Clearwater Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 1517 East Knickerbocker Drive, Stockton, California 95210
- CMS Provider Number
- 555307
- Inspections on file
- 50
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Clearwater Healthcare Center during CMS and state inspections, most recent first.
A resident with sepsis, acute osteomyelitis, type 2 DM, a PICC line for IV antibiotics, homelessness, and a documented history of meth use was admitted without development of a care plan addressing drug use or elopement risk, despite facility policies requiring a baseline care plan and specific interventions for residents at risk of wandering. The resident asked an RN for a lighter, packed belongings, and left the building unnoticed; later camera review showed the resident exiting the facility gate. The resident remained unaccounted for more than a day, during which family reported he walked a long distance, complained of foot pain, may have attempted to remove his PICC line with scissors, and used drugs. The ADON described an elopement process that included notifying regulatory and protective agencies, but the Administrator acknowledged he did not report the incident to the Department, Ombudsman, or APS as required by facility policy.
A resident admitted with sepsis, acute osteomyelitis, and type 2 DM had a recent methamphetamine use history documented in the acute hospital H&P, but the facility’s admission nursing assessment recorded that the resident had never used drugs. During interviews, the SSD confirmed the resident’s drug use history and acknowledged it had been missed, and the ADON confirmed the discrepancy and stated the responsible nurse completed the assessment incorrectly, noting that staff often rush these assessments. Facility policy and the LVN job description require complete and accurate documentation in the medical record, which was not followed in this case.
A resident with significant mobility and vision impairments was discharged home without confirmation that home health agency (HHA) services were in place, despite orders and recommendations for such services. Facility staff sent referrals but did not verify HHA acceptance before discharge, resulting in the resident being without needed therapy and nursing support at home. The discharge was marked as per resident preference, but therapy and nursing staff indicated it was against medical advice due to ongoing care needs and lack of support.
A resident with significant mobility and mental health needs was unable to use his motorized wheelchair in the facility and requested a transfer to another facility that would accommodate his needs. Despite this request being known to staff, referrals to other SNFs were delayed by about two months, and no follow-up was conducted after the referrals were sent, contrary to facility policy. This resulted in ongoing distress for the resident.
A resident with severe dementia and a history of wandering and behavioral disturbances was placed on 1:1 observation for safety, but was left unattended and entered another resident's room, where they were punched in the chest. Staff and records confirmed that the required continuous supervision was not provided at the time of the incident, leading to physical abuse.
A resident with recent bilateral lower extremity amputations missed a scheduled post-surgical physician appointment because the facility did not provide necessary transportation and Spanish interpretation support. Staff were unable to coordinate a Spanish-speaking staff member or family member to accompany the resident, resulting in a delay in follow-up care for surgical wounds.
A resident with multiple medical conditions did not receive prescribed doses of three medications because the drugs were unavailable or the resident was sleeping. Nursing staff did not follow facility policy to check the e-kit, notify the physician, or document actions taken in the medical record. The pharmacy consultant confirmed that medications should have been accessible through the dispensing machine or e-kit, but required notifications and documentation were not completed.
Multiple residents requiring assistance with mobility and toileting experienced significant delays in call light response, with some waiting up to 30 minutes for staff to provide help. Observations and interviews confirmed that staff did not consistently respond promptly, despite facility policy and expectations for timely assistance.
Two residents with significant mobility impairments missed or were late to scheduled medical appointments due to the facility's failure to arrange timely transportation and communicate appointment schedules among staff. Miscommunication and lack of awareness among nursing staff contributed to these deficiencies.
A resident with muscle weakness and paraplegia was denied readmission after being cleared for return from a hospital, following a facility-initiated transfer due to alcohol intoxication. Despite not signing an AMA form and being cleared by the hospital, the facility refused readmission, resulting in the resident's temporary loss of residence and emotional distress.
A resident transferred to a hospital was not provided with written notice of bed hold, transfer, or discharge, nor was the required notification sent to the Ombudsman. The facility did not issue these documents at the time of transfer, despite policy and regulatory requirements, resulting in the resident not being fully informed of their rights and experiencing emotional distress due to a prolonged hospital stay and temporary loss of residence.
A resident with multiple medical and mental health conditions was scheduled for discharge after skilled services ended, but neither the resident, her representative, nor the Ombudsman received the required written discharge notice. Instead, discharge information was communicated verbally, and the lack of formal notice led to confusion, anxiety, and a delayed appeal process. The facility's failure to provide written notification violated regulations and policy regarding discharge procedures and residents' rights.
Four residents with significant mobility impairments and at risk for pressure ulcers did not receive repositioning every two hours as required by their care plans. Staff interviews and record reviews confirmed that these residents were dependent on staff for turning, but documentation showed missed or delayed repositioning events. The DON verified that the care plan interventions were not consistently implemented or documented according to facility policy.
A resident with frequent yelling behavior, who is mostly non-verbal and unable to use the call light, was verbally threatened and physically confronted by her roommate, who was on hospice care and agitated by the noise. Staff and care plans failed to provide individualized interventions or effective monitoring, resulting in the resident experiencing fear and distress.
A live baby cockroach was observed on a clean colander in the kitchen, and multiple kitchen items were found with brownish residues, indicating inadequate cleaning. The Food Services Director confirmed the pest sighting and the process for reporting it, while the Registered Dietitian and Maintenance Director described the pest control service schedule. Facility policies required routine cleaning and monthly pest control, but these were not effectively implemented.
Surveyors found that food items in the kitchen, including frozen foods and spices, were not properly labeled or dated, and some were expired. Cooking equipment and utensils, such as pots, pans, a toaster oven, and stove grates, were observed with visible residues and discoloration, despite facility policies requiring regular cleaning and sanitation. The Food Services Director acknowledged these issues as food safety risks, and these failures had the potential to impact all residents receiving facility-prepared meals.
Staff who declined the flu vaccine did not wear required masks, a resident on airborne precautions for COVID-19 had their room door left open against policy, and hand hygiene was not performed or offered to residents during meal service. These actions were contrary to facility policy and CDC guidelines, as confirmed by interviews and record review.
Two residents with urinary catheters were observed with uncovered catheter drainage bags, despite facility policy and staff acknowledgment that dignity bag covers should be used to protect privacy. Both a nurse and the DON confirmed that catheter bags should be covered at all times to maintain resident dignity and prevent emotional distress.
A resident who was responsible for their own care and required surgical aftercare was not informed of a scheduled follow-up appointment with a cardiothoracic surgeon, resulting in a missed appointment. Facility staff confirmed the appointment was documented but not communicated to the resident, contrary to policy.
A resident's representative did not receive the required Notice of Medicare Non-Coverage (NOMNC) before skilled nursing services ended. The NOMNC was sent by regular mail without verification, no follow-up was made, and the address used was incorrect. As a result, the resident and representative were not informed of the end of Medicare coverage or their appeal rights.
A resident admitted with dementia, psychosis, and anxiety disorder did not receive a required PASRR Level II evaluation after a positive Level I screening for serious mental illness. Despite state notification and multiple attempts to arrange the evaluation, facility staff did not respond or ensure the process was completed, with interviews revealing confusion over staff responsibilities and a lack of adherence to facility policy.
Two residents with significant mobility and self-care deficits did not receive scheduled showers as required, with records and staff interviews confirming missed showers and lack of documentation. Both residents required substantial assistance with bathing, and the facility's policy for hygiene and skin assessment was not followed.
A resident with a recent periprosthetic knee fracture and a care plan for pain management experienced severe pain for approximately two hours without assessment or administration of ordered pain medication. Despite repeated requests and staff notifications, the resident's pain was not addressed in a timely manner, even though the medication was available in the emergency kit.
A resident did not receive their scheduled morning medications, which included treatments for hypertension, pain, depression, and respiratory conditions, until after noon, despite repeated requests. Staff confirmed that the medications were due earlier in the morning but were administered late, resulting in some noon medications being missed. The DON verified that this late administration was outside facility policy and contradicted physician orders.
Surveyors found that two medication carts contained opened medications without opened-on dates, an opened probiotic that required refrigeration but was not stored properly, a hazardous medication not kept in a protective bag, and a resident's rings stored in a medication cart drawer. LNs and the DON confirmed these practices did not follow facility policy and proper medication storage protocols.
The facility did not follow prescribed portion sizes for yams and vegetables and served roast beef with blackened edges during a lunch meal, affecting 107 residents. Despite posted guides and in-services, staff used incorrect scoop sizes and did not remove overcooked portions, resulting in meals that did not meet menu specifications for various prescribed diets.
A resident in an LTC facility received duplicate blood thinner medications for 3.5 days due to a clerical error in the electronic health record system. The concurrent administration of Rivaroxaban and Dabigatran was not clarified with the medical doctor, resulting in critically high PT/INR levels. The resident suffered severe complications, including internal bleeding and cardiogenic shock, leading to their death. The facility's medication administration and communication policies were not adequately followed.
A facility failed to administer medications on time for three residents, including a resident with Parkinsonism who experienced delays in receiving critical medications, leading to increased tremors. Another resident with diabetes and heart failure received medications late, risking blood glucose fluctuations and inconsistent blood pressure control. Additionally, a resident's constipation was not addressed promptly, and incorrect identification photos were used, risking treatment errors.
A facility failed to maintain resident confidentiality when medication for a resident with hypertension was mistakenly sent home with another resident. The DON confirmed the error, highlighting a risk of incorrect medication use and a HIPAA compliance issue. The facility's LVN job description stresses the importance of maintaining confidentiality.
A resident with chronic respiratory failure, muscle weakness, and morbid obesity was discharged from an LTC facility without adequate preparation for her home environment, leading to her readmission to the hospital. The discharge was marked as planned, but there was confusion about whether it was against medical advice. The facility failed to ensure a safe transition of care, and Adult Protective Services noted the discharge was unsafe.
A resident with a history of inappropriate behavior inappropriately touched two other residents in a LTC facility. Despite being aware of the resident's behavior, the facility's monitoring was inadequate, with incomplete documentation and lapses in supervision. The facility's policy on abuse prevention was not effectively implemented, leading to repeated incidents.
Failure to Care Plan and Supervise Resident With Drug Use History, Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for wandering and elopement received adequate supervision and an appropriate care plan addressing known drug use. The resident was admitted in January 2026 with diagnoses including sepsis, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus, and had a PICC line in place for IV antibiotics. The acute hospital H&P dated 1/15/26 documented a recent history of methamphetamine use. The Social Services Director and the ADON both confirmed that, despite this known history, no care plan was developed to address the resident’s drug use, and no psychiatric consultation was obtained. Facility policies required a baseline care plan within 48 hours of admission and specified that residents identified as at risk for wandering or elopement must have care plan strategies and interventions to maintain safety. On the early morning of 1/25/26, a licensed nurse reported that the resident requested a lighter to smoke cigarettes during the medication pass. When told a lighter was not available, the resident began packing his belongings while the nurse continued the medication pass. At approximately 5:15 a.m., the nurse returned to the resident’s room and found the resident was no longer there. The nurse searched the building but could not locate the resident and then reported the missing resident to the ADON and another nurse. Subsequent review of facility camera footage by another licensed nurse showed the resident exiting the facility’s outside gate at 4:57 a.m. without staff awareness. Family later reported that the resident, who was known to be homeless with a long history of drug use, walked a long distance to a family member’s home, complained of foot pain, had scissors and was possibly attempting to remove the PICC line, and had used drugs after leaving the facility. The resident was unaccounted for approximately 27 hours and 30 minutes and was later at a local hospital. The ADON stated that the facility’s elopement process included contacting the Department, police, Ombudsman, and other key personnel, and acknowledged concern for the resident’s safety given the unsafe neighborhood, time of day, weather, PICC line, and drug use history. The Administrator confirmed he did not contact the Department, Ombudsman, or Adult Protective Services after the resident left, despite facility policy requiring reporting of unusual occurrences that affect the health, safety, or welfare of residents to appropriate agencies within specified time frames.
Inaccurate Documentation of Substance Use History on Admission Assessment
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for one of two sampled residents when the substance use history section of the admission nursing assessment was inaccurately documented. The resident was admitted in January 2026 with diagnoses including sepsis, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus. The acute hospital history and physical dated 1/15/26 documented a history of recent methamphetamine use. However, the facility’s admission nursing assessment dated 1/16/26 indicated under the substance use history section that the resident had never used drugs, creating conflicting information between the hospital record and the facility’s assessment. During interviews and concurrent record reviews, the Social Services Director confirmed that the resident had a history of drug use and acknowledged that this information had been missed when reviewing the record. The Social Services Director stated that a care plan and psychiatric consultation were not completed for the resident. The Assistant Director of Nursing confirmed the discrepancy between the hospital H&P and the admission nursing assessment and stated that the licensed nurse responsible for the admission assessment documented it incorrectly. The ADON further stated that staff often complete these assessments incorrectly because they are rushing. Review of facility policy indicated that documentation in the medical record is required to be objective, complete, and accurate, and the LVN job description requires maintaining accurate and up-to-date medical records, including nursing assessments and care plans.
Failure to Ensure Safe Discharge with Home Health Services Established
Penalty
Summary
A deficiency occurred when a resident was discharged home without ensuring that home health agency (HHA) services were established, despite orders and recommendations for such services. The resident, who was admitted for rehabilitation following a displaced left femur fracture and had generalized muscle weakness and legal blindness, was discharged home at her own request. The discharge orders included the need for physical therapy, occupational therapy, registered nurse services, and durable medical equipment, with the expectation that these would be provided through HHA. However, the facility failed to confirm that the HHA could initiate services prior to discharge. Interviews and record reviews revealed that the social services department sent referrals for HHA and necessary equipment, but only learned after discharge that the HHA could not accept the resident due to her not being established with a primary care physician. Multiple staff members, including the case manager, assistant director of nursing, and director of therapy, confirmed that HHA services should have been verified and established before discharge, especially given the resident's high risk factors such as living alone, impaired mobility, and vision loss. The resident's emergency contact also expressed concerns about her safety at home without adequate support. Documentation showed that the discharge was marked as being per the resident's preference, but therapy and nursing staff indicated that the discharge was against medical advice due to the resident's ongoing need for supervision and therapy. The lack of established HHA services resulted in a gap in care and placed the resident at risk, as confirmed by staff interviews and progress notes. The facility did not document the discharge as being against medical advice, nor did it ensure that the interdisciplinary team was fully informed of the lack of HHA services prior to discharge.
Failure to Provide Timely Social Services Support for Resident Transfer Request
Penalty
Summary
The facility failed to provide timely and appropriate social services support for a resident who wished to leave the facility due to being unable to use his motorized wheelchair. The resident, who had a history of generalized muscle weakness, major depressive disorder, an amputation below the knee, and multiple sclerosis, expressed his desire to transfer to another facility that would accommodate his motorized wheelchair approximately one month after admission. Despite this, referrals to alternative facilities were not sent until about three months after his initial request, and there was no documented follow-up by staff to check on the status of these referrals. Interviews with facility staff revealed that the resident's request to transfer was known to the social services department, but the Case Manager Assistant did not document the request in the medical record. The Business Office Assistant sent referrals to three other skilled nursing facilities at the resident's request, but received no responses and did not follow up, as this responsibility was assigned to the social services department. The Social Services Assistant confirmed that no follow-up was conducted after the referrals were sent, despite facility policy indicating that follow-up should occur within a few days. Facility policies and job descriptions reviewed indicated that the social services department was responsible for discharge planning, including making referrals and following up to ensure residents' needs and preferences were met. The failure to act in a timely manner and to follow up on the resident's transfer request resulted in the resident experiencing stress and anxiety due to being unable to use his motorized wheelchair, which was essential for his mobility and psychosocial well-being.
Failure to Maintain 1:1 Supervision Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with unspecified dementia and severe cognitive impairment was placed on continuous one-to-one (1:1) observation due to behaviors such as wandering, entering other residents' rooms, hitting staff, and attempting to leave the facility. The care plan and staff interviews confirmed that the expectation was for a staff member to be with the resident at all times to ensure safety and prevent incidents. Despite these interventions, the resident was left unattended and wandered into another resident's room. During this time, another resident became agitated and punched the resident in the chest. Multiple staff members, including CNAs and nurses, confirmed that the resident on 1:1 observation did not have a staff member present at the time of the incident, which was contrary to facility policy and the resident's care plan. Facility records and staff interviews indicated that the 1:1 observation was implemented specifically to prevent such incidents, and that staff were aware of the procedures requiring continuous supervision. The failure to maintain 1:1 supervision resulted in the resident being physically abused by another resident, as documented in care plans, progress notes, and staff statements.
Missed Post-Surgical Appointment Due to Lack of Transportation and Interpreter Coordination
Penalty
Summary
The facility failed to ensure that a resident with bilateral below-the-knee amputations received necessary assistance with transportation and interpretation services to attend a scheduled post-surgical physician appointment. The resident, who had recently undergone amputation and required follow-up care for surgical wounds, missed her appointment because no staff member was available to accompany her and provide Spanish interpretation, as required for her to communicate effectively during the visit. The facility attempted to contact the resident's family to provide interpretation, but the responsible party was unable to assist due to language barriers. Interviews with facility staff revealed that the process for arranging transportation and interpretation was not effectively coordinated. The receptionist received the order to schedule the appointment and was informed of the need for a Spanish-speaking staff member to accompany the resident. However, due to staffing shortages on the day of the appointment, no staff member was available to go with the resident. The nursing and administrative staff indicated that they expected either a staff member or a family member to accompany the resident, but this was not arranged in time for the appointment. The facility's policy on language access states that individuals with limited English proficiency must have meaningful access to services, and that family members should not be relied upon for interpretation unless explicitly requested by the resident. Despite this, the facility's actions did not ensure that the resident had access to interpretation services for her medical appointment, resulting in the missed appointment and a delay in post-surgical care.
Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident, resulting in missed doses of three prescribed medications. The resident, who had a history of a displaced intertrochanteric fracture of the right femur and hypertension, was admitted with orders for Amlodipine for hypertension, Famotidine for GERD, and Linzess for irritable bowel syndrome. On the date in question, documentation showed that the 9 a.m. doses of Amlodipine and Linzess were not administered due to the medications being unavailable, and the 6 a.m. dose of Famotidine was not given because the resident was sleeping. Interviews with nursing staff revealed that the standard procedure when a medication is unavailable is to check the emergency kit (e-kit) and, if not found, notify the physician and document the actions taken in the resident's progress notes. However, review of the resident's electronic medical record showed no documentation that the physician or pharmacy was notified about the missed doses, nor was there any record of follow-up actions or communication regarding the unavailability of the medications. The nurse supervisor confirmed that the facility's policy was not followed in this instance. The pharmacy consultant confirmed that the facility had a new medication dispensing machine and that medications should be accessed from this machine first, with the e-kit as a backup. Despite these resources, the medications were not administered as ordered, and required notifications and documentation were not completed. Facility policy required medications to be administered in a timely manner and within one hour of the prescribed time, which was not adhered to in this case.
Delayed Call Light Response for Residents Needing Assistance
Penalty
Summary
The facility failed to ensure that residents' needs were accommodated by not responding to call lights in a timely manner for at least two of four sampled residents. Observations and interviews revealed that one resident waited an extended period for assistance with changing an incontinent brief and for help moving from bed, with a call light remaining unanswered for at least 27 minutes. The resident's care plan indicated a need for substantial assistance with activities of daily living due to weakness and impaired mobility. Another resident reported waiting up to 30 minutes for staff to respond to call lights, and was observed with a call light on for 12 minutes before staff responded. This resident also required assistance with toileting and used an incontinent brief due to generalized muscle weakness and mobility issues. Additional interviews with other residents confirmed similar delays, with one resident stating the longest wait was 20 minutes and that response times were longer during the evening shift. The Assistant Director of Nursing stated that the expectation was for call lights to be answered within 1-2 minutes, or at least less than 5 minutes, and acknowledged that waits of 15 minutes or more were too long. Facility policy required prompt response to call lights by all staff, regardless of assignment. These findings demonstrate that the facility did not consistently meet its own standards or residents' needs for timely assistance.
Failure to Arrange Timely Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure transportation was properly arranged for two residents, resulting in missed or delayed medical appointments. One resident, with a history of hemiplegia and generalized muscle weakness, missed a scheduled primary care appointment because transportation was not arranged in a timely manner. The receptionist was only notified of the appointment on the day it was scheduled, and when transportation arrived, the resident was not ready. The charge nurse assigned to the resident was unaware of the appointment, and the facility's progress notes indicated that transportation was servicing another resident at the time, necessitating a reschedule. Another resident, diagnosed with a left tibia fracture, foot sprain, and generalized muscle weakness, arrived late to an orthopedic appointment due to delayed facility-owned transportation and was unable to be seen by the physician. The resident reported feeling unimportant due to the lack of prioritization for her scheduled pick-up. Staff interviews revealed miscommunication and lack of awareness among nurses and CNAs regarding residents' appointments, contributing to the missed and delayed appointments.
Failure to Readmit Resident After Hospital Clearance
Penalty
Summary
The facility failed to ensure that a resident, who had diagnoses including generalized muscle weakness and paraplegia, was readmitted after being cleared for return from a general acute care hospital. The resident had left the facility without notifying staff, returned the same day, and was subsequently sent to the hospital due to alcohol intoxication. Despite being cleared by the hospital for return, the facility denied readmission, citing the resident's altered mental status and considering the situation as an 'Against Medical Advice' (AMA) discharge, even though the resident did not sign an AMA form. Interviews with facility staff revealed inconsistent application of AMA procedures and a lack of clear documentation regarding the resident's discharge status. The resident remained at the hospital after being denied readmission, resulting in a temporary loss of residence and reported emotional distress. Facility records and staff interviews confirmed that the discharge was initiated by the facility after the resident returned intoxicated, and that the facility's policy allows for return after emergency hospital transfers unless a facility-initiated discharge is warranted. The facility's actions did not align with their own policy, as the resident was not permitted to return despite being cleared by the hospital and not having formally left AMA.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
The facility failed to provide required documentation and notifications related to a resident's transfer to a General Acute Care Hospital (GACH). Specifically, the facility did not issue a written notice of bed hold to the resident at the time of transfer, despite the policy requiring such notice both at admission and at the time of transfer or within 24 hours if the transfer was emergent. Although the resident had previously declined a bed hold during admission, the facility did not provide the required written notice at the time of the hospital transfer, as confirmed by both the DON and the Administrator during record reviews and interviews. Additionally, the resident was not given a written notice of transfer or discharge in a manner that could be understood, nor was the required notice sent to the Ombudsman’s office. The facility staff considered the transfer to be facility-initiated due to the resident's condition at the time of transfer, but did not provide the necessary documentation or notifications. The DON and Administrator both confirmed that the notice of transfer or discharge was not issued to the resident or the Ombudsman, contrary to facility policy and regulatory requirements. As a result of these failures, the resident was not fully informed of their rights regarding bed hold, return to the facility, or the right to appeal the discharge. The lack of notification and documentation led to the resident experiencing a prolonged stay in the hospital emergency room and a temporary loss of residence, which resulted in emotional distress for the resident.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a required written discharge notice to a resident, the resident's representative, and the Office of the Long-Term Care Ombudsman prior to a planned discharge. The resident, who had a history of cerebral infarction, muscle weakness, gait abnormalities, dysphagia, major depressive disorder, and anxiety disorder, was scheduled for discharge to home with support following the cessation of skilled services. Although the discharge disposition was discussed verbally with the resident's daughter and referrals for post-discharge support were made, no formal written notice of discharge was given to the resident, her representative, or the Ombudsman as required by regulation. Interviews revealed that the Social Services Director acknowledged the lack of a formal discharge notice, stating that it was not provided because the discharge was still pending. Both the resident and her family member confirmed that they were verbally informed of the impending discharge about a week in advance, but did not receive the required written notice. The family member appealed the discharge, and the Ombudsman was involved after being contacted by the family. The Ombudsman also confirmed that no written notice was received and that the resident was anxious due to the discharge process and lack of communication. Facility policy requires documentation of transfer or discharge and communication with the receiving provider, as well as preparation of the resident in advance. Federal and state regulations mandate that written notice be provided to the resident, their representative, and the Ombudsman at least 30 days in advance, or as soon as practicable, with an opportunity to appeal. In this case, the absence of a written notice removed the opportunity for timely advocacy and appeal, and resulted in confusion and distress for the resident and her family.
Failure to Implement and Document Repositioning Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and document the required repositioning interventions for four residents who were assessed as being at risk for pressure ulcer development. Each of these residents had significant mobility impairments, such as hemiplegia, anoxic brain damage, paraplegia, or other abnormalities of gait and mobility, and were dependent on staff for turning and repositioning in bed. Their care plans specifically included interventions for turning and repositioning every two hours and as needed, in accordance with facility policy and recognized standards of practice. Observations and interviews with staff confirmed that these residents were unable to reposition themselves and relied entirely on staff for this care. However, a review of the electronic health records and point of care documentation for a specific date revealed significant gaps in the documentation of turning and repositioning. For each of the four residents, the documented times for repositioning did not meet the care plan requirement of every two hours, with long intervals between recorded repositioning events. The Director of Nursing confirmed that the documentation did not show that the residents were turned and repositioned as frequently as required by their care plans. The facility's own policies require that residents who are bed-bound and dependent on staff be repositioned at least every two hours, and that care plans be implemented as written to address identified risks. The lack of documented evidence that these interventions were carried out as planned constituted a failure to implement the care plans and facility policy, potentially exposing the residents to the risk of pressure ulcer development.
Failure to Protect Resident from Verbal Threats and Aggression by Roommate
Penalty
Summary
The facility failed to implement individualized and effective interventions to protect a resident with known yelling behavior from verbal threats and physical aggression by her roommate. On the evening of the incident, a certified nursing assistant (CNA) heard the resident screaming in a manner that was described as frightened and different from her usual vocalizations. Upon entering the room, the CNA observed the roommate standing over the resident, holding her down by the shoulder with a fist raised to her face, and verbally threatening to hit her if she did not stop yelling. The resident was visibly frightened, with a surprised look on her face, and became quiet after the intervention of the CNA. Multiple staff interviews and observations confirmed that the resident who was threatened is mostly non-verbal, calls out frequently as a means of communication, and does not understand how to use the call light. Staff reported that her calling out is her baseline behavior and that she is unable to express her needs verbally. The roommate who made the threats was on hospice care and had a history of room changes, some of which were related to roommate issues, but there was no clear documentation of previous aggressive incidents involving other residents. The roommate admitted to being agitated by the yelling and confirmed that she threatened and physically confronted the resident. A review of care plans and facility policies revealed that the interventions in place for the resident with yelling behavior were not sufficiently individualized or effective in preventing the incident. The care plan included general interventions such as explaining procedures and discussing behaviors, but did not address the specific risks associated with her communication style or the potential for conflict with roommates. Documentation and behavior monitoring for both residents were found to be lacking or incomplete, and staff did not consistently respond to the resident's calls for assistance. The facility's failure to implement and update appropriate interventions resulted in the resident experiencing fear and potential psychosocial distress.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
A deficiency was identified when a live baby cockroach was observed crawling on a clean colander on a shelf next to the stove in the kitchen, where meals were prepared for 107 residents. During the same inspection, multiple pieces of kitchen equipment, including a pot on the stove, a flat pan, a frying pan, and a toaster oven, were found with brownish, gummy, or flaky substances, indicating inadequate cleaning. These findings were confirmed by the Food Services Director (FD) during concurrent observation and interview. The FD acknowledged the presence of the cockroach and stated that the process was to report pest sightings to Maintenance, noting the risk to food safety. The Registered Dietitian (RD) confirmed that the facility was addressing the cockroach issue and that two pest control companies serviced the facility, one monthly and the other every two weeks. The Maintenance Director confirmed the pest control service schedule. Facility policies reviewed indicated that routine cleaning and pest control procedures should be followed, and that monthly pest control inspections and services were required, with additional servicing as needed.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and equipment sanitation practices. In the walk-in freezer, there were open and unlabeled boxes of frozen chicken patties, whole kernel corn, green peas, and green leaf spinach. Additionally, an opened container of seasoning salt with an expired date was found in the dry storage area, and the Food Services Director (FD) confirmed uncertainty about whether the date was an expiration or opened date. These issues were acknowledged by the FD as food safety risks. Further inspection of the kitchen revealed that a large pot being used to prepare resident meals had a thick, brownish gummy substance on its bottom and sides. A flat pan and a frying pan, both stored with clean pots and pans, were found with caked and flaky brownish substances on their inner edges. The toaster oven next to the stove had a brownish substance on its shelves, and the stove top grates showed grayish discoloration. The FD confirmed that these conditions posed food safety risks and stated that the stove was only cleaned monthly. A review of the facility's policies and procedures indicated requirements for labeling and dating all food items, proper storage of dry and frozen foods, and regular cleaning of kitchen equipment and utensils. The facility's practices did not align with these policies or with the US FDA Food Code, which requires food-contact and nonfood-contact surfaces to be kept clean and free of residue. These failures had the potential to affect all 107 residents who received facility-prepared meals.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for its census of 115 residents. Two unvaccinated staff members, the assistant director of staff development and the receptionist, were observed walking inside the facility without wearing masks, despite having declined the influenza vaccine for the 2024/2025 season. Facility policy, as well as CDC guidance, required unvaccinated staff to wear masks during flu season, and both the infection preventionist and director of nursing confirmed that this was a mandated practice to prevent the spread of influenza to residents and staff. A resident with a recent admission diagnosis of COVID-19 was placed on airborne precautions, with medical orders and care plans specifying that the room door should remain closed. However, multiple observations confirmed that the resident's door was left open on several occasions because the resident was yelling and did not want the door closed. Staff, including CNAs and licensed nurses, acknowledged that the door should be closed for airborne isolation, and that leaving it open increased the risk of spreading infection. The facility's own policies and CDC recommendations were not followed, as the door remained open without alternative containment measures consistently in place. Additionally, during a lunch tray pass, the assistant director of nursing was observed delivering meal trays to residents without offering them hand hygiene opportunities or performing hand hygiene between residents. The ADON admitted to not knowing what to offer residents for hand cleaning and did not use hand sanitizer herself during the process. The director of nursing confirmed that facility policy required staff to perform hand hygiene and offer it to residents before meals, and acknowledged that this protocol was not followed during the observed tray pass.
Failure to Cover Urinary Catheter Bags Compromises Resident Dignity and Privacy
Penalty
Summary
Two residents with urinary catheters were not provided with dignity bag covers for their catheter drainage bags, resulting in a failure to protect their privacy and dignity. One resident, who had paraplegia and neuromuscular dysfunction of the bladder, was observed lying in bed with an uncovered catheter bag and expressed a preference for the bag to be covered. A licensed nurse confirmed the lack of a cover and acknowledged that catheter bags should be covered to maintain privacy and dignity. Another resident, diagnosed with benign prostatic hyperplasia and chronic kidney disease, was also observed with an uncovered catheter bag while lying in bed. The same licensed nurse confirmed this observation and stated that the absence of a cover could cause emotional distress and violate the resident's privacy. The Director of Nursing further confirmed that catheter bags should always be covered to protect residents' privacy, as outlined in the facility's policy on dignity.
Resident Not Informed of Post-Surgery Follow-Up Appointment
Penalty
Summary
A deficiency occurred when a resident, who was admitted with a diagnosis requiring surgical aftercare following circulatory system surgery and was his own responsible party, was not informed about a scheduled post-surgery follow-up appointment with a cardiothoracic surgeon. The hospital discharge summary included instructions for this follow-up, and the appointment was documented in the facility's records. However, the resident stated he was not told about the appointment and therefore missed it. The outside medical office confirmed the resident was a no-show, and the appointment had to be rescheduled. Interviews with facility staff, including the Appointments, Scheduling and Transportation Coordinator (ASTC) and the Director of Nursing (DON), confirmed that the appointment was noted in the discharge orders and that the facility had a process for tracking appointments. Despite this, the resident was not consulted or informed about the appointment, as required by facility policy. The ASTC acknowledged the failure to notify the resident, which led to the missed appointment.
Failure to Properly Deliver Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that a Notice of Medicare Non-Coverage (NOMNC) was properly delivered to a resident or her representative prior to the termination of Medicare-covered skilled nursing services. The resident, who was her own responsible party, had opted for her representative to receive and sign the NOMNC form. The case manager mailed the NOMNC form to the representative using standard mail, did not use certified mail or any method that could verify delivery, and did not follow up to confirm receipt. The NOMNC form was not signed by the resident or her representative, and no follow-up call was made to ensure the notice was received. During an interview, the resident's representative stated she never received the NOMNC form or any phone call from the facility regarding the Medicare notice. Additionally, the mailing address used by the facility was incorrect, as indicated on the Medicare Attestation Form. Facility policy and CMS instructions require that residents or their representatives be informed in advance of changes to their bills and that the NOMNC be delivered in a manner that provides signed verification of delivery. In this case, the facility did not meet these requirements, resulting in the resident and her representative not being informed of the end of coverage or their appeal rights.
Failure to Complete Required PASRR Level II Evaluation After Positive Screening
Penalty
Summary
The facility failed to complete the required Pre-Admission Screening and Resident Review (PASRR) Level II evaluation for a resident who had a positive Level I screening for serious mental illness (SMI). The resident was admitted with diagnoses including dementia, psychosis, and anxiety disorder. Documentation from the California Department of Health Care Services indicated that a Level II evaluation was required, but the evaluation was not completed due to unresponsiveness from facility staff to multiple attempts at communication by the state. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for ensuring the PASRR Level II evaluation was scheduled and completed. The Social Services Director confirmed that the process was expected to be completed as part of admissions, but had not personally handled it. The Admissions Coordinator, Business Office Manager, and MDS Coordinator each described different understandings of their roles in the PASRR process, with none taking ownership of the follow-up required after a positive Level I screening. The facility's own policy stated that new admissions with possible mental disorders, intellectual disabilities, or related conditions should be referred for Level II evaluation, with the social worker responsible for making referrals to the state authority. Despite this, the required evaluation was not completed for the resident, and staff interviews confirmed that the process was not followed as outlined in facility policy.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents who were unable to perform activities of daily living independently. One resident, admitted with multiple fractures, generalized muscle weakness, and mobility issues, did not receive any showers since admission, despite being scheduled for showers twice weekly. This was confirmed by both the resident and facility staff, who acknowledged that the resident had missed scheduled showers and that there was no documentation of showers being provided. Another resident, admitted with hemiplegia, muscle weakness, and impaired mobility, also did not receive scheduled showers as required. The resident reported only receiving one shower since admission and was unaware of her shower schedule. Review of records and interviews with staff confirmed that scheduled showers were missed, and the resident required substantial to maximal assistance with bathing. Facility policy required documentation of showers and skin assessments, but records indicated these were not completed as scheduled for the affected residents.
Failure to Provide Timely Pain Management for Resident with Acute Pain
Penalty
Summary
A deficiency occurred when a resident with a history of a periprosthetic fracture around the right knee joint, following an assault and subsequent surgical repair (ORIF), experienced unmanaged pain. The resident's care plan identified a risk for acute and chronic pain and directed staff to anticipate and respond immediately to pain complaints, including administering medication as ordered. Despite these directives, the resident reported severe pain (10/10) and had been requesting pain medication since 3:00 PM. Observations confirmed the resident was in visible distress, and the call light was used multiple times to request assistance. Certified nursing staff (CNA) reported notifying the licensed nurse (LN) three times about the resident's pain, but the LN had not assessed the resident or administered pain medication, citing that the ordered Norco had not yet been delivered by the pharmacy. The Assistant Director of Nursing (ADON) confirmed that Norco was available in the emergency kit and should have been administered as ordered. The facility's medication administration policy required timely and safe medication delivery based on resident need, not staff convenience. The failure to assess and provide pain relief resulted in the resident waiting approximately two hours without intervention.
Failure to Administer Medications as Prescribed and on Schedule
Penalty
Summary
A deficiency occurred when a resident did not receive their scheduled morning medications in a timely manner. The resident, who typically received medications at 7:30 AM, reported not having received any of her morning medications by 12:05 PM, despite using the call light multiple times to request them. Staff interviews confirmed that the resident's medications, which included treatments for high blood pressure, pain, depression, and respiratory conditions, were due at 8 AM and 9 AM but were not administered until after noon. The licensed nurse acknowledged that thirteen morning medications were given late, and as a result, some noon medications could not be administered as scheduled due to the close timing. Review of the Medication Administration Record (MAR) and facility policy confirmed that the medications were documented as given after 12 PM, outside the facility's policy requiring medications to be administered within 60 minutes of the scheduled time. The Director of Nursing verified that the late administration contradicted physician orders and facility procedures. The resident's medical conditions included high blood pressure, COPD, asthma, and pain, and the medications involved were critical to managing these conditions. The failure to administer medications as prescribed was directly observed and confirmed through interviews and record review.
Medication Storage and Labeling Deficiencies Identified in Medication Carts
Penalty
Summary
Surveyors identified multiple failures in medication storage practices involving two out of five medication carts. Opened medications, including antacids, multivitamins, iron tablets, probiotics, nephro vitamins, and folic acid, were found in the carts without opened-on dates. Licensed nurses confirmed that these medications should have been labeled with the date they were first opened, as required by facility policy. The Director of Nursing (DON) also acknowledged that over-the-counter medications in the carts should have been labeled accordingly. Additionally, an opened bottle of acidophilus, an over-the-counter probiotic, was found stored in a medication cart drawer instead of being refrigerated as required by the manufacturer's instructions. The DON confirmed that the medication was not stored according to the guidelines on the bottle's label, which could result in reduced effectiveness and potency. Facility policy requires medications needing refrigeration to be stored in a designated refrigerator in a secure location. Further, a hazardous medication, risperidone, was found in a bubble pack labeled as hazardous but was not stored in a protective plastic bag as required. The DON stated that hazardous medications should be stored in such bags to prevent staff exposure. In another instance, a resident's rings were found in a plastic bag labeled only with a room number and stored in a medication cart drawer. The DON confirmed that resident belongings should not be kept in medication carts and should be given to Social Services, as storing them in the cart poses a risk of loss.
Failure to Follow Prescribed Menu Portion Sizes and Serve Palatable Food
Penalty
Summary
During a lunch service, the facility failed to follow the prescribed portion sizes for mashed sweet potatoes (yams) and vegetables, and served roast beef with blackened edges to 107 residents. Observations revealed that the cook used a gray scoop for all yams and vegetables, regardless of the specific portion sizes indicated for different diets on the facility's Spring Cycle Menus. The roast beef was plated with blackened edges and covered with barbecue sauce without removing the overcooked portions. The Food Services Director (FD) acknowledged that the expectation was for better preparation in the future and confirmed that the overcooked roast beef was not palatable. Review of the menus and interviews with the Registered Dietitian (RD) and FD confirmed that the correct scoop sizes and portion amounts, as specified for various diets, were not followed during the meal service. The RD stated that different portion sizes were required for different prescribed diets and that the cook's spreadsheet and posted charts provided this information. The FD confirmed that the facility's policy for portion sizes was not followed, despite in-services and posted guides. The facility's policy also stated that poorly prepared food should not be served, but this was not adhered to during the observed meal service.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to ensure safe medication practices for a resident who was admitted after experiencing multiple health complications, including a gallbladder rupture and a blood clot in the lung. Upon admission, the resident was prescribed two blood thinner medications, Rivaroxaban and Dabigatran, which were administered concurrently for 3.5 days. This concurrent administration was not clarified with the medical doctor, leading to a critically high Prothrombin Time/International Normalized Ratio (PT/INR) and subsequent transfer to the Emergency Department. The error in medication administration was attributed to a clerical mistake in the facility's electronic health record system, which reset the start date for Dabigatran. The nursing staff followed the computer system prompts for medication administration without recognizing the duplication. The facility's Assistant Director of Nursing (ADON) and Licensed Nurses (LNs) involved did not identify the error until after the medications had been administered for several days, and there was a delay in contacting the medical doctor to address the issue. As a result of the medication error, the resident suffered severe complications, including internal bleeding, cardiogenic shock, and ultimately death. The facility's policies on medication administration and communication with medical providers were not adequately followed, contributing to the oversight and delay in addressing the critical condition of the resident.
Medication Administration and Identification Failures
Penalty
Summary
The facility failed to ensure professional standards of care were met for three residents, resulting in untimely administration of medications. Resident 1, diagnosed with Parkinsonism, experienced delays in receiving Parkinson's medications, which were administered hours after the scheduled times on multiple occasions. This delay was confirmed by the Medication Admin Audit Report and acknowledged by the Director of Nurses (DON), who emphasized the importance of timely medication administration for maintaining therapeutic efficacy. Resident 2, with heart failure and type 2 diabetes, also experienced delays in receiving diabetes and blood pressure medications. The medications were administered nearly two hours late on consecutive days, as confirmed by the Medication Admin Audit Report and a licensed nurse. Similarly, Resident 3, diagnosed with hypertensive heart disease, received her medications over three hours late. The DON confirmed that medications should be administered within one hour of their scheduled time to maintain consistent blood levels and prevent complications. Additionally, Resident 1 did not receive timely interventions for constipation, with no bowel movement recorded from admission until nine days later, despite family notification of the issue. The facility's bowel care protocol was not followed, as laxatives were only administered after a significant delay. Furthermore, Resident 1's clinical documents contained a photo of another resident, raising concerns about potential misidentification and incorrect treatment. The DON acknowledged the importance of accurate resident identification through photos and ID bands to prevent medication errors.
Medication Mismanagement Leads to Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records when medication intended for one resident was mistakenly sent home with another. Resident 4, who was admitted with a diagnosis of essential hypertension, had an order for clonidine tablets, which were delivered to the facility. However, these medications were inadvertently sent home with Resident 1 upon their discharge. This error resulted in unauthorized access to Resident 4's health and personal information. The Director of Nurses (DON) acknowledged that Resident 4's clonidine had been discontinued the same day it was ordered, and the medication was supposed to remain in the medication storage room until proper disposal. The DON explained that the nurse responsible for discharging a resident is expected to review all medications to ensure the correct ones are sent home. The failure to do so not only posed a risk of incorrect medication usage for Resident 1 but also constituted a HIPAA compliance risk for Resident 4. The facility's job description for Licensed Vocational Nurses emphasizes the responsibility to maintain the confidentiality of all resident care information.
Unsafe Discharge of Resident Without Adequate Support
Penalty
Summary
The facility failed to ensure a safe and effective transition of care for a resident who was discharged home despite being unable to care for herself. The resident, who had chronic respiratory failure, muscle weakness, gait abnormalities, and morbid obesity, was discharged without adequate preparation for her home environment, which included three steps at the entrance. The physical therapy evaluation noted that the resident was not tested on stairs due to safety concerns, and the occupational therapist indicated that the resident required assistance that was not available. The discharge was marked as planned, but there was confusion regarding whether it was against medical advice (AMA). The Social Services Director stated that the resident's insurance did not allow for an extension of stay, leading to the discharge decision. The resident's family expressed concerns about her ability to manage at home, citing her weight and mobility issues, and reported that the facility threatened to discharge her to the street. The family had to call the Fire Department to assist the resident back to the hospital after her discharge. The facility's actions were further questioned by Adult Protective Services, which stated that the facility discharged the resident knowing it was unsafe. The facility's policy required a physician's order for discharge unless it was AMA, but there was no AMA form in the resident's record. The facility also failed to assist the resident with safe discharge planning or completing necessary applications for public health insurance, contributing to the unsafe discharge situation.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, who had a history of inappropriate behaviors. Resident 2, with an intact memory as indicated by a BIMS score of 15, inappropriately touched Resident 1's thigh and Resident 3's abdomen and groin without consent. Resident 1 reported that Resident 2 entered his room multiple times, causing fear and distress, leading to his discharge against medical advice. Resident 3 was also a victim when Resident 2 entered his room while he was sleeping and touched him inappropriately. The facility's documentation and monitoring of Resident 2 were inadequate. Despite being aware of Resident 2's inappropriate behavior, the facility's 30-minute monitoring forms were incomplete, with missing dates, resident names, and initials, making it impossible to confirm Resident 2's whereabouts. Interviews with staff revealed that Resident 2 was able to enter other residents' rooms unnoticed, indicating lapses in supervision and monitoring. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident 2. The Social Services Director confirmed that Resident 2 continued to enter other residents' rooms despite being instructed not to. The Administrator acknowledged the gaps in monitoring documentation and recognized Resident 2's behaviors as predatory, posing a risk to other residents.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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