Cedarwood Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 1090 Rio Lane, Sacramento, California 95822
- CMS Provider Number
- 055296
- Inspections on file
- 46
- Latest survey
- June 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cedarwood Post Acute during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, preparation, and service, including wet-stacked utensils, visibly unclean cups, missing freezer thermometers, unlabeled open food items, and uncovered meal trays during distribution. These failures were confirmed by dietary staff and increased the risk of foodborne illness.
Two outside garbage dumpsters were found with lids that had openings, allowing odors and flies to escape, and bags of garbage were visible inside. The DM confirmed the lids were not securely closed, and the MD stated that the lids did not meet facility policy for tight-fitting covers to prevent pest and rodent activity.
A wheelchair and standing fan were found partially blocking an emergency exit, and two Hoyer lifts were stored with unlocked wheels, creating safety concerns. Additionally, a resident's urinary catheter bag was left uncovered, two residents were fed by staff who remained standing, and two residents were not asked about their preference for clothing protectors, all of which failed to uphold resident dignity.
Several residents with physical or cognitive limitations were found unable to access or use their call lights, with some call lights placed out of reach and others lacking appropriate accommodations such as touch pads. Care plans for two residents did not address their inability to use the call light system, and staff confirmed these deficiencies during interviews and observations.
Surveyors observed that multiple residents received medications in ways that did not follow prescriber orders or manufacturer instructions, such as not providing the required amount of water, not ensuring medications were taken with food, and administering pain medication outside of its ordered parameters. These actions resulted in a medication error rate significantly above the regulatory threshold.
Staff failed to properly disinfect a shared BP cuff between residents, with one nurse not cleaning the cuff at all between uses and another using only a small alcohol prep wipe. The infection preventionist confirmed that this did not meet facility policy, and staff interviews revealed a lack of awareness of proper cleaning procedures.
Surveyors found that a resident's urinary catheter bag was left uncovered, two residents were assisted with eating by staff who stood over them rather than sitting at eye level, and two residents were made to wear clothing protectors during meals without being asked for their preference. These actions did not honor resident dignity or individual choice, as required by facility policy.
Two residents did not have their care plans updated to reflect current needs: one self-administered eye drops without a documented assessment or care plan, and another used hand bandages for amputations without care plan interventions, despite requiring assistance with daily care. The DON confirmed these omissions did not align with facility policy.
The facility failed to develop comprehensive care plans for two residents with wound care needs, leading to potential inadequate care. One resident with a diabetic foot ulcer and another with a surgical wound requiring NPWT lacked documented care plans in their electronic health records. Interviews with staff confirmed the absence of these essential care plans.
A resident with end-stage renal disease missed four hemodialysis appointments due to transportation issues, leading to a hospital visit for potential fluid retention. The facility failed to notify the physician of the missed appointments, contrary to policy. Despite attempts to reschedule, transportation was not available or did not enter the facility to pick up the resident.
A resident in an LTC facility did not receive appropriate indwelling catheter care due to missing physician orders, leading to a deficiency. The resident, dependent on staff for toileting hygiene, had no documented catheter care or change for several months, resulting in two UTIs. Facility staff confirmed the oversight, which was contrary to the facility's policy requiring catheter care every shift.
The facility failed to follow professional standards of care, including not changing oxygen equipment weekly, not implementing physician orders for feeding assistance and adaptive devices, and not transcribing medication orders into the MAR. Additionally, there were issues with medication administration and documentation, such as a nurse not observing a resident take medication and undocumented doses of IV antibiotics. These deficiencies increased the risk of unmet therapeutic needs for residents.
The facility failed to secure and properly dispose of resident medical records, as observed when a box containing confidential health information was found unsecured in the Physical Therapy Department. Interviews confirmed that records were not disposed of daily as required, violating the facility's confidentiality policy.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents, with discrepancies found between the Medication Administration Record (MAR) and Controlled Drug Record (CDR). Additionally, emergency medication kits were not properly secured, with one kit found in an unlocked drawer and opened kits not exchanged with the pharmacy as required by facility policy.
A medication error rate of 12.82% was observed in an LTC facility, involving three residents. Errors included incorrect timing and administration of medications such as Losartan, Brovana, and insulin aspart. Medications were not given according to prescriber's orders, potentially affecting residents' clinical conditions.
A resident missed 25 doses of Brovana, a medication for breathing issues, because nursing staff did not check the medication storage room refrigerator. The resident, who had a physician's order for Brovana due to congestive heart failure, reported feeling short of breath. The Director of Nursing confirmed the medication was overlooked.
The facility's kitchen staff failed to demonstrate proper sanitation procedures, risking foodborne illness for 49 residents. Dietary aides were unable to correctly test sanitation solutions, and dishwashing processes did not meet required concentration levels. The facility used incorrect test strips, highlighting a lack of training and adherence to sanitation policies.
The facility failed to meet food safety standards, with issues including unsealed food packages, a dirty fan blowing on clean items, incorrect dishwasher test strips, and improperly labeled resident food. These deficiencies could lead to contamination and safety risks, as acknowledged by the Certified Dietary Manager and Director of Nursing.
A resident was administered psychotropic medications without documented informed consent. Despite facility policies requiring informed consent before administering such drugs, the necessary documentation was missing. Interviews with staff confirmed the oversight, with the DON acknowledging the physician's responsibility in obtaining consent.
A facility failed to ensure accurate assessments for a resident admitted with metabolic encephalopathy and generalized weakness. The resident was observed without a urinary catheter, contradicting the MDS assessments. The DON confirmed the inaccuracy, highlighting a potential for incorrect baseline data and treatment.
A facility failed to create a comprehensive care plan for a resident's BiPAP machine use, despite physician orders indicating its necessity at bedtime. The resident, with Type 2 Diabetes and Neurocognitive Disorder, was observed with the BiPAP machine in their room, but no care plan was documented in their EHR. The Clinical Reimbursement Director confirmed the absence of the required care plan, which is against the facility's policy for comprehensive care planning.
A facility failed to ensure proper medication storage when a medication cart and a treatment cart were found unlocked and unattended. Staff interviews confirmed that carts should be locked when not attended, aligning with facility policy requiring all drugs to be stored in locked compartments.
A resident on a renal diet was incorrectly served mashed potatoes, a high-potassium food, despite dietary restrictions noted on their meal tray ticket. The CDM and RD confirmed the error, emphasizing the importance of adhering to renal diet guidelines to prevent potential heart issues.
The facility failed to adhere to infection control practices when a CNA was observed carrying trash bags between resident rooms, allowing them to touch her clothing. Additionally, a resident's BiPAP equipment was improperly stored, left exposed to dust and contamination, against facility policy. The resident has Type 2 Diabetes and a neurocognitive disorder with Lewy Bodies.
A resident with a history of lung tumor and respiratory failure consented to receive a pneumococcal vaccine upon admission. However, due to an error, the resident's record was updated to indicate a declination, and the vaccine was not administered. The Infection Preventionist confirmed the resident's eligibility for the vaccine, which was not provided as per facility policy.
The facility failed to maintain a reach-in freezer in safe operating condition, with ice build-up observed on the freezer ceiling. The freezer door gasket was misshapen, potentially causing the issue. The CDM confirmed the ice build-up could lead to freezer burn and affect food safety. The MS noted the problem might be due to the freezer door not closing tightly. The freezer manual advises defrosting when frost accumulates, and the FDA Food Code stresses proper equipment maintenance for consumer safety.
A resident with dementia and anxiety was unable to use the provided call light due to physical limitations, and the facility failed to document the need for an alternative device in the care plan. Staff confirmed the resident's inability to use the call light, which was not addressed until later, potentially leading to unmet needs and delayed response.
The facility failed to follow infection control practices for two residents. A Social Services Assistant entered a resident's room without PPE, despite MRSA precautions. Similarly, a CNA entered another resident's room without full PPE, despite COVID-19 isolation requirements. Both staff members acknowledged the oversight, and the Infection Preventionist confirmed the necessity of PPE use.
A facility failed to coordinate a Level II PASRR evaluation for a resident with mental illness, despite positive Level I screening results. The resident, with a history of mental illness and frequent hospitalizations, was involved in a physical altercation, highlighting unmet care needs. The DON confirmed the oversight, acknowledging potential links between the resident's behavior and unidentified needs.
The facility failed to notify the Department, LTCOP, and Local Law Enforcement within 2 hours of an alleged abuse incident involving two residents. The incident resulted in one resident sustaining a faint discoloration and a laceration below the eye. Despite staff awareness of the reporting requirement, the state agency was not informed until several hours later, delaying the investigation process.
Deficiencies in Food Storage, Preparation, and Service
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's dietary department. During an initial tour, nine plate cover lids and two metal bowls were found stored upright with water collected at the bottom, indicating they were stacked while still wet. Both the Dietary Manager and Registered Dietician confirmed that these items should have been air dried before storage to prevent bacterial growth, as required by FDA Food Code standards. Additionally, two plastic cups with visible white film buildup were found on a shelf, and both the Dietary Manager and Registered Dietician acknowledged that these cups were not clean to sight and touch, which is a violation of food safety standards. Further inspection revealed that both freezers in the kitchen were missing thermometers, which are necessary to monitor and ensure safe food storage temperatures. The Dietary Manager confirmed the absence of thermometers and acknowledged that staff would not be able to verify if food was being stored at safe temperatures. Open food items, including frozen waffles, corn, spices, and a box of cream of wheat, were also found without use-by dates, contrary to facility policy and food safety guidelines. The Registered Dietician confirmed that the lack of labeling could result in food being stored for excessive periods without proper tracking. During meal distribution, it was observed that meal trays with desserts were not covered while being transported to residents' rooms. The delivery cart used had plastic bags covering only three sides, and staff had rolled up the coverings, leaving the desserts exposed. The Registered Dietician confirmed that food items should be covered during transport to prevent contamination. These combined failures in food handling, storage, and distribution practices increased the potential for foodborne illness among the facility's residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 812
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors by not ensuring that two outside garbage dumpsters were properly secured with closed lids. During observations, it was noted that the dumpster lids had openings, and bags of garbage were visible inside the bins. There was a noticeable bad odor, and flies were observed coming out from the openings in the lids. The Dietary Manager confirmed that the lids were not securely closed at the time of inspection. Further, the Maintenance Director acknowledged that the lids should have been closed with tight-fitting covers according to facility policy, and that the current lids with openings could not prevent pest and rodent activity. A review of the facility's policy and procedure on food-related garbage and refuse disposal indicated that all garbage and refuse containers must have tight-fitting lids or covers and be kept covered when stored, with food waste stored in a manner inaccessible to pests. The facility census at the time was 49 residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25
Environmental Safety and Resident Dignity Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation, a wheelchair and a standing fan were found partially blocking an emergency exit in one of the facility's wings, which could impede access in the event of an emergency. Additionally, two Hoyer lifts were stored in the same area with their wheels unlocked, presenting a risk of equipment movement and potential injury. The facility's policy requires that all equipment and clinical devices be stored in a safe manner, but this was not followed in these instances. Further deficiencies were identified in the treatment of residents with dignity and respect. One resident's urinary catheter bag was not covered by a dignity bag, compromising privacy. Two residents were assisted with feeding by staff who were standing rather than sitting, which does not align with best practices for respectful care. Additionally, two other residents were not asked about their preference regarding the use of clothing protectors during meals. These actions failed to ensure that residents were treated with dignity and respect as required.
Plan Of Correction
How the corrective action(s) will be monitored to ensure the practice will not recur: Maintenance director and Administrator will conduct daily rounds for 2 weeks, then weekly rounds to verify adherence to the policy of Equipment and device storage. Any issues identified during these audits will be immediately corrected. This plan of correction has been integrated into the facility's Quality Assurance program, and the results of these audits will be reviewed quarterly until substantial compliance is achieved. Plan of Correction completion date: 6.30.25 F 921
Failure to Provide Accessible and Usable Call Lights for Multiple Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences regarding the accessibility and usability of call lights for seven residents. Multiple residents were observed with call lights out of reach or unable to operate their call lights due to physical or cognitive limitations. For example, one resident with muscle weakness and impaired cognition was found lying in bed unable to reach the call light, and another resident with Parkinson's disease and severe cognitive impairment was seated in a wheelchair with the call light hanging from the wall, out of reach. In both cases, staff confirmed the call lights were not accessible as required by facility policy and the residents' care plans. Additional deficiencies were identified for two residents who had severe memory problems and were unable to use the call light system, yet their care plans did not include interventions addressing this inability. One resident was observed calling out for assistance with pain, unable to locate or use the call light, while another could not retrieve food on her tray and did not know where her call light was. Staff interviews confirmed that the lack of specific care plan interventions for these residents' inability to use the call light could result in unmet needs and neglect of care. Another resident with hands wrapped in elastic bandages due to a history of stroke was observed struggling to activate the standard call light, requiring multiple attempts and significant effort to do so. Staff acknowledged that the resident's needs were not accommodated with an appropriate call light device, despite facility policy requiring evaluation and provision of special accommodations such as touch pads or larger buttons. These failures were confirmed through observations, interviews, and record reviews, and were inconsistent with both facility policy and the individualized care plans for the affected residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 558 F 558
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors observing an error rate of 25.81% during medication administration for four out of six residents. Multiple instances were documented where medications were not administered according to prescriber orders or manufacturer specifications. For example, a nurse administered chewable aspirin to a resident without instructing them to chew it, and provided only 5 oz of water instead of the required 8 oz, despite the order specifying the medication should be chewed and taken with food or a full glass of water or milk. Additionally, omeprazole was not given before eating as directed by the manufacturer. Another resident received medications including chewable aspirin, metoprolol, and potassium chloride with only 5 oz of water and no food, even though the orders and manufacturer instructions required administration with food and a full glass of water. The nurse confirmed that the resident had eaten breakfast earlier, but did not provide food or the correct amount of water at the time of administration. The pharmacy consultant emphasized the importance of following these instructions to ensure proper absorption and minimize gastrointestinal irritation. Further observations included a nurse administering tramadol for severe pain when the order specified it was for moderate pain only, and giving carvedilol without food, contrary to the order and manufacturer instructions. Another resident was given allopurinol without food or the required amount of water, despite orders to administer with both. The facility's policy required medications to be administered as prescribed and in accordance with manufacturer specifications, but these procedures were not followed during the observed medication passes.
Plan Of Correction
How the corrective action(s) will be monitored to ensure the practice will not recur: DON/Designee will conduct weekly medication administration audits. Any issues identified will be reported to the Director of Nursing and immediately corrected. This plan of correction has been integrated into the QA program, and the results of these audits will be reviewed quarterly as needed until substantial compliance is achieved. Plan of Correction completion date: 6.30.25 F 759 F 759 F 759 F 759 F 759
Failure to Properly Disinfect Shared Blood Pressure Cuffs Between Residents
Penalty
Summary
Surveyors observed that staff failed to properly clean and disinfect a shared blood pressure (BP) cuff between uses on multiple residents. On one occasion, a licensed nurse took the BP of a resident using a cuff from the medication cart, did not sanitize it after use, and then used the same cuff on another resident without cleaning it in between. The BP cuff was repeatedly placed back into the medication cart without being sanitized after each use. Another incident involved a different licensed nurse who, after taking a resident's BP, cleaned the cuff only with a small alcohol prep wipe before returning it to the cart. The infection preventionist later confirmed that the facility's expectation was to use a specific type of disinfectant wipe for cleaning BP cuffs between residents, and that using a small alcohol prep pad was not effective or acceptable for this purpose. Interviews with staff revealed a lack of awareness regarding the facility's policy on cleaning BP cuffs between resident uses. Review of the facility's policy indicated that reusable items are to be cleaned and disinfected or sterilized between residents, but this procedure was not followed as observed during the survey.
Failure to Maintain Resident Dignity During Care and Mealtimes
Penalty
Summary
Multiple deficiencies related to resident dignity and rights were identified during the survey. One resident with metabolic encephalopathy and a Foley catheter was observed in bed with the urinary catheter bag uncovered, despite a dignity bag being available on the resident's wheelchair. Both a registered nurse and the Director of Nursing confirmed that the catheter bag should have been covered, as per facility policy, to maintain the resident's dignity. In the dining area, two residents with neurological impairments were observed being assisted with eating by restorative nurse assistants who remained standing over them, rather than sitting at eye level. The staff could not explain the importance of sitting while assisting with feeding, and the DON acknowledged that standing over residents during feeding is a dignity issue. Training records indicated that the staff involved had previously received training on dignity and feeding practices. Additionally, two residents with intact cognition were observed wearing clothing protectors during meals without being asked for their preference. One resident expressed that staff did not ask if he wanted to wear a bib, while another stated that wearing the clothing protector made him feel like a baby and contributed to feelings of depression. There was no documentation in their care plans regarding their choice or preference for wearing clothing protectors, contrary to facility policy that emphasizes honoring resident choices and preferences.
Failure to Update Care Plans for Self-Administration and Wound Dressing
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents to reflect their current health status and needs. One resident, who had been admitted with Sjögren's syndrome and required supervision with activities of daily living, was observed to have Carboxymethylcellulose Sodium Ophthalmic Solution (eye drops) at her bedside and reported self-administering the medication daily since admission. However, there was no documented assessment, physician order, or care plan indicating that she was permitted or able to self-administer her medication, as required by facility policy and federal regulations. Another resident, admitted with a history of stroke and requiring supervision with self-care, was observed with both hands wrapped in self-adhering elastic bandages. The treatment nurse confirmed that the resident chose to keep his hand amputations covered, but there was no care plan with goals or interventions addressing the use of the bandages. A certified nursing assistant also noted that the resident needed assistance with care, including eating meals, due to the bandages. In both cases, the Director of Nursing acknowledged that the care plans should have been updated to reflect the residents' current needs and interventions. The facility's policies require that care plans be comprehensive, person-centered, and revised as residents' conditions change, but these requirements were not met for the two residents identified.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 657
Lack of Comprehensive Wound Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for wound care interventions for two residents, leading to potential inadequate care. Resident 2, who had a diabetic foot ulcer, did not have a care plan documented in their electronic health record despite having a treatment order for the ulcer. During an interview, Resident 2 confirmed the presence of a wound on the right foot with dressings changed every other day, yet no care plan was in place to guide this treatment. Similarly, Resident 4, who had a surgical wound requiring Negative Pressure Wound Therapy (NPWT), also lacked a documented care plan in their electronic health record. The treatment order specified NPWT dressing changes three times a week, but no care plan was available to ensure these interventions were consistently applied. Interviews with a Licensed Nurse and the Director of Nursing confirmed the absence of care plans for both residents, acknowledging that care plans should have been initiated to address their specific wound care needs.
Failure to Provide Hemodialysis Services Due to Transportation Issues
Penalty
Summary
The facility failed to provide hemodialysis services per policy for a resident who missed four outpatient hemodialysis appointments due to transportation issues. The resident, who was admitted with multiple diagnoses including end-stage renal disease, was dependent on hemodialysis. The facility's records indicated that the resident missed appointments on four occasions due to transportation not being available or the driver not entering the facility to pick up the resident. Despite attempts to reschedule appointments, the resident was not transported to the dialysis clinic, leading to a hospital visit for potential fluid retention. The facility's staff, including the Director of Nursing and Social Services Director, acknowledged the missed appointments and transportation issues. Interviews with staff revealed that the physician was not consistently notified of the missed appointments, and there was no documentation of such notifications in the resident's progress notes. The facility's policy required that the physician be informed of any changes in treatment, including missed dialysis sessions, but this was not adhered to in this case. The resident expressed experiencing shortness of breath and was sent to the emergency department after several missed dialysis sessions. The facility's policy emphasized the importance of ensuring safe transportation and communication with the physician regarding any changes in treatment. However, the lack of proper notification and transportation arrangements resulted in the resident missing critical dialysis treatments, which are essential for managing their end-stage renal disease.
Failure in Indwelling Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care and services for a resident who did not have a physician order for catheter care nor a catheter change for several months after admission. The resident, who was admitted with diagnoses including benign prostatic hyperplasia and a stage 4 sacral pressure ulcer, was dependent on staff for toileting hygiene and had an indwelling catheter. Despite the presence of the catheter, there was no documented evidence of catheter care or change from March to June, and the first documented catheter change occurred in July. The lack of catheter care and change orders was confirmed by interviews with facility staff, including a Licensed Nurse, Treatment Nurse, Director of Nursing, and Infection Preventionist. They acknowledged that the absence of orders led to missed care, increasing the risk of urinary tract infections (UTIs), which the resident developed twice during the period in question. The facility's policy required catheter care every shift, but this was not followed due to the missing orders, highlighting a significant oversight in the resident's care management.
Deficiencies in Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of care in several instances, leading to deficiencies in the care provided to residents. For instance, the oxygen tubing and humidifiers for three residents were not labeled, dated, or changed as per the facility's policy, which requires weekly changes to prevent infection. This oversight was confirmed by both a licensed nurse and the Director of Nursing (DON), who acknowledged that the equipment should have been changed and labeled correctly. Additionally, the facility did not implement physician orders for specific residents, which compromised their care. One resident, who required one-on-one feeding assistance due to dysphagia, was left to feed himself, resulting in inadequate food intake. Another resident, who needed a plate guard with meals due to muscle weakness, did not receive this adaptive device, as the dietary staff was not informed of the order. Furthermore, a resident's medication order for a Budesonide inhaler was not transcribed into the Medication Administration Record (MAR), leading to the medication not being administered as prescribed. The facility also failed to ensure proper medication administration and documentation. A nurse did not observe a resident ingest his medication, and there were six undocumented doses of intravenous antibiotics for another resident, which the DON admitted to administering without recording. Additionally, a resident's BiPAP equipment was not stored properly, exposing it to potential contamination. These failures increased the risk of unmet therapeutic needs and potential worsening of medical conditions for the residents involved.
Failure to Secure and Dispose of Resident Medical Records
Penalty
Summary
The facility failed to properly store and maintain the confidentiality of multiple residents' medical records, as observed during a survey. On a specific date, a large open cardboard box containing confidential health information of residents receiving Physical Therapy and Occupational Therapy was found underneath a desk in the Physical Therapy Department. This box was located near a doorway frequently accessed by other residents and visitors, posing a risk of unauthorized access to sensitive information. The facility lacked confidential records bins within the department, with the nearest bins located outside the main entrance, approximately 10 to 12 feet away from where the box was found. Interviews with the Physical Therapist and Administrator confirmed that the box contained treatment records and reports, which were supposed to be disposed of daily into confidential records bins for shredding. However, a review of the box's contents revealed records of both discharged and current residents dating back several months, indicating that the records were not disposed of daily as required. The facility's policy on confidentiality, which mandates that paper notes or reminders with residents' personal or medical information should not be left unattended or viewable by unauthorized persons, was not adhered to, leading to this deficiency.
Controlled Medication Accountability and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Random audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) revealed discrepancies where medications signed out on the CDR were not documented as administered on the MAR. Specifically, for Resident 9, oxycodone was signed out but not recorded on the MAR on two occasions. Similarly, for Resident 28, hydrocodone/APAP was signed out but not documented on the MAR. Resident 296 also had multiple instances where oxycodone was signed out without corresponding entries on the MAR. Interviews with Licensed Nurse 3 and the Director of Nursing confirmed the expectation for documentation on both the CDR and MAR to ensure accurate drug accountability. Additionally, the facility did not implement a system to accurately document and secure emergency medications (E-Kit). During an inspection, it was found that one of the two E-kits containing controlled medications was stored in an unlocked drawer, and opened E-kits were not properly secured. The Director of Nursing acknowledged that E-kits should be securely stored and exchanged with the pharmacy once opened. The facility's policies indicated that controlled substances should be stored under double-lock key and that emergency medications must be replaced upon the next routine drug order, which was not adhered to in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 12.82% during a medication pass observation, exceeding the acceptable threshold of 5%. This was observed when five medication errors occurred out of 39 opportunities. The errors involved three residents, where medications were not administered according to the prescriber's orders, potentially affecting the residents' clinical conditions. One of the errors involved a resident who was supposed to receive Losartan in the evening with a meal, as per the discharge orders. However, the medication was administered in the morning, contrary to the physician's instructions. Additionally, the same resident was given a B-Complex with Vitamin C supplement that did not match the prescribed order. The Licensed Nurse confirmed the discrepancies during a review of the resident's discharge orders. Another error was observed when a resident did not receive their scheduled dose of Brovana, a medication for treating breathing issues, because the nurse could not locate it in the medication cart. It was later found in the medication storage room refrigerator. Furthermore, a third resident received an incorrect administration of insulin aspart and ondansetron ODT. The insulin pen was not primed, and the injection was not held under the skin long enough, potentially leading to an incorrect dose. The ondansetron ODT was swallowed with other medications instead of being allowed to dissolve on the tongue as prescribed.
Failure to Administer Brovana Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident missed 25 doses of Brovana, a medication used to treat breathing problems. This occurred because the nursing staff did not know to check for the medication in the medication storage room refrigerator. During a medication pass observation, a licensed nurse was unable to locate the Brovana in the medication cart and therefore could not administer it as scheduled. The resident had a physician's order for Brovana to be administered twice daily for congestive heart failure. However, the medication administration record indicated that the resident did not receive the medication on multiple days in July and August. The resident reported feeling short of breath due to not receiving the medication as ordered. An inspection of the medication storage room refrigerator revealed multiple orders of the resident's Brovana, which the Director of Nursing confirmed had been overlooked by the nursing staff.
Inadequate Kitchen Sanitation Procedures
Penalty
Summary
The kitchen staff at the facility failed to demonstrate appropriate competencies in kitchen sanitation, which could potentially lead to foodborne illness for the 49 residents consuming facility-prepared food. During an initial kitchen tour, a dietary aide was unable to correctly demonstrate the procedure for testing the concentration of sanitation solution in red buckets, as they held the test strip in the solution for longer than the manufacturer's instructions. Another dietary aide, who had been working at the facility for two months, admitted to not being trained in the procedure. Additionally, a staff member responsible for the dinner meal was unaware of the testing procedure, indicating a lack of proper training and adherence to the facility's policy on routine cleaning and disinfection. Further observations revealed issues with the dishwashing process. A dietary aide was unable to demonstrate effective testing of the sanitizing solution at the plate level, and repeated tests showed that the concentration did not meet the desired level. The Certified Dietary Manager intervened by changing the sanitizing solution and test strips, but the concentration still failed to meet the required level. It was later discovered that the facility had been using incorrect test strips for their contracted sanitation supply company's product. This oversight, combined with the lack of proper training and adherence to policies, contributed to the deficiency in ensuring sanitary conditions for dishwashing.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Firstly, a bag of previously opened shredded cheddar cheese was found unsealed in the kitchen, which the Certified Dietary Manager (CDM) acknowledged could lead to contamination and bacterial growth. This was in violation of the facility's policy on food safety, which mandates that food be stored in a manner that prevents contamination. Additionally, the United States Food and Drug Administration (FDA) 2022 Food Code requires that food packages maintain their integrity to prevent adulteration. Another deficiency was observed with a dirty fan blowing onto clean plate guards in the kitchen. The CDM confirmed the presence of dirt on the fan and acknowledged that this could lead to contamination of the clean plate covers. This was contrary to the facility's policy on routine cleaning and disinfection, which aims to maintain a sanitary environment and prevent infection transmission. The FDA Food Code also stipulates that non-food-contact surfaces of equipment should be free from dust, dirt, and other debris. Furthermore, the facility was using incorrect test strips to check the sanitation concentration level of the dishwasher, which could lead to ineffective sanitation and cross-contamination. The CDM admitted that the wrong test strips were being used, and the correct ones were only provided after the sanitation company was contacted. Lastly, an ice cream container in the resident refrigerator was labeled only with a room number, lacking the resident's name and date, which the Director of Nursing (DON) acknowledged could lead to potential issues such as allergic reactions or choking hazards. This was against the facility's policy on the use and storage of food brought in by family or visitors, which requires proper labeling to ensure resident safety.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medications for one resident, identified as Resident 447. This resident was admitted with diagnoses including dementia, bipolar disorder, and schizophrenia. The medical records indicated that the resident was prescribed risperidone and trazodone, both psychotropic medications, without documented informed consent. The Medication Administration Record showed that these medications were administered on multiple occasions without the necessary consent documentation. Interviews with facility staff, including a Licensed Nurse (LN 3) and the Director of Nursing (DON), confirmed that the informed consent forms for these medications were not signed by the physician, as required. The facility's policy and procedure, as well as an All Facilities Letter, mandate that informed consent must be obtained and documented before administering psychotropic drugs. The DON acknowledged that the physician was responsible for obtaining this consent, which was not done in this case, leading to the deficiency.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure accurate resident assessments for one resident out of nineteen sampled, specifically Resident 15. Resident 15 was admitted in April 2024 with diagnoses including metabolic encephalopathy and generalized weakness. During an observation and interview, it was noted that Resident 15 did not have a urinary catheter, contrary to what was documented in the Minimum Data Set (MDS) assessments dated May and August 2024. The Director of Nursing confirmed that the MDS reports were inaccurate, as there was no urinary catheter ordered or in use for Resident 15. This inaccuracy in the resident's assessment had the potential to establish incorrect baseline data and treatment.
Failure to Develop BiPAP Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for the use of a BiPAP machine for one resident, identified as Resident 10. This deficiency was identified during a survey that included observation, interview, and record review. Resident 10 was admitted with diagnoses of Type 2 Diabetes and Neurocognitive Disorder with Lewy Bodies, which affects cognitive abilities. During an initial observation, Resident 10 was found lying in bed, appearing comfortable but confused about time and place. A BiPAP machine, which was ordered to be used at bedtime and turned off upon waking, was observed in the room, but there was no corresponding care plan in the resident's Electronic Health Record (EHR). The Clinical Reimbursement Director Nurse Consultant (CRD/NC) confirmed the absence of a care plan for the BiPAP machine after reviewing Resident 10's physician's orders and care plans. The facility's policy, dated March 1, 2023, mandates the development and implementation of a comprehensive person-centered care plan for each resident, which should include measurable objectives and time frames to meet the resident's needs. The lack of a care plan for the BiPAP machine meant that Resident 10 was at risk of receiving inaccurate and inadequate care, as the necessary services to maintain their well-being were not documented or planned for.
Medication Storage Deficiency Due to Unlocked Carts
Penalty
Summary
The facility failed to ensure that medications were stored correctly, as observed during a survey. A medication cart and a treatment cart, both of which are lockable cabinets on wheels used to store drugs and supplies, were found unlocked and unattended. This was confirmed during an observation and interview with the Activities Director, who noted that the treatment cart was unlocked with keys hanging from the lock cylinder while no staff were present. Similarly, Licensed Nurse 1 confirmed that medication cart A was unlocked while unattended, acknowledging that it should have been locked to prevent unauthorized access. Interviews with staff, including Licensed Nurse 4, the Clinical Reimbursement Director/Nurse Consultant, and the Director of Nursing, revealed a consensus that medication and treatment carts should be locked when not attended by staff. The Clinical Reimbursement Director/Nurse Consultant emphasized the importance of locking the carts even when a nurse is nearby but not directly in front of them. The facility's policy, dated March 1, 2023, supports this practice by stating that all drugs and biologicals must be stored in locked compartments, with access limited to authorized personnel.
Failure to Adhere to Renal Diet Restrictions
Penalty
Summary
The facility failed to provide a resident with the appropriate nutritive profile matching the physician-prescribed renal diet. During an observation of a lunch meal, the resident was served turkey, mashed potatoes, and broccoli, despite being on a renal diet that restricts high potassium foods like potatoes. The resident pointed out that potatoes were not allowed on their renal diet, and the tray ticket confirmed that a renal diet had been ordered, with potatoes listed as a dislike. Interviews with the Certified Dietary Manager (CDM) and the Registered Dietitian (RD) revealed that the renal diet restrictions were noted on the meal tray tickets to guide food servers. The CDM confirmed that the resident should not have received mashed potatoes, and the RD explained that the renal diet limits phosphorus and potassium intake to prevent heart issues. The facility's Nutrition Manual indicated that the renal diet is used for residents with renal insufficiency or failure not on dialysis, regulating sodium, potassium, and protein intake to reduce kidney workload.
Infection Control Breach and Improper Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as observed with Certified Nursing Assistant 5 (CNA 5), who was seen carrying trash bags from one resident room to another and allowing them to rest against her clothing. This action was contrary to the infection control guidelines, which prohibit taking trash from one resident room into another and require staff to hold trash away from their body to prevent the spread of germs. CNA 5 acknowledged the breach in protocol, and the Infection Preventionist, Licensed Nurse 4, and the Director of Nursing confirmed the importance of adhering to these guidelines to prevent infection transmission. Additionally, the facility did not properly store respiratory equipment for Resident 10, who was on BiPAP therapy. The BiPAP mask and tubing were left exposed and unprotected from dust and contamination, contrary to the facility's policy, which requires such equipment to be stored in a clean bag when not in use. Resident 10, who has Type 2 Diabetes and a neurocognitive disorder with Lewy Bodies, was observed in a confused state, and the Director of Nursing confirmed the improper storage of the BiPAP equipment.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to one of the sampled residents, identified as Resident 15. Resident 15 was admitted to the facility in April 2024 with a history of having a tumor in the lungs and respiratory failure. Upon admission, Resident 15 consented to receive the pneumococcal vaccine, as indicated in the informed consent dated 4/27/24. However, a review of the Minimum Data Set (MDS) dated 8/3/24 incorrectly indicated that Resident 15 had declined the vaccine. An interview with the Infection Preventionist on 8/22/24 revealed that Resident 15's health record was mistakenly updated to show a vaccine declination, despite the resident's consent. The Infection Preventionist confirmed through the California Immunization Registry that Resident 15 had not been previously vaccinated and was eligible for the pneumococcal vaccine. The facility's policy requires offering the vaccine to residents unless contraindicated or previously immunized, but this was not followed in Resident 15's case.
Ice Build-Up in Freezer Compromises Food Safety
Penalty
Summary
The facility failed to maintain the reach-in freezer in a safe operating condition, as observed during a kitchen inspection. Ice build-up was found on the ceiling of the freezer, with ice crystals approximately 1/2 inch in diameter. The freezer door gasket appeared misshapen in the upper, outer corners, which may have contributed to the issue. The Certified Dietary Manager (CDM) confirmed the ice build-up and acknowledged that it could lead to freezer burn and potentially affect food safety by allowing bacteria to grow when the air is warmed. The Maintenance Supervisor (MS) noted the ice build-up and suggested it might be due to the freezer door not being closed tightly. The Artic Air commercial freezer manual advises defrosting and cleaning the freezer when 1/4 to 1/2 inch of frost accumulates, as frost tends to build up faster on the upper part of the freezer due to warm, moist air entering when opened. The FDA 2022 Food Code emphasizes the importance of maintaining equipment to manufacturer specifications to ensure proper operation and consumer safety.
Inaccessible Call Light for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was not physically able to use the type of call light provided. The resident, who was admitted with dementia and anxiety, was always incontinent and dependent on staff for toileting hygiene. The care plan indicated that the call light should be within reach and the resident should be encouraged to use it for assistance. However, during an observation, the resident was unable to pull the string of the call light to signal for help. Interviews with staff confirmed that the resident could not use the provided call light and had not been offered an alternative until later. The facility's policy required special accommodations for call lights to be documented in the resident's care plan, but there was no documentation indicating the resident's inability to use the call light or the need for special accommodations. This oversight had the potential to result in unmet resident needs and delayed staff response.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to potential infection spread. For Resident 4, who was admitted with sepsis and MRSA, the Social Services Assistant (SSA) entered the room without wearing the required Personal Protective Equipment (PPE), despite Enhanced Barrier Precaution signage and PPE supplies being available. The SSA acknowledged the oversight and confirmed the need to wear PPE to prevent infection spread. Similarly, for Resident 5, who was admitted with sepsis, gangrene, and a post-procedure infection, the Certified Nursing Assistant (CNA 1) entered the room without full PPE, despite the presence of Droplet Precaution signage and PPE supplies. Resident 5 was on contact isolation for COVID-19, and the CNA confirmed the failure to wear gloves, face shield, and gown as required. The Infection Preventionist confirmed the necessity of PPE use to prevent infection transmission.
Failure to Coordinate PASRR Evaluation for Resident
Penalty
Summary
The facility failed to coordinate with the PASRR evaluation program for a resident with a mental disorder, who had positive results on Level I screening, indicating the need for a Level II screening. This oversight placed the resident at risk of not receiving necessary rehabilitative services. The resident's clinical record showed diagnoses including mental illness, mood disorder, unspecified dementia with behavioral disturbance, noncompliance with treatment, and a history of frequent hospitalizations. Despite these indicators, there was no documented evidence that the facility referred the resident for a Level II PASRR evaluation as required. The deficiency was further highlighted by an incident where the resident was involved in a physical altercation, resulting in injuries and subsequent hospitalization. The Director of Nursing confirmed that the Level II screening had not been completed, acknowledging that the resident's altercation, noncompliance, and frequent hospitalizations could have been linked to unmet needs related to their mental illness. The facility's policy required coordination with the PASRR program to ensure appropriate care, but this was not adhered to, leaving the resident's specialized care needs unaddressed.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to notify the Department, Long-Term Care Ombudsman Program (LTCOP), and Local Law Enforcement Agency within 2 hours of an alleged abuse incident involving two residents. The incident occurred when a CNA heard a commotion in a room and found one resident standing over another. The resident who was standing had accidentally touched the other resident's face, resulting in faint discoloration and a laceration below the eye. The injured resident was subsequently picked up by an ambulance, and vital signs remained stable with no reported pain. Interviews with staff, including the Director of Nursing (DON), Licensed Nurse (LN), Social Services Director (SSD), and Director of Staff Development (DSD), revealed that they were aware of the requirement to report abuse within two hours. However, the DON did not notify the Administrator until 7:30 a.m., and the state agency was not contacted until 9:16 a.m., well beyond the required two-hour window. The facility's policy clearly stated that all alleged violations must be reported immediately, no later than two hours after observing or obtaining knowledge of the incident. The delay in reporting was confirmed through a review of various documents, including the facility's Abuse Investigation Report and Fax Transmission Result. The report indicated that the incident occurred at 1:45 a.m., but the state agency was not informed until 9:16 a.m. The facility's failure to adhere to its own policy and regulatory requirements resulted in a delay in the investigation process and decreased the potential to protect residents from harm.
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.
