Countryside Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 925 North Cornelia, Fresno, California 93706
- CMS Provider Number
- 056281
- Inspections on file
- 30
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Countryside Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a functioning call light system for 11 of 59 beds, with several residents lacking working call lights or any call light device at their bedside. One cognitively intact resident with muscle weakness and a history of repeated falls reported his call light had worked intermittently since admission, had stopped working again, and that he had previously gotten out of bed and yelled for help and once waited about an hour for incontinence care due to the nonfunctioning call light. In another room, a resident reported having no call light, and her roommate had only a small silver bell despite hand deformities that made its use difficult. The DOM and staff identified loose wall connections, missing cords, and long-standing issues in multiple rooms, with some residents given bells or portable call buttons instead of functioning call lights, while CNAs, an LVN, the scheduler, and the DON gave conflicting accounts of their awareness of these ongoing problems and the reporting process.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors. These lapses resulted in a deficiency related to environmental safety and resident supervision.
A resident with severe cognitive impairment and multiple risk factors for falls experienced three unwitnessed falls within two weeks due to the facility's failure to provide adequate supervision and timely, effective fall prevention interventions. Despite being identified as high risk and requiring supervision while ambulating, the resident was only checked every 15 minutes rather than receiving direct in-room supervision, and interventions were not adjusted after repeated falls.
A resident with moderate cognitive impairment was left at a doctor's office for several hours without a meal due to a failure in transportation arrangements. The resident was ready to return to the facility by noon but was not picked up until the evening, resulting in emotional distress and hunger. The facility's process for managing appointments was not followed, and the Social Services Director did not ensure the resident's timely return.
A resident at high risk for falls was not properly placed on the facility's Red Sneaker Program, a fall prevention initiative. Despite having a fall risk score indicating high risk, the necessary visual symbols and red bracelet were missing, contrary to the facility's policy. The resident's medical history included conditions like osteomyelitis and muscle weakness, but their MDS indicated no cognitive impairment. Interviews with the DON and an LVN confirmed the oversight in implementing the required interventions.
A resident with Alzheimer's and severe cognitive impairment, identified as a high fall risk, experienced an unwitnessed fall resulting in a skin tear. Despite being part of a fall prevention program, the resident was left unsupervised after breakfast, leading to the incident. Staff interviews confirmed the resident's need for supervision, especially when tired, was known but not adequately provided.
The facility failed to maintain a safe and comfortable environment for residents when the dining room temperature fell below the acceptable range of 71 to 81 degrees Fahrenheit. Three residents, including one with dementia and another with COPD, expressed discomfort due to the cold conditions. The Director of Maintenance confirmed the low temperatures, and the Director of Nursing emphasized the importance of maintaining the specified temperature range to ensure a homelike setting.
The facility failed to implement comprehensive care plans for three residents, leading to potential health risks. A resident's medication refusal was not addressed in their care plan, another resident's skin assessments were not conducted, and a third resident's call light was not within reach, contrary to their care plan. These oversights indicate a failure to adhere to care planning policies.
The facility failed to meet professional standards by not explaining medications to residents during administration, not notifying a physician of a resident's medication refusal, and not performing current vital assessments before a hospital transfer. Nurses admitted to not informing residents about their medications, and outdated assessments were used for a resident with shortness of breath.
A resident was given divalproex without a specific diagnosed condition documented in their clinical record. The medication was used off-label for mood disorders, despite effective non-pharmacological interventions. The resident had a history of dementia and other mental health issues, and the facility's policy required a specific diagnosis before administering psychotropic medications.
The facility failed to maintain the required temperature in the high temperature dishwasher, with readings below the necessary 155 degrees Fahrenheit during the wash cycle. This failure could potentially expose 52 out of 55 highly susceptible residents to foodborne illnesses due to cross-contamination. Staff interviews confirmed the importance of correct temperatures for sanitation, and the facility's policy emphasized adherence to manufacturer's recommendations.
The facility failed to maintain an effective pest control program, as flies were observed in the kitchen on two consecutive days. The Certified Dietary Manager acknowledged the lack of a fly light trap and recognized the infection control issue posed by flies. The Registered Dietician expected a pest-free kitchen, emphasizing the risk of illness for residents. The facility did not provide a specific pest control policy, and a review of the FDA Food Code highlighted the need to protect food establishments from pests.
The facility was found to have three rooms (Rooms 1, 2, and 14) each accommodating six residents, exceeding the regulatory limit of four residents per room. Despite this, the rooms were noted to have sufficient space and facilities to meet the residents' needs, and the health and safety of the residents were not deemed to be adversely affected by this arrangement.
A resident at high risk for falls, with severe cognitive impairment and multiple medical conditions, was left unattended by a CNA assigned to provide one-on-one supervision. The CNA briefly left the resident's side to assist another CNA, resulting in the resident falling and sustaining head injuries. The facility lacked a specific policy for one-on-one supervision, contributing to the deficiency.
Failure to Maintain Functioning Call Light System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning resident call light system in multiple rooms and beds, including bathrooms and bathing areas, leaving residents without a reliable means to summon staff assistance. Surveyors observed that 11 of 59 beds (8A, 8B, 11A, 11B, 11C, 14A, 14B, 15A, 15B, 17B, 17D) had nonfunctioning or missing call lights. In one room, a resident reported that his call light had worked intermittently since admission and had stopped working again the day before the survey; when he pressed the button, there was no light above the door and no sound or light at the bed station panel. The panel had a splitter adapter with two cords plugged in, but the system did not activate. This resident stated he had previously gotten out of bed on his own and gone to the door to yell for help and that on one occasion he waited about an hour to be cleaned after a bowel movement because the call light was not working. The same resident’s records showed diagnoses including mastoiditis, Bell’s palsy, muscle weakness, and repeated falls, and his MDS BIMS score indicated he was cognitively intact. He reported that the Director of Maintenance (DOM) had attempted to fix the call light about three weeks earlier but was unsuccessful, and that the DOM had said he ordered the wrong part or that parts were not coming in. During the interview, the DOM entered the room with a call light cord, stating he had a work order to replace the cord, but then left the room without replacing it. Later, the DOM stated there were five call lights not working in the facility and that he had received work orders for rooms 8, 11, and 14 on a recent Sunday, and he asserted it was the first time he had heard that the resident’s call light had been intermittently nonfunctional for approximately six weeks. In another room shared by two residents, one resident stated she did not have a call light and believed it had been stolen; surveyors confirmed there was no call light near her bed. The other resident in the same room had a small silver bell on her overbed table instead of a call light, and she had partial deformity of her hands, making use of the bell difficult. Additional observations with the DOM showed that call lights in multiple rooms and beds did not activate when pressed, including beds 8A, 8B, 11C, 14A, 14B, 15A, 15B, 17B, and 17D, and that beds 11A and 11B had no call lights at all. In some cases, the DOM identified loose plugs or bad connections in the wall panels and noted that silver bells or portable call buttons had been used when the call lights were not working. Staff interviews revealed inconsistent awareness and reporting of the call light problems. A CNA assigned to affected rooms stated she was unaware the call lights were not working and that the previous shift had not reported any issues. Another CNA reported that one room’s call light would not work at times because the cord would come slightly out of the panel and had to be pushed back in. An LVN stated she did not know that call lights in a particular room were not working, while another LVN reported that call lights in one room had not worked for about two months and that portable call buttons had been provided. The scheduler, who conducted Angel Rounds for certain rooms, stated that call lights in one room had not been working for approximately two months and that residents were initially given silver bells and later portable call buttons, but she was unaware that one resident in that room did not have a call light or bell. The DON stated that call lights in one room had not been working since January and that portable call lights were given due to connection issues, and she was unaware that a resident in another bed did not have a call light. Review of maintenance request forms showed repeated reports of call light problems over several weeks, including nonworking call lights in room 14 for all beds, a bad wall connection in room 8B, a need for call lights for both beds in another room, and a missing call light in bed 11A. Some forms documented completion dates and comments that call lights were working again or that parts such as split connectors had been ordered. Angel Rounds documentation for certain dates noted a broken call light button in room 11. The facility’s call light policy stated that staff would be educated on proper use of the call system, ensure resident access to call lights, and report problems to a supervisor or maintenance director, and the maintenance director’s job description required maintaining the building and equipment in safe order and ensuring a safe and secure environment for staff, residents, and guests. Despite these policies, survey findings showed multiple nonfunctioning or missing call lights and inconsistent communication and follow-through regarding identified call light issues.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and implement effective fall prevention interventions for a resident assessed as high risk for falls. The resident, who had diagnoses including osteoporosis, type 2 diabetes, dementia, gait abnormalities, and muscle weakness, was severely cognitively impaired and required supervision while ambulating. Despite being identified as high risk through multiple fall risk assessments and care plans, the resident experienced three unwitnessed falls within a two-week period. The facility's care plans and fall prevention program, including the Red Sneaker Program, outlined interventions such as supervision, environmental safety checks, and regular monitoring. However, the resident was placed on Level 2 supervision, which involved staff checking every 15 minutes, rather than direct in-room supervision, even after repeated falls. The care plans included interventions like assessing dizziness, monitoring for injury, and providing education, but staff acknowledged that the resident's dementia prevented retention of safety education or reminders. Interviews and record reviews revealed that the interdisciplinary team (IDT) did not increase the level of supervision to direct, in-room monitoring until after the third fall. The Director of Nursing confirmed that Level 2 supervision was not effective for this resident, as evidenced by the repeated falls. The facility's own policies required individualized, resident-centered interventions and modification of interventions if falls recurred, but these were not implemented in a timely manner for this resident.
Resident Left at Doctor's Office Due to Transportation Failure
Penalty
Summary
The facility failed to ensure adequate transportation for a resident returning from a doctor's appointment, resulting in the resident being left at the doctor's office for several hours without a meal. The resident, who was moderately cognitively impaired, was admitted with conditions including cellulitis, muscle weakness, and mobility issues. On the day of the incident, the resident was picked up for a morning appointment and was ready to return to the facility by noon, but was not picked up until the evening. Interviews and record reviews revealed that the facility's process for managing resident appointments was not followed. The scheduler received a call from the doctor's office at 12:30 p.m. indicating the resident was ready to be picked up and forwarded the call to the Social Services Director (SSD). The SSD provided the doctor's office with a phone number for transportation but did not follow up to ensure the resident was picked up. The Director of Nursing (DON) later stated that the facility was ultimately responsible for ensuring the resident had something to eat and drink. The incident was documented in the resident's records, noting the delay in transportation and the resident's return to the facility. The facility's policy indicated that social services representatives were responsible for assisting with transportation arrangements, but this was not effectively executed. The resident experienced emotional distress, hunger, and was without a jacket in cold weather, highlighting the facility's failure to uphold the resident's right to dignity and adequate care.
Failure to Implement Fall Prevention Program for High-Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident identified as being at high risk for falls. The resident, who had a history of falls both at home and within the facility, was not properly placed on the facility's Red Sneaker Program (RSP), a fall prevention initiative. Despite the resident's fall risk care plan being updated after a recent fall, the necessary interventions outlined in the RSP were not executed. This included the absence of visual symbols such as red sneakers by the resident's name placard outside their room, above their bed, and the lack of a red bracelet on the resident. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the resident had a fall risk score of 13, indicating a high risk of falls. The facility's policy required that residents on the RSP be identified with specific symbols and a red bracelet to alert staff of their fall risk. However, during observations, these indicators were missing, and the resident was not wearing the required red bracelet. The DON acknowledged the oversight and confirmed that these measures should have been in place as per the resident's care plan and the facility's fall prevention policy. The resident's medical history included conditions such as osteomyelitis of the vertebra, muscle weakness, cognitive communication deficit, and end-stage renal disease. Despite these conditions, the resident's Minimum Data Set (MDS) indicated no cognitive impairment. The facility's policies on comprehensive person-centered care plans and safety and supervision of residents emphasized the need for targeted interventions to reduce individual risks, which were not adequately implemented in this case.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as a high fall risk, resulting in an unwitnessed fall. The resident, who has a history of falls and a known behavior of placing herself on the floor when tired, was found on the floor with a skin tear on her right elbow. The incident occurred after the resident ambulated unattended from the dining room, where she had been left unsupervised by a CNA who was assisting another resident. The resident's medical history includes Alzheimer's Disease, Type 2 Diabetes Mellitus, muscle weakness, and dementia, with a severe cognitive impairment as indicated by a BIMS score of 01 out of 15. The resident was part of the facility's Red Sneaker Program, which identifies individuals at high risk for falls. Despite this, the resident frequently walked unsupervised, and staff acknowledged that she required supervision, especially when tired, to prevent falls. Interviews with facility staff, including CNAs, an LVN, the MDS Coordinator, the DON, and the Administrator, revealed that the resident's need for supervision was well-known. The facility's policy emphasized the importance of individualized safety measures and adequate supervision for residents at risk of falls. However, the resident's care plan and fall risk assessments were not effectively implemented, leading to the unwitnessed fall and subsequent injury.
Facility Fails to Maintain Safe Temperature in Dining Room
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for three residents when the dining room temperature was below the acceptable range of 71 to 81 degrees Fahrenheit. This deficiency was observed during a survey where residents expressed discomfort due to the cold temperature in the dining room. Resident 22, who has a history of dementia, muscle weakness, and falls, mentioned needing a coat because the dining room was always cold. Resident 29, who is cognitively intact and has conditions such as shortness of breath and osteoarthritis, also reported that the dining room was too cold while wearing a sweater. Resident 42, with chronic obstructive pulmonary disease (COPD) and asthma, stated that the dining room was cold even at night and had previously contracted pneumonia. The Director of Maintenance confirmed the low temperatures in the dining room, with readings of 69, 67, and 69 degrees Fahrenheit. The Director acknowledged that closing the dining room door before meals contributed to the cold environment and emphasized the importance of maintaining the temperature within the specified range to ensure a homelike setting. The Director of Nursing also stated that the facility's expectation was to keep the temperature between 71 and 81 degrees Fahrenheit to provide a safe and comfortable environment for residents. The facility's policy on providing a homelike environment includes maintaining comfortable and safe temperatures. Professional references cited in the report highlight the negative impact of low indoor temperatures on residents, particularly those with dementia and respiratory conditions. These references indicate that deviations from the recommended temperature range can lead to increased agitation and respiratory issues, underscoring the importance of maintaining appropriate indoor temperatures for the well-being of residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential risks for their health and safety. Resident 13's care plan did not include interventions for his refusal of medications, which was not documented or communicated to the attending physician. This oversight occurred despite multiple refusals of his inhaler, which could exacerbate his Chronic Obstructive Pulmonary Disease (COPD). The Licensed Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN) acknowledged the absence of a specific care plan addressing the medication refusal, indicating a failure to adhere to the facility's care planning policy. Resident 8's care plan was not implemented for skin assessments, resulting in a lack of monitoring for skin tears, bruising, or wounds. During observations, a wound was noted on Resident 8's forearm, which she reported was not being treated by the staff. The Registered Nurse Supervisor (RNS) confirmed that there was no documentation of the wound in Resident 8's medical record, and the care plan did not include wound care for the forearm. The facility's policy required daily skin checks during activities of daily living and showers, but these were not consistently documented or communicated to the nursing staff. Resident 16's care plan was not followed regarding the placement of the call light within reach, which is crucial for a resident with a history of falls and severe cognitive impairment. The call light was observed out of reach, and the resident expressed difficulty in accessing it. The Activity Assistant and Certified Nursing Assistant (CNA) confirmed the call light was not within reach, contrary to the care plan's intervention to prevent falls. The Director of Nursing (DON) stated that the call light should always be within reach, highlighting a failure to implement the care plan as intended.
Failure to Meet Professional Standards in Medication Administration and Resident Assessment
Penalty
Summary
The facility failed to provide services that met professional standards of practice for several residents. Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 did not explain the medication names and indications to multiple residents during medication administration. This oversight was observed during medication pass observations, where medications were administered without informing the residents about the medications they were receiving. Interviews with the nurses confirmed that they did not explain the medications, acknowledging that residents have the right to know the medications they are receiving. The facility also failed to notify the attending physician of a resident's ongoing refusal of a prescribed inhaler. The resident had multiple episodes of refusal, which were not documented or communicated to the physician as required by the facility's policy. This lack of communication and documentation could potentially affect the resident's health condition, as the inhaler was prescribed to manage a chronic lung disease. Additionally, the facility did not perform current oxygen saturation and respiration assessments on a resident before transporting them to the hospital for shortness of breath. The assessments used were outdated, and there was no documentation of vital signs taken prior to the hospital transfer. The Registered Nurse Supervisor acknowledged that vital signs should have been checked and documented before the transfer, as per the facility's policy.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Resident 39 was administered divalproex, an anticonvulsant medication, without a specific condition diagnosed and documented in the clinical record. The medication was prescribed for an unspecified mood disorder manifested by irritability and abusive language, despite the fact that non-pharmacological interventions had been documented as effective. The Pharmacist Consultant acknowledged that divalproex was being used off-label for mood disorders and that other medications could have been used on-label for the resident's diagnoses. Observations and interviews revealed that Resident 39 had bruising on her forehead, nose, and around her left eye, and had fallen out of bed. The resident had a history of dementia, muscle weakness, unspecified psychosis, and unspecified mood disorder. The Director of Nursing stated that divalproex was being used as a mood stabilizer and acknowledged that the expectation was for residents to have a specific diagnosis before administering psychotropic medications. The facility's policy indicated that medications should not be administered without a clinical indication to treat a specific condition, and non-pharmacological approaches should be used to minimize the need for medications.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to adhere to professional standards for food service safety when the high temperature dishwasher did not reach the required temperature during the wash cycle. Observations revealed that the dishwasher's temperature was below the necessary 155 degrees Fahrenheit, with readings as low as 145 degrees Fahrenheit. Dietary Aide 1, responsible for operating the dishwasher, incorrectly stated that the wash cycle temperature should be above 135 degrees Fahrenheit, while the actual requirement was 155 degrees Fahrenheit as per the dishwasher's data plate. This discrepancy in temperature could potentially expose 52 out of 55 highly susceptible residents to foodborne illnesses due to cross-contamination. Interviews with various staff members, including the Certified Dietary Manager and the Registered Dietician, confirmed the importance of maintaining the correct dishwasher temperatures for sanitation and infection control. The facility's policy and procedure for dishwashing emphasized the need for the dishwasher to operate within the manufacturer's recommended temperatures, and if not achievable, to resort to manual dishwashing. Despite these guidelines, the dishwasher was not consistently reaching the required temperatures, posing a risk to resident safety.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in the kitchen area on two consecutive days. On the first day, a fly was observed flying around the food serving area. The following day, two flies were seen in the kitchen by the food serving and dishwasher areas during an observation and interview with the Certified Dietary Manager (CDM). The CDM acknowledged the presence of a fly fan at the back entrance but noted the absence of a fly light trap to attract and eliminate flies. The CDM also mentioned that pest control services were scheduled once a month and recognized that flies posed an infection control issue, potentially leading to illness among residents consuming food from the kitchen. The Registered Dietician (RD) expressed an expectation for the kitchen to be free of flies and pests, emphasizing the risk of residents becoming ill. The RD indicated that the CDM was responsible for ensuring the kitchen's cleanliness and pest-free status. A review of the facility's infection control policy highlighted the goal of maintaining a safe, sanitary, and comfortable environment to prevent disease transmission. However, the facility did not provide a specific policy for pest control or kitchen sanitation upon request. Additionally, a professional reference from the FDA Food Code 2022 underscored the importance of protecting food establishments from insects and rodents to prevent contamination of food and food-contact surfaces.
Exceeding Resident Capacity in Rooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey conducted from August 19 to August 23, 2024, it was observed that three rooms (Rooms 1, 2, and 14) each accommodated six residents, exceeding the allowed capacity. Despite this non-compliance, the report notes that the rooms were adequately equipped to meet the residents' needs, providing sufficient space for nursing care, ambulation, and storage. The report also mentions that the health and safety of the residents would not be adversely affected by the continuance of this waiver, suggesting that the facility had previously been granted a waiver for this requirement.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was at high risk for falls, resulting in the resident falling and sustaining injuries. The resident, who had severe cognitive impairment and multiple medical conditions including dementia and muscle weakness, was assessed to require one-on-one observation for safety. Despite this assessment, a CNA left the resident unattended to assist another CNA with a different resident, leading to the resident's fall. The incident occurred during the night shift when the resident was restless and attempting to get out of bed frequently. The resident had been given medications for anxiety and pain, which could cause drowsiness and unsteady gait, increasing the risk of falls. The CNA assigned to the resident's one-on-one care left the resident's side briefly, believing the resident was asleep, and closed the curtain for privacy while assisting another resident. During this time, the resident fell and sustained lacerations and contusions to the head, necessitating transfer to the emergency department. Interviews with facility staff, including the Administrator, LVN, and DON, confirmed that the resident's one-on-one supervision was not maintained as required. The facility did not have a specific policy and procedure for one-on-one supervision, which contributed to the failure in providing adequate supervision. The DON acknowledged that the CNA should not have left the resident unattended, and the lack of a policy for one-on-one supervision was noted as a deficiency.
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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