Casa De Las Campanas
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 18655 W. Bernardo Drive, San Diego, California 92127
- CMS Provider Number
- 555362
- Inspections on file
- 33
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Casa De Las Campanas during CMS and state inspections, most recent first.
A resident with a history of right femur fracture and muscle weakness, identified as high risk for falls, experienced a fall while attempting to reach a wheelchair without activating the call light. Although new fall prevention interventions were discussed, there was no documentation of these interventions or an updated care plan after the resident returned from the hospital. The DON confirmed the care plan was not revised to reflect the incident or new measures.
A nurse failed to verify a resident's identity and administered medications orally instead of via G-tube as ordered, resulting in the resident choking and requiring emergency intervention. The nurse did not follow facility policy or the five rights of medication administration.
A resident with an overactive bladder did not receive their prescribed Oxybutynin Chloride due to its unavailability in the medication cart. Despite this, the MAR inaccurately recorded the medication as administered. The LN admitted to the error, and interviews with the DSD and DON highlighted that proper procedures for handling unavailable medications were not followed.
During a Covid-19 outbreak, staff at the facility failed to adhere to infection control precautions. Despite signage instructing mask use, LN 1, CNA 1, and CNA 2 were observed without masks. Interviews revealed awareness of the importance of mask-wearing, yet compliance was lacking. The DON confirmed the policy requiring mask use, highlighting a deficiency in infection control practices.
The facility failed to provide adequate training for kitchen staff in food sanitation and safety, resulting in improper testing of sanitizer solutions and incorrect food cooling procedures. Additionally, in-services on food safety were not conducted by qualified personnel, leading to potential risks of foodborne illnesses for residents.
The facility failed to develop an emergency menu that met the nutritional and therapeutic needs of its residents. During an inspection, it was found that the facility lacked a therapeutic menu for three days, and the emergency food supply was not calculated specifically for the health center residents. The emergency menu plan did not include provisions for residents on therapeutic diets, as required by facility policy.
The facility failed to maintain food safety and sanitation practices, with unclean ice machines, improper air gap systems, and grimy refrigerators. Cutting boards were worn, and food items were left uncovered, risking contamination. These deficiencies could lead to foodborne illness among residents.
The facility failed to follow its policy on the storage of outside food brought in by family members, risking foodborne illness. A CNA noted that food should be labeled and stored in the nursing station fridge, but an expired orange juice bottle was improperly labeled. The DSD admitted no specific training was provided on the policy, which requires discarding food after 72 hours. The DON stated food should be stored in a separate fridge to prevent contamination, and expired items should be discarded like medications.
A resident's room temperature was recorded at 88°F, exceeding the facility's policy range of 71°F to 81°F. The resident, who was cognitively intact and had a history of knee pain and falls, expressed discomfort due to the heat. The maintenance technician confirmed the high temperature, and the Director of Plant Operations acknowledged the importance of maintaining appropriate room temperatures for resident comfort.
A resident with Parkinson's disease received medications from an LPN who did not prepare them, leading to a potential safety issue. The LPN admitted the error, and the DON confirmed that the facility's policy requires the nurse who prepares medications to administer them to ensure safety.
The facility failed to implement physician's orders and notify the physician for three residents, leading to potential health risks. A resident refused physical therapy due to discomfort with the Rehabilitation Manager, and the physician was not informed. Another resident's daily weights were not recorded, and the physician was not notified of refusals. A third resident did not receive daily wound treatment as ordered, with no documentation of refusal.
The facility failed to ensure proper medication administration for four residents, including lack of parameters for PRN pain medications, incorrect timing of Parkinson's medication, and unavailability of a prescribed supplement. These issues were confirmed through interviews with staff and review of records, indicating potential unsafe medication practices.
A facility exceeded the acceptable medication error rate with two errors out of 30 opportunities. One resident did not receive Zinc Sulfate for wound healing due to unavailability in the medication cart, and another resident missed a Thera M Plus supplement during the morning medication pass. The DON confirmed that all medications should be administered per physician orders.
A medication cart's drawer containing residents' medications was left unlocked and unattended by nursing staff, as observed in the facility hallway. Licensed Nurse (LN) 34 confirmed the drawer was unlocked and unattended, acknowledging that all medication cart drawers should be securely locked when unattended. The Director of Nursing (DON) reiterated that nursing staff should always lock medication carts to prevent unauthorized access. The facility's policy requires medication carts to be closed and locked when out of sight.
The facility failed to provide palatable and flavorful meals, as residents reported dissatisfaction with the food being dry and lacking flavor. The Resident Council had previously raised concerns about tough meat and confusing menus. A test tray confirmed the BBQ chicken was dry, and the Dietary Supervisor was unaware of these issues. Additionally, residents on pureed diets did not receive nutritionally equivalent meals.
A resident at risk of weight loss due to poor intake was not provided meals in accordance with the finger food diet policy. Despite needing substantial assistance with eating, the resident was served a meal that did not comply with dietary recommendations, potentially impacting their nutritional status.
A staff member at the facility failed to perform hand hygiene before entering a resident's room, as observed during a survey. This action was against the facility's infection control policy, which requires all personnel to adhere to hand hygiene practices to prevent cross-contamination. Interviews with various staff, including the MRS, DSD, IP, and DON, confirmed the importance of this practice in protecting residents, staff, and visitors.
The facility failed to maintain kitchen equipment safely, with worn refrigerator gaskets and a damaged ice machine, risking contamination. The Dietary Supervisor and Food and Beverage Director acknowledged the issues, which violated the 2022 FDA Food Code and facility policy.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident who was identified as high risk for falls and had a recent history of a right femur fracture and generalized muscle weakness. The resident experienced a fall while attempting to reach his wheelchair to go to the bathroom, resulting in a skin tear on the back of the head and pain in the right hip. The incident occurred when the resident's call light was not activated, and he was found on the floor with his head slightly under the bed. The resident was assessed by the supervising nurse and subsequently transported to the hospital per physician's order, returning the same day. Despite the fall and the implementation of new interventions such as reiterating the use of the call light, lowering the bed, and using fall mats, there was no documentation in the resident's record reflecting these interventions upon return from the hospital. The Interim Director of Nursing confirmed that the care plan was not updated to reflect the fall or the new interventions. Facility policy requires staff and physicians to identify and document interventions to prevent subsequent falls and monitor the resident's response, but this was not completed in this case.
Failure to Follow Medication Administration Protocols for G-Tube Resident
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications to a resident with Myasthenia Gravis and a G-tube according to physician orders. The resident, who was tube-fed and not to receive anything by mouth, was found sitting in the hallway with her feeding tube disconnected. The nurse did not verify the resident's identity or the correct route of administration, crushed the medications, mixed them with applesauce, and gave them orally. This resulted in the resident choking and requiring suctioning and emergency services. Record review confirmed that the resident's medication orders specified administration via G-tube, with no recent changes to these orders. Facility policy required verification of resident identity and the five rights of medication administration, which were not followed in this incident. The nurse's last observed medication pass was several months prior, and the DON confirmed multiple failures in following medication administration protocols.
Medication Administration Error Due to Unavailability
Penalty
Summary
The facility failed to ensure proper medication administration for a resident with an overactive bladder. During a medication pass, it was observed that the resident's prescribed medication, Oxybutynin Chloride, was not available in the medication cart. Despite this, the Medication Administration Record (MAR) indicated that the medication had been administered. Upon review, the Licensed Nurse (LN) admitted that the medication was not given because it was not available and acknowledged that it was incorrectly documented as administered. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) revealed that the facility's procedures were not followed. The DSD stated that if a medication is not available, a note should be written, and the pharmacy should be followed up with. The DON emphasized the importance of notifying the physician and using an urgent pharmacy form to obtain medications promptly. The facility's policy requires documentation if a medication is withheld or given at a different time, which was not adhered to in this case.
Infection Control Deficiency During Covid-19 Outbreak
Penalty
Summary
The facility failed to ensure staff adhered to infection control precautions during a Covid-19 outbreak, as observed during an unannounced visit. Despite a sign on the entrance door indicating the presence of Covid-19 and instructing visitors to wear masks, staff members were observed not complying with these precautions. At 5 A.M., LN 1 was seen at nursing station 1 without a surgical mask, despite acknowledging the presence of a Covid-19 positive resident in the facility. Similarly, CNA 1 and CNA 2 were observed entering the hallway from resident rooms without masks, with CNA 1 admitting to having been in a resident room without a mask. Interviews with the staff further highlighted the deficiency in infection control practices. CNA 2 acknowledged the importance of wearing masks to prevent asymptomatic spread of Covid-19, while CNA 1 admitted to not wearing a mask when required. The Infection Preventionist confirmed that one resident was still on precautions for Covid-19. The Director of Nursing stated that it was the facility's policy and expectation for all staff to wear surgical masks during the outbreak, indicating that LN 1, CNA 1, and CNA 2 were not in compliance with the facility's infection control policy.
Deficiencies in Kitchen Staff Training and Food Safety Practices
Penalty
Summary
The facility failed to ensure that kitchen staff received appropriate training in food sanitation and safety, leading to several deficiencies. Three dietary aides demonstrated improper methods for testing sanitizer solutions used for sanitizing equipment and prep surfaces, which could lead to cross-contamination. One aide incorrectly tested the chlorine solution in a dish machine, while another used an ammonia test strip incorrectly and did not log the results. A third aide recognized incorrect sanitizer levels but did not take immediate corrective action. The facility's sanitation logs were incomplete, and the staff did not adhere to the facility's policies and procedures for sanitation. Additionally, two cooks were unable to correctly verbalize the two-step cool down process for foods, which is crucial for preventing bacterial growth. One cook incorrectly described the process and was unaware of the time required to cool foods using a blast chiller. The facility's policy and the FDA Food Code require specific cooling procedures to ensure food safety, which the cooks failed to follow. The facility also did not conduct staff in-services on food safety and sanitation by a qualified kitchen staff member. The Sous Chef, who conducted some in-services, did not have the necessary Certified Dietary Manager credentials. There was no documentation of specific in-services on food safety and sanitation topics conducted by qualified personnel between January 2021 and January 2024. This lack of proper training and documentation could potentially expose residents to foodborne illnesses.
Failure to Develop Adequate Emergency Menu
Penalty
Summary
The facility failed to ensure an emergency menu with appropriate food and water supplies was developed to meet the nutritional and therapeutic needs of the residents. During an observation and interview, it was revealed that the facility did not have a therapeutic menu for three days to feed 50 residents. The Acting Administrator, Safety and Transportation Director, Dietary Supervisor, Food and Beverage Director, Executive Chef, and Sous Chef acknowledged that the facility's 3-day food supply was combined with emergency foods for the entire senior residential care community. The meal count and water supply needed to be calculated specifically for the health center facility beds, and there was a lack of a sufficient menu to meet the medical and therapeutic needs of the residents. Further review of facility documents and interviews with the Registered Dietitian and Dietary Supervisor confirmed that the emergency menu plan did not include residents on therapeutic diets or provide clear instructions for feeding residents on therapeutic and textured diets. The facility's policy and procedure documents indicated that therapeutic diets should be planned and served according to the state-approved Diet Manual and that a preplanned emergency menu should be available. However, the facility's current emergency menu did not meet these requirements, potentially compromising the nutritional and health status of the residents.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in dietary services, as observed in several areas. Two ice machines were not cleaned and maintained according to the manufacturer's instructions, with visible mold and debris inside the machines and expired water filters. The facility contractor demonstrated the cleaning process but acknowledged that certain parts, such as the baffle and water filters, were not cleaned or replaced. The facility's policy required regular cleaning, but the maintenance logs indicated lapses in adherence to these schedules. Additionally, the facility did not ensure proper air gap systems for three ice machines and one dish machine, which are necessary to prevent backflow of contaminated fluids. Observations revealed that pipes were improperly extended into floor sink drains, and the Director of Plant Operations confirmed the need for an air gap space. This oversight contravenes the Federal FDA Food Code, which specifies the required air gap dimensions to prevent contamination. The facility also failed to maintain cleanliness in food storage areas. Two reach-in refrigerators had grimy debris on the door gaskets, and the facility's cleaning schedules were not provided upon request. Furthermore, cutting boards were found to be heavily worn and discolored, and multiple food items were left uncovered during transport, increasing the risk of cross-contamination. These deficiencies had the potential to cause widespread foodborne illness among the residents receiving food from the kitchen.
Failure to Implement Policy on Outside Food Storage
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought in by family members for residents, which could potentially lead to foodborne illnesses. During an observation, a Certified Nursing Assistant (CNA) revealed that outside food is stored in the nursing station nourishment room refrigerator and should be labeled with the resident's name and date. However, a 32-ounce bottle of unopened orange juice was found labeled only with a room number and was expired. The Director of Staff Development (DSD) acknowledged that outside food should be discarded after 72 hours, not one week, and admitted that no specific in-service training had been provided to the nursing staff regarding this policy. The Director of Nursing (DON) stated that outside foods should not be stored in the nursing station fridge but in a separate resident nourishment fridge in the dining room to prevent cross-contamination. The facility's policy from 2013 indicated that refrigerated foods must be labeled with the resident's name, room number, and date, and discarded within 72 hours. Another policy from 2015 stated that food items should not be stored in medication refrigerators. The DON emphasized that expired food should be treated like medications and discarded to prevent foodborne illnesses, and that nursing staff should be aware of the 72-hour discard rule.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to ensure a comfortable environment for one of its residents, identified as Resident 216, when the room temperature was recorded at 88 degrees Fahrenheit. Resident 216, who was cognitively intact and admitted with diagnoses including right knee pain and a history of falls, was observed fanning himself with a table napkin and expressed discomfort due to the heat. This observation was made during an interview on June 4, 2024, at 9:43 A.M. Further investigation revealed that the facility's maintenance technician confirmed the room temperature using a thermal gun, which registered 88 degrees Fahrenheit, while Resident 216's preferred room temperature was 79 degrees Fahrenheit. The Director of Plant Operations later stated that the room temperatures for all residents should be maintained between 71 and 81 degrees Fahrenheit to ensure comfort. The facility's policy on maintaining a homelike environment, revised in February 2021, also specified that room temperatures should be kept within this range.
Medication Administration Error Due to Staff Miscommunication
Penalty
Summary
The facility failed to ensure the safe administration of medications for one resident, identified as Resident 500, due to improper medication handling by the nursing staff. Resident 500, who was admitted with diagnoses including Parkinson's disease, muscle weakness, and restless legs, was involved in an incident where medications were administered by a nurse who did not prepare them. During an observation, Resident 500 questioned the nurse, LN 31, about the medications in the cup, to which LN 31 admitted she did not prepare them and would need to consult with LN 2, who had prepared the medications. Interviews with the involved staff revealed that LN 31 acknowledged she should not have administered the medications since she did not prepare them, and LN 2 admitted she should have administered the medications herself to ensure safety. The Director of Nursing confirmed that the facility's policy requires the nurse who prepares the medications to administer them to prevent confusion and ensure a safe environment. The facility's policy on administering medications emphasizes verifying the right resident, medication, dosage, time, and method before administration.
Failure to Implement Physician's Orders and Notify Physician
Penalty
Summary
The facility failed to implement physician's orders and notify the physician for three residents, leading to potential health risks. Resident 61, who was admitted with a fractured left femur, had a physician's order for physical therapy five times a week. However, the resident refused treatment due to discomfort with the Rehabilitation Manager, and the physician was not informed of these refusals, contrary to the facility's policy. Resident 45, diagnosed with esophageal obstruction and severe protein-calorie malnutrition, had a physician's order for daily weights. The resident's weights were not recorded on multiple occasions, and the resident reportedly refused to be weighed. Despite this, the physician was not notified of the refusals, which was necessary to address the resident's reasons for refusal and discuss potential consequences. Resident 55, with diabetes mellitus and an acute embolism, had a physician's order for daily wound treatment on the left lower leg. The treatment was not performed on two consecutive days, and there was no documentation of refusal. The lack of treatment and documentation was against the physician's order and the facility's policy, which required daily wound care to monitor and prevent deterioration.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper procedures for medication administration for four residents, leading to potential unsafe medication practices. Resident 314 and Resident 315 were prescribed PRN medications for pain without clear parameters for administration, such as a pain scale or numeric pain level. Interviews with the Director of Nursing and the Director of Staff Development confirmed that PRN medications should have specific indications for use, which were not provided in these cases. Resident 316 did not receive their Carbidopa-Levodopa medication in accordance with the physician's order, which specified administration one hour before meals. The medication was instead given at times that coincided with or followed meal times, contrary to the prescribed schedule. This discrepancy was confirmed through interviews with the resident, the Minimum Data Set Coordinator, and the facility's Pharmacy Consultant, all of whom acknowledged the importance of adhering to the prescribed timing to ensure the effectiveness of the treatment. Resident 61 did not receive their prescribed Zinc Sulfate due to its unavailability in the medication cart. The Licensed Nurse responsible for administering the medication confirmed its absence, and the Pharmacy Consultant emphasized that all prescribed medications should be readily available for administration. The Director of Nursing also stated that medications should be accessible at all times to meet residents' needs, highlighting a failure in the facility's medication management system.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 6.67%, exceeding the acceptable threshold of 5%. This was due to two medication errors occurring out of 30 opportunities during medication administration. The first error involved a resident who was admitted with a diagnosis of a fractured left femur. The resident had a physician's order for Zinc Sulfate 220 mg daily for wound healing, but the medication was not administered by the licensed nurse during the observed medication pass. The nurse stated that the Zinc Sulfate was not available in the medication cart, which led to the failure to administer the prescribed medication. The second error involved another resident who had a physician's order for Thera M Plus, a multivitamin supplement, to be taken orally once daily. During the medication pass observation, the licensed nurse was unable to administer the supplement as prescribed. The nurse acknowledged that the resident should have received the supplement during the morning medication pass. The Director of Nursing confirmed that all prescribed medications should be administered by the nursing staff according to physician orders. The facility's policy on administering medications, revised in April 2019, states that medications are to be administered safely, timely, and as prescribed.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that medications were securely locked inside a medication cart, as observed on June 4, 2024, at 9:27 A.M. A medication cart's drawer containing residents' medications was left unlocked and unattended by a nursing staff member in the facility hallway. During a joint observation and interview on June 6, 2024, at 9:29 A.M., Licensed Nurse (LN) 34 confirmed that the medication cart's drawer was unlocked and unattended. LN 34 acknowledged that all medication cart drawers should be securely locked when unattended to prevent unauthorized access to medications. An interview with the Director of Nursing (DON) on June 7, 2024, further confirmed that nursing staff should always lock medication carts to prevent unauthorized access. A review of the facility's policy titled 'Administering Medications,' revised in April 2019, indicated that the medication cart should be kept closed and locked when out of sight of the medication nurse or aide.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during a dining session. Several residents expressed dissatisfaction with the food, describing it as unappetizing, dry, and lacking flavor. The Resident Council meeting minutes from February to April 2024 highlighted ongoing dietary concerns, including tough meat and confusing menus. During a test tray observation, the BBQ chicken was found to be dry and lacking seasoning, which was acknowledged by the Dietary Supervisor and the Food and Beverage Director. The Registered Dietitian confirmed mixed reviews about the meals, noting that they were often described as boring and sometimes tough. Additionally, residents on pureed diets did not receive nutritionally equivalent meals compared to those on regular diets. The Dietary Supervisor was unaware of the resident council's concerns, indicating a lack of communication and follow-up on dietary issues. The facility's policy on addressing food complaints was not effectively implemented, contributing to the deficiency.
Failure to Follow Finger Food Diet for Resident
Penalty
Summary
The facility failed to adhere to dietary recommendations for a resident on a finger food diet, which was crucial for addressing the resident's risk of weight loss. The resident, who was admitted with paroxysmal atrial fibrillation and had moderate cognitive impairment, required substantial assistance with eating. A nutritional evaluation indicated the resident was at high nutritional risk due to poor intake and a recent weight loss of 3.8 pounds over six days. Despite these concerns, during a dining observation, the resident was served a meal that did not comply with the finger food diet policy, as the sandwich was not cut into fourths as required. Interviews with the facility's Registered Dietitian and Dietary Supervisor confirmed that the resident preferred finger foods and was on a regular texture diet. They acknowledged the oversight in meal preparation, which did not align with the facility's Finger Food Diet policy. This failure to provide food in the correct form had the potential to negatively impact the resident's food intake and exacerbate weight loss, as supported by the Academy of Nutrition & Dietetics' findings on unintended weight loss and increased mortality in older adults.
Failure to Perform Hand Hygiene Before Entering Resident's Room
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by a staff member, specifically in the case of a Medical Records Staff (MRS) who did not perform hand hygiene (HH) before entering a resident's room. This incident was observed on June 4, 2024, when the MRS entered the room of a resident to respond to a call light without washing hands or using hand sanitizer. This action was contrary to the facility's policy, which mandates that all personnel adhere to hand hygiene practices to prevent the spread of infections. Interviews conducted with the MRS, the Director of Staff Development (DSD), the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the MRS should have performed hand hygiene before entering the resident's room. Each of these staff members acknowledged the importance of hand hygiene in preventing cross-contamination and protecting residents, staff, and visitors from potential infections. The facility's policy, revised in October 2023, clearly states the expectation for all personnel to follow hand hygiene protocols.
Deficiency in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed during a survey. Two reach-in refrigerators had door gaskets that were worn, torn, and detaching, which could compromise the seal and lead to contamination. The Dietary Supervisor and the Food and Beverage Director acknowledged the issue and stated that the gaskets needed replacement. According to the 2022 Federal FDA Food Code, non-food contact surfaces must be kept free of debris to prevent microorganism growth, which could be transferred to food. Additionally, an ice machine in the main kitchen had a broken plastic piece on the bin door, leaving a large hole, and the rubber seals were torn and covered with calcium-like deposits. The inside of the ice machine showed discoloration, indicating potential contamination. The facility's ice machine maintenance log showed scheduled maintenance dates, but the issues persisted. The Director of Plant Operations expected all equipment to be operational and on a preventive maintenance schedule. The facility's policy required equipment to be maintained according to manufacturer's instructions, which was not adhered to in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
