interviews conducted on September 30, 2024, it was confirmed that the water temperatures in these bathrooms ranged from 120.2 F to 122.2 F. Certified Nurse Assistants and a Housekeeper verified these temperatures, expressing concerns about the potential for burns or scalds due to the excessively hot water. Residents also expressed fear and caution when using the water, indicating awareness of the hazard. The facility's policy and procedure on water temperatures, dated May 2024, stipulates that water heaters in bathrooms should be set between 105 degrees Fahrenheit and 120 degrees Fahrenheit. However, the observed temperatures exceeded this range, indicating a failure to adhere to the established guidelines. This oversight could potentially place residents at risk of accidental scalds or burns, particularly given the fragility of the residents' skin as noted by the staff.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional risks. Resident 51, who has severe memory impairment and requires a mechanically altered diet, was served a regular sandwich instead of a meal that met her dietary needs. Despite her confusion and the meal ticket indicating a regular diet order, the Infection Preventionist confirmed the meal was not aligned with her preferences. Resident 60, with mild memory impairment and dietary restrictions, expressed dissatisfaction with the meals provided, specifically being served pasta despite disliking it. The meal ticket confirmed her dislikes, yet the meal did not reflect her preferences. The Licensed Nurse acknowledged the oversight but noted that the resident did not communicate her hunger or need for a replacement meal. Resident 82, who is at risk for malnutrition, repeatedly received meals with sauces despite expressing a dislike for them. The Assistant Director of Nursing verified the presence of sauce on the meal and offered a replacement. Similarly, Resident 20, with moderate memory impairment, was served a sandwich for lunch, which did not align with her expectations or the meal ticket indicating her preferences. The Infection Preventionist was unable to explain why both Resident 20 and Resident 51 received the same meal, highlighting a systemic issue in meal preparation and delivery.
Antibiotic Stewardship Guidelines Not Followed
Penalty
Summary
The facility failed to adhere to antibiotic stewardship guidelines for a resident who was prescribed an antibiotic without a specified end date. The resident, who was admitted in 2012 with conditions including diabetes, kidney disease, and a history of urinary tract infections (UTIs), was prescribed Cephalexin 250 mg daily for a UTI. However, the physician's order did not include a stop date for the antibiotic, and there was no documented evidence of monitoring for signs and symptoms of a UTI. Interviews with facility staff, including the Facility Pharmacist and the Director of Nursing, revealed that there was confusion and lack of clarity regarding the necessity and duration of the antibiotic treatment. The Facility Pharmacist expressed concerns about the indefinite use of the antibiotic and the potential for adverse effects such as Clostridium difficile infection. The Director of Nursing confirmed that there were no specific orders to monitor for UTIs and that the antibiotic order had not been reviewed or updated in 2024. The facility's policy on antibiotic stewardship required prescribers to provide a start and stop date or specify the number of days of therapy, which was not followed in this case.
Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact and required substantial assistance with toileting hygiene. The resident had multiple medical conditions, including depression, a history of stroke, and an amputation above the knee. During an interaction, the resident requested assistance from CNA 1, who responded with profanity and refused to help, leaving the resident feeling intimidated and verbally abused. The incident was corroborated by another resident and staff members who witnessed the exchange. A second resident observed CNA 1's inappropriate behavior and noted that CNA 1 returned to the room laughing after the confrontation. Licensed nurses and the Director of Staff Development also confirmed CNA 1's use of foul language and aggressive demeanor, describing him as having a short temper and being easily flustered. The Director of Nursing and the Administrator acknowledged the unprofessional conduct of CNA 1, who was suspended and subsequently terminated for misconduct. The facility's policies on resident rights and abuse prevention emphasize treating residents with respect and protecting them from abuse, including verbal abuse. However, these policies were not adhered to in this instance, resulting in a deficiency in the facility's care standards.
Failure to Monitor Resident's Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for a resident who was taking multiple non-prescription supplements and vitamins without evaluation or monitoring by health professionals. The resident, who had a history of chronic inflammation disorder affecting nerves, diabetes, pain, and hallucinations, was observed with numerous bottles of vitamins and supplements on their bedside table. These included nerve pain supplements, immune boosters, and dietary supplements, none of which were prescribed by a doctor or listed in the physician orders. Additionally, the resident had two medication cups with loose pills, which they reported taking three to four hours after their prescribed medications. The facility's policy required an evaluation by the interdisciplinary team (IDT) to determine if self-administration was clinically appropriate and safe, with documentation in the medical record and care plan. However, there was no such evaluation or documentation for this resident. The Licensed Nurse and Director of Nursing confirmed the lack of evaluation and monitoring, acknowledging the potential safety concerns and medication errors due to the resident's unsupervised self-administration of medications. The facility's failure to adhere to its policy resulted in the resident taking duplicate medications and multiple supplements without professional oversight.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
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