Country Crest Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Oroville, California.
- Location
- 50 Concordia Lane, Oroville, California 95966
- CMS Provider Number
- 555802
- Inspections on file
- 38
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Country Crest Post-acute during CMS and state inspections, most recent first.
A resident with diabetes, dementia, and chronic kidney disease experienced a significant decrease in brief changes and elevated blood glucose levels, but staff failed to recognize or report these changes to the MD or DON as required. Additionally, a lab order was not completed due to lack of follow-up after an initial refusal, and the MD was not informed that the labs were not drawn. The resident's condition deteriorated, leading to hospitalization and death.
A resident with multiple risk factors, including recent surgery, malnutrition, and incontinence, developed a stage 2 pressure ulcer after staff failed to perform and document required skin assessments and apply preventative treatments as ordered. Despite care plans and physician orders, CNAs and nursing staff did not identify or report skin changes, and interviews confirmed gaps in training and compliance with facility policy.
A facility failed to notify the MD about a resident's cognitive decline, despite assessments indicating severe impairment. The resident, diagnosed with Alzheimer's and dementia, was still listed as their own decision-maker. The facility's policy required notifying the MD of significant changes, but this was not done, leading to a deficiency.
A resident with severe cognitive impairment reported rough handling by a male staff member, but the facility failed to report the abuse allegation to authorities as required by their policy. The administrator, also the abuse coordinator, did not report the incident, believing it was unsubstantiated due to the resident's condition. No documentation of an investigation was found, and the responsible party was not contacted.
The facility failed to investigate an abuse allegation reported by a resident with severe cognitive impairment and did not report it to authorities. Additionally, the facility did not ensure the Behavior Management Committee reviewed the extended use of PRN Lorazepam for another resident with moderate cognitive impairment and anxiety disorder, lacking documentation of the rationale for the medication's extended use.
A resident was prescribed Lorazepam for an extended period without documented rationale, exceeding the 14-day limit for PRN psychotropic drugs. The facility's administrator and DON confirmed the absence of necessary documentation in the resident's medical record, which could lead to unsafe medication use.
The facility failed to maintain sanitary conditions during meal preparation and service. Pizzas were served at unsafe temperatures, and an employee did not follow proper hand hygiene and glove use while preparing salad. The Food Services Director acknowledged the lack of a specific policy for safe food holding temperatures, and the Culinary Director noted repeated infractions by the new hire involved.
The facility failed to keep the dumpster closed, as required by the U.S. FDA 2022 Food Code and facility policy. Observations showed the dumpster was open, confirmed by the FSD, who stated it had always been left open. The DON acknowledged the regulation to keep lids closed, while the Administrator was unsure of expectations but preferred the dumpster to be closed. This could potentially affect all 56 residents.
The facility failed to administer oxygen therapy correctly for three residents, leading to deficiencies in respiratory care. One resident received higher oxygen flow rates than prescribed, another received significantly less than ordered, and a third had a malfunctioning humidifier bottle on their oxygen concentrator. These issues were confirmed by staff, highlighting a lack of adherence to physician orders and proper equipment checks.
A facility failed to maintain effective infection control for residents with urinary catheters and those receiving respiratory care. A resident's catheter bag was observed dragging on the floor, contrary to policy. Respiratory equipment for two residents was improperly stored, with tubing and nebulizer parts left exposed, risking contamination. Staff interviews confirmed these practices violated infection control protocols.
The facility failed to accurately code oxygen use on the MDS assessments for two residents, despite documentation of oxygen administration in their MARs. Interviews with staff confirmed that the residents' oxygen use should have been reflected on the MDS, as per CMS guidelines. This deficiency highlights a lapse in the facility's assessment process.
A facility failed to ensure a Level I PASRR accurately reflected a resident's serious mental disorder and prescribed psychotropic medication. The resident, diagnosed with bipolar disorder and prescribed Depakote, had a PASRR completed after a temporary evacuation that incorrectly indicated no serious mental illness. Interviews revealed confusion among staff about responsibility for PASRR accuracy, with the DON acknowledging the error and the Administrator emphasizing the need for accurate PASRRs.
A facility failed to create a comprehensive care plan for a resident with a cardiac pacemaker, despite the resident's medical history and facility policy requirements. The care plan lacked documentation for pacemaker care and monitoring, as acknowledged by the DON and Administrator.
A facility failed to address pharmacy recommendations for a resident receiving antipsychotic medications. The resident, with a history of schizophrenia and bipolar disorder, required timely AIMS assessments as per the pharmacy's recommendation. However, the assessments were delayed, and the Director of Nursing acknowledged the oversight. The Pharmacy Consultant and Administrator expected adherence to the recommendations.
A resident with anxiety disorder received PRN phenobarbital without a stop date, contrary to facility policy requiring a 14-day limit unless extended with documented rationale. Despite multiple administrations over months, staff interviews revealed a lack of adherence to policy, with the Medical Director unaware of restrictions and the DON acknowledging the oversight.
A facility failed to maintain a medication error rate below 5%, affecting two residents. One resident received chewable aspirin instead of delayed release, and another was given metoprolol without a pulse check. Both errors were acknowledged by the LVNs involved, who admitted to not following proper medication administration protocols.
A facility failed to maintain a complete medical record for a resident with a cardiac pacemaker, missing crucial details such as the model, serial number, and implant date. Despite the resident's intact cognition and a care plan indicating the risk of pacemaker malfunction, the required information was not documented, which was acknowledged as an oversight by the DON and Administrator.
The facility did not update daily staffing postings with actual hours worked for 24 days, affecting 56 residents. Staff were unaware of the requirement to update postings every shift, and no specific person was assigned to this task for after-hours and weekends. The facility lacked a policy on staff postings.
A resident with multiple diagnoses, including dementia and diabetes, was found with an unexplained injury that was not reported to CDPH within the required timeframe. The DON did not document the injury or inform the administrator, resulting in a three-day delay in reporting.
Failure to Recognize and Report Change in Condition and Complete Ordered Labs
Penalty
Summary
The facility failed to provide necessary care and services for a resident with multiple complex medical conditions, including type 2 diabetes, dementia, and hypertensive chronic kidney disease. Staff did not recognize or report a significant change in the resident's condition, specifically a marked decrease in the frequency of daily brief changes, which was a notable deviation from her baseline of 15-20 changes per day. Multiple CNAs and a licensed nurse confirmed that the reduced number of brief changes was abnormal for this resident, yet this change was not documented or communicated to the Medical Director or Director of Nursing as required by facility policy. Additionally, the facility failed to ensure that a laboratory blood test ordered by the Medical Director was completed. After the resident initially refused the lab draw, staff did not follow up by placing a new lab slip in the requisition binder or entering a new electronic order, resulting in the lab not being drawn as instructed. The Medical Director was not notified that the labs were not completed, and there was no follow-up to ensure the order was fulfilled. Interviews revealed confusion among staff regarding responsibility for ensuring lab orders were carried out, and the DON acknowledged that it was his responsibility to follow up on lab work but did not do so in this case. The resident subsequently exhibited further signs of deterioration, including persistently elevated blood glucose levels, calling out for help, and a thready pulse with low oxygen saturation. Despite these changes, there was inadequate assessment and communication with the Medical Director. The resident was eventually transferred to the hospital, where she was diagnosed with septic shock, acute respiratory failure, profound hyperkalemia, acute kidney injury, and other critical conditions. She was placed on hospice care upon return to the facility and passed away shortly thereafter.
Failure to Implement and Document Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received wound preventative measures as ordered, resulting in the development of a stage 2 pressure ulcer on the coccyx. The resident, who had a history of an intertrochanteric fracture with surgical repair, protein-calorie malnutrition, panic disorder, and hypokalemia, was assessed as being at moderate risk for pressure ulcers. The resident was also noted to be occasionally incontinent of urine and always incontinent of bowel, with moisture-associated skin damage to the buttocks and groin documented at admission. Despite care plans and physician orders indicating the need for regular skin assessments and the application of zinc oxide for skin maintenance, documentation from CNAs and nursing staff did not reflect any skin issues or changes for the resident over several weeks. Shower sheets and skilled services documentation consistently failed to note any redness, rash, or breakdown, even though the resident was at risk and had existing skin concerns. The facility's policy required frequent skin inspections and prompt reporting of any changes, but these procedures were not followed. Interviews with staff revealed that CNAs were not consistently documenting skin assessments or reporting changes, and there were acknowledged challenges with training and compliance among newer CNAs. Both the Director of Staff Development and the Administrator confirmed that staff did not adhere to the facility's skin assessment policy, and this lack of assessment and documentation contributed to the development of the pressure ulcer.
Failure to Notify MD of Resident's Cognitive Decline
Penalty
Summary
The facility failed to notify the Medical Director (MD) regarding the need to alter the healthcare decision-maker for a resident who was cognitively impaired. The resident, who had been diagnosed with Alzheimer's disease and dementia, had a St. Louis University Mental Status (SLUMS) examination score of 3 out of 30, indicating severe cognitive impairment. Despite this, the resident was still listed as their own Responsible Party (RP) and was only notified of an alleged abuse allegation. The facility's policy required prompt notification of changes in a resident's medical or mental condition to the resident, their physician, and their representative, but this was not adhered to in this case. The resident's Minimum Data Set (MDS) assessments showed a decline in cognitive function from moderately impaired to severely impaired over several months. Despite these assessments and the SLUMS examination results, the resident's capacity to make and understand decisions was not updated, and the MD was not notified. Interviews with facility staff, including the Administrator (ADMIN) and Director of Nursing (DON), revealed a lack of communication and documentation regarding the notification of the MD about the resident's cognitive status. The ADMIN admitted to not recalling whether the alleged abuse report was filed with the proper authorities and believed the Social Services Director (SSD) was investigating the allegation. The DON could not locate any documentation indicating that the MD was notified about the SLUMS examination results. The facility's failure to update the resident's decision-making capacity and notify the MD of significant changes in the resident's cognitive status contributed to the deficiency identified in the report.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation involving a resident who informed a Certified Nursing Assistant (CNA) that a male staff member was rough with her while assisting her in and out of bed. The resident described the staff member as tall, male, attractive, with light-colored hair, and claimed he grabbed her hard and intended to hurt her. Despite the resident's severe cognitive impairment due to Alzheimer's disease and dementia, the facility's policy required immediate investigation and reporting of such allegations to the appropriate authorities, which was not done. The facility's Abuse Prevention Program policy mandates a thorough investigation of abuse allegations, including interviews with all involved parties and reporting to the California Department of Public Health (CDPH) and other authorities within a two-hour timeframe. However, the facility administrator, who was also the abuse coordinator, did not report the incident, believing the allegation was unsubstantiated due to the resident's cognitive condition and the absence of a staff member matching the description. The administrator admitted to not recalling if the report was filed and assumed the Social Service Director (SSD) was responsible for the investigation. Upon review, it was found that there was no documentation of an investigation by the SSD, who also did not recall conducting one. The administrator acknowledged that the resident's care plan and documentation should have been updated to reflect the investigation, and the resident's responsible party should have been contacted. The failure to report the abuse allegation and properly document the investigation process was a significant oversight, potentially placing residents at risk for undetected abuse.
Failure to Investigate Abuse and Manage Psychotropic Medication
Penalty
Summary
The facility failed to ensure that the social services department met the needs of two residents, leading to deficiencies in care. For the first resident, an allegation of abuse was reported to a Certified Nursing Assistant, but the Social Service Director did not investigate or report the incident to the authorities. The resident, who had severe cognitive impairment due to Alzheimer's disease, described an incident involving a male staff member who was rough and allegedly intended harm. Despite the resident's impaired cognition, the facility's administrator and Social Service Director did not document or follow up on the investigation, nor did they notify the resident's family or update the care plan accordingly. In the second case, the facility failed to address the use of psychotropic medication for another resident. This resident, who had moderate cognitive impairment and an anxiety disorder, was prescribed PRN Lorazepam for an extended period without documented rationale. The facility's policy required that the Behavior Management Committee assess the appropriateness of such medications and consider gradual dose reduction. However, there was no documentation of the committee's review or discussion regarding the extended use of Lorazepam, nor was there any note from the provider justifying the extended prescription period. These failures highlight the facility's lack of adherence to its policies and procedures regarding abuse reporting and medication management. The Social Service Director did not fulfill their responsibilities to investigate and document the alleged abuse, nor did they ensure the Behavior Management Committee addressed the psychotropic medication use. This lack of action could have led to unreported abuse and inappropriate medication use, potentially affecting the residents' well-being.
Failure to Document Rationale for Extended Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for a resident who was prescribed Lorazepam for an extended period without documented rationale. The resident, who was not their own healthcare decision-maker, had diagnoses including dementia and anxiety disorder. The resident's Medication Administration Record indicated a prescription for Lorazepam to be administered every 8 hours as needed for anxiety over a 30-day period, which exceeded the 14-day limit for PRN psychotropic drugs without documented justification from the attending physician. During interviews and record reviews, both the administrator and the Director of Nursing confirmed the absence of documentation justifying the extended use of Lorazepam in the resident's medical record. The facility's interdisciplinary care team was expected to discuss and document the rationale for such prescriptions during their monthly meetings, but no such documentation was found for this resident. This oversight could contribute to the unsafe use of psychotropic medications, potentially placing residents at risk for adverse consequences.
Sanitation and Food Safety Deficiencies in Meal Preparation
Penalty
Summary
The facility failed to ensure sanitary preparation and service of meals, as observed during a survey. The temperature of pizzas being served to residents was initially recorded at 136 degrees Fahrenheit and later dropped to 122 degrees Fahrenheit, which is below the safe holding temperature. Despite this, the pizzas were served to residents. The Food Services Director (FSD) acknowledged that the staff should have discarded the pizzas and served those from the food warmer, but there was no facility policy specific to safe holding temperatures for foods. Additionally, improper hand hygiene and glove use were observed during food preparation. An employee, identified as [NAME] #7, was seen mixing lettuce with gloved hands, then touching a high-contact surface (the refrigerator door) without changing gloves or washing hands before continuing to prepare the salad. The Culinary Director noted that [NAME] #7 was a new hire and had been frequently written up for similar infractions. The FSD stated that she was not involved in the hiring or training of kitchen staff and would expect food to be discarded if such infractions were observed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster used for refuse disposal was kept closed, as required by both the U.S. FDA 2022 Food Code and the facility's own policy. Observations on two consecutive days revealed that the dumpster behind the building was open, which was confirmed by the Food Services Director (FSD) during interviews. The FSD acknowledged that the dumpster should be closed and admitted that it had always been left open during her tenure. The dumpster was used to discard paper, containers from the kitchen, and nursing materials. Interviews with the Director of Nursing (DON) and the Administrator further highlighted the deficiency. The DON confirmed that regulations required the dumpster lids to be closed, while the Administrator expressed uncertainty about the expectations but stated a preference for the dumpster to be closed when possible. This failure to maintain the dumpster closed had the potential to attract vermin and pests, potentially affecting all 56 residents residing in the facility.
Oxygen Therapy Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper administration of oxygen therapy for three residents, leading to deficiencies in respiratory care. Resident #204, who was admitted with chronic obstructive pulmonary disease and acute respiratory failure, was observed receiving oxygen at higher flow rates than prescribed. Despite an order for 2 liters per minute, observations showed the resident receiving 2.5 to 3 liters per minute. This discrepancy was confirmed by LVN #1, who acknowledged the incorrect setting. Resident #17, with a history of chronic respiratory failure, was also affected by improper oxygen administration. The resident's orders specified oxygen at 2 liters per minute to maintain adequate oxygen saturation. However, observations revealed the resident receiving less than 0.5 liters per minute. LVN #1 confirmed the incorrect setting and acknowledged her responsibility to ensure the correct flow rate. Resident #11, who had severe cognitive impairment and required oxygen therapy for ineffective gas exchange, was observed with a malfunctioning humidifier bottle on the oxygen concentrator. Although the oxygen was set at the correct flow rate, the humidifier bottle was not producing bubbles, indicating a potential issue with oxygen delivery. LVN #1 and LVN #2 confirmed the humidifier was not properly attached, which could lead to oxygen leakage. The DON and Administrator emphasized the importance of ensuring equipment functionality and adherence to physician orders.
Infection Control Deficiencies in Catheter and Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for residents with urinary catheters and those receiving respiratory care. Specifically, Resident #38, who had a suprapubic catheter due to obstructive uropathy, was observed multiple times with their catheter drainage bag dragging on the floor as they propelled themselves in a wheelchair. This was contrary to the facility's policy, which required catheter tubing and drainage bags to be kept off the floor to prevent infection. Interviews with facility staff, including Licensed Vocational Nurses and the Director of Nursing, confirmed that the catheter bag should not touch the floor due to the risk of bacterial contamination. Additionally, the facility did not adhere to its policy for storing respiratory equipment properly. Resident #204, who had chronic obstructive pulmonary disease and acute respiratory failure, was observed with nebulizer tubing lying on top of a nightstand and over-the-bed table, with fluid noted in the cannister. Resident #17's oxygen tubing was stored improperly on top of the oxygen concentrator, and Resident #37's nebulizer equipment was left connected to the machine with fluid and debris present. The facility's policy required that such equipment be stored in a bag when not in use to prevent contamination. Interviews with staff, including LVNs and the Director of Nursing, revealed that the facility's procedures for storing respiratory equipment were not consistently followed. Staff acknowledged that oxygen and nebulizer equipment should be stored in bags to prevent contamination and that nebulizer medication cups should be rinsed out if not fully used. The Administrator also confirmed that respiratory equipment should be stored appropriately, indicating a lapse in adherence to infection control protocols.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to accurately code oxygen use on the Minimum Data Set (MDS) assessments for two residents, leading to a deficiency in ensuring accurate resident assessments. Resident #17, who was admitted with a diagnosis of chronic respiratory failure, had orders for oxygen administration as needed to maintain oxygen saturation above 88%. Despite documentation in the Medication Administration Record (MAR) indicating oxygen was administered every shift during the lookback period, the MDS did not reflect this oxygen use. Interviews with the MDS Resource Staff, Director of Nursing (DON), and Administrator confirmed that the resident's oxygen use should have been coded on the MDS. Similarly, Resident #11, admitted with a medical history including dementia and anxiety disorder, had orders for oxygen administration to maintain oxygen saturation at 90% or greater. The MAR documented oxygen administration every shift during the lookback period, yet the MDS did not indicate the resident received oxygen therapy. Interviews with the MDS Resource Staff, DON, and Administrator reiterated that the resident's oxygen use should have been captured on the MDS. The deficiency was identified through a review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides coding instructions for oxygen therapy. The manual specifies that oxygen use should be coded if administered continuously or intermittently during the lookback period. The failure to accurately code oxygen use on the MDS assessments for these residents highlights a lapse in the facility's assessment process, as confirmed by the staff interviews.
Inaccurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a Level I PASRR accurately reflected the presence of a serious diagnosed mental disorder and the use of prescribed psychotropic medication for a resident. The resident, who was admitted to the facility with an active diagnosis of bipolar disorder, was prescribed Depakote for this condition. However, the Level I PASRR completed upon the resident's return from a temporary evacuation did not indicate the presence of a serious mental illness or the use of psychotropic medication, resulting in a negative screening and no Level II evaluation being required. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring the accuracy of Level I PASRRs. The Medical Records Director was unaware of who was responsible, while the Marketing Director indicated that the DON reviewed PASRRs for accuracy. The DON acknowledged that the PASRR for the resident in question was completed incorrectly and should have indicated a serious mental illness, which would have triggered a Level II evaluation. The Administrator also stated that PASRRs should accurately reflect residents' histories and diagnoses.
Failure to Develop Care Plan for Resident with Cardiac Pacemaker
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a cardiac pacemaker. The resident, who was admitted to the facility with a medical history that included a cardiac pacemaker, atrial fibrillation, and a prosthetic heart valve, did not have a care plan that addressed the care and monitoring of the pacemaker. Despite the presence of a facility policy requiring care plans to include measurable objectives and timeframes, the care plan for this resident, last reviewed in August 2024, lacked documentation related to the pacemaker. Interviews with facility staff revealed an acknowledgment of this oversight. The Director of Nursing admitted that the care plan was not updated to reflect the resident's cardiac pacemaker status. The facility's Administrator also expressed that the expectation was for care plans to accurately reflect the resident's medical and health status, indicating a lapse in meeting this standard for the resident in question.
Failure to Address Pharmacy Recommendations for Antipsychotic Medication Monitoring
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident reviewed for unnecessary medications. The facility's policy required that recommendations be acted upon within 30 calendar days or per facility-specific protocols. The resident, who had a medical history of schizophrenia, bipolar disorder, and major depressive disorder, was receiving antipsychotic medications. The care plan included monitoring for adverse reactions and consulting with the pharmacy and medical doctor for dosage reduction when clinically appropriate. An Interim Medication Regimen Review recommended performing an AIMS test within 30 days of admission and every six months thereafter. However, the AIMS assessments for the resident were not completed in a timely manner, with the last assessment done only after the surveyor's inquiry. The Director of Nursing acknowledged the oversight and stated it was his responsibility to ensure the AIMS assessment was completed as recommended by the pharmacist. The Pharmacy Consultant confirmed that the AIMS test should be completed as requested, and the Administrator expected the facility staff to follow pharmacy recommendations.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication use was limited to 14 days for a resident with a diagnosis of anxiety disorder. The facility's policy on psychotropic medication use, revised in February 2024, specifies that PRN orders for psychotropic drugs should be limited to 14 days unless the attending physician documents a rationale for extending the order. However, the resident's order for phenobarbital, a medication used to calm anxiety, did not include a stop date, and the resident received the medication multiple times over several months without a documented rationale for extending the PRN order. Interviews with facility staff revealed a lack of awareness and adherence to the policy. The Medical Director was unaware of restrictions on using phenobarbital as a psychotropic for anxiety on an as-needed basis, and the Pharmacy Consultant expected the physician to clarify the duration of use before prescribing. The DON acknowledged that as-needed antianxiety medications should have stop dates but was unaware of why the resident's prescription lacked one. The Administrator expected staff to follow regulations concerning as-needed psychotropic medication, indicating a disconnect between policy and practice.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 5.55% during a survey. This deficiency affected two residents during medication administration. One resident, with a medical history including atrial fibrillation and a personal history of pulmonary embolism, was prescribed aspirin 81 mg delayed release tablets for stroke prevention. However, a Licensed Vocational Nurse (LVN) administered a chewable aspirin instead of the delayed release form as ordered. The LVN realized the error after returning to the computer to sign out the medications and acknowledged the mistake, stating she should have double-checked the order with the medication label. Another resident, with a medical history of atrial fibrillation and essential hypertension, was prescribed metoprolol succinate 25 mg with specific instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the apical heart rate was below 60 beats per minute. An LVN administered the medication without checking the resident's pulse, which was later found to be 64 beats per minute. The LVN admitted to forgetting to check the pulse before administration and recognized the need to follow the physician's orders completely. Interviews with the Director of Nursing and the Administrator confirmed that nurses should compare medications with orders and obtain necessary vital signs before administration.
Incomplete Medical Record for Resident with Pacemaker
Penalty
Summary
The facility failed to maintain a complete medical record for a resident with a cardiac pacemaker. Specifically, the medical record for the resident did not include essential information such as the model and serial number of the pacemaker, as well as the date of its implantation. This oversight was identified during a review of the resident's care plan and medical records, which revealed that while the pacemaker brand and manufacturer's telephone number were documented, the model/serial number and implant date were missing. The resident, who was admitted to the facility with a medical history that included a cardiac pacemaker, paroxysmal atrial fibrillation, and cardiomegaly, had intact cognition as indicated by a BIMS score of 13. The facility's policy required that such information be documented in the medical record and on a pacemaker identification card upon admission. Interviews with the Director of Nursing and the Administrator confirmed that the necessary pacemaker information was not obtained or documented, which they attributed to an oversight.
Failure to Update Daily Staffing Postings
Penalty
Summary
The facility failed to ensure that daily staffing postings were updated every shift for a period of 24 days, from September 1, 2024, through September 24, 2024. This deficiency was identified through an observation on September 25, 2024, which revealed that the staff postings were not being updated with the actual hours worked. Instead, the postings only reflected the scheduled hours. This oversight had the potential to affect all 56 residents residing in the facility. Interviews conducted with facility staff revealed a lack of awareness and responsibility regarding the updating of staffing postings. The Staffing Scheduler stated she was instructed to post staffing for the previous, current, and next day but was unaware that updates with actual hours worked were required every shift. The Director of Nursing (DON) indicated that either he or the Staffing Scheduler should update the postings, but no specific person was assigned this task for after-hours and weekends. The Administrator also confirmed the lack of awareness about the requirement to update postings every shift and acknowledged the absence of a policy regarding staff postings.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident within the required 2-hour timeframe to the California Department of Public Health (CDPH). The facility's policy mandates immediate reporting of all allegations of abuse, neglect, exploitation, or injury of unknown origin to the Abuse Prevention Coordinator (APC) and subsequently to local CDPH, Long Term Care Ombudsman, and Local Law Enforcement. However, the Director of Nursing (DON) did not document the injury in the progress notes or update the administrator, resulting in a delay of three days before the injury was reported to CDPH. Resident 1, who had been admitted with diagnoses including a urinary tract infection, dementia, cognitive communication deficit, and diabetes, was observed with a circular, dark purple discoloration on her upper left arm. The injury was initially reported to the DON by a family member, but the DON did not document it or inform the administrator, leading to a failure in timely reporting. The administrator confirmed that the injury should have been reported immediately and acknowledged the delay in reporting to CDPH.
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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