Driftwood Healthcare Center - Hayward
Inspection history, citations, penalties and survey trends for this long-term care facility in Hayward, California.
- Location
- 19700 Hesperian Boulevard, Hayward, California 94541
- CMS Provider Number
- 555533
- Inspections on file
- 22
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Driftwood Healthcare Center - Hayward during CMS and state inspections, most recent first.
Two residents with acute and chronic respiratory failure did not receive tracheostomy care according to MD orders and the care plan. For one resident, the RT repeatedly cleaned and reused the trach inner cannula over multiple days instead of changing it daily as ordered, with documentation showing cleaning on several specific days rather than daily replacement. For another resident, observation showed that required emergency trach equipment, including a spare inner cannula, was not kept at the bedside, despite the RT, RN supervisor, DON, and the respiratory care plan all indicating that necessary emergency supplies should be readily available to maintain a clear, open airway.
A resident with a history of stroke, depression, and intact cognition had an active PRN order and care plan for Oxycodone to manage moderate to severe pain, but did not receive the medication when requested because the facility had run out of it. The resident reported waiting over 24 hours for pain relief, feeling upset and frustrated, and not wanting to get out of bed without the pain medication. The CN on duty acknowledged the resident’s pain complaint and request for Oxycodone but did not administer it due to lack of stock, while the RN supervisor confirmed that pain medications should be given as ordered and that the facility’s pain management policy required administering ordered pain medication.
Two residents engaged in a physical altercation on a patio, during which they faced each other in wheelchairs, hit one another, and yelled profanities, resulting in one cognitively intact resident sustaining a cut to the hand and pain in the ear and later reporting fear and feeling unsafe. The other resident involved had severe cognitive impairment and did not recall the event. A third resident reported the incident to nursing staff, and social services notes documented that the injured resident admitted striking the other resident out of frustration. These events occurred despite a facility abuse prevention policy requiring protection of residents from abuse by anyone, including other residents.
Two residents sharing a bathroom became involved in a verbal dispute that escalated into shoving and a physical assault with a cane while a CNA was present. One resident had intact cognition and a documented history of aggressive behavior with care plan interventions that included separating involved parties, while the other had moderate cognitive impairment and late-onset cerebellar ataxia. The CNA, unfamiliar with the residents and working her first shift at the facility, attempted only verbal de-escalation and did not physically separate the residents or call for help until after one resident struck the other. The DON later confirmed that staff, including registry staff, were expected by policy to immediately separate residents during verbal altercations or call for assistance, and written policies required protecting residents from abuse and separating residents involved in altercations.
The facility failed to ensure nursing staff had physician orders, policy, and training for using an enteral tube clog removal tool on two residents. The tool was used without proper authorization or training, potentially risking enteral tube perforation. The DON confirmed no training was provided, and the facility's policy lacked procedures for the tool's use.
The facility failed to properly document and destroy 14 controlled medications found in the DON's cabinet, leading to potential drug diversion. These medications, associated with discharged residents, lacked proper documentation and were not destroyed according to state law and facility policy. The DON admitted to not knowing the procedure for destroying medications without documentation, and the facility's method of using water for destruction was deemed unacceptable.
The facility failed to ensure proper puree preparation for residents on a pureed diet, as observed when a cook added excess cooking water to vegetables, resulting in a diluted and bland puree. Despite previous training, the cook did not follow the recipe or taste the food, leading to a product that lacked flavor and proper consistency, putting residents at risk for decreased nutritional intake.
The facility did not follow prescribed menu portions for residents, serving incorrect amounts of orzo, baked apples, and Boston cream pie. A Dietary Aide served 1/2 cup of orzo instead of the required 1/3 cup for CCHO diet residents, used a #12 scoop for baked apples instead of a #10 scoop, and provided a 1x2 inch square of Boston cream pie instead of the specified 2x3 inch portion.
The facility failed to clean the juice machine according to the manufacturer's instructions, risking foodborne illness for 56 residents. A kitchen aide soaked the juice bar gun in hot water instead of lukewarm water and did not perform the required weekly flushing of hoses and lines. There was no log or cleaning schedule to document these activities.
A long-term care facility failed to follow infection control policies, including using non-sterile gloves for tracheostomy suctioning, neglecting hand hygiene between residents, and lacking necessary equipment for respiratory care. Additionally, open system tube feeding lines were used beyond the recommended time, and a wound was not cleansed as per physician's orders, increasing infection risks.
A resident with quadriplegia and cerebrovascular disease did not receive complete fingernail care, resulting in long, pointed nails on one hand. The resident was dependent on staff for personal hygiene and expressed a preference for evenly clipped nails. Interviews with staff indicated that CNAs were responsible for trimming non-diabetic residents' nails, and the importance of nail care for dignity and infection prevention was emphasized.
A resident experienced a 21.27% weight gain over a year due to the facility's failure to implement dietician recommendations for tube feeding adjustments. Despite the resident's complex medical history and reliance on tube feeds, the facility continued administering Glucerna 1.5 at 70 ml/hour for 24 hours, contrary to the dietician's advice. This oversight led to significant weight gain, highlighting a deficiency in the facility's management of the resident's nutritional needs.
A resident receiving hemodialysis at an LTC facility did not receive proper care due to staff's lack of knowledge about managing arterial-venous fistula complications and failure to administer Renagel as prescribed. The resident missed several doses of the medication during dialysis days, leading to elevated phosphorus levels. The facility's policy on hemodialysis care was not adequately followed, indicating a need for improved staff training and adherence to care protocols.
The facility did not ensure the Kitchen Manager completed the required six hours of inservice training on California dietary service requirements. The KM, although certified as a dietary manager, confirmed the lack of training, and the Registered Dietician had not developed or administered it. This resulted in the KM lacking necessary competencies, potentially risking residents' safety.
A resident admitted for pain management and rehabilitation after a hip fracture developed a stage 2 pressure ulcer that worsened and became infected due to the facility's failure to develop a care plan, monitor the ulcer, provide a pressure-reducing mattress in a timely manner, and reposition the resident consistently.
The facility failed to secure medications for 76 residents when three medication carts were found unlocked and unattended. A nurse confirmed the carts were usually locked to prevent unauthorized access, and the DON stated that nurses are expected to lock the carts for resident safety. The facility's policy requires medication carts to be locked after use.
Failure to Follow Tracheostomy Orders and Maintain Emergency Airway Equipment
Penalty
Summary
The facility failed to provide tracheostomy care consistent with physician orders and professional standards for two residents with respiratory failure. One resident, admitted with acute respiratory failure and with a physician’s order dated 12/7/23 to have the tracheostomy inner cannula changed daily by respiratory therapy, did not have the inner cannula changed for a total of five days, including three consecutive days. Progress notes from 2/13/26 through 2/22/26 documented that the inner cannula was cleaned, rather than changed, on multiple dates (2/13/26, 2/16/26, 2/20/26, 2/21/26, and 2/22/26). The respiratory therapist reported cleaning and reusing the inner cannula for a couple of weeks because replacement inner cannulas were not available, and acknowledged that the inner cannula should have been changed daily per the physician’s order. The RN supervisor also stated it was important to change the inner cannula daily so it would not be clogged and that reusing it multiple times could have been a risk for infection. A second resident, admitted with chronic respiratory failure and with a tracheostomy order specifying a Shiley Covidien size 4 tube, did not have all necessary emergency tracheostomy equipment at the bedside. During observation and interview with the respiratory therapist, the resident was noted to be without a spare inner cannula readily available at bedside, despite the therapist stating that a spare inner cannula was part of the necessary emergency tracheostomy equipment that should be present. The RN supervisor stated that emergency tracheostomy equipment, including the inner cannula, was important to have at bedside to prevent the tracheostomy hole from closing. The DON also stated that emergency equipment, including inner cannulas, should have been at residents’ bedsides. The resident’s respiratory care plan documented the presence of a tracheostomy with risk for congestion and SOB, with a goal to maintain a clear, open airway and an approach of keeping all necessary emergency supplies readily available at all times, which was not followed.
Failure to Provide Ordered PRN Oxycodone for Pain
Penalty
Summary
The facility failed to provide ordered pain medication to a resident with a physician’s order for Oxycodone 7.5 mg PO every 4 hours PRN for moderate to severe pain. The resident, admitted with diagnoses including cerebral infarction and depression, had a BIMS score of 14, indicating intact cognition, and a care plan problem of altered comfort and daily activity due to pain, with an approach to administer Oxycodone as ordered. On the date in question, the Medication Administration Record showed that the resident did not receive any Oxycodone. The resident reported having to wait over 24 hours for Oxycodone because the facility had run out of the medication, stating they felt upset and frustrated and did not want to get out of bed without their pain medication. The charge nurse assigned to the resident’s unit that day stated the resident complained of moderate generalized body pain and requested Oxycodone, but the nurse did not administer it because the facility had no Oxycodone available. The nurse reported informing the resident that there was no more Oxycodone and that it had been ordered but had not yet arrived, and confirmed it did not arrive during that shift. The registered nurse supervisor stated that when residents complain of pain, pain medications should be given as ordered by the physician and that relieving pain is important because it could increase irritability and vital signs. The facility’s pain management policy required administering pain medication as ordered by the physician, but this was not followed for this resident on the identified date.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse when they engaged in a physical altercation with each other. One resident, who was cognitively intact with a BIMS score of 13/15, reported that another resident hit him on the head with a closed fist, causing pain to his right hand and left ear and leaving him feeling fearful and unsafe in the facility. The other resident involved had severe cognitive impairment, with a BIMS score of 4/15, and later stated he had no recollection of the altercation. Progress notes documented that a third resident witnessed the incident and alerted nursing staff that the two residents were facing one another in their wheelchairs on the patio, hitting each other and yelling profanities. Nursing notes indicated that the cognitively intact resident sustained a cut on his right knuckle and complained of pain in his left ear. Social services documentation showed that this resident acknowledged striking the other resident and justified his actions by stating he felt frustrated. These events occurred despite the facility’s Abuse Prevention Program policy, which states that the administrator will protect residents from abuse by anyone, including other residents.
Failure to Timely Intervene in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate interventions during a resident-to-resident altercation, allowing a verbal dispute to escalate into a physical altercation without timely staff separation. Resident 1, admitted in November 2023 with acute respiratory syndrome and an anxiety disorder, had a Brief Interview for Mental Status (BIMS) score of 15 on 9/30/25, indicating intact cognition. Resident 1’s care plan dated 11/12/24 documented a history of aggressive behavior toward other residents, with interventions that included emphasizing the resident’s responsibility for physical aggression, describing possible outcomes to self and others, and neutralizing situations by separating involved parties. Resident 2, admitted in June 2025 with late-onset cerebellar ataxia and a BIMS score of 12 on 9/26/25 indicating moderate cognitive impairment, shared a bathroom with Resident 1’s room. According to Resident 2’s interview, the incident occurred early one morning in November 2025 when Resident 2 used the shared bathroom and heard loud yelling from the adjacent room. Resident 2 entered Resident 1’s room through the shared bathroom and observed a staff member present, then told the staff to address the yelling. Resident 2 reported that Resident 1 began yelling and ordered Resident 2 to leave the room, leading to a verbal argument in which they were “challenging each other.” Resident 2 stated that the argument escalated into a physical altercation when Resident 1 struck Resident 2 on the head with a cane, and that staff did not intervene until after the physical contact occurred, at which point male nursing staff separated them. CNA 1, who was providing care to Resident 1’s roommate at the time, stated it was her first time working at the facility and she did not know Resident 2 was assigned to another room. She reported that Resident 2 entered through the shared bathroom and requested that she make the roommate stop yelling. CNA 1 said Resident 1 became upset, began arguing with Resident 2, and told Resident 2 to get out of the room. CNA 1 stated she also instructed Resident 2 to leave, but both residents continued to yell. She observed Resident 1 get up from the bed and both residents began shoving each other. CNA 1 did not physically intervene because she did not want to get in the middle of them and instead attempted verbal de-escalation while “keeping an eye on them” as they continued to argue. She reported that she saw Resident 1 grab a cane and hit Resident 2 on the head, and only then called for assistance, after which male nursing staff separated the residents. The DON stated staff, including registry staff, were expected to immediately separate residents as soon as a verbal altercation occurs or call for assistance if unable to safely manage the situation. Facility policies on abuse prevention and resident-to-resident altercations required protecting residents from abuse and separating residents involved in altercations and instituting measures to calm the situation.
Improper Use of Enteral Tube Clog Removal Tool
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary physician orders, facility policy, and training to use an enteral tube clog removal tool for two residents receiving medications through an enteral tube. This deficiency was identified during observations and interviews with nursing staff and the Director of Nursing (DON). The nursing staff used a plastic clog removal tool on the enteral tubes of two residents without a physician's order or proper training, which could potentially lead to enteral tube perforation or gastrointestinal damage. Resident 274 was admitted for gastrostomy care, tracheostomy care, muscle wasting and atrophy, and chronic respiratory failure. The resident had a physician's order to use a declogger when indicated, but the nursing staff used the clog removal tool without following the facility's policy or receiving training. Similarly, Resident 45, admitted for gastrostomy care, tracheostomy care, chronic respiratory failure, and dysphagia, did not have a physician's order for the use of a clog removal tool, yet the tool was used by the nursing staff. The Director of Nursing acknowledged that there was no inservice or training provided on the use of the clog removal tool and that the facility's policy did not include procedures for its use. The Director of Staff Development confirmed that the orientation record for the involved nurse did not include training on the clog removal tool. The nursing staff was expected to unclog enteral tubes by massaging the tube or using warm water or an enzymatic solution, and to contact the provider for tube replacement if necessary.
Improper Documentation and Destruction of Controlled Medications
Penalty
Summary
The facility failed to ensure the proper documentation and destruction of 14 controlled medications, which were found in the Director of Nursing's (DON) controlled medications cabinet. These medications, which included Norco, Hydromorphone, Lorazepam, Morphine, and Alprazolam, were not destroyed according to state law and facility policy, leading to a potential risk for drug diversion. The medications were associated with discharged residents, and many lacked proper documentation, such as receipt dates, discontinuation dates, and count sheets. During an interview, the DON stated that the primary pharmacist, Pharmacist Consultant 1 (PC 1), was responsible for the monthly destruction of controlled medications alongside the DON. However, the DON admitted to not knowing the procedure for destroying medications without proper documentation. The facility's method of using water to dissolve medications was also found to be unacceptable by Pharmacist Consultant 2 (PC 2), who was completing documentation for the destruction of the medications. The facility's policies on medication destruction and disposal were reviewed, revealing that the facility was expected to destroy controlled medications within 90 days of receipt and to use substances like coffee grounds or kitty litter for destruction, not water. The policies also required documentation of the destruction process in a drug destruction log book, as per state and federal law. The failure to adhere to these policies resulted in the controlled medications not being destroyed in a timely and compliant manner.
Improper Puree Preparation in Dietary Services
Penalty
Summary
The facility failed to ensure that cooks had the necessary education and skills to properly puree food for residents on a pureed diet. This deficiency was observed during multiple instances where a cook, identified as C-1, improperly processed vegetables by adding excess cooking water to the blender, resulting in a diluted and watery puree. The cook did not taste the pureed vegetables upon completion, which is a required step according to the facility's procedure. This improper preparation led to pureed food that was bland, lacked flavor, and did not meet the expected texture and consistency. During a review of the facility's recipe for pureed carrots, it was noted that water was not listed as an ingredient, yet it was inadvertently added during preparation. Additionally, the facility's training records indicated that dietary staff had previously received education on how to puree food and adhere to recipes. However, the observed practices did not align with the training provided, as the cook failed to follow the recipe and did not perform a taste test to ensure the food's palatability. This failure put residents at risk for decreased satiety and nutritional intake, which could potentially lead to weight loss.
Non-compliance with Prescribed Menu Portions
Penalty
Summary
The facility failed to adhere to the prescribed menu portions for residents on a Controlled Carbohydrate (CCHO) diet, as well as for those on regular diets. During an observation and record review, it was noted that a Dietary Aide served 1/2 cup of orzo to residents on a CCHO diet, whereas the Spring/Summer 2024 Diet Spreadsheet specified a portion of 1/3 cup. Additionally, the Dietary Aide used a #12 scoop to serve baked apples, while the spreadsheet required a #10 scoop for both regular and CCHO diets. Furthermore, residents were served a 1x2 inch square of Boston cream pie, contrary to the specified 2x3 inch portion. These discrepancies in portion sizes could potentially affect the residents' ability to maintain normal body weight and receive appropriate nutritional values.
Improper Cleaning of Juice Machine
Penalty
Summary
The facility failed to ensure proper cleaning of the juice machine according to the manufacturer's instructions, which posed a risk of foodborne illness to 56 residents receiving juice. During an observation and interview, a kitchen aide was seen soaking the juice bar gun in hot water, contrary to the manufacturer's procedure that required soaking in lukewarm water. Additionally, the facility did not perform the required weekly flushing of all hoses, pumps, and bar gun lines. The kitchen aide also mentioned that there was no log or cleaning schedule to document these cleaning activities.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control policies and procedures, resulting in multiple deficiencies. Staff did not use sterile gloves when performing tracheostomy suctioning on a resident, despite the expectation to maintain sterility to prevent respiratory infections. The registered nurse supervisor used non-sterile gloves during the procedure, and the sterile gloves provided in the suction catheter package were not utilized. This oversight was observed by a respiratory therapist and acknowledged by the infection preventionist and the director of nursing, who confirmed the requirement for sterile technique. Additionally, staff failed to perform proper hand hygiene when switching between residents requiring tracheostomy care. A respiratory therapist was observed moving between residents without washing hands or changing gloves, which is against the facility's hand hygiene policy. This lapse in protocol was noted by the infection preventionist and the director of nursing, who emphasized the importance of hand hygiene in preventing infections, especially in residents with tracheostomies. The facility also lacked necessary equipment to change suction canisters and ventilator circuits, as required by their policy. Observations revealed that suction canisters were not dated or changed regularly, and a resident's ventilator circuit was soiled and overdue for replacement. The respiratory therapist confirmed the shortage of supplies, and the director of nursing acknowledged past issues with equipment ordering. Furthermore, open system tube feeding lines were used beyond the recommended 24-hour period, increasing the risk of bacterial growth and gastrointestinal infections. Lastly, a licensed nurse did not cleanse a resident's wound with normal saline before applying treatment, contrary to the physician's order, which could lead to infection.
Failure to Provide Complete Fingernail Care for a Resident
Penalty
Summary
The facility failed to provide complete fingernail care for one of the residents, identified as Resident 25, who was dependent on staff for personal hygiene and grooming due to quadriplegia and cerebrovascular disease. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and a need for assistance with activities of daily living (ADL). During an observation, it was noted that the resident's left-hand fingernails were long and pointed, while the right-hand fingernails were clipped. The resident expressed a preference for having all fingernails clipped evenly. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Director of Staff Development (DSD), revealed that CNAs were responsible for trimming the fingernails of non-diabetic residents. The DSD emphasized the importance of nail care for maintaining resident dignity and preventing skin injuries and infections. The facility's lesson plan on nail care highlighted the need for daily cleaning and regular trimming to prevent infections and skin problems. The failure to provide complete fingernail care left Resident 25 feeling helpless and at risk for potential infections and self-injury.
Failure to Implement Dietician Recommendations for Tube Feeding
Penalty
Summary
The facility failed to ensure consistent intervention and recommendations were carried out for a resident who relied solely on tube feeds for nutrition. This oversight resulted in an unintended and unplanned weight gain of 21.27% over the course of a year. The resident, who had a complex medical history including chronic respiratory failure with ventilator dependency, hypertension, hyperlipidemia, diabetes, and difficulty swallowing, experienced significant weight changes that were not adequately addressed by the facility. The resident's weight was monitored monthly, and despite recommendations from the registered dietician to adjust the tube feeding rate, the facility continued to administer Glucerna 1.5 at 70 ml/hour for 24 hours. The dietician had recommended a reduction in the feeding rate to 70 ml/hour for 22 hours and later suggested switching to Glucerna 1.2 due to notable weight gain related to edema. However, these recommendations were not consistently implemented, leading to continued weight gain. The facility's policy on weight measurements required that progressive weight changes be reported to the attending physician and documented in the medical record. Despite this policy, the resident's significant weight gain was not effectively managed, as evidenced by the continued administration of the same feeding regimen despite dietician recommendations and the facility's awareness of the weight gain. This lack of action contributed to the deficiency identified in the report.
Deficiencies in Dialysis Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate care and services for a resident receiving hemodialysis, leading to two main deficiencies. Firstly, a Licensed Nurse (LN) was not fully knowledgeable about managing complications at the resident's arterial-venous fistula site post-dialysis. This lack of knowledge could result in improper intervention and delayed physician notification in case of a dysfunctional access site condition. The Registered Nurse Supervisor admitted uncertainty about the correct interventions for major bleeding at the fistula site, indicating a need for further training on dialysis care. Secondly, the facility did not ensure the resident received Renagel, a phosphate binder, as prescribed three times daily with meals. The medication was not administered during the 12 p.m. dose on dialysis days, as the resident was unavailable due to being at the dialysis center. This oversight was not communicated to the physician, leading to elevated phosphorus levels in the resident, which could potentially harm the resident's heart. The Licensed Vocational Nurse confirmed the missed doses and acknowledged the lack of documentation informing the physician or dialysis center about these omissions. The resident, who has a history of diabetes mellitus and end-stage renal disease, was dependent on renal dialysis. The facility's policy on hemodialysis care was not adequately followed, as evidenced by the lack of proper medication administration and insufficient staff training on managing dialysis-related complications. These deficiencies highlight the need for improved staff education and adherence to care protocols to ensure the resident's well-being.
Failure to Provide Required Dietary Training
Penalty
Summary
The facility failed to ensure that the Kitchen Manager (KM) completed the required six hours of inservice training on the specific California dietary service requirements as mandated by the California Code of Regulations (CCR) Title 22. This deficiency was identified during an interview with the KM, who confirmed that she worked full time and was certified as a dietary manager but had not received the necessary training. Additionally, the Registered Dietician (RD) acknowledged that she had not administered or developed the required training for the KM. This oversight resulted in the KM lacking the competencies and skills needed to carry out food and nutrition functions, potentially putting residents at risk for foodborne illness.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and treatment for a resident who was admitted for pain management and rehabilitation after a left hip fracture. Upon admission, the resident was assessed to be at high risk for developing pressure ulcers, with a Braden score of 12, indicating very limited mobility and confinement to bed. Despite this high risk, the facility did not develop a care plan for the resident's pressure ulcer upon its discovery, nor did they monitor the ulcer effectively. The resident developed a 1 cm x 1 cm stage 2 pressure ulcer on the right buttock, which grew to 7 cm x 7 cm and became abscessed over 25 days due to lack of proper care and monitoring. The facility also failed to provide a pressure-reducing mattress in a timely manner. Although a physician's order for a low air loss (LAL) mattress was placed on 4/3/23, the resident was not documented to be on the mattress until 4/27/23. This delay in providing the necessary equipment contributed to the worsening of the pressure ulcer. Additionally, the facility did not consistently reposition the resident to alleviate pressure on the affected area. Progress notes from 4/4/23 to 4/26/23 did not indicate that the resident was repositioned, and there was no documentation of the resident refusing repositioning or wound care. Interviews with staff revealed that certified nursing assistants (CNAs) were instructed to reposition residents but did not document the times or positions of turning and positioning. Licensed nurses were responsible for this documentation but failed to do so. The facility's policy and procedure for pressure ulcer and skin care management required the development of a care plan and consistent interventions by all staff, which were not followed in this case. As a result, the resident's pressure ulcer worsened and became infected, necessitating a course of antibiotics and further medical intervention.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure medications were secure for a census of 76 residents when three medication carts were found unlocked and unattended. During an observation, three medication carts in the sub-acute hall were seen up against the wall, side by side, and left unattended and unlocked. A Licensed Nurse confirmed that the carts with prescription medications were unlocked and stated that they usually lock the carts before leaving them to prevent unauthorized access. The Director of Nursing also confirmed that the expectation is for nurses to lock the carts before leaving them to ensure the safety of residents. The facility's policy and procedure on the use of medication carts indicated that the nursing staff should lock the medication cart with the key or locking bar after use.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
