Crystal Ridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grass Valley, California.
- Location
- 396 Dorsey Drive, Grass Valley, California 95945
- CMS Provider Number
- 555283
- Inspections on file
- 29
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Crystal Ridge Care Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and a very high elopement risk score eloped from the facility after leaving through a door near a smoking area, unlatching a gate, and walking to a nearby road, where a truck picked the resident up and transported the resident to an apartment complex. The resident had orders for a wander guard on the left ankle to be checked every shift and a care plan intervention to ensure an identification band or other identification was in place, but staff reported the resident frequently tried to elope and would remove or cut off the wander guard. On observation, the resident was found without an identification band, and staff confirmed this, while also reporting that no alarm was heard at the time of the elopement, demonstrating a failure to provide adequate supervision and monitoring for a known high-risk resident.
A resident with dementia and a high risk for elopement was able to leave the facility unsupervised and undetected, despite staff awareness of recent exit-seeking behaviors and a care plan identifying the risk. The resident was missing for 45 minutes before being found by police, indicating a failure to provide adequate supervision as required by facility policy.
Surveyors found expired and undated food items in the freezer and dry food cupboards, including cream puffs, dried parsley, brown gravy mix, cereal, and cherry jello mix. Both the DS and RD confirmed that staff are expected to label and discard expired or undated foods, in accordance with facility policy.
Three residents experienced deficiencies in care when medications were left at bedside without proper supervision, a cervical collar was used without a current physician order, and a gastrostomy tube was not checked or flushed as ordered before medication administration. Nursing staff did not follow established protocols or physician orders, resulting in lapses in safe medication and treatment practices.
A resident with dementia and a history of wandering was observed without a required wanderguard bracelet, despite staff documentation indicating it was in place. Staff confirmed the absence of the device, which was ordered for safety and required to be checked each shift, resulting in a failure to follow established safety protocols.
A resident with anxiety received frequent PRN lorazepam administrations over several months without a required stop date on the medication order. The pharmacy consultant confirmed that the medication regimen review did not identify this irregularity, and facility policy required such orders to have clear documentation and periodic review.
A resident with Guillain-Barre Syndrome and adult failure to thrive developed a stage four pressure ulcer to the sacrococcyx, but the facility did not initiate a significant change in status assessment (SCSA) as required. The MDS Coordinator confirmed the assessment was not completed, and facility policy mandates such assessments after significant changes in condition.
A resident with moderate cognitive impairment and a history of mental illness was found self-administering vitamin D3 and storing multiple unidentified medications in their room without staff knowledge. Nursing staff and the Infection Preventionist were unaware of these behaviors, and there was no documentation of behavior monitoring in the clinical records or MAR, despite facility policy prohibiting self-administration and requiring comprehensive care plans.
A resident with dementia and diabetes, requiring assistance with eating, was observed seated at a dining table that was too high for comfortable eating during a meal. Staff placed the meal tray on the table at chest level, and a nurse confirmed the table's inappropriate height. Facility policy required staff to assist residents to a comfortable dining position, but this assistance was not provided.
A resident with Alzheimer's Disease experienced pain due to thick, discolored, and long toenails that were not evaluated or treated by a podiatrist. Despite the facility's process for monthly podiatry visits and a binder for tracking ancillary services, there was no evidence the resident received podiatric care since admission. Staff acknowledged the condition and pain, but the necessary referral and treatment were not provided.
A resident with multiple chronic conditions and moderate cognitive impairment was not seen by a physician every 30 days during the first 90 days of admission, as required. Facility records and staff interviews confirmed the absence of documented physician or nurse practitioner visits for two consecutive months, resulting in noncompliance with mandated visit intervals.
Three residents experienced medication administration errors when nurses failed to follow physician orders, including not checking respirations before giving an opioid, not verifying gastrostomy tube placement or flushing before medication administration, and not wearing gloves when handling a hazardous drug. These actions resulted in a medication error rate of 12%.
A resident with multiple chronic conditions did not receive timely follow-up dental care as recommended by a hygienist, despite documented need for additional cleaning and preventative services. Observation revealed decayed and missing teeth, and the resident reported oral pain. The Social Services Director was unable to find evidence that the recommended dental treatment was provided.
A resident with dysphagia, muscle weakness, and severe cognitive impairment was not given ordered adaptive eating equipment, including a plate guard and two-handled cup with lid, during meals. This resulted in food and drink spills and increased dependence on staff, despite documented recommendations and facility policy requiring these devices.
Two residents were exposed to infection risks when a nurse reattached a contaminated gastrostomy tube cap after it fell on the floor, and a CNA touched the inside of a nosey cup with bare hands and long fingernails before assisting a resident with a drink. Both actions were acknowledged by staff as breaches of infection control policy.
A resident with significant mobility impairments and dependent on staff for ADLs was found in bed with the call light on the floor and not within reach. An LPN confirmed the call light was not accessible, and the DON stated that the expectation is for call lights to be within reach to allow residents to request assistance. Facility policy also requires call lights to be easily accessible to residents.
A facility failed to follow its medication administration policy when an LN documented administering medication to a resident, despite another nurse actually administering it. The resident, with a history of diabetes and depression, refused the LN's presence, leading to another nurse administering the medication. However, the LN signed the MAR, resulting in inaccurate documentation.
A resident was found storing prescribed medications in an unlocked bedside drawer, contrary to the facility's policy requiring medications to be stored in a locked cart. The resident, with a history of congestive heart failure, had medications including a blood thinner and diuretic in their room. A nurse confirmed the medications were prescribed to the resident and should have been securely stored, as per policy.
A resident's room in an LTC facility had a persistently sticky floor, posing an infection control concern. The issue was attributed to the resident frequently spilling his urinal and his roommate urinating on the floor. Despite daily mopping, the floor remained sticky, and staff interviews confirmed the ongoing problem. The infection preventionist acknowledged the sticky floor as an infection control issue.
A facility failed to administer medications on time to three residents due to technical issues with the medication dispensing software. Despite assistance from the DON, an LVN was unable to complete the morning medication pass, resulting in delays for residents with conditions such as COPD, hypertension, and diabetes. The facility's policy requires medications to be given within one hour of the prescribed time, which was not met in this instance.
A resident with COPD did not receive an incentive spirometer (IS) as prescribed, despite documentation indicating otherwise. The resident was supposed to receive IS treatments four times daily, but staff failed to provide the device, leading to a potential adverse impact on the resident's health.
The facility failed to properly store and label medications, leading to potential errors. A discontinued medication was not removed from a medication cart, which was also left unlocked and unattended. Additionally, there was a discrepancy between the physician's instructions and the pharmacy label for Pradaxa, risking medication errors. A resident expressed concerns about missing medications.
A resident with specific dietary preferences did not receive a requested meal change, resulting in hunger throughout the night. Despite submitting a request for a grilled cheese sandwich instead of raviolis, the kitchen staff did not fulfill the request due to miscommunication and lack of awareness of alternate meal procedures. The resident was given snacks instead, which he did not want.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with severe cognitive impairment and a very high elopement risk score of 14. The resident had diagnoses including unspecified dementia with anxiety and mood disturbance and was care planned with a goal that the resident would not leave the facility without a responsible party, with an intervention to assure an identification band or other form of identification was in place. Physician orders directed staff to check the placement of a wander guard on the resident’s left ankle every shift, monitor skin, and notify the physician as needed. Staff interviews revealed that the resident frequently attempted to elope and would remove or cut off the wander guard. According to the Director of Staff Development, the resident left the facility through a door near the smoking area, unlatched a gate, and walked to a road behind the facility, where a truck picked the resident up and transported the resident to a nearby apartment complex, and a person there called 911. A nurse who was present on the day of elopement stated she did not hear an alarm and confirmed the resident had a history of trying to elope and manipulating or removing the wander guard. During an observation in the resident’s room, the resident was not wearing an identification band, and the nurse confirmed this finding. The DON acknowledged that a wander guard is only effective when worn and that residents have the right to be safe in the facility. The facility’s wandering and elopement policy stated that the facility will identify residents at risk of unsafe wandering and strive to prevent harm.
Failure to Prevent Elopement in High-Risk Resident with Dementia
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a high risk for elopement from leaving the premises unsupervised and undetected. The resident, who was admitted with a diagnosis of dementia and assessed as having no cognitive understanding, had a documented high risk for wandering and elopement. The care plan identified the resident as being at risk for elopement due to dementia. Despite these assessments, the resident began exhibiting exit-seeking behaviors several days prior to the incident, which was noted by staff. On the day of the incident, the resident was last seen in their room by the DON, but was later found missing and subsequently located by the police after being gone for 45 minutes. Staff interviews confirmed awareness of the resident's exit-seeking behavior and high elopement risk, but increased supervision was not implemented. Facility policy required identification and intervention for residents at risk of unsafe wandering, but these measures were not effectively carried out for this resident.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards, as evidenced by the presence of expired or undated food items in both the freezer and dry food cupboards. During a kitchen tour with the Dietary Supervisor, surveyors observed an undated bag of cream puffs in the dessert freezer, as well as undated dried parsley, brown gravy mix, and a bowl of cereal in a covered plastic container in the cupboards. Additionally, a powdered cherry jello mix was found with a preparation date but was past its use-by date. The Dietary Supervisor confirmed these findings and stated that dietary staff are expected to properly label and discard expired foods. The Registered Dietician also confirmed that undated or expired food should be thrown out. Review of the facility's policy indicated that opened dry food items must be tightly closed, labeled, and dated.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for three residents. For one resident with moderate cognitive impairment and a history of mental illness, a licensed nurse left a cup containing eight medications at the bedside, including an antibiotic, vitamins, and other prescribed medications. The nurse did not observe the resident taking the medications and documented administration in the electronic Medication Administration Record before confirming ingestion. The resident was not authorized to self-administer medications, and facility policy prohibits leaving medications at the bedside unless a physician and the interdisciplinary team have determined the resident is capable of self-administration. Another resident, who had undergone cervical spine fusion and was admitted with a cervical disc disorder, was observed wearing a cervical collar. The resident reported being told by nursing staff to always wear the collar per doctor's order. However, the physician's order for the cervical collar had been discontinued, and the surgical incision had resolved with no further treatment ordered. Nursing staff failed to clarify or follow the current physician's order regarding the use of the cervical collar. A third resident with dysphagia and a gastrostomy tube (GT) had a physician's order to check GT placement and flush the tube with water before and after medication administration. During medication administration, a nurse did not check the GT placement or perform a pre-flush as ordered, instead administering the medication without confirming tube position or patency. The nurse acknowledged not following the order and not using a stethoscope to check placement, which was required for the resident's safety. Facility policy requires checking tube placement and flushing before and after medication administration.
Failure to Ensure Wanderguard Use for Resident with Wandering Risk
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of wandering and exit-seeking behavior was not wearing a wanderguard bracelet as ordered. The resident's medical record included a physician's order for a wanderguard to be worn on the right ankle, with nursing staff required to check its placement every shift. Despite this, during an observation, the resident was seen without the wanderguard, even though the Medication Administration Record for that shift had been signed off by the nurse as if the device was in place. Staff present at the time confirmed the absence of the wanderguard and speculated that the resident may have removed it. The facility's policies on wandering and elopement, as well as on assistive devices, require identification of at-risk residents and the provision of safety interventions such as wanderguards. The Director of Nursing confirmed in an interview that the resident should always have the wanderguard on as ordered. The failure to ensure the resident was wearing the wanderguard as prescribed constituted a lapse in following safety protocols for residents at risk of wandering.
Failure to Ensure PRN Psychotropic Medication Order Included Required Stop Date
Penalty
Summary
A deficiency occurred when the facility failed to identify and address an irregularity in the medication regimen review for a resident admitted with anxiety. The resident had a physician's order for lorazepam, an anti-anxiety psychotropic medication, to be administered every four hours as needed (PRN), but the order did not include a required stop date. The medication was administered frequently over several months, as evidenced by the Medication Administration Record, which showed the resident received lorazepam 31 times in March, 38 times in April, and 27 times in May. During an interview, the Pharmacy Consultant confirmed that the PRN lorazepam order lacked an end date and stated that a medication regimen review should have prompted a recommendation to the physician to include a 14-day stop date, in accordance with regulations. Facility policies reviewed indicated that PRN psychotropic medications require clear physician documentation for continued use and that monthly medication regimen reviews should identify medications that need to be tapered, discontinued, or changed. The failure to follow these procedures resulted in the resident potentially receiving unnecessary medication.
Failure to Complete Significant Change Assessment After Development of Stage Four Pressure Ulcer
Penalty
Summary
The facility failed to initiate a significant change in status assessment (SCSA) for a resident who developed a stage four pressure ulcer to the sacrococcyx. The resident, admitted with Guillain-Barre Syndrome and adult failure to thrive, was found to have a stage four pressure ulcer as documented in multiple wound care consult notes. Despite the presence of this severe wound, which was being treated per physician orders, the required SCSA was not completed within the mandated timeframe after the ulcer was identified. During interviews and record reviews, the MDS Coordinator confirmed that the SCSA was not performed and acknowledged that it should have been initiated 14 days after the wound was established. The Director of Nursing stated that it was her expectation for MDS assessments to be completed properly and on time. Facility policy also required a comprehensive assessment following a significant change in a resident's condition, in accordance with OBRA regulations, but this was not followed in this case.
Failure to Implement and Monitor Care Plan for Resident Self-Administering Medications
Penalty
Summary
The facility failed to ensure that a comprehensive care plan to monitor newly identified behaviors was followed for a resident with a history of schizophrenia, PTSD, and other mental disorders. The resident, who had moderate cognitive impairment and was under conservatorship, was observed taking a bottle of vitamin D3 from his closet and stated he had been self-administering the medication daily, contrary to the prescribed every-other-day regimen. Staff interviews revealed that the nursing staff were unaware of the presence of this medication in the resident's room, and facility policy did not allow residents to keep medications at bedside or self-administer medications. The resident also disclosed that he had collected other medications in his room since admission and was unsure of their identity or whether he had reported not taking them. Further interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that they were not aware of the resident storing or self-administering medications. The care plan had been updated to address the resident's psychosocial behaviors, such as hiding medications and ordering over-the-counter medications from outside sources, but there was no evidence of behavior monitoring documented in the clinical records or Medication Administration Record (MAR). The facility's policy required comprehensive care plans with measurable objectives and timetables, but this was not implemented for the resident's newly identified behaviors.
Resident Seated at Inappropriately High Dining Table During Meal
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia and diabetes mellitus, was seated at a dining room table that was too high for comfortable eating during a lunch meal. The resident's Minimum Data Set indicated severely impaired cognition and a need for set up or clean-up assistance with eating, and the care plan identified moderate nutritional risk with interventions to assist the resident to the dining room for meals and provide queuing and feeding assistance as needed. During observation, staff placed the resident's lunch tray on a table that was at chest level, making it difficult for the resident to eat comfortably. A licensed nurse confirmed the table was too high, and the Director of Nursing stated that staff are expected to assist residents to a comfortable position while dining. The facility's policy required assistance with meals as needed, but this was not provided in this instance.
Failure to Provide Timely Podiatry Care for Resident with Painful Toenails
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease was not evaluated or treated by a podiatrist despite having thick, discolored, and long toenails. The resident was admitted to the facility in January 2025, and concerns about his toenails were first noted by his responsible party in March, who observed that the toenails were long and appeared to have fungus. The responsible party did not attempt to trim the nails due to their thickness. On observation, the resident's toenails were found to be thick, long, curved inward, and discolored yellow and black. The resident reported foot pain, and a CNA and a licensed nurse both acknowledged the condition of the toenails, with the nurse stating that the nails appeared to have fungus and could cause pain or potentially cut the skin. Further investigation revealed that the facility had a process for scheduling monthly podiatrist visits and maintaining a binder listing residents needing ancillary services, including podiatry. However, there was no evidence that the resident had received any podiatric care since admission. The facility's policy indicated that social services were responsible for making referrals for ancillary services such as podiatry, but this was not done for the resident in question.
Failure to Provide Timely Physician Visits During Initial Admission Period
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required during the first 90 days of admission. Specifically, documentation and interviews confirmed that the resident was not seen by the attending physician every 30 days, as mandated by both facility policy and federal regulations. The Medical Records Director verified that there was no evidence of a physician or nurse practitioner visit in the resident's medical chart for two consecutive months. The Medical Director acknowledged challenges in maintaining the required visit schedule due to difficulties in finding practitioners to assist at the facility. The resident in question was admitted with multiple diagnoses, including diastolic heart failure, sleep apnea, and peripheral vascular disease, and had moderate cognitive impairment as indicated by a BIMS score of 12. During interviews, the resident expressed uncertainty about the frequency of physician visits, and the DON confirmed the expectation for monthly visits during the initial 90-day period. The lack of documented visits for November and December was substantiated through record review, confirming the deficiency in meeting required physician visit intervals.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12% error rate for three sampled residents. In one instance, a licensed nurse administered Dilaudid 6 mg to a resident with chronic pain without first counting the resident's respirations, as required by the physician's order. The nurse acknowledged not following the order, which specified withholding the medication if the resident's respiratory rate was less than 12. Another incident involved a nurse administering medication via gastrostomy tube (GT) to a resident with dysphagia without checking the tube's placement or flushing it with water prior to administration, both of which were required by the physician's order. The nurse admitted to not performing these steps, stating she forgot her stethoscope and did not verify the tube's position or perform the pre-flush for safety. A third deficiency occurred when a nurse handled and administered Finasteride, a hazardous drug, to a resident with a cancer diagnosis without wearing gloves, contrary to the medication's instructions and facility policy. The nurse acknowledged not following the required safety precautions, which were clearly indicated on the medication packaging and in the physician's order. Facility policies reviewed confirmed the necessity of adhering to prescriber orders and infection control procedures during medication administration.
Failure to Provide Timely Dental Care Following Clinical Recommendation
Penalty
Summary
The facility failed to ensure that a resident received timely dental treatment as recommended by a dental hygienist. The resident, who was admitted with diagnoses including diastolic heart failure, sleep apnea, and peripheral vascular disease, was evaluated by a traveling hygienist who documented heavy calculus and inflammation, and recommended additional cleaning visits, a fluoride varnish, and regular preventative maintenance. The hygienist specifically advised a follow-up visit in three months. Despite these recommendations, there was no evidence that the resident received the necessary follow-up dental care. During an observation, the resident was noted to have several decayed and missing teeth and reported experiencing mouth and tooth pain. The Social Services Director confirmed that although dental services were available monthly and a tracking binder was maintained, there was no documentation of the recommended dental treatment being provided to the resident.
Failure to Provide Adaptive Eating Equipment During Meals
Penalty
Summary
A deficiency occurred when a resident with dysphagia, generalized muscle weakness, and severe cognitive impairment was not provided with adaptive eating equipment as ordered and recommended. During a meal observation, the resident did not have a plate guard or a two-handled cup with a lid, resulting in food spilling off the plate and onto the table and clothing. The CNA present stated that she frequently reminded kitchen staff to provide these items, and the SLP confirmed that the resident should have had these assistive devices during meals, as previously recommended to support self-feeding and prevent spills. Record reviews showed that the resident's meal ticket, SLP evaluation, and physician orders all specified the need for a plate guard and two-handled cup with lid at all meals. Facility policy also required that adaptive devices be provided as ordered and documented on tray cards. Despite these documented needs and orders, the resident did not receive the necessary adaptive equipment during the observed meal.
Failure to Maintain Infection Control During Enteral Medication Administration and Mealtime Assistance
Penalty
Summary
A deficiency occurred when a licensed nurse, while administering medications via a gastrostomy tube (GT) to a resident with dysphagia, dropped the red cap of the GT port onto the floor and then reattached the contaminated cap to the GT port. The nurse acknowledged that this action could result in infection, and the facility's policy required strict aseptic technique during enteral nutrition administration. The resident's medical record indicated a need for regular GT tube flushing before and after medication administration. Another deficiency was observed when a certified nursing assistant (CNA) assisted a resident with a history of COVID-19 and severe cognitive impairment during mealtime. The CNA, while separating two stacked nosey cups, touched the inside of the cup with her bare hands and long fingernails before pouring a drink and assisting the resident. Both the infection preventionist and the CNA acknowledged that this practice did not adhere to infection control standards, and the facility's policy required following standard precautions in all situations.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia and hemiparesis, who required substantial to maximal assistance with activities of daily living and was dependent for toileting, was found in bed with the call light on the floor and not within reach. During observation and interview, a licensed nurse was unable to locate the call light on the bed and confirmed it was on the floor, acknowledging that it should have been within the resident's reach. The resident's care plan indicated a need for assistance due to bed-bound status and included an intervention to encourage the use of the call light for assistance. The Director of Nursing stated that the expectation was for the call light to be within reach, noting that its absence could make it difficult for the resident to request assistance for needs such as pain medication, toileting, and transferring. Review of the facility's policy and procedure on answering call lights confirmed that staff are required to ensure the call light is within easy reach of residents who are in bed or confined to a chair.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to adhere to its medication administration policy and procedure for a resident, resulting in inaccurate documentation. The policy required that the individual administering medication must document the administration on the electronic Medication Administration Record (eMAR) with their signature and title. However, a Licensed Nurse (LN) documented administering medication to a resident when, in fact, another nurse administered the medication on their behalf. This discrepancy was confirmed during a review of the Medication Administration Record (MAR) and interviews with the involved LN and the Director of Nursing (DON). The resident involved had a history of type 2 diabetes with diabetic neuropathy and major depressive disorder. The resident scored a 15 on the Brief Interview for Mental Status, indicating intact memory. The resident refused to allow the LN into their room, preferring another nurse to administer medications. Despite this, the LN prepared the medications and had another nurse administer them, but still signed the MAR as if they had administered the medications themselves. This occurred on multiple occasions, as evidenced by the MAR records, leading to inaccurate documentation and potential confusion.
Medication Storage Deficiency in Resident's Room
Penalty
Summary
The facility failed to ensure the safe storage of medications for one resident, who was found to have medication stored in an unlocked drawer of their bedside table. This was observed during an interview and record review, where the resident produced a small container with capsules and a pill, stating that they sometimes received incorrect dosages and would store the medication in the drawer when the nurse was not present. The resident had a history of diastolic congestive heart failure and was prescribed medications including a blood thinner, which they identified as being stored in their room. Licensed Nurse B confirmed that the medications found in the resident's room were indeed prescribed to the resident and should have been stored in the locked medication cart, as per the facility's policy. The Director of Nurses also confirmed that medications were to be stored in the locked cart and not in resident rooms. This oversight had the potential for unauthorized access to medications not prescribed to others, highlighting a lapse in adherence to the facility's medication storage policy.
Infection Control Concern Due to Sticky Floor in Resident's Room
Penalty
Summary
The facility failed to maintain a sanitary environment for a resident, leading to a potential infection control issue. The deficiency was identified when the floor in the resident's room was observed to be sticky, with visible footprints and tracks from a wheelchair. The resident confirmed that the floor was consistently sticky. The housekeeper acknowledged the issue, stating that the resident frequently spilled his urinal on the floor, and his roommate also contributed to the problem by urinating on the floor and tracking it with his wheelchair. Despite daily mopping, the floor remained sticky. Interviews with various staff members, including licensed nurses, a certified nurse assistant, and the housekeeping supervisor, confirmed the persistent issue of the sticky floor. The facility's infection preventionist also recognized the sticky floor as an infection control concern. The housekeeping supervisor admitted to being unaware of the specific cause of the sticky floor until the day of the interview, despite the problem persisting for several months since the resident moved into the room.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications to three residents in a timely manner as per physician's orders and professional standards. This deficiency was identified during an observation, interview, and record review. The facility's policy required medications to be administered safely and timely, in accordance with prescribed orders. However, on the day of the survey, three residents did not receive their morning medications within the required time frame, which is one hour before or after the prescribed time. Resident 2, who has chronic obstructive pulmonary disease, kidney failure, gout, and hypertension, reported not receiving all her morning medications. The Medication Administration Record (MAR) confirmed that her 8:00 am medications, including allopurinol, aspirin, vitamin B12, and metoprolol, were not signed as given. Similarly, Resident 3, with conditions such as hypertension, glaucoma, depression, and dementia, had multiple medications not administered on time, including cyclosporine emulsion, docusate sodium, and several others. Resident 4, diagnosed with diabetes, heart disease, seizures, and hypertension, also had numerous medications not signed as given, including metformin, hydralazine, and gabapentin. The delay in medication administration was attributed to technical issues faced by LVN A, who was logged out of the computer software used for dispensing medications multiple times. Despite assistance from the Director of Nursing (DON), the issue persisted, leading to incomplete medication passes for the residents. The DON confirmed that the medications were not administered within the required time frame, as per the facility's policy.
Failure to Provide Incentive Spirometer to Resident with COPD
Penalty
Summary
The facility failed to provide an incentive spirometer (IS) to a resident with chronic obstructive pulmonary disease (COPD), despite having a physician's order for its use. The resident was admitted with diagnoses including COPD, kidney failure, and dysphagia, and was supposed to receive IS treatments four times per day for 14 days. However, during an observation and interview, it was revealed that the resident had never received the IS since being admitted to the facility, and there was no IS present in the resident's room. The facility's records indicated that the IS treatments were documented as given, but interviews with staff revealed discrepancies. A registered nurse confirmed the absence of the IS in the resident's room, and a licensed vocational nurse admitted to documenting the treatment as given without actually administering it, mistakenly believing that a respiratory therapist was responsible for the treatment. This failure to provide the prescribed respiratory care had the potential to adversely affect the resident's health and well-being.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, leading to potential medication errors and drug misuse. A discontinued medication, glipizide, was not removed from an active medication drawer in Medication Cart B2, and was mistakenly prepared for administration to a resident. This resident, who was admitted with diagnoses including type 2 diabetes, liver failure, heart disease, and depression, was at risk of receiving a medication that should have been discontinued. Additionally, the medication cart was observed unlocked and unattended, which is against the facility's policy for medication storage. Furthermore, there was a discrepancy between the physician's instructions on the Medication Administration Record (MAR) and the pharmacy label instructions for Pradaxa, a medication used to prevent blood clotting. The MAR indicated a dosage of 75 mg, two tablets once a day, while the pharmacy label indicated 150 mg, one tablet. This inconsistency was confirmed by the Licensed Vocational Nurse, highlighting a potential for medication errors. The resident expressed concerns about missing medications, indicating a lack of confidence in the medication administration process.
Failure to Provide Requested Meal Leads to Resident Hunger
Penalty
Summary
The facility failed to provide a nourishing meal to a resident, resulting in the resident being hungry throughout the night. The resident, who had intact cognition and specific food preferences documented in his Nutrition Care Plan, requested a change to his dinner menu from raviolis to a grilled cheese sandwich, salad, and chicken noodle soup. He submitted this request to a Certified Nursing Assistant (CNA) by 9:15 am. However, when dinner was served, the resident received raviolis, which he sent back, expecting the requested substitute meal. The kitchen staff did not fulfill this request, and the resident was instead given snacks, which he did not want. The incident was further complicated by a lack of communication and understanding among the staff. The CNA who took the resident's request to the kitchen was informed by a kitchen staff member that the kitchen was closed and no more food would be prepared. The Dietary Coordinator later acknowledged that the Dietary Assistant was unaware of the procedure for alternate meals and did not relay the resident's request. This miscommunication resulted in the resident not receiving the meal he requested and being left hungry that night.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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