Covenant Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 3408 East Shields Avenue, Fresno, California 93726
- CMS Provider Number
- 055996
- Inspections on file
- 38
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Covenant Post Acute during CMS and state inspections, most recent first.
A resident experienced an unwitnessed fall in a shared room while a CNA was assisting the roommate behind a privacy curtain. An LVN responded, found the resident on the floor between the beds with left hip and lower back pain, facial grimacing, and inability to move the legs due to pain, and arranged transfer to the hospital per physician order. The Director of Business Development confirmed with the hospital that the resident had sustained a hip fracture and required surgery and reported this information to the DON and Administrator. Although facility policy required reporting unusual occurrences affecting resident welfare to appropriate agencies within 24 hours, the Administrator and DON did not report the fall with hip fracture to the state agency until two weeks after they were informed of the serious injury.
A resident with intact cognition and multiple chronic conditions was housed in a room where the shared bathroom toilet remained nonfunctional for an extended period, forcing reliance on an uncovered bedside commode and resulting in a strong urine odor. The toilet was observed covered with a plastic bag and labeled out of order, with visible feces in the bowl and urine discoloration on the floor, while staff acknowledged the persistent odor and the resident’s ability and preference to use a regular toilet. Multiple staff, including CNAs, maintenance, social services, and the administrator, confirmed awareness of the broken toilet and unpleasant bathroom conditions, which conflicted with facility policies requiring a safe, clean, comfortable, and homelike environment and proper odor control in resident bathrooms.
A resident with severe cognitive impairment, PTSD, dementia, and a documented history of sudden physical aggression toward peers and staff was care planned and ordered for continuous 1:1 supervision when out of the room, with staff required to follow at a safe distance. On the day of the incident, a new CNA on orientation was informally told to follow this resident but was not clearly informed that she was responsible for uninterrupted 1:1 supervision. When lunch trays arrived, the CNA left the resident unattended in his room to help pass trays. During this lapse in supervision, the aggressive resident left the room unnoticed, approached another wheelchair-bound, cognitively intact resident with bilateral below-knee amputations from behind near the therapy area, and punched him in the mouth, causing a split, swollen upper lip with a scratch and bleeding that required first-aid treatment. Staff interviews and records confirmed that the resident’s need for 1:1 supervision was known and in place prior to the altercation, but the supervision was not maintained or clearly communicated to the assigned CNA.
A resident with severe cognitive impairment and involuntary movements was found with a black eye of unknown origin, but staff did not immediately report the injury to the DON, administrator, or required authorities as per facility policy. Multiple staff observed the injury and assumed others had reported it, resulting in a two-day delay before the incident was reported to state agencies and the ombudsman, and documentation of timely notification was lacking.
A facility's infection prevention and control program was compromised when a boiler malfunction led to laundry being washed in temperatures below the required 71-77°F. The boiler's gas valve failure resulted in cold water washing, contrary to the facility's P&P. The Director of Maintenance and Director of Nursing confirmed the deviation, with the Infection Preventionist on vacation. This placed 117 residents at risk for cross-contamination.
A boiler system failure in the facility resulted in a lack of hot water for three days, affecting resident hygiene and kitchen operations. Residents were unable to shower or received cold bed baths, and kitchen staff had to use cold water for handwashing, increasing the risk of cross-contamination. The facility's maintenance policy was not followed, as routine maintenance was not scheduled for the boilers.
A resident in an LTC facility received a cold bed bath due to a non-functional boiler system, which left the facility without hot water. The CNA assigned to the resident was unaware of an alternate hot water source in the breakroom, leading to the resident experiencing discomfort and chills. Despite in-services provided to staff about using the breakroom's hot water dispenser, the information was not effectively communicated, resulting in a violation of the resident's right to a homelike environment.
The facility failed to ensure accurate MDS assessments for four residents, leading to deficiencies in documenting medical conditions and treatments. A resident with a central venous catheter, another using a BiPAP machine, a third receiving insulin and antibiotics, and a fourth on antipsychotic medication all had inaccuracies in their MDS documentation. The MDS Coordinator and DON acknowledged these oversights, emphasizing the importance of accurate documentation for proper care planning.
A facility failed to complete and transmit a discharge MDS assessment for a resident discharged to an acute hospital. The MDS Coordinator overlooked the assessment, which should have been completed and submitted according to CMS guidelines. The resident had a history of type 2 diabetes and was last assessed in September before discharge in December.
A facility failed to implement proper infection control measures during wound care for a resident with a surgical wound. Despite policies requiring enhanced barrier precautions (EBP) for residents with open wounds, no signage or PPE was available, and nursing staff did not wear gowns. Additionally, reusable equipment was not disinfected after use. The deficiency was attributed to a lack of communication and adherence to protocols by the staff and Infection Preventionist (IP).
A resident's medications were left unattended at the bedside by an LVN, contrary to facility policy, which requires medications to be administered within an hour of the scheduled time. Additionally, a medication cart was found unlocked and unattended, posing a risk of unauthorized access. The DON confirmed these actions violated the facility's protocols, emphasizing the importance of secure medication administration.
Failure to Timely Report Unwitnessed Fall With Hip Fracture to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to follow its written policy and procedure for timely reporting of an unusual occurrence when a resident sustained an unwitnessed fall with a serious injury. On the early morning of 3/4/26, a CNA was assisting the resident’s roommate behind a privacy curtain when the CNA felt something touch her back; upon turning, the CNA found the resident on the floor between the two beds. LVN 2 was called to the room at approximately 5:30 a.m., assessed the resident on the floor, and documented that the resident complained of lower back and left hip pain, had facial grimacing, and was unable to move her legs due to pain. LVN 2 kept the resident on the floor to avoid further movement, contacted the physician, and obtained an order to transfer the resident to the hospital via 911. The Director of Business Development (DBD) stated that, as part of her responsibilities, she contacted the hospital on 3/4/26 and confirmed that the resident had been admitted with a hip fracture due to the fall and was scheduled for surgery the following day. She reported that she notified both the DON and the Administrator of the hip fracture on that same day and later entered this information as a late entry progress note dated 3/9/26 for the events of 3/4/26. The hospital’s emergency department to hospital admission documentation indicated that imaging on 3/4/26 showed an acute fracture of the femoral neck with impaction and angulation, and that the resident underwent a left hip hemiarthroplasty. Despite the facility’s policy requiring that unusual occurrences affecting the welfare, safety, or health of residents be reported by telephone to appropriate agencies within 24 hours, the Administrator and DON did not report the fall with hip fracture to the California Department of Public Health (CDPH) until 3/18/26. The DON acknowledged that a hip fracture is a serious injury and stated that a report should be made to CDPH as soon as the facility knows a resident has an injury, and that they could have reported without having the hospital records. The Administrator confirmed he was responsible for reporting falls with severe injuries, acknowledged being notified on 3/4/26 that the resident had a hip fracture, and stated that the fall with fracture was reported to CDPH on 3/18/26. The facility’s incident report, completed on 3/18/26, documented the unwitnessed fall on 3/4/26, the resident’s complaints of pain and inability to move due to pain, the transfer to the hospital, and that hospital documentation was not received until 3/18/26.
Nonfunctional Toilet and Odorous Bathroom Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for a cognitively intact resident whose bathroom toilet was not functional, requiring use of a bedside commode (BSC) instead of the toilet. The resident, admitted with polymyalgia rheumatica, asthma, COPD, and chronic respiratory failure, reported that the toilet in her room had not worked since she moved into the room and that she was unable to use it. Surveyors observed the bathroom shared between two rooms, noting a toilet completely covered with a tied plastic bag and an uncovered BSC placed across from the sink. The bathroom had a strong urine odor similar to ammonia. The resident stated she had reported the toilet problem to the prior Director of Maintenance, who told her it was fine, and that she had also informed the administrator, but the toilet still had not been fixed. She reported feeling useless, not cared about, and unimportant due to the ongoing toilet issue. Staff interviews and observations further documented the ongoing nature of the problem and its impact on the environment. A CNA confirmed that the resident usually used the bathroom or a BSC placed by the bed and acknowledged the strong urine smell in the bathroom, stating the BSC lacked a lid and that a functioning toilet and absence of strong odor would be more homelike. Another CNA stated that toilets in the facility frequently became clogged due to residents flushing excessive toilet paper or paper towels, confirmed that the resident was alert, oriented, and able to use the toilet, and noted that BSCs without lids can cause rooms to smell. The Director of Maintenance stated the resident’s toilet was clogged due to excessive wipes being flushed and that a plumber had been called to unclog it, but during observation the toilet remained bagged, with an “Out of Order” sign, a strong urine odor, discoloration on the floor likely from urine, and visible feces in the toilet bowl. Additional staff interviews corroborated that the toilet had been nonfunctional over time and that the bathroom environment was not acceptable. An LVN stated the toilet had been broken when the resident first moved into the room, that the prior maintenance director had said it was working again, and that a plumber had come a few days earlier to fix it, but the bathroom still had a bad odor. The Social Services Director reported that when the resident moved into the room it was discovered the toilet was not working, that it was later reported to have acted up again, and that she had noticed the plastic bag over the toilet during rounds; she stated the bathroom should not smell like that and emphasized the importance of a working toilet for the resident’s independence. The administrator acknowledged that the toilet had a weak flush with a blockage, that he was unsure if it was the resident’s preference to use the toilet, that the odor persisted despite housekeeping cleaning, and that the plumber had indicated the piping would need to be replaced. Facility policies on Resident Rights and Safe and Homelike Environment required a safe, clean, comfortable, homelike, and sanitary environment, including resident rooms and bathrooms, and minimizing odors, which were not met in this situation.
Failure to Maintain Required 1:1 Supervision for Aggressive Resident Resulting in Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with known physically aggressive behaviors. Resident 1 had severe cognitive impairment with a BIMS score of 3/15, diagnoses including dementia, anxiety disorders, alcohol abuse, and PTSD, and a documented history of resident-to-resident altercations and aggression toward staff and peers. The resident’s behavior care plan and behavior documentation indicated verbal and physical aggression, including punching, pushing, and grabbing, and required that when the resident ambulated throughout the facility, a designated staff member remain in close proximity at a safe distance to provide immediate redirection and ensure other residents were not placed at risk. Prior to the incident, Resident 1 had been agitated, pacing, yelling, and cursing at staff and peers, and had a history of repeated aggressive behaviors. On the day of the incident, Resident 1 was supposed to be on 1:1 supervision when out of his room due to his unpredictable and violent behavior. Staff interviews confirmed that Resident 1 was known to become suddenly violent, strike out at staff and residents, and that he required continuous 1:1 supervision for safety, with staff following at a safe distance because he became agitated if they walked next to him. The charge nurse assigned a new CNA (CNA 3), who was still on orientation, to follow Resident 1 and “just watch him” because he was combative. CNA 3 followed Resident 1 for a period until he returned to his room. When lunch trays arrived, CNA 3 left her observation of Resident 1 and began helping other CNAs pass meal trays, leaving Resident 1 unattended in his room despite his need for continuous supervision when out of his room and his known rapid mood changes and aggression. While Resident 1 was left without direct supervision, he left his room unnoticed, walked to an area near the therapy room and front window, and approached Resident 2 from behind. Resident 2, who was cognitively intact with a BIMS score of 15/15 and had significant physical impairments including bilateral below-knee amputations and osteomyelitis, was seated in his wheelchair near the therapy room. Resident 2 reported that Resident 1 came up very close behind him; he turned his wheelchair around and told Resident 1 not to approach from behind. At that point, Resident 1 punched Resident 2 in the mouth. Documentation and assessments indicated that Resident 2 sustained a split, swollen upper lip with a scratch on the top left side of the lip and bleeding, requiring cleansing with normal saline and application of triple antibiotic ointment. Multiple staff, including the Administrator, DON, Social Services Director, and rehabilitation staff, heard yelling and responded, observing Resident 1 striking Resident 2 in the facial area. The incident occurred at a time when Resident 1 was documented and acknowledged by staff and the care plan to require 1:1 supervision, but the assigned staff member had left the resident unattended to assist with meal tray distribution, resulting in the resident leaving his room undetected and physically assaulting another resident. Interviews with the Administrator, DON, CNAs, LVNs, and Social Services Director consistently confirmed that Resident 1 had a history of aggressive behaviors, frequent mood changes, and prior altercations with other residents, and that he required 1:1 supervision when out of his room. Staff also confirmed that on the morning of the incident, Resident 1 was agitated and that his usual anti-anxiety medication was not effective. Despite this, the new CNA assigned to follow Resident 1 was not clearly informed that she was responsible for providing continuous 1:1 supervision and left her assignment to help pass lunch trays. The facility’s own Safety and Supervision of Residents policy required that specific interventions, such as supervision levels, be communicated to all relevant staff, that responsibility for carrying out interventions be clearly assigned, and that interventions be implemented correctly and consistently. The failure to ensure that the assigned staff member maintained continuous 1:1 supervision of Resident 1, and the failure to effectively communicate and enforce this supervision requirement, directly led to Resident 1 leaving his room unsupervised and physically assaulting Resident 2, causing injury.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in accordance with its abuse policy and procedure for one of three sampled residents. A resident with Huntington's Disease and severe cognitive impairment was found with discoloration around the right eye, which was not reported to the California Department of Public Health (CDPH) and adult protective services until two days after the injury was discovered. The injury was unwitnessed, and the resident was unable to explain how it occurred, meeting the criteria for an injury of unknown source. Staff interviews revealed that multiple CNAs and LVNs observed the injury but did not immediately notify the abuse coordinator or administrator as required by facility policy. There was confusion among staff regarding who was responsible for reporting, and documentation was lacking to show timely notification to the appropriate authorities. The Director of Nursing (DON) and other staff acknowledged that the facility's policy required immediate reporting of suspected abuse or injury of unknown source, but this was not followed in this case. The facility's own policy and the State Operations Manual both require that injuries of unknown source be reported immediately to the administrator and relevant agencies. In this incident, the report was not made to CDPH and the ombudsman until two days after the injury was discovered, and there was no documentation of timely notification to law enforcement. This delay resulted in a postponement of the investigation into the cause of the resident's injury.
Inadequate Laundry Water Temperature Due to Boiler Malfunction
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program when one of its two boiler systems malfunctioned, leading to laundry being washed in temperatures below the facility's policy and procedure (P&P) requirements. The boiler's ignition control module was replaced, but a failed gas valve could not be ordered until a later date, resulting in a lack of hot water. Consequently, laundry was washed in cold water, contrary to the facility's P&P, which required a minimum temperature of 71-77°F for low-temperature processing. The laundry aide and housekeeping supervisor confirmed the use of cold water, and the water temperature was measured at 66.9°F, below the required minimum. The Director of Maintenance and the Director of Nursing acknowledged the deviation from the P&P, with the latter noting that the Infection Preventionist, who would typically oversee such practices, was on vacation. The facility's P&P and a professional reference from the CDC were reviewed, both indicating the importance of maintaining specific water temperatures to reduce microbial contamination. The deficiency placed the 117 residents at risk for cross-contamination due to improperly washed and sanitized laundry.
Boiler Failure Leads to Lack of Hot Water
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition when one of its two boiler systems, responsible for heating water throughout the facility, was not monitored or maintained, leading to its failure from March 15 to March 18, 2025. This resulted in the facility being unable to provide hot water for showers, laundry, and kitchen use, affecting the hygiene and comfort of residents. The Director of Maintenance (DOM) reported that the boiler's ignition control module was replaced, but a failed gas valve, which was not in stock, prevented the boiler from functioning. Residents were directly impacted by the lack of hot water. Resident 1 reported receiving a cold bed bath, which was uncomfortable and not thorough, while Resident 2 did not receive a shower or bed bath for six days. Other residents, such as Resident 3 and Resident 4, had to resort to washing themselves with cold water. The facility's kitchen operations were also affected, with staff using cold water for handwashing and relying on a hot water dispenser for dishwashing, which posed a risk of cross-contamination and foodborne illness. The facility's maintenance policy required the Maintenance Department to keep equipment in a safe and operable manner, but routine maintenance was not scheduled for the boilers. The Vendor confirmed that they were only called for emergencies and seasonal transitions, not for regular maintenance. This lack of preventive maintenance contributed to the boiler's failure, leaving the facility without hot water and compromising the residents' hygiene and safety.
Resident Receives Cold Bed Bath Due to Boiler Failure
Penalty
Summary
The facility failed to provide a homelike environment for a resident when the boiler system was not functional, resulting in the resident receiving a bed bath with cold water. The issue began when the facility's boiler system, which heats water, became non-functional. The Administrator was informed by the Director of Maintenance that the boiler's ignition control module was replaced, but a gas valve had also failed and could not be ordered until a later date. Consequently, there was no hot water available for resident care. A resident, who was scheduled for showers on specific days, was given a bed bath with cold water by a CNA who was unaware of an alternate hot water source available in the breakroom. The resident expressed discomfort and chills during the bed bath, as the CNA had not been informed about the alternative hot water source. The CNA acknowledged feeling bad about the situation and noted that the resident was chilled and inquired about when hot water would be available again. Interviews with other staff members, including another CNA, the Director of Staff Development, and the Director of Nursing, revealed that in-services were provided to inform staff about using the hot water dispenser in the breakroom for bed baths. The facility's policy and procedure for bed baths emphasized the importance of using warm water to ensure resident comfort. However, the failure to communicate this information effectively to all staff members led to the resident receiving a cold bed bath, violating their right to a homelike environment.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their medical conditions and treatments. Resident #217 was admitted with a central venous catheter (CVC) for intravenous (IV) medications, but the MDS did not indicate the type of IV access site. The MDS Coordinator and Director of Nursing (DON) acknowledged the oversight, confirming that the central line section should have been coded. Resident #19, who had obstructive sleep apnea, was using a BiPAP machine, a non-invasive mechanical ventilator, which was not documented in the MDS. The MDS Coordinator and DON both confirmed that the BiPAP should have been coded to ensure the resident's care plan accurately reflected their needs. Similarly, Resident #64, who was readmitted with type 2 diabetes and a foot ulcer, received insulin and antibiotics during the assessment look-back period, but these were not coded in the MDS. The MDS Coordinator admitted to the error, and the DON confirmed that the medications should have been properly documented. Resident #68, diagnosed with bipolar disorder, was taking an antipsychotic medication, quetiapine fumarate, which was not accurately coded in the MDS. The section related to antipsychotic medication review was incorrectly marked, causing the assessment to skip information on gradual dose reduction. The MDS Coordinator and DON acknowledged the mistake, emphasizing the importance of accurate MDS documentation for proper care planning and communication with the Centers for Medicare and Medicaid Services (CMS).
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted for a resident who was discharged to an acute hospital. The facility's policy, revised in July 2017, mandates that the assessment coordinator or designee is responsible for submitting resident assessments to the CMS' QIES Assessment Submission and Processing system in accordance with federal and state guidelines. The CMS Long Term Care Facility Resident Assessment Instrument Manual specifies that a discharge assessment must be completed within 14 days after the discharge date and submitted within 14 days after the MDS completion date. Resident #30 was admitted to the facility on March 17, 2024, with a medical history of type 2 diabetes and was discharged to an acute hospital on December 7, 2024. The last completed MDS for this resident was a quarterly assessment on September 24, 2024, and no discharge assessment was completed. During interviews, the MDS Coordinator admitted to overlooking the completion of the discharge assessment, and the Director of Nursing confirmed that discharge assessments were expected to be completed by the MDS Coordinator once the facility was aware of the discharge.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, specifically regarding the use of enhanced barrier precautions (EBP) and the cleaning and disinfection of reusable equipment. The deficiency was observed during wound care for a resident with a surgical wound on the right foot. The resident, who had a severe cognitive impairment, was readmitted to the facility with a history of surgical amputation and required regular wound care. Despite the facility's policy requiring EBP for residents with open wounds, no signage or personal protective equipment (PPE) was available in the resident's room, and the nursing staff did not don gowns during the procedure. During the wound care observation, two licensed vocational nurses (LVNs) entered the resident's room, performed hand hygiene, and donned gloves but failed to wear gowns as required by EBP. After completing the wound care, one of the LVNs placed the scissors used during the procedure back into the treatment cart without cleaning or disinfecting them. Interviews with the LVNs revealed a lack of awareness and adherence to EBP protocols, as well as a failure to communicate the resident's need for EBP to the Infection Preventionist (IP). The IP and Director of Nursing (DON) acknowledged the oversight, stating that EBP should have been implemented for the resident due to the open wound. The IP was responsible for initiating EBP, but there was a communication breakdown between the IP and the treatment nurse, resulting in the failure to implement necessary precautions. The facility's policies on EBP and equipment disinfection were not followed, leading to the observed deficiencies in infection control practices.
Medication Administration and Security Lapses
Penalty
Summary
The facility failed to ensure that licensed nurses administered medications in accordance with professional standards of practice for one of the residents. On a specific date, a resident's morning medications were left unattended at the bedside by a Licensed Vocational Nurse (LVN). The resident, who was cognitively intact, stated that the nurse left the medications on the table for him to take later, as he preferred to take them around lunchtime. The medications included apixaban, a blood thinner, and various dietary supplements. This action was against the facility's policy, which requires medications to be administered within an hour of the scheduled time and not left unattended. Additionally, the facility's policy was not followed regarding the security of the medication cart. During an observation, it was noted that the medication cart was left unlocked and unattended by an LVN. The LVN admitted that the cart might have been left open, which posed a risk as anyone, including residents and visitors, could access the medications. The facility's policy mandates that the medication cart should be locked when not in direct use to prevent unauthorized access. The Director of Nursing (DON) confirmed that the facility's policy was not adhered to in both instances. The DON emphasized the importance of not leaving medications at the bedside and ensuring the medication cart is locked when not in use. The failure to follow these protocols posed a safety risk, as other residents could potentially consume medications not prescribed to them, leading to adverse effects. The facility's policy and professional standards require that medications be administered safely and securely, which was not the case in these incidents.
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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