Chowchilla Memorial Healthcare District
Inspection history, citations, penalties and survey trends for this long-term care facility in Chowchilla, California.
- Location
- 1104 Ventura Ave., Chowchilla, California 93610
- CMS Provider Number
- 555530
- Inspections on file
- 17
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Chowchilla Memorial Healthcare District during CMS and state inspections, most recent first.
The facility failed to maintain cleanliness standards in the kitchen, as observed with a sink faucet covered in a black and brown substance. The Dietary Supervisor and a staff member admitted that the faucet, located near the dishwashing machine, was not cleaned daily as required. This oversight placed 27 residents at risk for foodborne illness due to potential cross-contamination, contrary to the facility's sanitation policy.
The facility failed to create and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident with COPD had no care plan addressing their condition, while another resident's care plan inaccurately included a diagnosis of kidney failure and fluid restriction without medical evidence. These oversights were acknowledged by staff, indicating a lapse in adherence to care planning procedures.
The facility failed to communicate pharmacy recommendations for two residents, leading to deficiencies in care. One resident's recommendation for blood tests was not communicated to the hospice provider, risking treatment against their wishes. Another resident's recommendation to rinse their mouth after using an inhaler was not implemented, increasing the risk of oral infection. Documentation and communication lapses were identified.
An LTC facility failed to implement effective infection prevention and control practices for several residents. An LVN did not perform hand hygiene when entering and exiting rooms, did not remove gloves after patient care, and did not bring the medication cart to each room while administering medications. These actions increased the risk of cross-contamination and infection spread among residents.
A resident was subjected to an unjustified fluid restriction without clinical justification or a person-centered care plan. The resident, admitted with a cerebral infarction and other conditions, had no evidence of kidney failure or fluid overload. Facility staff, including the LVN, RD, and DON, confirmed the lack of objective evidence for the restriction, which was carried over from a previous facility without verification. The care plan was not individualized, leading to potential harm such as dehydration.
A resident with severe cognitive impairment was allowed to smoke without a protective apron, leading to ashes falling on his clothing and wheelchair. Facility staff admitted to not following the smoking policy, which requires offering a non-combustible apron to prevent burns.
A resident on a fortified diet did not receive the prescribed Magic Cup dessert during lunch, which is crucial for those with involuntary weight loss. The resident, with severe cognitive impairment and multiple health issues, was observed without the necessary dietary supplement. The dietary staff, supervisor, and registered dietician confirmed the oversight, which did not adhere to the facility's diet order policies.
A facility failed to follow its Hospice policy for a resident under hospice care by not communicating pharmacy recommendations for lab tests to the hospice provider and not implementing a hospice order to discontinue all lab tests. This lack of communication and coordination could have led to treatments against the resident's wishes, as confirmed by the DON and HDPCS.
A resident with a history of falls and moderate cognitive impairment experienced multiple falls due to inadequate supervision and insufficient interventions. Despite having alarms and visual checks, the resident continued to fall, particularly at night when supervision was lacking. The facility's DON acknowledged the falls as unavoidable, citing cost concerns for one-on-one supervision, but the lack of effective monitoring and intervention adjustments contributed to the resident's ongoing fall risk.
The facility failed to implement resident-centered care plans, leading to falls for two residents with severe cognitive impairment. One resident was left unsupervised in the shower room, and another was found ambulating unsupervised in the hallway, both resulting in injuries.
A resident with severe cognitive impairment fell after being left unsupervised in the shower room by a CNA. The facility failed to update the resident's care plan with new interventions following the fall, despite existing policies requiring such updates to prevent future incidents.
Failure to Maintain Cleanliness of Kitchen Sink Faucet
Penalty
Summary
The facility failed to maintain professional standards for food service safety by not ensuring the cleanliness of the kitchen sink faucet. During an observation and interview with the Dietary Supervisor (DS), it was noted that the sink faucet near the dishwashing machine was covered with a black and brown substance. The DS acknowledged that the base of the sink faucet was not clean and confirmed that it should be cleaned daily. This oversight was further corroborated by an interview with a staff member who admitted that the sink faucet was supposed to be cleaned daily but was not. The facility's policy and procedure document titled 'Sanitation in Preparation and Serving' emphasized the importance of cleaning and sanitizing all equipment before use to prevent food poisoning. However, the failure to adhere to this policy placed the 27 residents who received meals from the kitchen at risk for foodborne illness due to potential cross-contamination. The DS confirmed that the lack of cleanliness in the food preparation area could lead to illness among residents.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For Resident 12, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) among other conditions, there was no care plan created to address the COPD diagnosis. Despite the resident's need for routine and as-needed medication to manage breathing difficulties, the absence of a care plan meant that nursing staff lacked guidance on appropriate interventions. This oversight was acknowledged by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who confirmed that the facility's policy and procedure for care planning were not followed. Resident 78's care plan inaccurately included a diagnosis of kidney failure and a related fluid restriction, despite no medical evidence supporting such a condition. The resident's medical records and lab results did not indicate any kidney issues, and interviews with the Registered Dietician (RD) and the DON confirmed the absence of a kidney diagnosis. The care plan was created by the Director of Staff Development (DSD) without verifying the resident's actual medical needs, leading to an inaccurate and non-individualized care plan. This misstep was recognized by the DSD, who admitted to assuming the need for a fluid restriction without proper assessment. The facility's failure to adhere to its care planning policy resulted in a lack of appropriate, individualized care for both residents. The care plans were not based on comprehensive assessments, which are essential for ensuring that residents receive care tailored to their specific medical conditions and needs. The deficiencies in care planning were acknowledged by multiple staff members, including the LVN, RD, and DON, highlighting a significant lapse in the facility's adherence to its own procedures and standards of practice.
Failure to Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For Resident 10, the facility did not communicate a pharmacy recommendation to the hospice provider. The recommendation involved obtaining several blood tests, including Serum B-12, Creatinine Level, Liver Function, and BMP, which were necessary to monitor the resident's therapy. The Director of Nursing (DON) and the Director of Staff Development (DSD) confirmed that there was no record of this communication, which could have led to the resident receiving treatment or procedures against his wishes. For Resident 22, the facility did not implement a pharmacy recommendation related to the use of a Budesonide-Formoterol Fumarate Dihydrate inhaler. The recommendation was to rinse the mouth with water and spit back into a cup after using the inhaler to prevent oral thrush. The DON and the Infection Preventionist (IP) confirmed that there was no documentation of this recommendation being noted or acted upon, which could have increased the risk of the resident developing an oral infection. The facility's policies and procedures, including those related to charting and documentation, were reviewed and indicated that all services provided to residents should be documented in their medical records. This documentation is essential for facilitating communication between the interdisciplinary team regarding the resident's condition and response to care. However, in both cases, the lack of documentation and communication led to deficiencies in the care provided to the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure effective infection prevention and control practices were implemented for nine of 14 sampled residents. The Licensed Vocational Nurse (LVN) did not perform hand hygiene when entering and exiting the rooms of these residents. This included not washing hands after administering medications or performing patient care tasks such as checking blood pressure and blood sugar levels. The lack of hand hygiene was observed across multiple interactions with residents, despite the facility's policy requiring hand hygiene to prevent the spread of infections and cross-contamination. Additionally, the LVN did not remove gloves after providing patient care for several residents and exited the rooms while still wearing them. The LVN walked down the hallway back to the medication cart with gloves on, which posed a risk of cross-contamination. The facility's policy and professional guidelines clearly state that gloves should be removed before leaving a resident's room to prevent the spread of infections. Furthermore, the LVN did not bring the medication cart to each resident's room while administering medications and patient care. Instead, the LVN prepared medications at the nursing station and walked to the residents' rooms without the cart, which was often several feet away. This practice increased the risk of cross-contamination as the LVN had to walk back and forth between the medication cart and the residents' rooms, potentially spreading germs and compromising the health and safety of the residents.
Unjustified Fluid Restriction for Resident
Penalty
Summary
The facility failed to manage and monitor the quality of care for a resident when it unjustly implemented a fluid restriction without clinical justification, comprehensive assessment, or a person-centered care plan. The resident, who was cognitively intact, was admitted with a diagnosis of cerebral infarction, history of endocarditis, acute embolism, thrombosis, and hypotension. Despite these conditions, there was no evidence of kidney failure or fluid overload that would warrant a fluid restriction. The resident's care plan inaccurately indicated a potential fluid volume overload related to kidney failure, which was not supported by any medical diagnosis or evidence in the resident's medical record. Interviews with facility staff, including the LVN, RD, DON, and DSD, revealed that there was no objective evidence or clinical reason for the fluid restriction. The care plan was not individualized and was based on assumptions rather than a comprehensive assessment of the resident's needs. The facility's policy and procedure for care planning were not followed, as the care plan was not based on a diagnosis or resident assessment. The fluid restriction order was carried over from a previous facility without verification of its necessity. This oversight had the potential to cause harm to the resident, including dehydration and electrolyte imbalance, due to the inappropriate medical treatment and lack of freedom in fluid intake.
Resident Smoking Safety Deficiency
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 10, who was observed smoking without adequate protective measures. Resident 10, who has a diagnosis of dementia, cerebrovascular accident, and senile degeneration of the brain, was found to have a severely impaired cognitive status with a BIMS score of 5 out of 15. Despite these impairments, Resident 10 was allowed to smoke in the designated smoking area without wearing a smoking apron, resulting in ashes falling on his shirt and into his wheelchair, posing a risk of burns. Interviews with facility staff, including LVN 1, LVN 2, and the Director of Nursing, revealed that the facility's smoking policy, which requires residents to be offered a non-combustible apron prior to smoking, was not followed. Activities Personnel 1, who was present with Resident 10 during the smoking incident, admitted to not having received training on the facility's smoking procedures and forgetting to provide the smoking apron. This oversight was acknowledged as a safety issue by the staff, as the resident's cognitive impairments and lack of safety awareness increased the risk of injury from the hot ashes.
Failure to Provide Correct Fortified Diet to Resident
Penalty
Summary
The facility failed to provide the correct diet for one of the sampled residents during lunch tray assembly. Resident 2, who was on a fortified diet to increase calories and protein intake, did not receive the prescribed Magic Cup frozen dessert, which is essential for those experiencing involuntary weight loss. This oversight occurred on February 18, 2025, when the dietary staff did not follow the diet order, potentially impacting the resident's nutritional requirements necessary for sustaining or gaining weight. Resident 2's medical history includes hospice care, dementia, hypertension, muscle weakness, repeated falls, and atrial fibrillation. The resident's Minimum Data Set indicated severe cognitive impairment. During observations and interviews, it was confirmed that the lunch tray was missing the Magic Cup, which was acknowledged by the dietary staff, supervisor, and registered dietician. The facility's policies and procedures require adherence to diet orders, which was not followed in this instance, leading to the deficiency.
Failure to Communicate Hospice Orders and Recommendations
Penalty
Summary
The facility failed to adhere to its Hospice policy and procedures for a resident who was under hospice care. The pharmacy had recommended several laboratory tests, including Serum B-12, Creatinine Level, Liver Function, and BMP, due to the resident's medication potentially depleting vitamin B-12 and causing lactic acidosis. However, this recommendation was not communicated to the hospice provider, as confirmed by both the Director of Nursing (DON) and the Hospice Director of Patient Care Services (HDPCS). The lack of communication meant that the hospice provider was unaware of the need for these tests, which could have impacted the resident's care. Additionally, there was a failure to implement a hospice order to discontinue all laboratory tests for the resident. The hospice order was issued, but the facility staff did not have any record or proof of receiving this order, as stated by the DON and the Director of Staff Development (DSD). This oversight could have led to the resident receiving treatments or procedures against their wishes, as the facility did not follow the hospice's directive to stop routine labs. The facility's Hospice Program Policy and Procedure, which outlines the responsibilities of coordinating care between the facility and hospice staff, was not followed. The policy requires the facility to ensure that hospice staff are oriented on the facility's procedures, including record-keeping requirements. However, the designated person to coordinate care was not identified, and there was no documentation to support that the necessary communication and coordination occurred, leading to the deficiencies noted in the report.
Inadequate Supervision Leads to Repeated Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls for a resident identified as a high fall risk. This resident, who had a history of falls and was assessed as moderately cognitively impaired, experienced five falls over a period of approximately two months. Despite having interventions such as bed and chair alarms, frequent visual checks, and fall mats, the resident continued to fall, indicating that the measures in place were insufficient to prevent these incidents. Interviews with staff revealed that while the resident was supervised during the day, particularly when out of his room, there was a lack of consistent supervision at night. The resident was known to be impulsive and would often get out of bed without assistance, increasing his risk of falls. The facility's Director of Nursing acknowledged that the resident's falls were considered unavoidable, and the cost of providing one-on-one supervision was deemed too expensive. The resident's care plan included various interventions aimed at reducing fall risk, but these were not effectively implemented or monitored, particularly during nighttime hours. The facility's policy on fall prevention emphasized the need for staff to assist and supervise residents at risk of falls, yet the resident continued to fall, resulting in a fracture. The interdisciplinary team had determined that the falls were unavoidable, but the lack of adequate supervision and the failure to adjust interventions contributed to the ongoing risk of falls for the resident.
Failure to Implement Resident-Centered Care Plans Resulting in Falls
Penalty
Summary
The facility failed to implement a resident-centered comprehensive care plan for two residents, resulting in falls. Resident 1, who had severe cognitive impairment and was at risk for falls, was left unsupervised in the shower room by a CNA who went to get skin protectant cream. This led to Resident 1 falling and being found on the floor by the CNA upon her return. The care plan for Resident 1 indicated that the resident should be frequently observed and placed in a supervised area when out of bed, which was not followed by the staff involved. Resident 2, also with severe cognitive impairment and a history of muscle weakness and difficulty walking, was found ambulating unsupervised in the hallway by an activity assistant. Resident 2 lost balance and fell, resulting in a head laceration and other injuries. The care plan for Resident 2 required assistance with ambulation and transfers, including verbal cues for safety, which was not adhered to by the staff. The physical therapy notes also indicated that Resident 2 needed supervision and verbal cues for all functional mobility due to safety concerns. Both incidents highlight the failure of the facility staff to follow the care plans designed to ensure the safety of the residents. The care plans were not implemented as required, leading to falls and injuries for both residents. The facility's policy and procedure on care planning emphasized the importance of integrating assessment findings and developing reasonable and measurable goals for residents, which were not met in these cases.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for a resident who fell on a specified date. The resident, who had a severe cognitive impairment as indicated by a BIMS score of 7, was found lying on her left side next to a shower hose in the center shower room. Approximately two minutes prior, the resident had been assisted to the toilet in the shower room by a CNA, who then left the resident unsupervised to get skin protectant cream. Upon returning, the CNA found the resident on the floor. The care plan, dated several months prior, indicated the resident was at risk for falls due to generalized muscle weakness and required frequent observation and supervision when out of bed. However, the care plan was not updated with new interventions following the fall incident on the specified date, as confirmed by an LVN during a review of the resident's care plan and progress notes. The LVN acknowledged that care plan interventions should have been updated after the fall but were not. During an interview, the CNA admitted to leaving the resident unsupervised in the shower room, which led to the fall. The facility's policy on falls and fall risk management, reviewed with the Administrator, stated that staff should identify and implement interventions to prevent falls and minimize complications based on previous evaluations and current data. The policy also emphasized the importance of updating the care plan with input from the interdisciplinary team and the attending physician to reduce specific fall risk factors. The Administrator confirmed that care plan interventions should be updated and revised following falls to ensure resident safety.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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