Cottonwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodland, California.
- Location
- 625 Cottonwood Street, Woodland, California 95695
- CMS Provider Number
- 056098
- Inspections on file
- 31
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Cottonwood Healthcare Center during CMS and state inspections, most recent first.
Staff disposed of meal tray tickets containing residents' names and diet information in general trash bins accessible to the public, rather than following the expected procedure of collecting and shredding them, resulting in a failure to protect resident confidentiality.
Surveyors found that medications, including loose pills and opened inhalers and eye drops, were not properly labeled or stored in a medication cart. An LPN and the DON confirmed that loose pills were present, and several opened medications lacked required date labels or were not discarded after the recommended period, contrary to facility policy and professional standards.
Surveyors found that the facility's medication error rate was 5 percent or greater, indicating a failure to maintain medication administration accuracy within regulatory standards.
Multiple infection control deficiencies were identified, including a resident's uncovered catheter bag left on the floor, another resident's nebulizer tubing not changed weekly as required, and staff entering a contact isolation room without wearing the mandated PPE. These actions were inconsistent with facility policy and infection prevention standards.
A resident in need of pain management did not receive safe and appropriate pain control services, as the facility failed to meet the resident's pain management needs.
Two residents received controlled pain medication that was signed out from the Controlled Drug Record but not documented in the Medication Administration Record, as confirmed by staff interviews and record review. Both residents had intact cognition and relevant medical conditions, and facility policy requires dual documentation for controlled substances.
A resident experienced a significant medication error due to a failure in the medication administration process. The report does not provide further details about the circumstances or the resident's condition at the time.
A resident with encephalopathy and pneumonia was not administered Dornase Alfa as prescribed on nine occasions, and the physician was not informed of the medication's unavailability. The facility's policy required physician notification when medications were unavailable, which was not followed.
A resident's nasal cannula was found uncovered and undated on the side of the bed, contrary to the facility's infection control policy. The resident, with a history of congestive heart failure and acute respiratory failure, was aware that the cannula should be stored in a clear bag. The LN confirmed the improper storage, and the DON stated the expectation for proper storage to prevent contamination.
A resident with moderate cognitive impairment and mobility assistance needs was unable to access the call light, which was found on the floor under the bed. The resident had been looking for the call button for 2-3 days. The DON confirmed the call button should be within reach, and the facility's policy requires call devices to be placed within reach before leaving the room.
A resident with severe cognitive impairment physically abused another resident, resulting in an injury. The incident occurred when staff heard yelling and found the aggressive resident hitting and grabbing the other resident, causing an abrasion. The facility's policy requires reporting such altercations.
A resident in a LTC facility was subjected to undignified treatment when a CNA raised her voice and used profanity during a dining room altercation. The resident, who was cognitively intact, felt scared by the CNA's behavior. Witnesses confirmed the CNA's inappropriate language and actions, which violated the facility's policy on resident rights.
The facility failed to store medications properly, with expired sodium chloride found in the dispensing system and misplaced medications in carts, potentially leading to missed doses. A licensed nurse and the DON confirmed these findings, highlighting a lapse in adherence to medication storage policies.
The facility failed to ensure the competency of its food and nutrition services, affecting 87 residents. Dietary staff did not know the correct chlorine concentration for dishwashing and did not follow standardized recipes for green beans and pureed bread, leading to potential food contamination and nutritional inconsistencies.
The facility failed to store food properly, with expired items and unlabeled open food found in the kitchen. Additionally, there was missing documentation for testing the concentration of ammonium in the sanitizer for one shift, as confirmed by the Dietary Manager.
The facility did not ensure the QAA Committee met quarterly with required members, as the committee failed to meet in the first quarter of 2024, and the MD and DON missed two meetings. The absence of regular meetings and key members' input could delay feedback and priorities. The Administrator confirmed these issues, highlighting the need for the MD's clinical feedback.
Two residents in an LTC facility were inaccurately assessed, impacting their care plans. One resident's MDS failed to reflect behavioral issues despite documented episodes of resisting care and verbal outbursts. Another resident's MDS inaccurately indicated they were not receiving hemodialysis, despite having a catheter and physician's orders for the procedure. Staff interviews confirmed these inaccuracies, which could have affected the residents' care.
The facility failed to create comprehensive care plans for two residents, one with moisture-associated skin damage (MASD) and another using a wander guard for elopement risk. The care plans lacked necessary interventions and documentation, as confirmed by the DON, contrary to the facility's policy requiring person-centered care plans with measurable objectives.
A resident developed moisture-associated skin damage and a right hip pressure ulcer, but the facility failed to revise the care plan in a timely manner. Despite documented changes in the resident's condition, the care plan was not updated to include new interventions. The DON confirmed that the care plan should have been updated quarterly and as needed, in accordance with the facility's policy.
A resident with joint contracture and muscle wasting was not properly assessed for skin conditions, leading to the development of a pressure ulcer. Initial assessments showed no pressure ulcers, but later records indicated skin tears and moisture-associated damage. Despite this, the resident's skin was inaccurately assessed as intact, and a comprehensive assessment was not conducted. The resident eventually developed an unstageable pressure ulcer, confirmed by staff interviews.
A resident with heart failure was administered oxygen at 5L/min instead of the prescribed 2L/min, as observed during a survey. The resident expressed discomfort, and a nurse confirmed the discrepancy. The facility's policy requires adherence to physician orders, which was not followed in this case.
The facility did not complete annual performance evaluations for three CNAs, with one CNA having no evaluation since hire and others overdue. The DSD confirmed the evaluations were overdue, and the DON highlighted their importance for feedback and care improvement. Facility policy requires annual evaluations.
A facility failed to act on a Consultant Pharmacist's recommendation regarding a resident's use of risperidone, an antipsychotic medication prescribed for anxiety and depression. Despite the recommendation to re-evaluate the medication regimen, the physician disagreed without documenting the reason, and the medication continued to be administered without proper indication. The facility's policy requires such recommendations to be documented and acted upon, which was not followed.
A resident was prescribed risperidone for adjustment disorder without an adequate indication, contrary to the facility's policy. Despite a Consultant Pharmacist's recommendation to re-evaluate the medication order, the physician and nurse practitioner disagreed and did not document their reasoning, leading to continuous administration of the medication without proper justification.
A dietary staff member failed to follow infection control practices by not changing gloves or performing hand hygiene after cleaning a soiled kitchen cart and before handling clean items. This was confirmed by the Dietary Manager, who acknowledged the breach of the facility's Glove Use Policy.
A resident with a history of stroke and mobility issues was left soiled and undignified after a CNA refused to assist with personal hygiene. Despite the resident's clear communication and need for help, the CNA insisted he manage alone, leaving him distressed. The incident was witnessed by student nurses and confirmed by the DON, highlighting a breach in the facility's policy on resident dignity.
Failure to Protect Resident Confidentiality in Meal Ticket Disposal
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information when meal tray tickets containing residents' names and diet information were disposed of in the general kitchen garbage. During observation, a Dietary Aide was seen discarding these meal tickets into a garbage can, which was later emptied into an outside bin accessible to the public. The Dietary Aide confirmed that this was the usual practice for meal tickets left on trays. The Dietary Supervisor stated that the expected procedure was for staff to collect meal tickets and bring them to the supervisor's office for shredding, acknowledging that the tickets contained sensitive resident information. Review of facility policy confirmed residents' rights to confidential treatment of health records.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were properly labeled and stored according to facility policies and accepted professional standards. Specifically, five loose pills were found in a medication cart, which were confirmed by a licensed nurse, who acknowledged that staff would not be able to identify the medications. Both the consultant pharmacist and the director of nursing confirmed that loose pills should not be present in medication carts due to safety concerns and the need to keep carts clean. Additionally, opened Polymyxin B-tmp eye drops, Incruse Ellipta inhaler, and Symbicort inhaler were found without opened date labels, contrary to facility policy and manufacturer instructions, which require labeling with the date opened to ensure timely disposal. A used Latanoprost eye drop with an opened date exceeding 28 days was also found in the medication cart, despite the requirement to discard after 28 days. Both the consultant pharmacist and the director of nursing confirmed that these medications should have been labeled and discarded as per protocol.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than acceptable rate of medication errors. The deficiency was based on the surveyors' findings that the facility did not maintain medication error rates below the required threshold.
Infection Control Lapses in Catheter Care, Nebulizer Equipment, and PPE Use
Penalty
Summary
The facility failed to maintain safe and sanitary care practices for its residents, as evidenced by multiple infection control lapses. One resident with a history of sepsis, urinary calculus, and kidney infections was observed with an uncovered nephrostomy bag hanging from the bedrail and an uncovered urinary catheter bag lying on the floor. A licensed nurse confirmed that catheter bags should not touch the ground for infection control reasons, and the facility's policy also requires catheter tubing and drainage bags to be kept off the floor. Another resident, diagnosed with dementia, COPD, and congestive heart failure, was found to have nebulizer face mask tubing labeled with a date more than seven weeks prior, despite facility policy and staff statements that such equipment should be changed weekly. Both the infection preventionist and the DON confirmed that the tubing should be changed every seven days to prevent respiratory infections, but this was not done in accordance with the policy. Additionally, staff failed to adhere to required personal protective equipment (PPE) protocols for a resident on contact isolation precautions due to VRE and possible C. difficile infection. Despite signage indicating that gloves and gowns must be worn upon entering the room, staff members, including activities staff and a CNA, entered the room without the required PPE. The infection preventionist confirmed that the facility's practice was to wear PPE only when directly caring for the infected resident, which contradicted both facility policy and CDC guidance requiring PPE upon every entry into the room.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Document Controlled Drug Administration in Both CDR and MAR
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for two residents when controlled drug administrations were not properly documented in both the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For one resident with a history of femur fracture and muscle weakness, Norco was signed out from the CDR on three occasions, but these administrations were not recorded on the MAR. For another resident with Parkinson's disease, diabetic polyneuropathy, and muscle weakness, Norco was also signed out from the CDR on two occasions without corresponding documentation on the MAR. Both residents were assessed as having intact cognition at the time of the incidents. Interviews with nursing staff and facility leadership confirmed that the expected practice is to document controlled medication administration in both the CDR and MAR. Facility policy also requires this dual documentation. The discrepancies were identified during a random audit and were acknowledged by both the licensed nurse involved and the Director of Nursing, who described the correct process for administering and documenting controlled drugs. The failure to document these administrations in the MAR was directly observed and confirmed through record review and staff interviews.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Notify Physician of Unavailable Medication
Penalty
Summary
The facility failed to ensure that services met professional standards of quality for a resident when the resident's physician was not informed about a medication that was unavailable and not administered as prescribed. The resident, who was admitted with multiple diagnoses including encephalopathy and pneumonia due to pseudomonas, was prescribed Dornase Alfa Inhalation Solution to be administered twice daily. However, the Medication Administration Record (MAR) indicated that the medication was not administered on nine occasions, with notes citing reasons such as 'med not delivered this shift,' 'on order,' 'N/A,' and 'unavailable.' There was no documented evidence in the resident's clinical records that the physician was notified about the medication not being available for administration. The Director of Nursing confirmed the medication was not given nine times and acknowledged the lack of documentation regarding physician notification. The facility's policy and procedure required medications to be administered as prescribed and for the prescriber to be contacted if the medication would not be available, which was not adhered to in this case.
Inadequate Infection Control for Nasal Cannula
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for Resident 3, who was observed with a nasal cannula left uncovered and undated on the side of the bed when not in use. Resident 3, who was admitted with multiple diagnoses including congestive heart failure and acute respiratory failure with hypoxia, was cognitively intact and aware that the nasal cannula should be stored in a clear bag. However, the nasal cannula was found between the side rail and the mattress, contrary to the facility's policy. During an interview, the Licensed Nurse confirmed the improper storage of the nasal cannula and acknowledged that it should have been placed in a plastic bag to prevent contamination. The Director of Nursing also stated that the nasal cannula should be dated and stored properly when not in use, as per the facility's policy, which mandates changing the oxygen cannulae and tubing every seven days and storing them in a plastic bag when not in use. This oversight increased the risk of cross-contamination, as noted in the report.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident who was not physically able to use the call light when it was out of reach. The resident, who had been admitted with multiple diagnoses including orthopedic aftercare following surgical amputation and acquired absence of the left foot, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The resident required substantial to maximal assistance for mobility needs and had a care plan indicating a self-care deficit requiring assistance in various personal care activities. During an observation, the resident was found pointing with his left index finger to call the attention of a state surveyor, as his call button was on the floor underneath his bed. The resident stated he had been looking for the call button for 2-3 days. The Director of Nursing (DON) confirmed the call button should not be on the floor and that the expectation was for call lights to be within reach at all times. A Certified Nursing Assistant (CNA) mentioned that she normally clips the call button to the blanket but noted that the resident was constantly moving, and she had repositioned him an hour prior. The facility's policy indicated that the call device should be placed within the resident's reach before leaving the room.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident, who had severe cognitive impairment, hit and grabbed the resident, resulting in an injury. Resident 1, who had intact cognition, was admitted with diagnoses including heart failure and anxiety disorder. Resident 2, admitted with a stroke, depression, and communication difficulty due to cognitive impairment, had a BIMS score indicating severe cognitive impairment. On the evening of December 15, 2024, staff heard Resident 1 yelling and found Resident 2 striking Resident 1 on the arms and legs, causing an abrasion to Resident 1's left forearm. Interviews and record reviews revealed that Resident 1's arm was bruised and sore following the incident. A Licensed Nurse confirmed witnessing Resident 2 slapping Resident 1's legs and acting aggressively, making it difficult to redirect Resident 2. The Director of Nursing acknowledged that residents have the right to be free from any form of abuse. The facility's policy on resident-to-resident altercations requires reporting any willful action resulting in physical injury, such as hitting or slapping.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred during lunchtime in the dining room, where the resident was engaged in a conversation with another resident about an upcoming surgery. The CNA, who was feeding another resident, intervened in the conversation and began to raise her voice and use inappropriate language towards the resident, telling her to mind her own business and using profanity. The resident, who was cognitively intact and able to communicate effectively, reported feeling scared during the altercation. Witnesses, including other residents, confirmed the CNA's use of profanity and aggressive behavior. One resident recalled the CNA telling the resident that if she did not like the facility, she could leave. Another resident, who was being assisted by the CNA at the time, expressed frustration that the CNA stopped feeding her to engage in the argument. The facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to in this situation. The incident was reported to the Director of Nursing, and interviews with residents corroborated the account of the CNA's inappropriate conduct. The failure to uphold the resident's right to a dignified existence and respectful treatment was evident in the CNA's actions during the incident.
Improper Medication Storage and Expired Drugs Found
Penalty
Summary
The facility failed to ensure proper storage of medications, which was identified during an observation and interview process. Two bottles of sodium chloride, used for diluting medications, were found expired in the automatic dispensing system within the medication room of stations 1 and 2. The expiration date was verified by a licensed nurse, indicating a lapse in monitoring and replacing expired medications. Additionally, multiple medications were discovered improperly stored at the bottom of medication carts 3 and 5, behind the drawers. This was confirmed during observations and interviews with a licensed nurse, who acknowledged that residents might have missed scheduled doses due to this oversight. The Director of Nursing also confirmed that the pharmacy staff should have checked and replaced expired medications, as per the facility's policy and procedure on medication storage.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the competency of its food and nutrition services, affecting a census of 87 residents. Dietary Staff 2 (DS 2) was unable to state the correct chlorine sanitizing concentration required for manual dishwashing, as per the facility's policy. This policy mandates that the sanitizing solution in the third compartment of the dishwashing process must be tested with a test strip and recorded, with a required concentration of 200 parts per million. DS 2's lack of knowledge in this area could potentially lead to improper sanitization of dishes, increasing the risk of food contamination. Additionally, Dietary [NAME] 1 (DC 1) did not adhere to standardized recipes when preparing green beans, failing to add the required seasonings of salt, pepper, and butter, which are specified in the facility's recipe for seasoned green beans. This resulted in inconsistencies in the flavor and nutritional content of the food served to residents. Furthermore, DC 2 did not follow the recipe for pureed bread, using incorrect measurements of ingredients, which was confirmed by Dietary Manager 1 (DM 1). The absence of a policy mandating adherence to recipes was noted, contributing to these deficiencies in food preparation.
Deficiency in Food Storage and Sanitizer Documentation
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during a survey. Seven bags of cookies and a seasoning bottle were found stored past their expiration dates. Additionally, several food items, including salad oil, quick creamy wheat, and corn starch, were opened but lacked proper labeling with open dates and use-by dates. The Dietary Manager confirmed that these items should have been labeled and expired items discarded, as per the facility's policy on Sanitation and Infection Control. Furthermore, the facility did not maintain proper documentation for testing the concentration of ammonium in the quaternary sanitizer for one shift. The Dietary Manager acknowledged the missing documentation and stated there was no policy for ammonium concentration testing. The facility's Quaternary Ammonium Log required testing and recording the concentration of the sanitizer at least once per shift, but this was not done for one shift, as confirmed by the Dietary Manager.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee met at least quarterly with the required members for a census of 87 residents. Specifically, the QAA committee did not convene in the first quarter of 2024, and both the Medical Director (MD) and Director of Nursing (DON) were absent from two meetings. A review of the Class Attendance Roster from November 2023 indicated that a Quality Assurance and Performance Improvement (QAPI) meeting was held in October 2023, but the DON and MD did not attend. Additionally, a QA Meeting document from April 2024 confirmed a QAA meeting was held, and another document from August 2024 showed that the MD did not attend the meeting held on August 13, 2024. During an interview, the Administrator acknowledged that the QAA committee meetings were not held quarterly as required and confirmed the irregular attendance of the DON and MD. The Administrator expressed concern that the absence of regular QAA meetings and the lack of input from the DON and MD could result in delayed feedback and priorities being overlooked. The Administrator emphasized the necessity of the MD's presence for clinical feedback and direction.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately assess two residents, leading to deficiencies in identifying their care needs. Resident 9's Minimum Data Set (MDS) inaccurately indicated no behavioral symptoms, despite records showing numerous episodes of resisting care and behavioral disturbances, including attempts to hit staff and verbal outbursts. Interviews with facility staff, including the Licensed Nurse, Director of Social Services, MDS Coordinator, and Director of Nursing, confirmed the inaccuracies in Resident 9's MDS, which could have impacted his plan of care. The resident was on medication for mood disorder, and his care plan documented significant behavioral issues that were not reflected in the MDS. Similarly, Resident 79's MDS inaccurately reported that the resident was not receiving hemodialysis, despite having a hemodialysis catheter and physician's orders for the procedure three times a week. The MDS Coordinator acknowledged the inaccuracy, which might have led to missed care and treatment. The Director of Nursing stated that staff should have maintained accurate assessment records in accordance with facility policy. The facility's policy requires all personnel completing any portion of the MDS to sign and certify the accuracy of their assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. Resident 14 was admitted with diagnoses including joint contracture and muscle wasting. Despite documentation indicating the presence of moisture-associated skin damage (MASD), the care plan did not include interventions for MASD, such as applying barrier cream. The Director of Nursing (DON) confirmed the absence of a care plan for MASD, acknowledging that without it, nurses might be unable to identify and prevent further skin breakdown. Resident 82, diagnosed with dementia and agitation, was observed wearing a wander guard due to an elopement risk. However, the care plan did not address the use of the wander guard, despite an order for its use being documented. The DON confirmed that the care plan should have included the wander guard from the time it was ordered. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs, which was not adhered to in these cases.
Failure to Revise Care Plan for Resident with Skin Damage
Penalty
Summary
The facility failed to revise the care plan interventions in a timely manner following a change in condition for Resident 14, who developed moisture-associated skin damage (MASD) and a right hip pressure ulcer. Resident 14 was admitted with diagnoses including joint contracture and muscle wasting and atrophy. Despite the development of MASD noted in the Nurses Weekly Progress Notes and a deterioration in the right hip skin condition documented in the SBAR Communication Form, the care plan was not updated to reflect these changes. The care plan, last revised several months prior, did not incorporate new interventions to address the resident's deteriorating skin condition. During an interview, the Director of Nursing confirmed that the care plan should have been updated quarterly and as needed to personalize interventions when there were changes in care. The facility's policy on Comprehensive Person-Centered Care Plans mandates that the Interdisciplinary Team must review and update the care plan when there is a significant change in the resident's condition or when the desired outcome is not met. The failure to revise the care plan decreased the facility's potential to provide Resident 14 with a person-centered care plan and evaluate its effectiveness.
Failure to Assess and Monitor Skin Condition Leads to Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and monitor the skin condition of a resident, leading to the development of a pressure ulcer. The resident, who was admitted with conditions such as joint contracture and muscle wasting, initially had no pressure ulcers according to the Minimum Data Set assessment. However, subsequent records indicated the presence of skin tears and moisture-associated skin damage. Despite these indications, the resident's skin condition was inaccurately assessed as clear and intact at one point, and a comprehensive head-to-toe assessment was not conducted. The situation deteriorated when a communication form noted a worsening skin condition with discoloration and non-blanchable areas, yet the resident's skin was not assessed in the following weekly progress notes. Eventually, the resident developed an unstageable pressure ulcer on the right hip. Interviews with facility staff, including a licensed nurse and the Director of Nursing, confirmed the inaccuracies in the skin assessments and acknowledged that these failures contributed to the delayed identification and intervention for the resident's pressure ulcers.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards for a resident, identified as Resident 244, whose administered oxygen was not consistent with the physician's order. Resident 244 was admitted with diagnoses including heart failure and had a physician's order to use oxygen continuously via nasal cannula at 2L/min. However, during an observation on August 12, 2024, Resident 244 was found to be receiving oxygen at 5L/min, which was more than double the prescribed amount. The resident expressed that the oxygen felt excessive, indicating a discrepancy between the care provided and the physician's order. Licensed Nurse 7 confirmed during an interview and record review that the oxygen was set incorrectly at 5L/min instead of the ordered 2L/min. The Director of Nursing later stated that it was expected for staff to follow physician orders to ensure proper care for residents. The facility's policy on medication and treatment orders, revised in July 2016, emphasized that orders should be consistent with safe and effective order writing. This oversight in following the physician's order decreased the facility's ability to safely provide respiratory services and increased the risk of lung problems for Resident 244.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete the annual performance evaluations for three of seven sampled certified nursing assistants (CNAs), specifically CNA 1, CNA 2, and CNA 3. CNA 1 was hired on 5/15/07, with the last performance evaluation completed on 7/13/22. CNA 2, hired on 5/9/23, had no performance evaluation conducted. CNA 3, hired on 4/24/17, had their last performance evaluation on 5/28/23. During interviews, the Director of Staff Development confirmed that the performance evaluations were overdue and should have been completed annually. The Director of Nursing emphasized the importance of these evaluations for providing feedback and identifying areas for improvement in resident care. The facility's policy mandates that employee job performance be reviewed and evaluated at least annually.
Failure to Address Pharmacist's Recommendation on Antipsychotic Use
Penalty
Summary
The facility failed to act on the Consultant Pharmacist's (CP) Medication Regimen Review (MRR) recommendation for a resident when the physician did not address the recommendation related to the use of risperidone, an antipsychotic medication. The resident was admitted with diagnoses including schizophrenia and was receiving psychological services. The CP identified an irregularity in the use of risperidone, as it was prescribed for anxiety and depression, and recommended that the physician re-evaluate the regimen or update the order with the appropriate indication to comply with regulations. Despite the CP's recommendation, the physician, through the nurse practitioner, disagreed with the recommendation but did not document the reason for disagreement. The Director of Nursing (DON) confirmed that the facility received the MRR recommendation and acknowledged that the risperidone was still being administered without proper documentation of the indication for its use. The facility's policy requires that recommendations from the CP be acted upon and documented, and if the attending physician does not concur, the Medical Director should be contacted, which was not done in this case.
Inadequate Indication for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use. The resident, who was admitted with a diagnosis of schizophrenia, was prescribed risperidone, an antipsychotic medication, for adjustment disorder with mixed anxiety and depressed mood. This prescription did not have an adequate indication for use, as required by the facility's policy and procedure for psychotropic medication use. The facility's Consultant Pharmacist identified this irregularity during a medication regimen review and recommended that the physician re-evaluate the medication order to ensure compliance with regulations. Despite the Consultant Pharmacist's recommendation, the Director of Nursing confirmed that the physician and nurse practitioner disagreed with the recommendation and did not document their reasoning. Consequently, the risperidone was continuously administered to the resident without revising or updating the order to reflect an appropriate indication. This oversight placed the resident at risk for unnecessary psychotropic medication use, as the facility's policy stipulates that antipsychotic use must not be due to environmental or psychological stressors.
Infection Control Breach by Dietary Staff
Penalty
Summary
The facility failed to adhere to proper infection control practices, as observed with a dietary staff member. The staff member, while wearing gloves, was seen handling clean kitchen items on the clean side of the dishwasher. Without changing gloves or performing hand hygiene, the staff member then used a rag from a disinfecting solution to clean a soiled kitchen cart. Subsequently, the same gloves were used to handle a clean cooler and fill it with ice, before continuing dishwashing tasks. This sequence of actions was confirmed by the Dietary Manager, who acknowledged that gloves should have been changed and hands washed after cleaning tasks. The facility's Glove Use Policy, dated 2020, specifies that gloves should be changed before starting a different task and when they become soiled, such as during cleaning activities.
Resident Left Soiled Due to CNA's Inaction
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with a history of cerebral infarction, hemiplegia, and hemiparesis. The resident, who was cognitively intact and able to communicate effectively, required assistance with personal hygiene after using the bathroom. However, CNA 1 refused to assist the resident in cleaning and pulling up his brief, leaving him soiled and with his pants down in his wheelchair. The incident was witnessed by two student nurses who reported that CNA 1 was verbally inappropriate and insisted that the resident could manage on his own, despite his visible struggle and inability to do so. The CNA's refusal to provide necessary assistance resulted in the resident being left in a soiled state, which was emotionally distressing for him. The resident expressed feeling sad about the incident, which was corroborated by the student nurses' statements and the facility's documentation. The Director of Nursing (DON) substantiated the allegation, noting that CNA 1 did not provide a statement and her employment ended on the day of the incident. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not upheld in this case. The failure to assist the resident appropriately and maintain his dignity constitutes a deficiency in the standard of care provided by the facility.
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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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