Bridgewood Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 5901 Lemon Hill Ave, Sacramento, California 95824
- CMS Provider Number
- 055956
- Inspections on file
- 43
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bridgewood Post Acute during CMS and state inspections, most recent first.
Two residents with cognitive impairments physically assaulted other residents, resulting in one resident being punched while lying in bed and another wheelchair-bound resident being struck in the eye. In one case, a nurse entered a room during medication administration and saw a resident with schizophrenia standing over and punching another resident with Parkinson’s disease. In the other, a resident with schizoaffective disorder suddenly turned and hit a cognitively intact, hemiplegic resident in the eye while on the phone with his mother. These events occurred despite a facility abuse prevention policy stating residents must be free from physical abuse.
Two residents with complex mental health and cognitive diagnoses were involved in an altercation when one resident, attempting to pass in a hallway, pushed another's wheelchair, causing the startled resident to react physically. Staff intervened immediately and no injuries were noted, but the incident demonstrated a lapse in supervision as required by facility policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report notes that residents were not adequately safeguarded from mistreatment.
Four medication administration errors were identified among three residents, resulting in a medication error rate of 14.81%. Errors included a nurse not administering the correct dose of haloperidol for a resident with schizophrenia, two nurses failing to wear gloves when handling hazardous medications for residents with epilepsy and post-transplant status, and a nurse not administering prescribed aspirin as ordered. These actions did not follow physician orders, medication labels, or facility policy.
Surveyors found four unlabeled loose pills and four labeled medications misplaced behind drawers and at the back of a medication cart. Nursing staff and the DON confirmed that medications should not be loose or stored in these locations, and facility policy requires medications to be stored in original packaging and in an orderly manner. The failure to follow these procedures resulted in a deficiency.
Four dietary staff members did not demonstrate competency in essential food safety practices, with two unable to verbalize correct manual dishwashing procedures and two failing to perform proper hand hygiene before handling clean dishes. These failures, observed despite documented training and current food handler certificates, placed nearly all residents at risk for foodborne illness.
Several residents did not receive meals in accordance with their prescribed diets, including incorrect portion sizes, inappropriate food substitutions, and missing or incorrect garnishes. Dietary staff did not follow the facility's menu spreadsheet or portion control procedures, and the Registered Dietitian confirmed that substitutions and errors were made without proper evaluation.
Surveyors identified multiple deficiencies in dietary services, including an unclean ice machine with mineral and organic buildup, improper storage and labeling of food items, spoiled produce, personal belongings stored with food, and staff not following required hygiene and dishwashing procedures. Expired and unlabeled food was also found in the resident food refrigerator, with staff confirming these lapses in compliance with facility policy and professional standards.
Multiple deficiencies were identified, including broken or missing wardrobe drawers in several rooms, cracked toilet seats, and missing or non-functional call lights in resident bathrooms. Staff and residents confirmed these issues had persisted, and a piece of a broken windowsill with exposed nails was found on the floor next to a resident's bed, creating a safety hazard. Facility policies assign responsibility for maintenance and require prompt reporting and repair of such hazards.
A resident with dementia and a history of stroke was prescribed lorazepam for behaviors related to dementia without an adequate clinical indication, despite facility policy requiring documented justification for psychotropic medication use. The consultant pharmacist identified the lack of appropriate diagnosis and recommended re-evaluation, but no supporting rationale was provided by the prescriber.
A DON removed a PICC line from a resident with a history of infection and MRSA, but failed to measure the catheter length after removal as required by facility guidelines. The catheter was discarded without confirming it matched the documented pre-insertion length, which was observed and later acknowledged by the DON.
A resident did not receive the prescribed dose of haloperidol for schizophrenia because the correct tablet strength was not available at the time of administration. The nurse identified a discrepancy between the physician's order and the available medication, and the correct dose had not yet been delivered from the pharmacy. The DON confirmed that the medication should have been available, and facility policy required timely access to prescribed medications.
Four residents with serious mental health conditions did not receive multiple doses of critical medications, including antipsychotics and antidepressants, due to medication unavailability and delays in providing required lab results to the pharmacy. Nursing staff did not consistently reorder medications in advance or communicate necessary information, resulting in missed doses and, in one case, hospitalization.
A resident with impaired mobility and a history of falls did not have prescribed fall prevention interventions, such as a low bed position and a fall mat, consistently implemented. Staff confirmed the interventions were not in place and were not documented as declined by the resident, and the DON acknowledged these measures should have been maintained and documented.
A resident with a history of mental health issues exhibited aggressive behavior, resulting in a physical altercation where another resident was injured. Despite attempts to manage the situation, the aggressive resident threw a plate, causing a laceration on the victim's eyebrow. The incident highlighted lapses in monitoring and intervention by the facility staff.
A facility failed to create a care plan for a resident with weight loss and a stage 4 pressure ulcer. Despite the resident's complex medical history, including sepsis and hemiplegia, and documented treatment orders for the ulcer, no care plans were in place. The DON expected immediate implementation of care plans, but the facility could not provide their policy on care plans.
The facility failed to conduct initial background checks on two CNAs, as required by its policies, placing residents at risk. Despite being employed for several months, the CNAs' background checks were not completed, as confirmed by the DON and HR. This oversight compromised the facility's ability to protect residents from potential harm.
The facility failed to provide a safe, clean, and homelike environment for several residents, with issues such as disrepair of furniture, chipped paint, and lack of personal belongings in rooms. Residents and staff expressed concerns about the safety and comfort of the environment, highlighting a failure to adhere to the facility's policy on maintaining a homelike atmosphere.
The facility failed to develop comprehensive care plans for four residents, leading to potential risks. A resident with MRSA and ESBL infections lacked a care plan for isolation precautions, while another with diabetes had no plan for skin integrity, resulting in an unmanaged wound. A third resident with Alzheimer's had no care plan for denture use, and a fourth resident lacked a plan for monitoring gabapentin administration, risking medication interactions.
The facility failed to accurately document the administration of controlled medications, as evidenced by missing signatures on controlled drug count records and discrepancies in the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for two residents. This lack of documentation was confirmed by a Licensed Nurse and acknowledged by the Director of Nursing, highlighting a failure to follow the facility's policy and procedure for controlled substance accountability.
The facility failed to ensure proper medication storage and labeling, leading to expired medications being available for use, lack of open dates on multi-dose medications, and improper storage of medications with different administration routes. Expired medications were found in the storage room, and several inhalers lacked resident-specific labeling. The facility's policies for medication storage and labeling were not followed, posing risks to residents.
The facility failed to provide meal alternatives with similar nutritional value to the main entree, risking protein/calorie malnutrition for 44 residents. Alternatives like grilled cheese and peanut butter and jelly sandwiches offered significantly fewer calories and protein compared to the main meals, as observed by the Dietary Supervisor and noted by the Registered Dietitian.
The facility failed to provide correct portion sizes for the consistent carbohydrate diet (CCHO), potentially affecting blood sugar control for 11 residents. Observations revealed that dietary staff used incorrect scoop sizes for polenta and served smaller portions of chocolate cake than specified. The Registered Dietitian confirmed the importance of following the cook's spreadsheet to ensure proper nutrient distribution, as outlined in the facility's Diet Manual.
The facility exhibited multiple food safety deficiencies, including improperly sealed and labeled food items, unclean equipment, and inadequate thawing and dishwashing processes. The kitchen environment was in disrepair, with missing air gaps and fluctuating storage temperatures, posing risks of contamination and foodborne illness.
The facility failed to follow infection control guidelines, including not posting droplet precaution signs for a resident with MRSA and ESBL, not cleaning bandage scissors during wound care for another resident, and not implementing Enhanced Barrier Precautions for residents with high-risk conditions. These lapses increased the risk of infection transmission.
A resident with a history of falls and multiple diagnoses, including stroke and muscle weakness, experienced a fall incident. The facility failed to update the resident's care plan to include new interventions, such as a fall mat, which was found improperly positioned. Staff confirmed the oversight, and the facility's policy required care plan updates to reflect current needs.
A resident received the incorrect probiotic due to a failure by nursing staff to verify the medication against the physician's order. During a medication pass, a nurse administered lactobacillus with pectin instead of the ordered saccharomyces boulardii. The error was acknowledged by the nurse, and the DON emphasized the expectation for staff to ensure medication accuracy by reviewing orders and the MAR.
A resident with multiple health issues developed an unstageable pressure ulcer on the right heel due to the facility's failure to implement a care plan for skin protection. The absence of interventions for skin assessment, repositioning, and offloading was noted, and staff admitted to not checking the affected area. The facility's policy on pressure injury prevention was not adhered to, leading to this deficiency.
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutritional status. One resident lost 24 pounds, and another lost 26 pounds over six months. The facility did not document discussions about food preferences or assess the effectiveness of dietary interventions. Communication barriers and lack of family consultation contributed to the deficiency.
A resident with asthma received Advair Diskus 42 times past its expiration date in an LTC facility. The expired medication was found on a medication cart, and it was confirmed by a nurse that it had been administered despite the manufacturer's instructions to discard it after one month. The facility's policies required checking expiration dates and notifying the nurse manager if a medication was expired, but these procedures were not followed.
The facility failed to properly puree zucchini, potentially affecting the nutrition of four residents on pureed diets. A cook added unmeasured amounts of butter and thickener, deviating from the facility's recipe, resulting in a puree that did not conserve nutritive value and flavor.
A malfunctioning freezer in the facility's kitchen, observed during a tour, posed a potential food safety risk for 44 residents. The freezer, which was not maintaining the correct temperature, led to overcrowding in another freezer. Despite assurances of repair, delays occurred due to the busy schedule of cooling companies, with a faulty fan identified as the issue.
The facility failed to follow infection control practices for two residents, with issues including unlabeled oxygen tubing, a mislabeled urinal, and improper storage of urinals. Staff interviews revealed non-compliance with facility policies, emphasizing the importance of proper labeling and storage to prevent infection.
The facility failed to protect a resident from abuse when another resident struck him in the face and head. Despite no physical injuries being found, the incident caused mental anguish and fear. Both residents were evaluated at a GACH and returned without findings. The facility's policy defines such altercations as abuse, and staff confirmed the incident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by other residents. In the first incident, a resident with schizophrenia and moderate cognitive impairment (BIMS score of 10) was observed by a licensed nurse standing over another resident with Parkinson’s disease and moderate cognitive impairment (BIMS score of 10) and punching him while the victim lay in bed. The nurse confirmed that the punches made physical contact with the resident’s body, though he could not specify the exact locations. This altercation occurred in the victim’s room during a medication pass. In the second incident, a resident with schizoaffective disorder and severe cognitive impairment (BIMS score of 7) struck another resident who had hemiplegia/hemiparesis and was cognitively intact (BIMS score of 13). The cognitively intact resident was seated in a wheelchair while the aggressor was standing and talking on the phone with his mother. According to one licensed nurse, the aggressor suddenly swung around, used his right arm, and struck the wheelchair-bound resident in the right eye in a punch-like motion. Another licensed nurse present reported that the aggressor abruptly hung up the phone, turned toward the other resident, and the victim then stated, “He hit me.” The facility’s own Abuse Prevention Program policy states that residents have the right to be free from abuse, including physical abuse, but these incidents of resident-to-resident physical contact occurred nonetheless.
Failure to Provide Adequate Supervision Resulting in Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, both of whom were in wheelchairs and located near the nursing station. One resident, diagnosed with schizoaffective disorder, borderline personality disorder, and bipolar disorder, was sitting in her wheelchair in the hallway. Another resident, with diagnoses including encephalopathy, sepsis, and dementia, attempted to pass but was unable to due to limited space. The second resident reached out and pushed the first resident's wheelchair forward in an attempt to get by. This action startled the first resident, who reacted impulsively by reaching back and making contact with the second resident's arm. Staff immediately intervened and separated the residents. Both residents were assessed, and no injuries were noted. Interviews with staff and the residents confirmed that the incident occurred as described, with the first resident expressing that she was startled and did not intend to harm the other resident. Both residents were noted to be cognitively intact according to their most recent BIMS scores and had no prior incidents with each other or other residents. The facility's policy on safety and supervision emphasizes individualized supervision based on assessed needs and environmental hazards, but in this instance, the supervision provided was insufficient to prevent the altercation.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Medication Error Rate Exceeds 5% Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by four errors out of 27 observed opportunities during medication administration for three residents. For one resident with schizophrenia, a licensed nurse did not administer the prescribed dose of haloperidol as ordered, due to a discrepancy between the physician's order and the available medication dose in the facility. The nurse withheld the medication pending clarification, and it was confirmed that the correct dose should have been available for administration according to the physician's order and facility policy. Another resident with epilepsy was administered divalproex sodium by a licensed nurse who failed to wear gloves, despite the medication label and physician order specifying glove use due to the hazardous nature of the drug. The nurse acknowledged the omission and the reason for the glove requirement. The facility's policy also required adherence to manufacturer specifications and physician orders during medication administration. A third resident, a transplant recipient, was administered mycophenolate without the nurse wearing gloves, contrary to both the medication label and physician order, which required glove use. Additionally, this resident did not receive the prescribed aspirin during the observed medication pass, and the nurse was unable to clarify the timing or reason for the missed dose. The DON confirmed that the expectation was for nurses to follow the e-MAR and physician orders, and that the aspirin should have been administered as ordered.
Improper Storage of Medications in Medication Cart
Penalty
Summary
During an inspection of Medication Cart A, surveyors observed four unlabeled loose pills and four labeled pharmaceutical products located behind the drawers and at the back of the medication cart. Licensed nursing staff confirmed the presence of these medications, noting that the loose pills were found at the bottom of the drawer and the labeled medications were misplaced at the back of the cart. The staff acknowledged that such storage practices could result in medication errors, and stated that the cart should be checked daily to prevent medications from falling into inaccessible areas. The Director of Nursing confirmed that medications should not be loose in the drawers and that labeled medications should not be stored at the back of the cart behind the drawers. Facility policy requires that medications and biologicals be stored in their original packaging and containers, and that storage areas be maintained in a clean, safe, and sanitary manner. The policy also specifies that medications are to be stored in an orderly manner, with each resident's medications assigned to individual compartments to prevent mixing. The observed failure to adhere to these procedures led to the deficiency.
Dietary Staff Lacked Competency in Dishwashing and Hand Hygiene Procedures
Penalty
Summary
The facility failed to ensure that four dietary staff members possessed the necessary skills to safely and effectively perform daily food and nutrition service operations. Two dietary aides were unable to accurately verbalize the correct manual dishwashing procedure using a 3-compartment sink, specifically failing to state the required immersion time for sanitizing dishes. Although both aides had attended in-service training and were marked as competent in their files, their inability to recall critical steps was confirmed during interviews. The facility's policy required a 60-second immersion in sanitizer at 200 ppm, but this was not consistently known or articulated by the staff. Additionally, two cooks did not follow proper hand hygiene protocols before handling clean dishes. One cook used the same gloved hands to touch various surfaces, including a refrigerator handle and their clothing, before handling clean dishes. Another cook touched both soiled plates and clean dishes with bare hands without washing in between. These lapses were observed directly and acknowledged by the dietary supervisor and registered dietitian, both of whom stated that handwashing should occur before touching clean dishes to prevent cross-contamination. Facility policies and job descriptions required frequent handwashing and proper glove use, but these were not followed in practice. The failures in both manual dishwashing procedures and hand hygiene had the potential to place 45 out of 47 highly susceptible residents at risk for foodborne illness. Staff files showed that all involved employees had current food handler certificates and had attended relevant in-service trainings. However, the observed deficiencies indicated a lack of effective competency in critical food safety practices, despite documented training and policy requirements.
Failure to Follow Prescribed Menus and Dietary Requirements During Meal Service
Penalty
Summary
During a lunch meal service, the facility failed to follow prescribed menus and dietary requirements for multiple residents. One resident on a mechanical soft (MS) texture and small portion diet received an incorrect portion size of meatball, being served 1/3 cup instead of the required 3/8 cup. Another resident with MS, controlled carbohydrate (CCHO), and renal diets was served brown rice instead of the prescribed wheat pasta, despite wheat pasta being available. Additionally, a resident on an MS diet received a parsley sprig garnish instead of parsley flakes, which was specified in the menu. Six other residents did not receive any parsley garnish with their meals, contrary to the menu requirements. Interviews with the Dietary Supervisor and Registered Dietitian confirmed that dietary staff did not follow the facility's menu spreadsheet or use the correct scoop sizes and substitutions. The Registered Dietitian also noted that providing a whole parsley sprig instead of flakes to a resident on an MS diet could pose a choking risk. Job descriptions for dietary staff and the dietitian outlined responsibilities to prepare and serve food according to planned menus, portion control procedures, and special diet orders, which were not adhered to during this meal service.
Multiple Food Safety and Sanitation Deficiencies Identified in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, and distributed in accordance with professional standards, as evidenced by multiple observations and interviews. The ice machine was found to have a white chalky calcium deposit and significant black gelatinous substances on its mechanical and evaporator parts, indicating it had not been properly cleaned and sanitized according to the manufacturer's instructions and facility policy. The maintenance supervisor confirmed the presence of these substances and acknowledged the need for cleaning. Additionally, the facility's cleaning log did not have a current date for the last deep cleaning, and the registered dietitian confirmed that the ice machine was expected to be cleaned monthly. In the kitchen, pans were observed stacked while still wet and with food debris present, and opened packaged food products in both the refrigerator and freezer were not properly labeled or dated. Bread items labeled as 'keep frozen' were found defrosting in dry storage, and produce such as onions were found to be spoiled. Personal belongings were stored in the dry storage area alongside food items, contrary to facility policy. Staff were observed not following proper hygiene protocols, including a dietary aide using a mask instead of a beard net, and two cooks failing to perform handwashing before handling clean dishes. Two dietary aides were unable to correctly verbalize the manual dishwashing process, including the required immersion time for sanitizing dishes. In the resident food refrigerator, expired food items and items without proper labeling, such as resident names and received dates, were found. The infection preventionist confirmed these findings and stated that food should be labeled and discarded according to policy. These deficiencies were observed to have the potential to cause food-borne illness among all residents who consumed food from the facility kitchen or brought in from outside, with a census of 47 residents at the time of the survey.
Environmental Safety and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for its residents, staff, and the public, as evidenced by multiple deficiencies observed during survey. Several resident rooms had broken or missing wardrobe drawers, with residents confirming that these issues had persisted for extended periods and expressing a desire for repairs. Facility staff, including the contractor and administrator, acknowledged that all wardrobe drawers should be functional and easy to use, and facility policy assigns responsibility for maintenance to the Maintenance Director. Additional deficiencies were observed in resident bathrooms, including cracked toilet seats and missing or non-functional call lights. In some cases, the call lights had been missing for several days, and both staff and residents confirmed the absence of these essential safety devices. Residents and staff emphasized the importance of having accessible call lights in bathrooms for timely assistance and a sense of security. Facility policies require employees to report damaged items and ensure that call lights are functional and accessible. A further safety hazard was identified in a resident's room, where a broken windowsill with exposed nails was found on the floor next to the resident's bed. Staff confirmed the presence of this hazard and agreed it posed a risk to both residents and staff. The resident in this room had a recent history of an unwitnessed fall from bed. Facility policy requires the maintenance department to keep the building in good repair and free from hazards, but these observations indicate that this standard was not met.
Unnecessary Psychotropic Medication Prescribed Without Adequate Indication
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a stroke, and dementia was prescribed lorazepam, an antianxiety medication, twice daily for behaviors associated with dementia, such as yelling and removing clothes. The medication order was documented without an adequate clinical indication, as dementia is not an approved diagnosis for lorazepam use. The resident's medication regimen also included other psychotropic and sedative medications, such as Seroquel XR, melatonin, gabapentin, and fluoxetine. A review by the consultant pharmacist identified that lorazepam was being prescribed for an unapproved diagnosis and recommended a re-evaluation of the order or a rationale to support its use. The attending physician's response did not provide a rationale for the continued order. The facility's policy on psychotropic medication use requires a documented clinical indication in line with accepted clinical standards, which was not met in this case.
Failure to Measure PICC Line Length After Removal
Penalty
Summary
The facility failed to provide services according to professional standards of quality for one resident when the DON removed a Peripherally Inserted Central Catheter (PICC) from a resident's right upper arm and did not measure the length of the catheter before discarding it. The resident had been admitted with an infection and inflammatory reaction due to an internal left knee prosthesis and Methicillin Resistant Staphylococcus Aureus (MRSA), and was cognitively intact at the time of the incident. The clinical record documented the initial internal catheter length as 42 cm, and there was a physician's order for PICC removal. During the removal, the DON pulled out the PICC line and immediately threw it in the trash without measuring its length, as observed by surveyors. In a subsequent interview, the DON acknowledged not measuring the catheter and stated that this step should have been performed to ensure the entire catheter was removed, as per facility guidelines and best practices. Facility guidelines and external references both specify that the catheter should be measured after removal to confirm it matches the documented pre-insertion length.
Failure to Provide Prescribed Dose of Haloperidol Due to Pharmacy Service Lapse
Penalty
Summary
The facility failed to ensure that pharmacy services were maintained for one resident when the prescribed dose of haloperidol was not available for administration as ordered by the physician. Observation of medication administration revealed that the available haloperidol tablets were 5 mg, while the physician's order required 0.5 tablet (2.5 mg) to be given once daily. The nurse identified the discrepancy between the ordered dose and the available medication in the blister pack and did not administer the medication without clarification. The order for the new dosage had been changed the previous day, but the correct dose had not yet been delivered from the pharmacy at the time of the scheduled administration. Review of the resident's Medication Administration Record confirmed the order for haloperidol 5 mg, with instructions to give 0.5 tablet. The DON stated that the expectation was for the physician to sign the order promptly so the pharmacy could fill the prescription, but the medication dose was not available for the morning administration. The facility's policies required that the right dose be administered and that residents have a sufficient supply of their prescribed medications at all times. The failure to have the correct medication dose available resulted in a disruption of the resident's treatment plan.
Failure to Ensure Timely Availability and Administration of Critical Medications
Penalty
Summary
The facility failed to ensure the availability and timely administration of prescribed medications for four residents with significant mental health diagnoses. For one resident with paranoid schizophrenia, bipolar disorder, and major depressive disorder, there were missed doses of Venlafaxine and Clonazepam due to medication unavailability. Nursing notes and interviews confirmed that these medications were not available at the time they were due, and the pharmacy required blood work prior to dispensing, which was not always provided in a timely manner. Another resident with schizoaffective disorder, bipolar disorder, and major depressive disorder did not receive multiple doses of Clozapine because the medication was not available, as documented in nursing progress notes. The pharmacy required current lab results before dispensing Clozapine, and it was the responsibility of nursing staff to ensure these were sent. The DON confirmed the missed doses and indicated that staff were expected to notify him and the provider about such issues, but this did not occur. A third resident with schizophrenia missed several scheduled doses of Haloperidol Decanoate injections over multiple months. Documentation showed that the medication was not available on the scheduled dates, and there was no evidence the doses were administered after the medication arrived. Nursing staff reported difficulties with timely pharmacy deliveries and acknowledged that missed doses could lead to behavioral regression. A fourth resident with paranoid personality disorder and schizoaffective disorder missed nine consecutive doses of Clozapine and three doses of Austedo due to nursing staff not relaying required lab results to the pharmacy, resulting in a hospitalization. Facility policies required medications to be reordered at least three days before running out, but this was not consistently followed.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a care plan intervention to prevent falls for a resident with conversion disorder, decreased coordination, and impaired lower extremities who used a wheelchair for mobility. The resident had a documented fall, after which the care plan was updated to include keeping the bed in the lowest position and placing a fall mat on the floor. However, multiple observations revealed that the bed was not kept in the lowest position and the fall mat was not present. Staff interviews confirmed that the interventions were not consistently implemented, with one CNA stating the resident preferred the bed at a regular height and that the fall mat was missing. Record reviews and staff interviews further indicated that the required interventions were not documented as declined by the resident, nor was there evidence of consistent monitoring or documentation of the resident's response to the fall prevention measures. The DON confirmed that the expectation was for the bed to be kept in the lowest position and the fall mat to be in place whenever the resident was in bed, and that any resident preference for a different bed height should be documented, which was not done in this case.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a laceration on the victim's right eyebrow. Resident 1, who had a history of mental health issues including schizophrenia, bipolar disorder, and dementia, exhibited aggressive behavior on the day of the incident. Despite being sent to the hospital for evaluation, Resident 1 returned to the facility and continued to display aggression, ultimately throwing a plate at Resident 2, causing injury. Resident 1's behavior was documented as increasingly agitated, with staff noting physical and verbal aggression, as well as disruptive actions such as throwing items and refusing to cooperate. Staff attempted to redirect Resident 1, but were unable to prevent the incident. Resident 2, who had low vision and blindness, was unable to identify the assailant but expressed fear and distress following the attack. Interviews with staff revealed that Resident 1's behavior had been escalating, and despite increased supervision, the incident occurred during a lapse in monitoring. The facility's policies on resident-to-resident altercations and abuse prevention were reviewed, highlighting the need for staff to monitor and intervene in situations where aggressive behavior is present. However, the measures in place were insufficient to prevent the incident from occurring.
Failure to Develop Care Plan for Weight Loss and Pressure Ulcer
Penalty
Summary
The facility failed to develop a specific care plan for a resident who experienced weight loss and had a stage 4 pressure ulcer. The resident was admitted with multiple diagnoses, including sepsis, hemiplegia, hypertensive heart, and chronic kidney disease. A review of the resident's records indicated a significant weight change and a documented stage 4 pressure ulcer requiring specific treatment. However, during an observation and interview, it was confirmed by a licensed nurse that there were no care plans addressing the resident's weight loss or pressure ulcer. The Director of Nursing stated that care plans should be implemented immediately when orders are written, but the facility was unable to provide their policy and procedure for care plans.
Failure to Conduct Initial Background Checks on CNAs
Penalty
Summary
The facility failed to implement its policies and procedures for the prohibition and prevention of abuse, neglect, and exploitation by not conducting initial background checks on two Certified Nurse Assistants (CNAs) who were actively working in the facility. This oversight was identified during interviews and record reviews, revealing that CNA 1 had been employed for over a year and CNA 2 since December 2023, without the required background checks being completed. The Director of Nursing (DON) confirmed that the facility's policy mandates background checks during the hiring process and every two years thereafter, but the initial checks for these CNAs were not found. The Human Resources (HR) department confirmed that the facility's policy requires initial background checks for all employees, including contracted staff, students, volunteers, and consultants. Despite this, the HR department acknowledged that the background checks for CNA 1 and CNA 2 were never conducted. This failure placed all residents at risk for potential serious physical and/or psychosocial harm, as the facility could not ensure that employees did not have a criminal history of abuse, neglect, or exploitation.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as observed during a survey. The deficiencies included cabinet and closet drawers in disrepair, chipped and stained paint on the walls, and bare walls without personal belongings in residents' rooms. These issues were noted in the rooms of seven residents, who were part of the sample group. The residents expressed dissatisfaction with the state of their rooms, highlighting the lack of maintenance and personalization. Resident 9, who had mild memory impairment and required extensive assistance with activities of daily living (ADLs), reported that the cabinet drawers and doors in their room did not close properly and had been in disrepair for a long time. Similarly, Resident 18, with chronic lung disease and pneumonia, had a room with disrepair issues and chipped paint. Staff members, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), confirmed these findings and expressed concerns about the safety and homeliness of the environment. Other residents, such as Residents 153, 253, 254, 255, and 256, were found in rooms with bare walls and no personal belongings, which did not provide a homelike atmosphere. These residents had various diagnoses, including stroke, dementia, and major depressive disorder, and required extensive assistance with ADLs. Staff members, including CNAs and the Activity Director, acknowledged the lack of personalization in these rooms and the potential safety hazards posed by the disrepair of furniture. The facility's policy emphasized the importance of creating a homelike environment, but the observations indicated a failure to adhere to this policy.
Lack of Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks for unmet needs and negative impacts on their well-being. Resident 18, who was admitted with chronic lung disease and pneumonia, did not have a documented care plan for isolation precautions despite having MRSA and ESBL infections. Observations revealed that there was no sign for droplet precautions, and staff were not consistently following isolation protocols. Interviews with staff confirmed the absence of a care plan for isolation precautions, which should have been documented in the resident's medical record. Resident 15, with diagnoses including diabetes and chronic obstructive pulmonary disease, lacked a care plan for skin integrity. An observation revealed an open wound on the resident's right heel, which was not being properly managed or documented. Interviews with staff confirmed the absence of a care plan for skin protection, which should have included interventions for skin assessment and monitoring. Resident 204, diagnosed with adult failure-to-thrive and Alzheimer's disease, did not have a care plan for the use of dentures. Observations showed the resident was not wearing dentures during meals, and staff were unaware of the need for dentures. Interviews confirmed the lack of a care plan for dentures, which is essential for providing appropriate care. Resident 19, with multiple diagnoses including heart failure and diabetes, did not have a care plan for the administration and monitoring of gabapentin, a medication that can cause drowsiness and sedation. Staff interviews confirmed the absence of a care plan, which is crucial for monitoring potential interactions with other medications like amitriptyline.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to implement its policy and procedure for the accurate accountability of controlled medications. This was observed when controlled drug count records were not routinely signed by the outgoing and incoming nursing shifts. The controlled drug sign-in/sign-out sheets for Medication Cart B, dated from April 2024 to July 2024, showed missing signatures for each shift change, totaling 82 missing signatures. Licensed Nurse 3 confirmed the absence of signatures and acknowledged the importance of documenting in both the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for accountability and assessing the effectiveness of pain relief. The deficiency involved two residents who were prescribed controlled medications. One resident had a physician's order for hydrocodone/APAP, but the CDR indicated that the medication was removed from the cart on several occasions without corresponding documentation on the MAR. Another resident had a physician's order for oxycodone, and the CDR showed that the medication was removed without documentation on the MAR. Licensed Nurse 3 admitted to forgetting to document the administration of oxycodone for this resident on specific dates. The Director of Nursing stated that nursing staff were expected to document administered doses of controlled medications in both the MAR and CDR. The facility's policy and procedure required two licensed nurses to account for all controlled substances at the end of each shift and to document the administration of controlled substances in the MAR and narcotic book. The failure to adhere to these procedures resulted in inaccurate accountability of controlled medications, as evidenced by the discrepancies in the records for the two residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that multi-dose medications were dated with an open and discard date, prescription medications were appropriately labeled, and medications with different routes of administration were stored according to facility policy. During an observation and interview, expired medications such as hemorrhoidal suppositories, bisacodyl, and dry mouth moisturizing spray were found in the medication storage room. Licensed Nurse 2 confirmed these findings and acknowledged that expired medications should be removed and given to the Director of Nursing or Assistant Director of Nursing for destruction. Further inspection revealed that two Lantus Solostar pens lacked open dates, and vials of ipratropium/albuterol were found without pharmacy labels. Additionally, One-Care Pro test strips were missing an open date, and haloperidol injectable was improperly stored with oral medications due to space constraints. LN 2 confirmed these findings and noted that insulin has a shorter shelf life once removed from refrigeration. The manufacturer's guidelines for Lantus Solostar and One-Care Pro test strips were not followed, as they require specific storage conditions and discard timelines. In another inspection, several inhalers used to treat asthma were found without open dates or resident-specific labeling, including Incruse Ellipta, Combivent Respimat, Symbicort, Airsupra, Spiriva Respimat, Dulera, and an expired Advair Diskus inhaler. The DON confirmed that inhalers should have pharmacy labels and be stored separately according to their administration route. The facility's policy and procedures for medication storage and labeling were not adhered to, leading to the potential for residents to receive medications with reduced potency or incorrect administration.
Deficiency in Nutritional Value of Meal Alternatives
Penalty
Summary
The facility failed to provide meal alternatives of similar nutritive value to the main entree, potentially leading to protein/calorie malnutrition for 44 residents consuming facility-prepared meals. During an observation and interview, the Dietary Supervisor (DS 1) demonstrated the alternatives available to residents, such as a grilled cheese sandwich, which could be chosen if the menu meal was undesired. However, these alternatives were not equivalent in nutritional content to the main meals. The Registered Dietitian (RD) expressed concerns about the caloric content and visual appeal of these alternatives, noting uncertainty about the protein content monitoring. The facility's nutritional breakdown indicated an average of 2,197 calories and 97 grams of protein per day, translating to approximately 732 calories and 32 grams of protein per meal. In contrast, a typical peanut butter and jelly sandwich provided only 363 calories and 11.5 grams of protein, while a grilled cheese sandwich offered 336 calories and 11 grams of protein. These alternatives provided only about 34-36% of the typical meal's nutritional value, highlighting a significant deficiency in meeting residents' dietary needs.
Incorrect Portion Sizes for Consistent Carbohydrate Diet
Penalty
Summary
The facility failed to ensure that dietary staff provided the correct portions when plating the consistent carbohydrate diet (CCHO) for residents. During an observation of the lunch meal plating, it was noted that the dietary staff used a green handle scoop, which is 1/3 cup, instead of the required #16 scoop, which is 1/4 cup, for serving polenta to residents on the CCHO diet. Additionally, residents on the CCHO diet received a smaller portion of chocolate cake than specified in the cook's spreadsheet. The spreadsheet indicated a serving size of 2x2 1/2 inches, but residents received a piece approximately 1x1 1/4 inches. The Registered Dietitian (RD) confirmed that dietary staff should adhere to the cook's spreadsheet to ensure the correct calories and nutrients, such as carbohydrates, are provided. The facility's Diet Manual for the Controlled Carbohydrate Diet emphasizes the importance of consistent carbohydrate distribution to maintain stable blood sugar levels, particularly for diabetic residents and those with metabolic concerns. The failure to provide the correct portions had the potential to lead to poor blood sugar control for 11 residents on the CCHO diet.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as evidenced by multiple deficiencies observed during a kitchen tour. Opened food items, such as hamburger and turkey patties, were not properly sealed, exposing them to potential contaminants. Additionally, a tray of prepared drinks and a bottle of almond extract were found unlabeled and undated, which could lead to uncertainty about their safety for consumption. The facility's policy on date marking for food safety was not followed, as confirmed by the dietary supervisor. Further inspection revealed unclean food service items, including a food processor bowl with brown build-up and a cutting board with food residue. The kitchen environment was also in disrepair, with chipped paint and glue build-up on walls and ceilings, which could harbor pathogens. The thawing process for lunch meat was not conducted according to standards, as it was left in static water, increasing the risk of bacterial growth. Additionally, alcohol sanitizer containers were improperly placed in the kitchen, contrary to FDA guidelines for handwashing procedures. The dishwashing process was inadequate, with wet pans stored without proper air drying, and the air-drying area was exposed to potential contamination from a handwash sink. Air gaps were missing on the ice machine and the fruit and vegetable wash sink, posing a risk of backflow contamination. The dry storage area was too warm, potentially affecting food quality, and the resident refrigerator temperatures fluctuated outside safe ranges, risking food spoilage. Lastly, a chipped can opener blade was identified, which could introduce metal fragments into food, posing a risk of injury.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control guidelines for several residents, increasing the risk of infection transmission. Resident 18, who was admitted with chronic lung disease and pneumonia, was placed under contact/droplet precautions due to MRSA in the nares and ESBL in the urine. However, the facility did not post a sign for droplet precautions on the resident's door, and staff were observed not wearing masks when entering the room. Interviews with staff, including the Director of Nursing (DON) and Infection Preventionist/Director of Staff Development (IP/DSD), confirmed the lack of proper signage and adherence to droplet precautions, which was not safe for other residents sharing the room. Resident 13, diagnosed with necrotizing fasciitis and sepsis, underwent wound care treatment where bandage scissors were not cleaned between uses. The Licensed Nurse (LN) performing the dressing change used the same pair of scissors to cut foam dressing and clear bandage without disinfecting them, placing the resident at risk of infection. The facility's policy on wound treatment management emphasizes evidence-based treatments to promote wound healing, which was not followed in this instance. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Residents 2 and 19, who were at high risk due to their medical conditions. Resident 2, with a stage 4 pressure injury and MRSA, did not have EBP signs or gowns available during wound care. Similarly, Resident 19, with a dialysis catheter, lacked EBP signage and gowns, despite staff coming into contact with the catheter. The facility's policy requires EBP for residents with wounds or indwelling medical devices, which was not adhered to in these cases.
Failure to Update Fall Risk Care Plan for a Resident
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for Resident 153 after a fall incident, which was identified during a survey. Resident 153, who was admitted with diagnoses including stroke, difficulty walking, muscle weakness, and expressive language disorder, was at risk for falls. The Nursing Care Plan dated February 2, 2024, indicated the resident was at risk for falls due to poor safety awareness. However, after a fall incident documented on July 6, 2024, the care plan was not updated to include new interventions such as the use of a fall mat. Observations and interviews revealed that the fall mat intended to prevent injuries was not positioned correctly, rendering it ineffective. Certified Nursing Assistant 5 and the Director of Nursing both confirmed the fall mat was too far from the bed. Licensed Nurse 7 acknowledged that the care plan needed revision to include the fall mat as an intervention, which had not been done despite the resident's frequent falls. The facility's policy required that care plans be updated and revised to reflect the resident's current needs, which was not adhered to in this case.
Failure to Verify Probiotic Leads to Medication Error
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for a resident when nursing staff did not verify the contents of a probiotic administered. During a medication pass observation, a licensed nurse was seen preparing medications for a resident, including lactobacillus with pectin, which did not match the physician's order for saccharomyces boulardii. The nurse was unaware of the discrepancy and acknowledged the error upon review. The Director of Nursing stated that nursing staff were expected to review the medication administration record and physician's orders to ensure accurate medication administration. The facility's policy on medication administration required nurses to verify the medication name, form, dose, route, and time with the medication administration record. The failure to adhere to these procedures resulted in the resident receiving the incorrect probiotic, with potential implications for their gut health.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident who developed an unstageable pressure ulcer on his right heel. The resident, admitted in mid-2023, had multiple diagnoses including diabetes, chronic obstructive pulmonary disease, dependence on renal dialysis, and acute kidney failure. A review of the resident's clinical record revealed the absence of a care plan with interventions for skin assessment, repositioning, monitoring, offloading, heel protectors, and hygiene/shower. During an observation and interview, an administrative assistant noted an open wound on the resident's right heel with a slight odor and a dark black hard crust in the center. The licensed nurse confirmed the absence of a care plan for skin protection and admitted to only checking the resident's left foot. The Director of Nursing acknowledged that there should have been a care plan in place to assist staff in caring for the resident. The facility's policy on pressure injury prevention and management emphasized the importance of a systematic approach for prevention and management, which was not followed in this case.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to ensure that two residents, Resident 16 and Resident 33, maintained acceptable nutritional status, resulting in significant weight loss over a six-month period. Resident 33, who was admitted with multiple diagnoses including mild cognitive impairment and type 2 diabetes, lost 24 pounds, equating to a 21.6% body weight loss. The facility did not document any discussions about food preferences upon admission or during the weight loss period. The Registered Dietitian (RD) recommended dietary supplements and appetite stimulants, but there was no evidence these interventions were communicated to the resident or their representative, nor assessed for effectiveness. Resident 16, diagnosed with dementia and other conditions, lost 26 pounds, a 16.3% body weight loss over six months. Observations showed that Resident 16 ate less than 50% of her meals, yet the facility did not assess the cause of her reduced intake or evaluate the effectiveness of current nutritional interventions. The Interdisciplinary Care Team (IDT) noted the weight loss but did not discuss food preferences with the resident's family or representative. The RD recommended an appetite stimulant but did not document actions to address the cause of poor intake or obtain food preferences. Interviews with facility staff revealed communication barriers, as the Dietary Supervisor relied on staff to communicate in Spanish with residents like Resident 16 and Resident 33. The facility failed to consult Resident 16's family regarding food preferences, and no nutrition screens were located for either resident. The Nutrition Care Manual suggests involving the patient and family in care decisions, but this was not evident in the facility's actions.
Expired Medication Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of an expired medication. Resident 10, who was admitted with a diagnosis of asthma, received Advair Diskus, a medication used to treat asthma, 42 times past its expiration date. The medication was found on Medication Cart B during an inspection, and it was confirmed by Licensed Nurse 3 that the inhaler had expired. The manufacturer's instructions clearly stated that the device should be discarded one month after opening or when the dosing indicator reads '0'. Despite this, the expired medication continued to be administered to the resident. The Director of Nursing acknowledged that nursing staff are expected to check expiration dates before administering medications and notify the physician if an expired medication is given. The facility's policy and procedure for medication administration also required nurses to identify expiration dates and notify the nurse manager if a medication was expired. Additionally, the facility's policy on medication storage indicated that the pharmacy and medication rooms should be routinely inspected for outdated medications by the consultant pharmacist. However, these procedures were not followed, leading to the administration of expired medication to Resident 10.
Improper Pureeing of Zucchini
Penalty
Summary
The facility failed to properly puree zucchini in a manner that conserved its nutritive value and flavor, potentially leading to poor intake and malnutrition for four residents consuming pureed meals. During an observation, a cook (Ck 1) was seen removing zucchini from the oven and placing it into a processor bowl, adding an unmeasured amount of melted butter, and blending the mixture. The resulting puree was too thin and runny, prompting Ck 1 to add an unmeasured amount of thickener before blending again. The final mixture was placed into a steam table pan and returned to the oven. The facility's provided recipe for pureed vegetables indicated specific steps and measurements to achieve the desired consistency, which were not followed by Ck 1, leading to the deficiency.
Freezer Malfunction Leads to Potential Food Safety Risk
Penalty
Summary
The facility failed to maintain one of its reach-in freezers, which had the potential to lead to food-borne illness for the 44 residents consuming meals prepared by the facility. During an initial kitchen tour, it was observed that one of the freezers was not functioning properly, with a temperature of 38 degrees Fahrenheit, which is above the safe temperature for storing frozen foods. This freezer contained various frozen desserts, and due to its malfunction, the contents had to be moved to another freezer, which was already filled with meat products. The Dietary Supervisor (DS 1) confirmed that the freezer was not working and mentioned that it would be repaired soon. Subsequent visits to the kitchen revealed that the freezer had not been repaired, and DS 1 experienced difficulty finding space to store new food deliveries. Interviews with the Corporate Chief Nursing Officer and DS 1 indicated that the repair was delayed due to the busy schedule of cooling companies. Eventually, it was discovered that a fan in the freezer was out, and it would take additional days for the repair to be completed. The report references guidelines from the US Food and Drug Administration and other sources, emphasizing the importance of maintaining equipment in good repair to prevent food deterioration and potential health risks.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for two residents. During an initial tour, it was observed that a urinal half-filled with yellow amber fluid was placed on a bedside table in a room shared by three residents. Additionally, multiple white shiny pieces of food were found on the floor next to a bed. The urinal was mislabeled, indicating it belonged to a different bed than the one it was placed near. Furthermore, another resident's oxygen tubing was not labeled, which is against the facility's policy. Interviews with staff revealed a lack of compliance with the facility's infection control policies. A CNA confirmed the urinal was mislabeled and identified the trash on the floor as possibly being an eggshell. An LVN stated that urinals should not be on tables and should be dated and labeled correctly, emphasizing the importance of infection control for resident safety. The DON also confirmed that staff should follow the policy for tubing and urinals, which should not be on tables. The facility's policies require bedpans and urinals to be handled to prevent infection and to be stored properly, and oxygen tubing to be changed every seven days or as needed.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that Resident 1 was free from abuse when Resident 2 struck him in the face and head. Resident 1, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, had moderate cognitive impairment. On the morning of the incident, a CNA heard scuffling from the room shared by Resident 1 and Resident 2 and witnessed Resident 2 hitting Resident 1. Resident 1 was assessed and transferred to a General Acute Care Hospital (GACH) for evaluation as a precaution, although no injuries were found. Resident 2, who had severe cognitive impairment and was diagnosed with unspecified dementia, was also transferred to the GACH for evaluation and returned without any findings. Interviews with Resident 1, the DON, the SSD, and the ADM confirmed the incident and acknowledged that Resident 1 had been physically abused by Resident 2, which the facility's policy defines as abuse. The facility's policy on Reporting Allegations of Abuse/Neglect, dated 1/1/24, stipulates that abuse includes the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This policy also covers resident-to-resident altercations, including hitting and slapping. The incident was confirmed by multiple staff members, and the facility acknowledged its responsibility to protect residents from abuse. Despite the lack of physical injuries, the event caused mental anguish and fear for Resident 1, highlighting a failure in the facility's duty to ensure a safe environment for its residents.
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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