Bayshire Riverwalk Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 350 Calloway Drive, Building C, Bakersfield, California 93312
- CMS Provider Number
- 555771
- Inspections on file
- 54
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Bayshire Riverwalk Post-acute during CMS and state inspections, most recent first.
A resident with a right shoulder rotator cuff tear, NWB order to the RUE, high fall risk, and dependence for lower body dressing was taken to the shower by a CNA who did not verify weight‑bearing restrictions. The CNA instructed the resident to hold the grab bar with both hands while standing on a wet, slippery shower floor, barefoot, and began removing the resident’s pants while the resident remained standing, causing the pants to tangle around the legs. The resident slipped on the wet floor, fell, and struck the back of the head and left arm, resulting in a head bump, left forearm skin tears and bruising, pain, and increased nervousness about showers and ADLs. Interviews and records confirmed that the NWB order to the RUE was not followed, the resident was not seated in the shower chair during undressing, and the shower floor was not kept dry and non‑slippery.
Staff did not respond in a timely manner to call lights for three cognitively intact residents who required assistance with ADLs and toileting hygiene. One resident with a femur fracture and on a diuretic reported waiting up to 40 minutes for brief changes and stated that staff often said they would notify someone else but no one followed through, causing anger. Another resident reported waiting up to an hour for help with restroom use and water, sometimes yelling out until someone came and feeling devalued by the delays, while a roommate described having to go to the nurses’ station to get staff because the call light had been on so long. A CNA acknowledged that when multiple call lights were on, she responded when she could and that emergencies could delay responses, despite facility policies requiring residents to receive care per their care plans and for staff to answer call system alerts in a reasonable and timely manner.
A resident with severe cognitive impairment and physical limitations was physically abused by a CNA during personal care. The CNA, after being scratched by the resident, struck the resident on the face, causing the resident to cry and develop facial redness. The incident was witnessed by another CNA, who reported it to the administrator. The CNA responsible admitted to the act during interviews, and the facility's policy prohibiting abuse was not followed.
A resident with neuropathy and limited upper extremity mobility sustained a second-degree burn to the finger after staff failed to check the temperature of soup heated in a microwave. The resident, unable to sense heat due to neuropathy, dipped a finger into the soup and was injured. Staff interviews and record reviews confirmed that facility policy required temperature checks, but this was not performed, and CNAs had not been trained on this procedure.
A resident's right to refuse care was not honored when a CNA changed the resident's incontinence brief despite the resident's verbal refusal and visible distress. The CNA proceeded with the care while the resident was screaming, contrary to facility policy that emphasizes dignity and respect for resident choices.
Two residents were assigned new roommates without receiving the required 72-hour written notification. Staff interviews confirmed that notifications were given verbally and not documented, contrary to facility policy, and there was no evidence that written notice was provided before the roommate changes.
A resident alleged that a CNA was rough with her during care and reported this to the DCS. The allegation was not reported to the administrator, state agency, or local ombudsman within the required timeframe, resulting in a delay of two days before authorities were notified, contrary to facility policy.
A resident alleged physical abuse by a CNA during care, but the facility did not immediately remove the CNA from the resident's care, failed to conduct a timely physical assessment, and did not initiate an investigation as required by policy. The resident continued to receive care from the accused CNA for several hours after the allegation was made.
A resident with severe cognitive impairment, dementia, and quadriplegia experienced ongoing visual hallucinations, which were observed and reported by nursing and CNA staff over several weeks. Despite staff awareness, no care plan was developed or implemented to address these hallucinations, and key facility leaders were unaware of the issue. This failure was not in accordance with facility policy requiring comprehensive, person-centered care plans for all identified resident needs.
A resident was the alleged victim of psychological/mental abuse, but the facility did not send the required abuse report to CDPH or the local ombudsman within 24 hours, nor did it submit the 5-day investigation report within the mandated timeframe, as required by policy and state law.
A facility failed to maintain an accurate controlled medication record for a resident, leading to a potential risk of unaccounted for and/or diversion of medications. The resident had an order for Percocet, but an extra dose was administered without documentation. An LVN discovered a discrepancy in the medication count, and the records did not align with the administration. The facility's policy on controlled substances was not followed.
A resident reported rough and rude treatment by a CNA to her daughter, who requested the CNA not be assigned to her mother. The Clinical Manager was informed but did not report the issue to the Administrator, resulting in an eight-day delay in reporting the abuse allegation to the CDPH, contrary to facility policy.
The facility failed to follow its policies for cleaning, drying, and storing dishes, leading to potential food contamination. Observations revealed improperly stored dessert dishes with debris, dusty trays, and incorrectly stored lids. The Certified Dietary Manager acknowledged these issues, which violated the facility's procedures for maintaining dish cleanliness and storage.
The facility failed to follow its infection control policies, as staff did not perform hand hygiene when entering and exiting rooms, and a clean linen cart had a ripped cover, risking contamination. Additionally, a resident with a Foley catheter did not have Enhanced Barrier Precautions (EBP) implemented, lacking necessary signage and PPE.
The facility failed to assess three residents for self-administration of medications, as required by policy. A resident was found with Lidocaine Viscous 2% for thrush pain without a physician's order or SAMDC form. Another resident had Voltaren Arthritis Pain 1% without authorization, and a third resident had an open container of Vicks VapoRub without a physician's order or training. The facility's policy mandates secure storage and proper authorization for bedside medications, which was not followed.
A facility failed to provide proper accommodations for a resident who was given a call bell that could not be heard at the nurse's station, leading to prolonged periods without assistance and resulting in a rash. Additionally, the facility did not adhere to its policy of responding to call lights within five minutes for eight other residents, causing delays in assistance and negatively affecting their psychosocial and personal hygiene needs.
The facility failed to ensure that four residents had their Advance Directives documented in their medical records, as required by the facility's policy. Despite indications in the Social Services Progress Notes that Durable Power of Attorney for Health Care documents were in place for some residents, no copies were found in their medical records during a survey review.
The facility failed to properly account for and dispose of controlled medications, as observed in three medication carts. Unaccounted wasted medications were found in sealed envelopes, not documented or counted each shift, and not properly disposed of according to the facility's policy. This oversight involved RNs and LVNs who were unsure of the correct procedures, leading to potential risks of drug diversion.
The facility failed to effectively implement its antibiotic stewardship program, as antibiotic use was not monitored for several residents. A resident was prescribed Vancomycin for a UTI without being tracked, while another was on Meropenem without specifying the infection type. Additionally, a resident was on Cefepime for an unspecified infection, and there was no tracking of antibiotic use for another resident on CefTRIAXone. The facility's policy emphasized the importance of monitoring antibiotic use, but this was not effectively executed.
The facility failed to maintain three residents' rooms in good repair, with issues such as discolored ceiling tiles, broken blinds, and curtain rods. The Maintenance Director was unaware of these problems, and the facility's inspection list did not include checks for ceiling tiles. The facility's maintenance policy requires keeping the building in good repair, which was not followed.
A resident's request to not be cared for by a specific CNA was ignored, leading to emotional distress. Despite the Clinical Manager's communication to the Scheduler, the CNA continued to be assigned to the resident for several shifts, violating the facility's policy on respecting resident preferences and dignity.
The facility failed to implement care plans for two residents, leading to unmet care needs. A resident with deep vein thrombosis did not have her legs elevated as required, despite her care plan and reports of pain relief from elevation. Another resident with a foley catheter lacked a care plan for its management, contrary to facility policy.
A resident with diabetes and peripheral vascular disease developed multiple pressure ulcers due to the facility's failure to ensure the use of a Prevalon boot and a special mattress as ordered. Despite physician instructions, the resident was observed without the boot, and the nursing staff did not dress the wounds correctly, leading to a deficiency in care.
A facility failed to implement fall precautions for a resident, as observed when fall mats were improperly placed in the resident's room. The resident's Physician Order required bilateral floor mats, and the facility's Falls Prevention Policy included the use of adaptive equipment like fall mats for high-risk residents. An LVN confirmed the mats should have been on the floor on each side of the bed.
The facility did not follow its policy requiring physician orders to include clinical conditions or symptoms for medications prescribed to two residents. The MARs for these residents showed the use of strong antibiotics without specifying the type of infection being treated. The Infection Preventionist Nurse confirmed the omission and had not reviewed one of the antibiotic orders.
A resident received eight doses of expired Morphine Sulfate due to the facility's failure to discard the medication by the specified date. The LVN administering the medication did not routinely check expiration dates, contrary to the facility's policy on medication disposal.
A resident experienced dental pain and difficulty eating due to rotting teeth, with no follow-up on a dental consult sent months prior. The facility also failed to implement care plan interventions for daily oral cavity monitoring and oral care, as required by the resident's care plan. The lack of documentation and follow-up was acknowledged by facility staff.
A resident with Gout was repeatedly served tomato juice despite informing staff of her dietary restriction against acidic juices. The meal tray ticket inaccurately listed tomato juice as a preference, which the clinical dietician confirmed was incorrect. This oversight contravened the facility's policy requiring accurate reflection of residents' nutritional needs and preferences.
A resident's call light system was not functioning, leading to delayed care. Despite being aware of the issue, staff provided an ineffective call bell, and maintenance did not resolve the IT problem. Facility policies requiring a functional call system and alternatives were not followed.
A facility failed to develop a comprehensive care plan for a resident with impaired skin integrity. Despite specific skin care instructions in the Treatment Administration Record, there were no care plans for the resident's right hip, scrotum, and right elbow. The DON acknowledged this oversight, which contradicted the facility's policy requiring detailed care plans to maintain residents' wellbeing.
A facility failed to follow its policy for routine clinical documentation for a resident at moderate risk for pressure ulcers. The resident's turning and repositioning were not consistently documented on several occasions, as required by the facility's policy. The DON acknowledged the documentation lapses, emphasizing the need for staff to complete records accurately.
A facility failed to monitor a resident's weight weekly as ordered, despite significant weight loss. The resident lost 11.8 pounds over 30 days, and the order for weekly weights was not followed on two occasions. Interviews with the DON and RD confirmed the oversight, and the facility's policy on weight management was not adhered to.
The facility failed to maintain sanitary conditions in the dry food storage room and water pitcher cabinets, as evidenced by the presence of lifeless and live roaches. Staff acknowledged the issue but admitted there were no cleaning logs for these areas, and pest control measures were not effectively communicated or followed.
A resident did not receive their Sodium Chloride IV solution as ordered, with missed doses documented on the MAR. Additionally, the resident received an incorrect dosage of Amiodarone due to a failure to adjust the administration schedule as per the physician's updated order, resulting in a total of 300 mg administered in one day instead of the prescribed 200 mg.
The facility failed to follow its policy for timely responding to a resident's call light, resulting in a delay in positioning a therapeutic knee pillow for a resident with contractures. The call light response time was thirty-eight minutes, significantly longer than the expected few minutes.
A resident admitted with back pain did not receive prescribed pain medications, Dilaudid and Morphine Sulfate, in a timely manner. The resident experienced delays of over two hours and eight hours, respectively, for these medications, and was only offered non-pharmacological interventions such as repositioning during this period. The LVN confirmed the medications were not available at the time they were requested.
Failure to Follow NWB Orders and Provide Safe Shower Conditions Leading to Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe shower environment and to follow a resident’s non‑weight‑bearing (NWB) order to the right upper extremity (RUE), resulting in a fall with injury. The resident was admitted with diagnoses including a complete rotator cuff tear/rupture of the right shoulder, a rib fracture, generalized muscle weakness, abnormal gait and mobility, and a history of falling. The admission orders and therapy plan required a right arm sling to be worn at all times and specified NWB status on the RUE. The resident’s MDS showed she was cognitively intact, had functional limitation in upper extremity range of motion, was dependent for lower body dressing, and required partial/moderate assistance for sit‑to‑stand. The care plan and Kardex instructed staff to follow MD orders for weight‑bearing status and identified the resident as high fall risk. On the date of the incident, the resident was taken to the shower room by a CNA who knew the resident wore a sling and had difficulty moving the right arm but did not know the resident’s weight‑bearing restrictions and did not ask nursing or therapy about them. The CNA instructed the resident to hold onto the grab bar with both hands while standing, despite the NWB order on the RUE. The CNA reported that the shower floor was “a little wet,” and that she typically turned on the water and waited for it to warm while undressing residents, which could leave water dripping onto the floor. The DON later confirmed the shower floor was wet from a prior shower. The resident was standing, barefoot, on this wet floor while the CNA partially removed her pants; the resident’s pants became tangled around her legs as she tried to remove them while standing. According to the resident, the CNA stepped away while she was still standing with her pajama bottoms being removed, and the resident slipped on the wet, slippery floor and fell, striking the back of her head on the wall and her left arm on the floor tile. The nurse who responded found the resident on the floor with no shirt, pants and briefs partly off, bare feet, a bump on the back of the head, two skin tears on the left forearm with bruising, and limited ROM of the RUE. The resident reported pain to the head and left forearm and was crying. Emergency department records documented a mechanical fall in the shower while being held by a new CNA, with complaints of left knee pain, a skin tear to the left forearm, and a right humeral head fracture. Social services documented that after the fall the resident felt nervous and fearful about showers, therapy, and ADLs and did not want to fall again. The facility’s falls management policy required evaluation of fall risk and implementation of interventions to promote resident safety, but the resident was left standing on a wet shower floor, barefoot, with clothing around her legs and instructed to use both hands on the grab bar despite an RUE NWB order, leading to the fall and injuries described. The facility also failed to ensure the resident was seated in the shower chair while being undressed. The CNA and DON both stated the resident was standing when her pants were being removed, and the CNA acknowledged the resident was trying to get her pants off one ankle while standing when she fell. The IDT post‑event analysis documented that the resident was in bare feet at the time of the fall and that she slipped on water and tangled her foot in her pant legs while trying to take them off, losing her footing and falling. A family member who was called into the shower room observed the resident lying on a wet floor, sobbing, with pants down below the knees, bare feet, and wet lower extremities. These observations confirm that the resident was not seated during undressing and was exposed to a wet, slippery surface while partially clothed and unsupported. Therapy documentation on the day of the incident reiterated the NWB order on the RUE, and the PTA stated the resident could only use the left arm to hold the grab bar in the shower and that going against the NWB restriction could delay healing or worsen the fracture. The PTA and CNA both stated that CNA 1 should have asked nursing or therapy about the resident’s weight‑bearing restrictions before taking her to the shower. The DON acknowledged that the resident was NWB on the RUE at the time of the fall and that the resident was asked to briefly stand so her pants could be partially removed. Collectively, the record review and interviews show that the facility did not follow the resident’s NWB order, did not ensure she was seated while being undressed, and did not ensure the shower floor was dry and non‑slippery, resulting in the resident slipping and falling on the wet shower floor, sustaining head and left forearm injuries, pain, and subsequent nervousness about showers.
Untimely Response to Resident Call Lights for ADL and Toileting Assistance
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to answer resident call lights in a timely manner for three cognitively intact residents who required assistance with ADLs, particularly toileting. One resident, with a left femur fracture and care plan interventions directing staff to encourage call bell use and provide assistance with ADLs, reported using the call light for brief changes due to frequent urination from a diuretic and stated he could wait up to 40 minutes for staff to respond. He reported that when he requested assistance, staff would say they would notify someone else, but no one followed through, which made him angry. His MDS documented a BIMS score of 15 and a need for substantial/maximal assistance with toileting hygiene. Another resident, also with a BIMS score of 15 and care-planned to use the call bell and receive assistance with ADLs including toileting hygiene, reported using the call light for restroom assistance and water and stated she had waited up to an hour for a response, timing the delay by looking at a clock across from her bed. She reported sometimes having to yell out until someone came and said the wait time made her feel like she was nothing. A third cognitively intact resident in the same room stated she would get up and go to the nurses’ station to find staff to help the second resident because the call light had been on so long. A CNA stated that when multiple call lights were on, she responded when she could and that during an emergency a resident’s call light might not be answered timely. Facility policies on resident rights and the resident call system required that residents receive services in accordance with their care plans, be treated with dignity and respect, and that staff respond to call system alerts in a reasonable and timely manner.
Resident Physically Abused by CNA During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident during care. While two CNAs were changing the resident's adult brief, the resident, who has Alzheimer's disease, major depressive disorder, and legal blindness, became agitated and began hitting and grabbing the CNAs. One CNA, after having her hand grabbed and scratched by the resident, responded by hitting the resident on the right side of his face with an open hand. This act was witnessed by the other CNA, who described the action as a slap delivered out of anger, and observed that the resident became upset, cried, and had visible redness on his cheek. The resident involved was severely cognitively impaired, wheelchair-bound, and required substantial assistance with activities of daily living, including toileting and hygiene. The care plan for the resident noted a history of physical behaviors related to Alzheimer's disease, with interventions to provide cues and positive feedback to alleviate anxiety. On the night of the incident, documentation indicated no behavioral symptoms prior to the event. The physical abuse was not reported by the CNA who committed it, but was instead reported by the witnessing CNA to the facility administrator. Interviews and documentation confirmed that the CNA admitted to hitting the resident and did not initially report the incident. The administrator and other staff corroborated the sequence of events, including the demonstration of the slapping motion during interviews. The facility's policy states that residents have the right to be free from abuse, neglect, and mistreatment, but this policy was not followed in this instance, resulting in the resident experiencing physical and emotional distress.
Failure to Check Hot Liquid Temperature Results in Resident Burn
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure the temperature of a cup of soup was checked prior to serving it to a resident with significant risk factors. The resident had a history of polyneuropathy, rheumatoid arthritis, contractures, and functional limitations in the upper extremities, resulting in reduced sensation and mobility. The care plan identified the resident as being at risk for hot liquid injury and specified that staff should assist with hot liquids and provide a cup with a lid. Despite these precautions, a Certified Nursing Assistant (CNA) heated the resident's instant cup of noodle soup in the microwave and did not take the temperature before serving it. The resident, who was cognitively intact but had limited sensation in his fingers, tested the soup's temperature by dipping his left pointer finger into the bowl. Due to his neuropathy, he was unable to feel the heat and sustained a second-degree burn, resulting in blistering and removal of the fingernail. The injury was observed and documented by nursing and therapy staff, and the wound required debridement. Interviews with facility staff, including the CNA, Licensed Vocational Nurse (LVN), Registered Dietician (RD), and Administrator, confirmed that the facility's policy required hot liquid temperatures to be checked before serving, but this was not done. Additionally, CNAs had not received training on taking food temperatures prior to serving residents. Facility policies reviewed emphasized the importance of monitoring hot liquid temperatures to prevent burns, particularly for residents with impaired sensation or mobility.
Resident's Right to Refuse Care Not Respected During Incontinence Brief Change
Penalty
Summary
A Certified Nursing Assistant (CNA) reported that a resident was found with dried feces on her bottom and did not want her incontinence brief changed. Despite the resident's verbal refusal and distress, the CNA proceeded to clean and change the brief while the resident was screaming. The CNA later expressed regret, stating she should have left the resident because of the resident's distress. The administrator confirmed that during the incident, the resident was standing, had a large bowel movement, and was repeatedly saying no while the CNA changed her brief. The facility's policy emphasizes treating residents with dignity and respect, including honoring their choices and preferences throughout their stay.
Failure to Provide Written Notice Before Roommate Changes
Penalty
Summary
The facility failed to provide 72-hour written notification to residents prior to assigning them new roommates, as required by both regulation and facility policy. Specifically, two residents were assigned new roommates without receiving advance written notice. Documentation review showed that one resident was temporarily moved to different rooms due to incompatibility with a previous roommate, resulting in new roommate assignments for two other residents. There was no evidence that these residents received the required written notification before the changes occurred. Interviews with facility staff, including the Social Service Director, Admission Coordinator, and Administrator, confirmed that notifications regarding new roommate assignments were conducted informally and verbally, with no documentation to support that written notice was provided. Review of the facility's policy indicated that all parties involved in a room or roommate change should receive a 72-hour advance written notice, including the reason for the change and information to help residents become acquainted with new roommates. However, staff were unable to provide documentation that this process was followed for the affected residents.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its Abuse, Neglect & Exploitation Policy by not reporting an allegation of abuse involving a resident within the required timeframe. On 11/6, a certified nursing assistant (CNA) assisted a resident to the restroom, during which the resident later alleged that the CNA was rough with her. The resident communicated her concerns to the Director of Clinical Services (DCS) on the same day. Subsequently, the resident informed her daughter that a CNA had hit her, and the daughter reported this to the facility on 11/8. Despite the policy requiring allegations of abuse to be reported to the administrator, the state agency, and the local ombudsman within 2 to 24 hours depending on the severity, the allegation was not reported to the appropriate authorities until two days after the initial disclosure. Interviews with staff confirmed that both the DCS and the CNA were aware of the resident's allegations on 11/6, but the administrator was not informed until 11/8. Record review and staff interviews indicated that the facility's reporting procedures were not followed, resulting in a delay in notifying the California Department of Public Health and the local ombudsman about the abuse allegation. The facility's own policy, revised in 10/22, outlines the necessity for prompt reporting, which was not adhered to in this instance.
Failure to Investigate and Protect Resident After Abuse Allegation
Penalty
Summary
The facility failed to follow its Abuse, Neglect & Exploitation Policy when an allegation of physical abuse was made by a resident against a Certified Nursing Assistant (CNA). On the day of the incident, the resident expressed to a visitor and the Director of Clinical Services (DCS) that she had been physically abused by the CNA during assistance in the restroom. Despite this allegation, the CNA was not immediately removed from providing care to the resident and continued to work with her for approximately six more hours. There was no immediate physical assessment of the resident, and no investigation into the abuse allegation was initiated at that time. The facility's policy requires that upon learning of an alleged abuse, the accused staff member should be suspended until the matter is investigated, and the resident should be provided with medical attention as appropriate. Additionally, the policy mandates that an internal investigation be initiated as soon as practicable and that a licensed nurse or physician should immediately examine the resident, with findings documented in the medical record. These steps were not followed, as confirmed by interviews with staff and review of records, resulting in a failure to protect the resident and to investigate the allegation in a timely manner.
Failure to Develop Care Plan for Resident with Visual Hallucinations
Penalty
Summary
Facility staff failed to develop and implement a care plan for a resident experiencing visual hallucinations. The resident, who was admitted with unspecified dementia, a history of falls, and quadriplegia, was observed and reported by both nursing and CNA staff to have ongoing episodes of seeing people outside her window attempting to enter her room. These hallucinations had been occurring for several weeks to months, as confirmed by interviews with staff. Despite this, there was no documentation or care plan addressing the resident's hallucinations in her electronic medical record. Interviews with the facility's administrator and social services director revealed that neither was aware of the resident's hallucinations, and both acknowledged that a care plan should have been developed. Review of the facility's policy indicated that a comprehensive, person-centered care plan should be created for each resident, including measurable objectives and interventions for identified needs. The lack of a care plan for the resident's hallucinations constituted a failure to meet this requirement.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its Abuse, Neglect & Exploitation Policy in response to an allegation of psychological/mental abuse involving a resident. Specifically, the Report of Suspected Dependent Adult/Elder Abuse (SOC) for the resident, dated 4/25/25, indicated an allegation of psychological/mental abuse. However, the SOC was not sent to the California Department of Public Health (CDPH) or the local ombudsman within the required 24-hour timeframe, as confirmed by the Administrator during an interview and record review. Additionally, the facility did not submit the required 5-day investigation report to CDPH or the local ombudsman within five days of the incident. The facility's policy, as well as state regulations, require timely reporting and investigation of abuse allegations, including written reports to appropriate agencies within specified timeframes. The failure to adhere to these procedures resulted in the potential for an incomplete investigation and lack of protection for the resident involved.
Controlled Medication Record Discrepancy
Penalty
Summary
The facility failed to maintain an accurate controlled medication record for a resident, which had the potential for unaccounted for and/or diversion of controlled medications. The resident had a physician's order for Percocet to be administered as needed for moderate to severe pain. However, an incident occurred where the resident received an extra dose of Percocet that was not documented. During an interview, an LVN noted a discrepancy in the Percocet count, finding 30 tablets instead of the expected 31. The Controlled or Antibiotic Drug Record indicated that a tablet was removed at a specific time, but the Medication Administration Record did not reflect this administration. The facility's policy required determining whether medication was given or not charted, but this was not adhered to in this instance.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health (CDPH) in a timely manner. The resident, who was admitted with a fracture of the thoracic vertebra, muscle weakness, and a history of falls, was cognitively intact as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The resident reported to her daughter that a Certified Nursing Assistant (CNA) was rough and rude during care. The daughter requested that the CNA not be assigned to her mother, but the request was not acted upon immediately. The Clinical Manager (CM) was informed of the issue but did not report it to the Administrator or leadership team, resulting in a delay in addressing the resident's concerns. The Administrator became aware of the situation eight days later and reported the allegations to CDPH. The facility's policy requires that allegations of abuse be reported to the state agency within specific timeframes, depending on the severity of the incident. The delay in reporting the incident resulted in a delayed investigation and the potential for continued abuse towards the resident. The facility's policy emphasizes the responsibility of the Administrator and staff to protect residents from abuse and to report allegations promptly to ensure resident safety.
Improper Cleaning and Storage of Dishes
Penalty
Summary
The facility failed to adhere to its policies for cleaning, drying, and storing clean dishes, which posed a risk of food contamination. During an observation in the kitchen, it was noted that plastic dessert dishes were improperly stored in open bins without lids, piled up and not placed upside down. Some of these dishes had visible debris, including dark residue from a blueberry dessert served the previous night. The Certified Dietary Manager (CDM) acknowledged that the dishes should have been air-dried upside down and stored in a clean area, and agreed that they needed to be rewashed. Further observations revealed additional issues with dish cleanliness and storage. An open cart containing trays with clean dishes was found to be dusty, as evidenced by a surveyor's finger being covered with dust after running it along the inside lip of a tray. The CDM confirmed that these trays needed washing. Additionally, lids for hot food plates were stored improperly with the inside facing up, exposing them to potential contamination. The facility's policies, which were reviewed, clearly stated that dish storage areas should be cleaned, sanitized, and kept covered, and that dishes should be stored to promote air drying.
Infection Control Deficiencies in Hand Hygiene, Linen Handling, and EBP Implementation
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in several deficiencies. Two staff members, a Certified Nursing Assistant (CNA) and a Student Licensed Vocational Nurse (SLVN), did not perform hand hygiene when entering and exiting residents' rooms, contrary to the facility's hand hygiene policy. This policy, dated April 2024, emphasizes hand hygiene as a primary means to reduce infection spread. Both staff members acknowledged their failure to perform hand hygiene, recognizing it as an infection control measure. Additionally, the facility did not follow its policy for laundry and bedding, as the cover of the clean linen cart was ripped and unable to cover the linen completely during transport. This issue was acknowledged by the Laundry Assistant and the Supervisor of Housekeeping and Laundry Services, who noted the potential for dust contamination. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling Foley catheter. The Infection Preventionist Nurse confirmed that EBP signage and Personal Protective Equipment (PPE) were not provided, despite the facility's policy requiring such measures for residents with indwelling medical devices.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that three residents were assessed for self-administration of medications, which is a requirement for residents who wish to manage their own medication intake. Resident 364 was observed with Lidocaine Viscous 2% on his bedside table, which he used to alleviate pain from thrush in his mouth. However, there was no physician's order or Self Administration of Medication Data Collection (SAMDC) form completed for him. Similarly, Resident 33 had Voltaren Arthritis Pain 1% in her room without a physician's order or SAMDC form, and Licensed Vocational Nurse 4 confirmed that she was not allowed to have medications in her room without proper authorization. Resident 3 was found with an open container of Vicks VapoRub on the bedside table, and there was no record of a physician's order or training for self-administration. The facility's policy requires medications to be stored securely and only provided at the bedside with a physician's order and approval by the Interdisciplinary Care Team. The lack of adherence to these policies and procedures indicates a failure to properly assess and authorize residents for self-administration of medications, potentially placing them at risk.
Failure to Ensure Timely Call Light Response and Proper Accommodations
Penalty
Summary
The facility failed to ensure proper accommodations for Resident 269, who was given a call bell that could not be heard at the nurse's station. Resident 269, a [AGE] year-old admitted after a fall resulting in a right hip fracture, was at risk for falls and required assistance with activities of daily living due to immobility. Despite the care plan indicating the need for a functioning call light within reach, Resident 269 was provided with a bell that staff could not hear, leading to prolonged periods without assistance. This resulted in the resident sitting in soiled briefs for hours, causing a rash and feelings of embarrassment. Interviews with staff revealed a lack of awareness and communication regarding the non-functioning call light and the use of a bell for Resident 269. The Director of Nursing believed the call light issue had been resolved and instructed staff to conduct hourly rounds, but this was not communicated effectively to the CNAs. Observations confirmed that the bell could not be heard from the nurse's station, and the resident's room was located seven doors away, further complicating timely assistance. Additionally, the facility failed to implement its policy and procedure for call system response times for eight other residents. These residents experienced significant delays in call light responses, ranging from 15 minutes to over an hour, contrary to the facility's policy of responding within five minutes. This failure to respond promptly to call lights negatively impacted the residents' psychosocial and personal hygiene needs, as documented in interviews and call light communication logs.
Failure to Document Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that four of six sampled residents had an Advance Directive (AD) documented in their medical records. This deficiency was identified during interviews and record reviews conducted by the surveyors. Specifically, the Social Services Progress Notes for Residents 93 and 414 indicated the presence of a Durable Power of Attorney for Health Care (DPAHC), yet no copies of these documents were found in their medical records upon review. Similarly, during concurrent interviews and record reviews, it was noted that Residents 164 and 76 also lacked copies of their ADs in their medical records. The facility's policy and procedure on Advance Directives, dated December 2016, clearly stated that a copy of the AD should be obtained and placed in the resident's medical record. The absence of these documents in the medical records of the aforementioned residents suggests a failure to adhere to this policy, potentially impacting the ability of responsible parties and medical professionals to honor the residents' healthcare wishes in emergency situations.
Failure to Account for and Dispose of Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and disposal of controlled medications, as observed in three out of five medication carts. During an observation and interview, it was found that medication cart 2 at nursing station contained 18 sealed envelopes with wasted controlled medications, which were not counted or documented each shift. RN 2 acknowledged that these medications should have been given to the Director of Nursing (DON) for disposal. Similarly, RN 1 at the same station was unsure about the procedure for handling two sealed envelopes of wasted controlled medications, which were also not included in the daily controlled medication counts and documentation. At another nursing station, medication cart 3 contained a sealed envelope with wasted controlled medications, which LVN 5 stated was to be given to the DON. The DON confirmed that discontinued and wasted controlled medications should be stored in a double-locked cabinet in her office and disposed of monthly with the pharmacy consultant. The facility's policy and procedure for controlled substances indicated that all controlled drugs should be properly stored, accounted for each shift, and disposed of in a timely manner. However, the facility failed to adhere to these procedures, leading to unaccounted controlled medications and potential risks of drug diversion.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of monitoring of antibiotic use for three sampled residents. Resident 414 was prescribed Vancomycin for a urinary tract infection, but the Infection Preventionist Nurse (IPN) did not have this resident's antibiotic use on her tracking sheet and had not communicated with the nurse about it. Similarly, Resident 164 was prescribed Meropenem, but the IPN noted that the physician's order lacked the type of infection and she had not reviewed the antibiotic order. Resident 57 was on Cefepime for an unspecified infection, and there was no tracking of this antibiotic use either. Additionally, the facility's Medication Administration Record for November 2024 showed that Resident 268 was prescribed CefTRIAXone for a possible infection, but the facility administrator confirmed there was no tracking of antibiotic use for the previous month. The facility's policy on antibiotic stewardship emphasized the importance of monitoring antibiotic use to prevent resistant organisms, yet the IPN's job description, which includes overseeing infection prevention and control, was not effectively executed in this instance.
Facility Maintenance Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain the rooms of three residents in good repair, which could potentially impact their psychosocial needs and quality of life. In Resident 10's room, large brownish discolorations were observed on the ceiling tiles in four areas. The Maintenance Director (MD) was unaware of these discolorations, as they were not reported or listed for repairs. The facility's maintenance inspection list did not include specific checks for ceiling tiles in residents' rooms, as confirmed by the Executive Director (ED). In Resident 56's room, there were missing and broken blinds, while Resident 51's room had broken blinds and curtain rods. Resident 51 mentioned that these issues had always been present. The MD acknowledged the broken and missing blinds and stated that they needed to be ordered. The facility's policy and procedure for maintenance service, dated December 2009, requires the maintenance department to keep the building in good repair and free from hazards, which was not adhered to in these instances.
Failure to Honor Resident's Preference in Care Assignment
Penalty
Summary
The facility failed to honor a resident's personal preference by continuing to assign a Certified Nurse Assistant (CNA) to the resident's care despite a request for reassignment. The resident, identified as Resident 84, and their family member reported that CNA 2 was rude, and a request was made on October 30, 2024, for CNA 2 not to be assigned to Resident 84. However, CNA 2 continued to be assigned to Resident 84 on multiple occasions, specifically on November 2, 3, 5, and 6, 2024. This resulted in emotional distress for Resident 84, who expressed fear of CNA 2. The Clinical Manager (CM) acknowledged the request for reassignment and communicated it to the Scheduler, expecting that CNA 2 would not be assigned to Resident 84 in the future. However, the Scheduler confirmed that CNA 2 was still assigned to Resident 84 for four shifts after the request. The facility's policy on resident rights emphasizes the importance of respecting resident preferences and ensuring their dignity and well-being, which was not adhered to in this case.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for two residents, resulting in unmet care needs. For Resident 18, observations revealed that her legs were not elevated as required to manage pain related to deep vein thrombosis and joint pain. Despite the care plan indicating the need for non-pharmacological pain interventions, including leg elevation, staff interviews confirmed that this intervention was not being implemented. Resident 18, who was cognitively intact with a BIMS score of 14, reported constant pain in her feet and stated that elevating her legs helped alleviate the pain, but staff did not follow through with this intervention. For Resident 268, the facility failed to have a care plan in place for her indwelling foley catheter. During an observation, the resident was unable to recall the reason or duration for having the catheter. A review of her records confirmed the absence of a care plan addressing the catheter, which was acknowledged by the Clinical Manager. The facility's policy on comprehensive care plans mandates that treatments and services should be described to assist residents in achieving their highest level of wellbeing, but this was not adhered to in Resident 268's case.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and promote the healing of pressure ulcers for one resident. The resident, who had a history of diabetes mellitus with foot ulcers, peripheral vascular disease, and difficulty walking, was observed with multiple open sores and black-colored wounds on his left foot and toes. Despite the physician's orders and care plan indicating the need for a Prevalon boot to be worn while in bed to alleviate pressure, the resident was repeatedly observed without the boot. The boot was found in the resident's closet, and the resident stated he had never worn it. Additionally, the resident did not have a special mattress or bed, which was noted as necessary for preventing and aiding the healing of pressure ulcers. The resident's medical records, including the Admission Skin Assessment and Physician Progress Notes, documented the presence of diabetic ulcers and a new pressure ulcer on the left heel. The nursing staff was noted for not dressing the wounds correctly, and the Prevalon boot was not consistently applied as ordered. The facility's policy on pressure ulcer treatment emphasized the need to follow the care plan for special needs, which was not adhered to in this case, leading to the deficiency in care.
Failure to Implement Fall Precautions for a Resident
Penalty
Summary
The facility failed to implement fall precautions for one of the residents, identified as Resident 48, which had the potential to result in falls and injuries. During an observation, it was noted that Resident 48 was in bed with a fall mat folded up next to the nightstand. Later, another observation revealed that one fall mat was folded and placed behind the bed, while another was folded next to the nightstand. A Licensed Vocational Nurse (LVN) confirmed that the fall mats should have been placed on the floor on each side of the bed. A review of Resident 48's Physician Order, dated September 1, 2023, indicated the requirement for bilateral floor mats. The facility's Falls Prevention Policy, dated August 2023, also stated that safety precautions for high-risk residents may include adaptive equipment at the bedside, such as fall mats.
Failure to Specify Clinical Conditions in Medication Orders
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Medication and Treatment Orders' by not ensuring that physician orders for two residents included the clinical condition or symptoms for which the medications were prescribed. For Resident 164, the Medication Administration Record (MAR) indicated the use of Meropenem, a strong antibiotic, but did not specify the type of infection being treated. Similarly, for Resident 57, the MAR showed the use of Cefepime, another strong antibiotic, without detailing the specific infection type. During interviews, the Infection Preventionist Nurse acknowledged the absence of specific infection types in the physician orders for both residents and admitted to not reviewing the antibiotic order for Resident 164. The facility's policy, dated July 2016, clearly states that medication orders must include the clinical condition or symptoms, which was not followed in these cases.
Failure to Discard Expired Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Morphine Sulfate. During an observation and interview, it was found that the medication cart contained syringes labeled with the resident's name and a discard date that had already passed. Despite this, the medication was administered to the resident multiple times after the discard date, as confirmed by the Controlled Substance Record and Medication Administration Record. The Director of Nursing acknowledged that the medication should have been discarded by the specified date but was not. Further investigation revealed that the Licensed Vocational Nurse responsible for administering the medication did not routinely check the expiration dates of medications before administration. The facility's policy and procedure documents outlined the requirement for timely disposal of expired or discontinued medications, but these protocols were not followed. This oversight led to the resident receiving eight doses of expired medication, highlighting a significant lapse in medication management and adherence to established procedures.
Failure to Provide Dental Care and Implement Care Plan
Penalty
Summary
The facility failed to provide necessary dental services and implement care plan interventions for a resident, identified as Resident 18. The resident reported having rotting teeth and experiencing dental pain, which affected their ability to eat. Despite a dental consult being sent on September 12, 2024, there was no follow-up action taken by the facility to ensure the resident received the required dental care. The resident had previously seen a dental hygienist for cleaning on September 4, 2024, and had an annual checkup on May 7, 2024, where a tooth was lost. The Social Service Director acknowledged the lack of follow-up on the dental consult, and the Clinical Manager confirmed that the resident had complained of dental pain, indicating a need for timely intervention. Additionally, the facility did not adhere to the care plan interventions for monitoring the resident's oral health. The care plan required daily monitoring of the oral cavity for signs of redness, pain, swelling, or changes in taste, and providing good oral care after meals and at bedtime. However, there was no documentation of daily oral cavity monitoring in the Treatment Administration Record for October and November 2024. The Director of Nursing confirmed the absence of such documentation, and the resident's Minimum Data Set indicated a need for setup or cleanup assistance with oral hygiene. The facility's policy required interventions to be implemented to meet the resident's needs, but this was not followed in the case of Resident 18.
Inaccurate Meal Tray Ticket for Resident with Gout
Penalty
Summary
The facility failed to ensure the accuracy and adherence to the meal tray ticket (MTT) for a resident diagnosed with Gout, a condition that requires dietary restrictions on acidic foods and beverages. The resident, identified as Resident 269, reported receiving tomato juice with every meal despite having informed the staff multiple times of her inability to consume acidic juices due to her condition. This discrepancy was observed during an interview and meal observation, where the resident was again served tomato juice, which she stated she could not have. Upon review of the resident's MTT, it was noted that tomato juice was incorrectly listed as a preference rather than a dislike. The clinical dietician acknowledged the error, stating that a resident with Gout should not be served tomato juice and that the MTT should have reflected the resident's dietary restrictions and preferences accurately. The facility's policy on Resident Nutrition Services mandates that each resident's nutritional needs and preferences be reviewed by an interdisciplinary team to develop an appropriate care plan, which was not adhered to in this case.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to ensure a functioning call light system for one of the residents, resulting in delayed care and unmet needs. During an observation and interview, it was found that the resident's call light was not working, and she was given a call bell instead, which she stated was ineffective as staff could not hear it, leading to delays in response. The resident reported being without a working call light for several days. Interviews with staff, including an LVN, CNA, and the DON, revealed that the issue had been known for a few days, but no effective action had been taken to resolve it. The maintenance technician confirmed that the problem was identified as an IT issue, but it was not followed up on. The facility's policies require a functional call system at all times and alternative means of communication if the system is down, which were not adequately provided in this case.
Failure to Develop Comprehensive Care Plan for Skin Integrity
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with impaired skin integrity. During an observation, the resident was found lying on his right side, and a review of the Treatment Administration Record (TAR) from March 2024 indicated specific skin care instructions for the resident's right hip, scrotum, and right elbow. However, upon reviewing the nursing care plans for March, April, and May 2024, it was discovered that there were no care plans developed for these areas of potential or actual skin impairments as listed in the TAR. The Director of Nursing (DON) acknowledged the absence of care plans for the resident's right elbow, right hip, and scrotum, despite the facility's policy and procedure requiring a person-centered, comprehensive care plan. The policy, dated November 2017, mandates that care plans describe treatments and services to help residents attain or maintain their highest level of wellbeing, including goals for care, identified issues, and measures to prevent or reduce declines in functional status. The lack of a comprehensive care plan for the resident's skin impairments had the potential to worsen the resident's condition.
Failure to Document Resident Care as per Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure for routine clinical documentation for a resident, which had the potential to not meet the resident's needs. During an observation, the resident was found lying on his right side. A review of the resident's Braden Scale assessment indicated a moderate risk for pressure ulcer development. However, the documentation survey report revealed multiple instances where the required turning and repositioning of the resident were not documented. These omissions occurred on several dates and times, indicating a lack of consistent documentation of care provided. The Director of Nursing acknowledged the absence of documentation and suggested there could be various reasons for the oversight, but emphasized that staff should complete the documentation. The facility's policy, dated February 2006, mandates that all services provided to residents be documented in their medical records. The failure to document the turning and repositioning of the resident as per the facility's policy represents a deficiency in maintaining accurate and complete medical records, which is crucial for ensuring the resident's care needs are met.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to its policy and procedure on weight management guidelines for a resident whose weight was not monitored weekly as ordered. The resident had an order for weekly weights for one month, but the facility did not record weights on two occasions, specifically on 5/19/24 and 5/26/24. This oversight occurred despite the resident experiencing a significant weight loss of 11.8 pounds over a 30-day period, from 4/29/24 to 6/2/24. The resident's weight loss was noted as significant, with a 6.9% decrease in one week, and the plan was to monitor weights weekly. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) revealed that the weekly weights order was not implemented, and there was uncertainty about why this occurred. The facility's policy indicated that the Nursing Department should provide the Food and Nutrition Services Department with monthly and weekly weights of each resident, and residents with significant weight variance should be identified and appropriate interventions implemented. However, this protocol was not followed, leading to the deficiency.
Sanitation Issues in Dry Food Storage and Water Pitcher Cabinets
Penalty
Summary
The facility failed to maintain the dry food storage room in a sanitary condition, as evidenced by the presence of lifeless roaches on the floor and in the drain. During an observation, three lifeless roaches were found in the drain and two in the corner of the dry storage room. The Assistant Dining Supervisor acknowledged seeing roaches the previous week and reported it to the maintenance department. The Dietary Dining Supervisor confirmed the presence of the dead roaches and admitted there was no log for cleaning the dry storage room. The Administrator stated that the last pest control check was performed recently, and no roaches were found at that time. However, a Certified Nurse Assistant reported seeing a live roach crawling towards the dining room and informed the licensed nurse about it. Additionally, the facility failed to ensure that the clean water pitcher storage cabinets were free from pests. During an observation, white residues were found on the shelves of the cabinets storing clean water pitchers, and a live roach was seen at the bottom of one of the shelves. The Dietary Dining Supervisor acknowledged the issue and stated that there was no log for cleaning the water pitcher storage areas. The facility's policy and procedure for maintaining dry storage and cabinets were not followed, contributing to the unsanitary conditions observed.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered according to the physician orders for a resident. Specifically, the resident's Sodium Chloride IV solution was not administered as ordered, with documentation gaps on the Medication Administration Record (MAR) indicating missed doses on two consecutive nights. This failure was confirmed during an interview and record review with the Clinical Nurse Specialist (CNS), who acknowledged the blanks in the MAR meant the medication was not documented and therefore not administered as required by the physician's order for continuous hydration over three days. Additionally, the facility did not administer Amiodarone as ordered for the same resident. The resident was initially prescribed 200 mg of Amiodarone once daily, but due to nausea and vomiting, the physician adjusted the dosage to 100 mg twice daily. However, on the day of the dosage change, the resident received both the original 200 mg dose in the morning and an additional 100 mg dose in the evening, resulting in a total of 300 mg for that day. This medication error was confirmed by the Director of Nursing (DON) and documented in the resident's progress notes, indicating a failure to adhere to the correct dosage and frequency, which had the potential to cause adverse effects such as changes in heart rate, nausea, and vomiting.
Failure to Timely Respond to Resident Call Light
Penalty
Summary
The facility failed to ensure its policy and procedure titled 'Resident Call System and Door Alarm Response- EME-1' was followed for one of the sampled residents. This failure resulted in a delay in positioning a therapeutic knee pillow for a resident with contractures. The resident, who had a BIMS score of 15 indicating cognitive intactness, reported waiting for a long time, feeling like hours, for his call light to be answered. The call light communication log confirmed a response time of thirty-eight minutes on the specified date, which was significantly longer than the expected response time of a few minutes as stated by the facility's staff and policy. During interviews, both a CNA and an LVN acknowledged that the resident's call light was on for an extended period and that the response time should have been quicker. The Director of Clinical Services also confirmed that a thirty-eight-minute response time was not within the facility's expectations. The facility's policy indicated that associates should respond to resident call system alerts in a reasonable and timely manner, which was not adhered to in this instance.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to ensure pain medications were administered as ordered for a resident who required such services. The resident, who had been admitted to the facility with back pain after receiving an epidural, did not receive his prescribed pain medications, Dilaudid and Morphine Sulfate, in a timely manner. Specifically, the resident requested Dilaudid for pain rated 8/10 at approximately 1:30 a.m. on 2/7/24 but did not receive it until 3:42 a.m., a delay of over two hours. Additionally, the resident was supposed to receive Morphine Sulfate at 10 p.m. on 2/6/24 but did not receive it until 6 a.m. on 2/7/24, an eight-hour delay. During this period, the resident was only offered non-pharmacological interventions such as repositioning. The Licensed Vocational Nurse (LVN) confirmed that the pain medications were not available at the time they were requested and that the pharmacy had not received the original hardcopy prescription. The facility's policies on pain management and medication administration were reviewed and indicated that medications should be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed time. The failure to adhere to these policies resulted in significant delays in pain management for the resident.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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