Elk Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Elk Grove, California.
- Location
- 9461 Batey Avenue, Elk Grove, California 95624
- CMS Provider Number
- 055308
- Inspections on file
- 49
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Elk Grove Post Acute during CMS and state inspections, most recent first.
A resident with impaired memory and no capacity for medical decision-making had their eyeglasses lost, and the facility did not replace them or reimburse the cost in a timely manner. The RP reported the missing glasses, and the SSA stated that a theft and loss form was supposedly completed, but neither the SSA nor the DON could locate this documentation. The SSA could not specify when the glasses were lost, only that it occurred over several months, and later records showed the resident declined new glasses despite lacking decision-making capacity, with no notification to the RP. The facility’s own theft and loss policy requiring prompt investigation, documentation, and notification of the resident or representative was not followed.
Two residents with histories of cerebral infarction, mobility limitations, and differing cognitive status became involved in a physical altercation when one, who had moderate cognitive impairment, grew impatient while trying to pass the other, who was seated in a wheelchair in their shared doorway. The impatient resident pushed the wheelchair into the hallway despite the seated resident’s resistance and then struck the seated resident in the eye. The seated resident responded by swatting back, causing scratches to the other resident’s face and neck. Witnesses, including another resident and a CNA, confirmed the hitting and scratching, and clinical assessments documented a subconjunctival eye injury for one resident and superficial facial and neck scratches for the other.
The facility failed to maintain a safe, clean, and homelike environment in resident shower rooms when three of five shower areas were found unclean and in disrepair. A cognitively intact resident with Type 2 DM reported that the shower rooms were dirty and caused discomfort. Surveyor observations, confirmed by LNs, the IP nurse, and the DON, identified mold on shower curtains, used bandages on the floor and shelves, hair on drains, an overfilled sharps container with razors protruding, cracked shelves, cracked tiles, peeled paint, and one shower room out of order. These conditions did not meet the facility’s own policy requiring a clean, sanitary, and orderly homelike environment.
Surveyors found that multiple shower rooms were left unclean and poorly maintained, with mold on curtains and tiles, used bandages (including one with dried blood) on floors and shelves, hair on drains, cracked tiles, peeled paint, overflowing trash with uncovered soiled items, and overfilled sharps containers with razors sticking out or overflowing. An LPN and the IP nurse confirmed these conditions in several shower rooms that are used by most residents, and acknowledged that the rooms were dirty and that improper cleaning and sharps disposal could spread infectious organisms or cause injury. The IP nurse also stated she did not conduct daily checks of the shower rooms, and the DON confirmed that staff were expected to clean shower rooms after each use and that overflowing sharps could have spread infectious organisms, contrary to the facility’s infection control and sharps disposal policies.
Two residents with intact cognition and mobility impairments, including hemiplegia, CHF, COPD, muscle weakness, and difficulty walking, were housed in a shared room that became cluttered and unsanitary when a third roommate packed belongings into multiple boxes stacked in front of beds and along the path to the bathroom, with additional personal items, towels, an empty soda can near a power cord, and overripe bananas left in the area. Both residents had care plans requiring a clutter-free environment due to fall risk, yet one resident’s family reported the room as very unsanitary and requested a room change, and the other resident recalled the room being cluttered and unclean without explanation from staff. After reviewing photos and video, housekeeping staff, CNAs, and LNs acknowledged the room was not kept clean or clutter-free, described it as unsafe, a potential fire hazard, and not homelike, and the administrator confirmed that residents are entitled to a safe, clean, and homelike environment under facility policy.
A cognitively intact resident with a wedge compression fracture reported that a CNA kissed the resident’s forehead and pushed the resident’s behind during incontinent care without any consent or warning, causing the resident to feel violated and disrespected. In a subsequent interview, the CNA admitted to kissing the resident’s forehead without asking permission while providing care and removing food from the bed. The DON acknowledged that residents have the right to be free from abuse, and facility policy states that residents must be free from abuse, neglect, misappropriation of property, and exploitation, making this conduct inconsistent with established resident rights.
A resident with end stage renal disease and moderately impaired cognition, who was care planned as being at risk for elopement due to wanting to go home, left the facility without staff knowledge or a Leave of Absence order and walked about 15 minutes to a local coffee shop. Staff only became aware of the resident’s location when an off-duty staff member called the on-duty nurse, prompting a missing-resident code and the resident’s return within a short time. The DON confirmed that facility staff did not know when the resident left, and a CNA reported finding the resident sitting on a bench at the coffee shop. Facility policy required identification of residents at risk for wandering/elopement and inclusion of safety strategies and interventions in the care plan.
Two residents with severe cognitive impairment were involved in an altercation when a CNA, after briefly checking on a yelling resident and leaving the room, returned minutes later to find another resident forcefully gripping the first resident’s throat. Documentation and interviews confirmed that the resident reported his neck and hands had been squeezed and continued to have hand pain afterward, and he stated he felt safe only when away from his former room. The DON acknowledged that the resident should not be subjected to physical abuse, and the facility’s abuse prohibition policy states that abuse is prohibited and that an abuse prevention program will be implemented.
A resident with cognitive impairment and significant physical disabilities was pushed to the floor by a roommate with dementia after rummaging through the roommate's closet, despite verbal warnings. The incident escalated with both residents using profanity and one attempting to retaliate with a cane before staff intervened. Facility records and staff interviews confirmed that the push was deliberate and that the facility did not prevent the physical altercation, resulting in a failure to protect the resident from abuse.
A resident with paraplegia and urinary retention did not receive a full dose of Bethanechol as ordered when an LPN crushed the medication without a physician order and left it in unlabeled cups at the bedside. The resident, not approved for self-administration, was unaware of the medication's purpose, and the DON confirmed this practice did not meet professional standards.
A resident with diabetes experienced a hypoglycemic episode resulting in unresponsiveness and required emergency intervention. Facility staff did not inform the resident or her family member about the change in condition or the treatment provided, and there was no documentation of such communication or education, despite facility policy requiring immediate notification and documentation.
A resident with CHF, diabetes, and schizoaffective disorder left the facility unnoticed and was missing for over 24 hours, during which time she did not receive nursing care and was exposed to unsafe conditions. Staff failed to provide adequate supervision, did not follow or report the resident's departure, and the facility's front door lacked an alarm, allowing the resident to exit without detection.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite wearing a Wanderguard bracelet. The resident exited through a door that lacked a Wanderguard sensor, and there was no person-centered care plan in place to address elopement risk prior to the incident. The resident was later found outside the facility.
A resident with a recent hip fracture and multiple comorbidities did not receive prescribed Norco for moderate to severe pain for two days after admission due to a delay in obtaining a signed prescription, resulting in unmanaged pain and reduced participation in therapy. Staff and therapy notes documented high pain levels, and the medication was not available from the emergency kit without pharmacy authorization.
A resident with multiple complex diagnoses became lethargic during therapy sessions, and both PT and OT staff notified nursing staff of this change. Despite these notifications, there was no documented nursing assessment or vital signs recorded until several hours later, when the resident was found to have significantly decreased oxygen saturation and increased lethargy. The DON confirmed the lack of timely assessment and the facility could not provide a policy for change of condition assessment.
A CNA was observed changing linen for a resident with an indwelling catheter under Enhanced Barrier Precautions without wearing a gown, as required by facility policy. The CNA acknowledged the omission, and the Infection Preventionist confirmed that both gloves and a gown are necessary PPE for such high-contact care activities.
Three residents with significant physical or cognitive impairments were found with long, untrimmed nails, despite care plans and facility policy requiring staff to assist with nail care as part of ADLs. Staff and the DON confirmed that nail care was not consistently provided, and residents reported their nails had not been trimmed since admission.
A resident with diabetes and paraplegia did not receive timely podiatry care, resulting in long, debris-laden toenails and dry, crusted feet. Despite requests from the resident and his family, no podiatry consult was initiated, and staff confirmed that the required referral process was not followed according to facility policy.
A resident with mild memory impairment and multiple medical conditions sustained a burn injury when another resident, known for verbally aggressive behavior and a mental health disorder, threw a cup of hot coffee during a verbal altercation. The incident occurred after the injured resident entered the aggressor's room and did not leave when asked, resulting in hot coffee splashing onto the resident's arm and hand. Staff and medical records confirmed the injury and the sequence of events, indicating a failure to protect residents from physical abuse.
The facility failed to meet professional standards of care for several residents, including a resident performing self-catheterization without a physician's order, another missing doses of prescribed antibiotics, and a resident wearing a mouth guard during meals against recommendations. Additionally, there was inconsistent documentation of urine output for a resident with a catheter.
The facility failed to maintain pharmacy services for two residents. Expired controlled medications were not removed from the medication cart for seven days, risking drug diversion. Additionally, a resident's Physician Order for an IV antibiotic was not followed, resulting in six omitted doses, putting the resident at risk for further infection complications.
The facility failed to properly store and label medications, as an opened bottle of oseltamivir was found without an expiration date, and staff personal belongings were stored in the medication room. LN 1 and the DON acknowledged these issues, which contradict the facility's policies requiring proper labeling and storage practices.
The facility's kitchen staff demonstrated deficiencies in competencies and hygiene practices, including incorrect dish machine temperature settings, improper sanitizer concentration testing, and inadequate hand hygiene. Additionally, a cook used the wrong cutting board, risking cross-contamination. These failures could potentially lead to foodborne illness for residents.
The facility failed to maintain food safety and sanitation standards, with issues such as improper food labeling, unsanitary kitchen conditions, and inconsistent use of hairnets. Food items were found without proper labels, and the kitchen had rust, dirt, and worn equipment. Additionally, food was transported uncovered, and maintenance work was conducted over food production areas, risking contamination.
The facility failed to maintain effective infection control, with staff not adhering to PPE protocols for residents on enhanced barrier precautions, improper storage and labeling of respiratory equipment, and inadequate hand hygiene practices. A CNA entered a droplet isolation room without full PPE, and a nasal cannula found on the floor was reused without replacement.
The facility failed to maintain essential kitchen equipment, including a leaking ice machine, a non-functional dish machine temperature gauge, and an unstable tray line rack, potentially compromising food safety for 125 residents. Ice build-up in the freezer and mold-like substance on the ice machine pipe were also observed.
The facility failed to ensure the call light system was accessible for four residents, potentially preventing them from communicating their needs for assistance. Residents with various physical and cognitive impairments were observed with call light buttons out of reach, contrary to facility policies. Staff confirmed the inaccessibility and acknowledged the importance of having call lights within reach.
Two residents were not treated with respect and dignity during meal assistance. A CNA stood over Resident 8, who has chronic pain and depression, causing emotional distress. Similarly, Resident 20, with hemiplegia and dementia, was fed by a CNA standing over him. The facility's policy requires feeding with attention to dignity, which was not followed.
A resident with hemiplegia, dementia, and contractures was unable to use the call light system due to its inaccessibility and unsuitability. Despite staff awareness of the resident's inability to use the standard call light button, an appropriate alternative, such as a soft touch pad, was not provided, contrary to facility policy.
The facility failed to provide adequate nail care for two residents, resulting in long and potentially harmful nails. One resident with multiple sclerosis and quadriplegia had long, jagged nails that could cause self-scratching, while another resident with hemiplegia and hemiparesis had sharp nails that cut into her hand. The facility's policy required regular nail care, but this was not adequately provided, leading to the deficiency.
A resident with senile degeneration of the brain and hearing impairment was not provided with resident-centered activities or communication aids, leading to feelings of loneliness and isolation. Despite requests for assistance and the importance of reading materials noted in the care plan, no accommodations were made. Staff interviews revealed a lack of communication tools and activities, and the facility's policy on activity programs was not effectively implemented.
Two residents in the facility did not receive consistent monitoring of their low-air loss mattresses (LALM) as per physician's orders, which were intended to aid in wound healing. Resident 44, with severe cognitive impairment and at risk for pressure ulcers, and Resident 59, with a Stage 4 pressure ulcer, both had gaps in the monitoring of their LALM settings over several shifts. The ADON and DON confirmed the inconsistency, which was against the facility's policy and procedure.
A facility failed to follow a physician's order for a resident's oxygen therapy, delivering oxygen at 1.5 LPM instead of the ordered 3 LPM. The resident had respiratory failure and COPD, requiring continuous oxygen therapy. Staff confirmed the discrepancy, and the DON acknowledged the risk of shortness of breath if the order is not followed.
A resident with multiple diagnoses, including diabetes and osteoarthritis, did not receive appropriate pain management as the facility failed to follow the physician's order for Percocet, which was to be given only for severe pain. The medication was administered on several occasions for moderate or mild pain, as confirmed by the ADON and DON, contrary to the facility's pain management policy.
A resident on a No Added Salt (NAS) diet received two salt packets with their meal, contrary to the physician's orders. The resident, who has dementia and hypertension, did not request the salt. Staff interviews confirmed the error, and facility policy requires dietary checks that were not followed.
A facility failed to administer PRN Clonidine HCl to a resident with high blood pressure as per physician's orders. Despite the resident's systolic blood pressure exceeding 170 on two occasions, the medication was not given, and the Medication Administration Record showed no indication of administration. Interviews revealed that the LVN did not follow the protocol of reassessing blood pressure and administering the PRN medication accordingly.
A resident with chronic pain syndrome experienced inadequate pain relief due to a delay in administering pain medication, as construction work in the facility was cited as a reason for the nurse's inability to provide timely care. Despite the resident's severe pain and the facility's policies emphasizing timely intervention, the medication was administered nearly three hours late, highlighting a failure in adhering to professional standards and care plans.
A resident with Alzheimer's disease and severely impaired memory was subjected to unwanted touching by another resident with no memory impairment. The incident occurred at the nurses' station, where staff witnessed the inappropriate contact and quickly intervened. Facility staff confirmed the non-consensual nature of the act, aligning with the facility's policy on abuse prohibition.
The facility failed to follow physician's orders for oxygen therapy and did not update care plans for two residents. One resident was using oxygen at 4.5 LPM instead of the ordered 2 LPM, and another was using 1 LPM instead of 2 LPM. The discrepancies were confirmed by the ADON, who also noted that the oxygen therapies were not reflected in the residents' care plans, contrary to facility policies.
Failure to Replace Lost Eyeglasses and Notify Resident Representative
Penalty
Summary
The facility failed to protect a resident’s personal belongings when the resident’s eyeglasses were lost and not replaced in a timely manner. The resident was admitted in late 2025 with a diagnosis that included a brain disease impairing memory, and an Order Summary Report dated 9/17/25 documented that the resident did not have capacity to make medical decisions. The resident’s responsible party (RP) reported that the facility had lost the resident’s glasses and had neither replaced them nor reimbursed the cost of replacement. The Social Service Assistant (SSA) stated that the usual process for a lost item was to complete a theft and loss form, communicate with family, and have the facility pay for the lost item if it was not located, with a copy of the form kept in the social services office. During interviews and record review, the SSA recalled that the RP had reported the glasses missing and that the facility had met with the RP to discuss the loss, and she stated that a theft and loss form had been completed. However, the SSA and DON were unable to locate any theft and loss form for the lost glasses, and the SSA could not identify the exact date the glasses were lost, only that it occurred sometime between September and December 2025. An eye exam form dated 1/22/26 showed the resident declined new eyeglasses after the exam, but the SSA confirmed the resident lacked capacity to make medical decisions and that the RP should have been notified, which did not occur. The SSA confirmed that nothing further had been done to replace the glasses and acknowledged that glasses were important to help residents see. The facility’s policy on investigating incidents of theft and loss required prompt and thorough investigation of theft or misappropriation, prompt response to complaints, and notification of the resident and/or representative of investigation results and corrective action, which was not demonstrated in this case.
Resident-to-resident altercation resulting in physical abuse and injury
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ right to be free from physical abuse when two roommates became involved in a physical altercation. One resident, with a history of cerebral infarction resulting in hemiplegia, hemiparesis, and difficulty walking, and with intact cognition (BIMS 15/15), was seated in a wheelchair in the doorway of the shared room. The other resident, who also had a history of cerebral infarction with hemiplegia and hemiparesis, dementia, communication deficit, difficulty walking, and a history of falls, and who had moderate cognitive impairment (BIMS 10/15), attempted to pass through the doorway and became impatient when unable to do so. According to interviews and documentation, the resident with moderate cognitive impairment pushed the wheelchair of the other resident in an effort to get past. The resident in the wheelchair reported telling the other resident to wait, but the pushing continued, moving the wheelchair into the hallway while the seated resident was resisting. During this interaction, the resident attempting to pass struck the resident in the wheelchair in the right eye, and the resident in the wheelchair responded by reaching back and swatting, which resulted in scratching the other resident. Witness accounts and clinical records confirmed the physical contact and resulting injuries. A fellow resident stated that one resident hit the other in the doorway and that the other resident “clawed back” and scratched the first resident’s face. A CNA reported seeing one resident hitting the other and observed bleeding from scratches on the forehead and neck of the resident with dementia. Change of Condition evaluations documented superficial scratches to the forehead and neck of the resident with dementia and subconjunctival redness of the right eye of the resident in the wheelchair, confirming that both residents sustained physical injury during the altercation.
Unclean and Non-Homelike Shower Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when three of five shower rooms were found unclean and unsanitary. A cognitively intact resident with Type 2 diabetes mellitus reported that the shower rooms were dirty and unclean, and stated feeling uncomfortable at the facility and wanting to leave. Surveyor observations, corroborated by staff, identified multiple issues in the South Station shower room, including mold on the shower curtain, a used tan bandage on the shower floor, a ball of hair on the shower drain, a used bandage on the shelf adjacent to the shower, and an overfilled sharps container with razors sticking out. Cracked, exposed shelves in the shower room were also noted as not homelike. Further observations and staff interviews revealed that the northwest shower room was out of order, mold was present in the northeast shower room, and cracked tiles and peeled paint were present in the north station shower room. Licensed nurses and the Infection Prevention Nurse confirmed that the shower rooms in use were unclean and did not represent a homelike environment for residents. The DON stated that the facility’s expectation was for staff to clean shower rooms after each use and acknowledged that the current condition of the shower rooms did not meet this expectation. Review of the facility’s “Home-like Environment” policy indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly setting, which was not met in these shower areas.
Failure to Maintain Clean Shower Rooms and Proper Sharps Disposal
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to unclean and poorly maintained shower rooms. Observations with a licensed nurse in the South Station shower room revealed mold on the shower curtain and tiles, used bandages (including one with dried blood) on the shower floor and adjacent shelf, a ball of hair on the drain, broken tiles, and an overfilled sharps container with razors sticking out. In the East Station shower room, the same nurse confirmed an overflowing trash bin with bagged soiled items and no cover, an overfilled sharps container with razors overflowing, a dirty yellow PPE gown on the floor, another gown on a bedside table, and an open air freshener can on the floor. The nurse stated the rooms were dirty, that most residents used these shower rooms, and that residents or staff could be hurt by the exposed sharps and that the rooms could have spread infectious organisms to residents. Further observations with another licensed nurse showed the northwest shower room was out of order, mold was present in the northeast shower room, and cracked tiles and peeled paint were present in the north station shower room, which the nurse confirmed was unclean and should have been cleaned after each use. The infection prevention nurse confirmed the presence of mold, cracked tiles, dirty bandages, dark mold on the shower curtain, overflowing sharps containers with razors sticking out and on top, used and packaged PPE gowns left in the shower rooms, an open air freshener can on the floor, and an overflowing trash bin with uncovered soiled items. The infection prevention nurse stated the shower rooms were dirty, that improper cleaning practices can lead to spread of infections, and that improper disposal of full sharps containers can result in cuts and transmission of infectious organisms. The infection prevention nurse also confirmed she did not perform daily checks of the shower rooms to ensure proper cleaning. The DON confirmed the expectation that shower rooms be cleaned after each resident use and acknowledged that overflowing sharps in the shower rooms could have spread infectious organisms to staff and residents, in contrast to the facility’s written infection prevention and sharps disposal policies.
Cluttered, Unsanitary Shared Room Compromises Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment for two residents whose room became cluttered and unsanitary. One resident, admitted in January 2026 with hemiplegia and hemiparesis following cerebrovascular disease, required assistance with personal care and had a care plan identifying risk for falls and impaired mobility, with an intervention to maintain a clutter-free environment. This resident’s daughter reported that during a visit the room was cluttered with multiple boxes and was very unsanitary, and she requested a room change. Photos and video from that visit showed multiple brown boxes stacked in front of the residents’ beds and along the path to the bathroom, personal items piled on the boxes, an empty box on a wheelchair, two white towels and an empty soda can near a power cord in front of the television, and overripe bananas and other personal items in front of one bed. The second resident, admitted in November 2025 with congestive heart failure, COPD, muscle weakness, difficulty walking, and a need for assistance with personal care, also had a care plan identifying risk for falls related to impaired mobility, with an intervention to maintain a clutter-free room. This resident recalled that the room had been cluttered with many boxes and was not clean during the prior week, and stated that staff did not explain the purpose of the boxes. The resident expressed dislike of the cluttered and unclean condition and stated that staff should have tidied and cleaned the room so it would be safe. Multiple staff interviews confirmed the cluttered and unsanitary condition of the room and acknowledged it was inappropriate. A housekeeper, after viewing the photos and video, stated staff should have tidied and cleaned the room and that the clutter could cause an accident. A nurse explained that the third roommate was moving out and packing personal items, which led to the accumulation of boxes, but agreed the room should not have been left cluttered and unsanitary due to resident safety and infection control concerns and that the environment was not homelike for the other two residents. Another nurse stated it was acceptable for the moving resident to have personal items but not to the extent of compromising roommates’ space, and noted the clutter could cause infection control and safety issues, especially in emergencies. A CNA stated the roommates had the right to a clean, home-like environment and that she would speak up if she saw such clutter. Another nurse reported seeing the room cluttered and unsanitary, describing it as unsafe and a potential fire hazard. The administrator acknowledged that the family requested a room change because the room was cluttered and unsanitary and affirmed residents’ rights to a safe, clean, and homelike environment, consistent with the facility’s homelike environment policy requiring a clean, sanitary, and orderly setting.
Failure to Obtain Consent Before Physical Contact During Care
Penalty
Summary
The deficiency involves a failure to protect a resident’s rights to dignity, respect, and freedom from abuse when a CNA kissed the resident’s forehead without consent. The resident had been admitted with a wedge compression fracture and had intact cognition per the MDS assessment. During an IDT conference, it was documented that the resident alleged inappropriate conduct by staff, including that a staff member kissed his forehead and pushed his behind during care. In a subsequent interview, the resident stated he felt violated, trashed, helpless, and disrespected, and reported that he had not consented to the kiss and had not been warned it would occur. In a telephone conversation, CNA 1 admitted to kissing the resident’s forehead without asking for consent while providing incontinent care and removing food from the bed. The DON confirmed that residents in the facility have the right to be free from any form of abuse by staff, visitors, or any individuals. Review of the facility’s Resident Rights policy indicated that federal and state law guarantee residents the right to be free from abuse, neglect, misappropriation of property, and exploitation. The CNA’s admitted action of kissing the resident without consent, in the context of hands-on care, conflicted with these stated resident rights and facility policy.
Failure to Supervise Elopement-Risk Resident Who Left Facility Unnoticed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and provide adequate supervision for a resident identified as at risk for elopement. The resident was admitted with end stage renal disease and had moderately impaired cognition per the MDS. A care plan dated late November indicated the resident was at risk of elopement related to wanting to go home or leave the facility, with directions to continue monitoring for elopement risk behaviors and to reassess elopement risk as needed. A progress note from early December documented that the resident was discussed in IDT due to being identified as an elopement risk based on history. Despite this identified risk and care plan, the resident left the facility without staff knowledge or a Leave of Absence order and walked to a local coffee shop unaccompanied. A progress note from early January documented that staff saw the resident at the coffee shop and brought the resident back, and that the resident verbalized persistent desires to go home and was still requesting discharge. During interviews, the p.m. shift nurse stated that the facility was notified by an off-duty staff member around mid-afternoon that the resident was at the coffee shop, after which a code for a missing resident was initiated and the resident was returned within about 30 minutes. The DON confirmed that staff did not know when the resident left the facility and could not provide an exact time of departure, and that the resident had no LOA order and did not notify staff when leaving. A CNA reported finding the resident sitting on a bench at the coffee shop and stated the walk from the facility to the coffee shop was approximately 15 minutes. The facility’s wandering and elopement policy stated that residents at risk for wandering or elopement would be identified and their care plans would include strategies and interventions to maintain safety.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical and mental abuse when one cognitively impaired resident forcefully grabbed another resident by the throat during an altercation. Resident 1, admitted in January 2023 with generalized weakness and Alzheimer’s disease, had a BIMS score of 3 indicating severe mental and cognitive impairment. Resident 2, admitted in December 2024 with dementia and a BIMS score of 4, also had severe cognitive impairment. On 12/26/25 at approximately 3 a.m., a CNA responded to Resident 1 yelling and asked if he needed to be changed; Resident 1 declined, and the CNA left to another room. After approximately 5–6 minutes, the CNA again heard Resident 1 yelling and, upon re-entering the room, observed Resident 2’s hand forcefully gripping Resident 1’s throat and immediately separated the residents. Nursing documentation for 12/26/25 reflected the CNA’s report that Resident 2’s hands were on Resident 1’s neck and that Resident 1 stated Resident 2 had been squeezing his hand and neck. During a later interview, Resident 1 reported that someone had grabbed his neck and hands, rubbed his wrists, and stated his hands had been hurting since the incident, and further indicated he felt safe only when not near his old room. The DON acknowledged that the facility was considered Resident 1’s home and that he should not be subjected to physical abuse. The facility’s Abuse Prohibition Policy and Procedure, revised 2/21, stated that the center prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents and that it will implement an abuse prohibition program through prevention of occurrences; however, the incident demonstrated that the resident was not protected from physical abuse by another resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents sharing a room. One resident, who had a history of moderate cognitive impairment, left femur shaft fracture, hemiplegia, hemiparesis, and a malignant brain tumor, was found sitting on the floor after being pushed by his roommate. The incident began when the first resident was rummaging through the roommate's closet, despite being told to stop. The roommate, also with moderate cognitive impairment and dementia, admitted to pushing the first resident in an attempt to stop him from going through his belongings. Multiple staff notes and interviews confirmed that the push resulted in the resident falling to the floor. The situation escalated further when the resident who was pushed attempted to retaliate with a cane, but staff intervened before any further physical contact occurred. Both residents were observed using elevated voices and profanity during the altercation, and the staff documented that the resident who pushed did so deliberately after verbal warnings were ignored. The facility's policy prohibits all forms of abuse, including the willful infliction of injury. Despite this, the incident was not prevented, and the resident was not protected from physical abuse by another resident. The deficiency was identified through observation, interviews, and record reviews, which consistently indicated that the facility did not ensure the safety of the resident involved in the altercation.
Medication Administration Not Performed as Ordered and Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a resident with a history of complete thoracic spinal cord lesion, paraplegia, depression, and urinary retention did not receive medication as ordered. The resident had an intact cognitive status and was not approved to self-administer medications. Physician orders specified that Bethanechol 25 mg, two tablets by mouth three times daily, was to be administered for urinary retention. However, observation revealed two unlabeled medication cups containing crushed and powdered yellow medication left at the resident's bedside. The resident reported that the nurse left the medication earlier and was unaware of its purpose. Further investigation confirmed that the nurse had crushed the Bethanechol without a physician order to do so and left it at the bedside, resulting in the resident not receiving the full dose. The facility's policy required medications to be administered as prescribed, with staff ensuring the full dose is ingested and not left at bedside, especially for residents not approved for self-administration. The DON and the nurse both confirmed that the medication was not administered according to professional standards and facility policy.
Failure to Notify Resident and Family of Change in Condition and Treatment
Penalty
Summary
The facility failed to inform a resident and her family member about a significant change in her medical condition and the subsequent plan of treatment following an episode of hypoglycemia. The resident, who was cognitively intact and had multiple diagnoses including diabetes, was found unresponsive and lethargic with a blood sugar level of 41 mg/dl. Staff attempted to administer sugar orally but were unsuccessful, and emergency services were called. Paramedics administered IV dextrose, after which the resident's blood sugar increased and she returned to her baseline condition. Despite the severity of the incident, there was no documentation that the resident or her family member was notified about the change in condition or the treatment provided. Interviews with nursing staff and the Assistant Director of Nursing (ADON) revealed that the facility's policy required immediate notification of the resident and their representative in the event of a significant change in condition. However, the ADON and nursing staff acknowledged that this communication and documentation did not occur as required. The facility's policies also mandated that residents be informed of their medical condition and participate in care planning, which was not followed in this case. Record reviews and staff interviews confirmed that there was no evidence in the progress notes or other documentation that the resident or her family member was educated or informed about the hypoglycemic episode or any changes to the care plan. The ADON and nursing staff admitted that information should have been provided and documented, but this was not done. The failure to communicate and document the change in condition and treatment plan constituted a violation of the facility's own policies and federal requirements regarding resident rights and notification.
Resident Elopement Due to Inadequate Supervision and Lack of Door Alarms
Penalty
Summary
A deficiency occurred when a resident left the facility unnoticed and remained missing for over 24 hours, resulting in the resident not receiving nursing care and being exposed to an unsafe environment. The resident, who had diagnoses including congestive heart failure, type II diabetes mellitus, and schizoaffective disorder, was assessed as cognitively intact. On the day of the incident, the resident was last seen in her room in the morning and was later observed by staff walking toward the front of the facility with her walker and personal belongings. Despite being seen by a CNA, the staff member did not follow or report the resident's departure, assuming others were aware. The facility's front door was not alarmed, and the resident was able to exit without staff intervention. The resident spent the night outside, sleeping in front of a library, and was returned to the facility the following evening by a neighbor. Upon return, the resident was found to be tachycardic, confused, and dehydrated, requiring emergency room evaluation and fluids. Interviews with staff revealed that the resident had asked for the facility's address and phone number prior to leaving, and that supervision was sometimes needed due to fall risk. The facility's policies required a safe environment and supervision to prevent elopement, but these were not followed, resulting in the resident's unsupervised exit and prolonged absence.
Resident Elopement Due to Inadequate Wanderguard Coverage and Lack of Care Plan
Penalty
Summary
A resident with diagnoses of Alzheimer's Disease and dementia, and documented severe cognitive impairment, was admitted to the facility and wore a Wanderguard monitor bracelet. Despite this, the resident was able to elope from the facility premises. The resident was found sitting on a sidewalk three houses down from the facility. Review of the resident's records showed that there was no documented evidence of a person-centered care plan addressing the risk of elopement prior to the incident, despite the resident's known cognitive impairments and risk factors. Further investigation revealed that although the resident was wearing a Wanderguard bracelet, the North-north exit door used by the resident to leave the facility did not have a Wanderguard system sensor installed. The Director of Nursing confirmed that the purpose of the Wanderguard system is to alert staff when a resident at risk for wandering approaches or exits through a monitored door, but this system was not in place on the door used during the elopement. Facility policy required adequate supervision and care planning for residents at risk of elopement, which was not implemented prior to the incident.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident admitted with multiple complex diagnoses, including a left hip fracture, did not receive prescribed pain medication for moderate to severe pain upon admission. The resident had a physician's order for acetaminophen-hydrocodone (Norco) to be administered every four hours as needed for pain, but the medication was not available or administered for two days after admission. During this period, the resident experienced significant pain, with documented pain levels as high as 9 out of 10, both at rest and with movement, as recorded by therapy staff. The resident's pain was severe enough to limit participation in physical and occupational therapy, as noted in therapy encounter notes. Despite the presence of an order for Norco, the medication was not given until two days after admission, and only a one-time dose of Tylenol was administered in the interim. Interviews with staff revealed that the Norco was not available because the pharmacy had not received a signed prescription from the physician, and the emergency kit could not be accessed for Norco without this authorization. Communication lapses were identified, as the pharmacy was not contacted to obtain the necessary script until the resident's pain was reported at a high level. The facility's pain management policy required prompt assessment and treatment of pain, including obtaining necessary medication orders and ensuring availability of prescribed medications. However, the process for securing the Norco prescription was delayed, resulting in the resident experiencing unmanaged pain and decreased comfort and participation in therapy. Staff interviews confirmed that the Norco was not administered until the required prescription was obtained from the physician and processed by the pharmacy.
Failure to Timely Assess Change of Condition After Therapy Notification
Penalty
Summary
Nursing and therapy staff identified a change in condition for a resident with multiple complex diagnoses, including a recent hip fracture, pneumonia, COPD, malnutrition, and schizoaffective disorder. On the day in question, both physical and occupational therapy staff documented that the resident was lethargic and notified nursing staff of this change. Despite these notifications, there was no documented nursing assessment or vital signs recorded by nursing staff after the initial reports of lethargy until several hours later. The clinical record showed that the resident's oxygen saturation dropped from 95% in the morning to 87% in the evening, at which point nursing staff finally documented an assessment noting lethargy, shortness of breath, and low oxygen saturation. The Director of Nursing confirmed that no change of condition assessment was documented after therapy staff notifications and stated that nurses are expected to assess residents after such notifications. Additionally, the facility was unable to provide a policy and procedure for assessment after a change of condition when requested by surveyors.
Failure to Use Required PPE During Linen Change in EBP Room
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow required infection control practices while changing linen in the room of a resident who was under Enhanced Barrier Precautions (EBP). The CNA was observed changing the linen without wearing a gown, which is required PPE for high-contact care activities in EBP rooms. The CNA acknowledged not wearing the gown and stated she should have worn both a gown and gloves during the task. The resident involved had a history of renal and ureteral calculous obstruction and had an indwelling catheter in place. Facility policy, as well as the Infection Preventionist, confirmed that gloves and a gown are required PPE when changing linen in EBP rooms, especially for residents with indwelling catheters. The failure to use appropriate PPE was directly observed and confirmed by both the CNA and the Infection Preventionist.
Failure to Provide Required Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for three out of five sampled residents who required help with activities of daily living (ADLs). Observations and interviews revealed that these residents had long, untrimmed fingernails or toenails, with one resident having visible debris and crusted areas on their feet, and another with nails digging into their wrist and palm. Staff interviews confirmed that nail care had not been performed as required, and residents reported that their nails had not been trimmed or cared for since admission. Care plans for all three residents indicated a need for assistance with personal hygiene and ADLs, but this assistance was not provided. The residents involved had significant medical conditions, including diabetes with poor wound healing, paraplegia, hemiplegia, hemiparesis, and chronic leg weakness, which increased their dependence on staff for personal care. Facility policy required daily cleaning and regular trimming of nails to prevent infection and injury, and staff were expected to check and provide nail care on shower days. Despite these policies, staff and the Director of Nursing acknowledged that nail care was not consistently performed, resulting in residents being left with long, untrimmed nails.
Failure to Provide Timely Podiatry Services for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including type 2 diabetes mellitus and paraplegia, was admitted to the facility and required assistance with personal care. Despite being cognitively intact, the resident did not receive timely podiatry services, resulting in long toenails with visible debris and dry, crusted areas on both feet. The resident reported discomfort and stated that neither he nor his sister's requests for podiatry treatment had been addressed since admission. Observations and interviews with facility staff, including CNAs, a licensed nurse, and the social service assistant, confirmed the resident's toenails were overgrown and that no podiatry consult had been scheduled. Staff acknowledged that diabetic residents require professional foot care and that the process for referral to a podiatrist had not been initiated. The facility's policy required referrals for residents with foot disorders or medical conditions associated with foot complications, but this was not followed in the resident's case.
Failure to Protect Resident from Physical Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when a resident with a history of mild memory impairment and multiple medical conditions, including chronic kidney disease and thrombotic disorders, sustained a burn injury after another resident threw a cup of hot coffee at him. The incident followed a verbal altercation between the two residents, during which the aggressor, who had a documented history of verbally aggressive behavior and schizotypal disorder, became upset when the injured resident entered his room and did not leave after being asked. The aggressor then threw a coffee cup, resulting in hot coffee splashing onto the other resident's right arm and hand, causing redness and a bruise. Medical records and staff interviews confirmed the sequence of events, with the injured resident reporting the incident to a treatment nurse, who observed scalding on the right arm. The aggressor admitted to throwing the coffee cup after repeated requests for the other resident to leave his room were ignored. Documentation in both residents' care plans and progress notes described the altercation and the resulting injury, with the aggressor's care plan noting a history of behaviors that could increase the risk of conflict with peers. The facility's policy on abuse prohibition defines abuse as the willful infliction of injury, and staff interviews, including with the DON, confirmed that the injury was the result of a willful act. The failure to prevent this resident-to-resident altercation resulted in physical harm and demonstrated a lapse in protecting residents from abuse as required by facility policy.
Deficiencies in Care Planning and Medication Administration
Penalty
Summary
The facility failed to meet professional standards of care for several residents, leading to potential health complications. Resident 21, who was admitted with paraplegia and a history of urinary tract infections, was observed performing self-catheterization without a physician's order or a care plan in place. Despite the resident's cognitive ability to understand the procedure, the lack of formal documentation and oversight from the facility posed a risk to the resident's health. The Director of Nursing (DON) confirmed the absence of a physician's order and care plan, which was against the facility's policy. Resident 27, admitted with an ulcer of the right lower extremity, did not receive the full course of prescribed antibiotics for cellulitis. The Medication Administration Record (MAR) showed that six out of 21 doses were missed, which the DON acknowledged. This oversight in medication administration was contrary to the facility's policy and placed the resident at risk for further infection complications. The presence of discontinued medications in the storage room further highlighted lapses in medication management. Resident 92, who was cognitively impaired and required assistance with meals, was observed wearing a mouth guard during feeding, contrary to the recommendations of the Speech Therapist (ST). The failure to remove the mouth guard before meals increased the risk of aspiration and bacterial growth. The DON confirmed that a care plan addressing the use of the mouth guard was not in place. Additionally, Resident 82, with an indwelling catheter, had inconsistent and inaccurate documentation of urine output, which was essential for monitoring the catheter's effectiveness. The DON confirmed that the documentation did not meet the required standards, as it lacked specific measurements necessary for proper assessment and reporting to the physician.
Failure to Maintain Pharmacy Services and Follow Physician Orders
Penalty
Summary
The facility failed to maintain proper pharmacy services for two residents, leading to potential risks. In the first instance, expired controlled medications belonging to a resident were not removed from the medication cart for seven days, creating an opportunity for drug diversion. The Director of Nursing (DON) acknowledged that 20 controlled medications, which expired on February 17, were not brought to her office for destruction until February 24. The facility's policy requires that discontinued medications be promptly removed and secured for future destruction, but this was not followed. In the second instance, Resident 27's Physician Order for an IV antibiotic to treat cellulitis was not followed, resulting in six omitted doses. The medication, which was supposed to be administered every eight hours for seven days, was found in the medication room, and the last dose was recorded on February 18. The DON confirmed that the expectation was for staff to follow all medication orders as prescribed and to remove discontinued medications. The failure to administer the antibiotic as ordered put Resident 27 at risk for further complications of infection.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. An opened multi-dose bottle of oseltamivir oral suspension was found in the refrigerator without an expiration date. Licensed Nurse (LN) 1 acknowledged the absence of the expiration date and stated that the expectation is for staff to label all medications with appropriate open and expiration dates to maintain potency and effectiveness. The Director of Nursing (DON) confirmed that medications should be labeled when opened to avoid administering expired medications. The facility's policy and procedure, as well as the package insert for oseltamivir, both indicated the necessity of labeling with an expiration date. Additionally, the survey revealed that staff personal belongings were stored in the medication storage room, which is against the facility's policy. LN 1 observed personal items in the medication storage room and acknowledged that staff are provided with lockers for personal storage. The DON confirmed that only medications and related supplies should be stored in the medication storage room to prevent infection transmission and drug diversion. The facility's policy emphasized that medication storage areas should be clean and free of clutter.
Deficiencies in Kitchen Staff Competency and Hygiene Practices
Penalty
Summary
The facility failed to ensure that the kitchen staff had the appropriate competencies and skill sets to safely carry out the functions of the food and nutrition service. During an observation, a dietary aide was unable to correctly identify the necessary dish machine temperature for effective cleaning, initially stating an incorrect range and then adjusting the response to match the incorrect gauge reading. The dish machine logbook showed consistent entries below the required temperature, indicating a lack of understanding of the proper operation specifications as outlined in the facility's sanitation policy and the FDA Food Code. Additionally, a prep cook demonstrated improper testing of sanitizer concentration in red buckets, initially testing for an incorrect duration and obtaining a reading that was significantly above the safe range. This was confirmed by the registered dietician, who noted that the high concentration could be harmful to residents. The facility's sanitation policy requires that service area wiping cloths be placed in a chemical sanitizing solution of appropriate concentration, which was not adhered to in this instance. Further observations revealed lapses in hand hygiene practices. A prep cook and diet aide were seen handling soiled equipment and engaging in activities that contaminated their hands without performing the necessary hand hygiene before returning to their duties. This was acknowledged by the dietary manager as a failure to follow the facility's infection control policy. Moreover, a cook was observed using a yellow cutting board, designated for raw poultry, to cut cooked roast beef, instead of the appropriate brown board, increasing the risk of cross-contamination. The dietary manager confirmed the importance of using the correct cutting board colors to prevent such risks.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Food items were found without proper labeling, including ice cream cups and supplemental shakes lacking use-by dates, and thickened apple juice and cottage cheese with incomplete dates. The Dietary Manager confirmed these labeling issues, acknowledging that labels are crucial for determining food safety. The FDA Food Code requires proper labeling and dating to ensure food safety, which was not followed in this instance. The kitchen environment was found to be unsanitary, with rust and dirt observed in various areas, including the ice machine, dry storage racks, and walk-in freezer. The stove and oven were discolored, and the food serving area was dirty. The can opener tip had dark spots, and plastic bowls were worn and scratched, making them unsanitary. The facility's sanitation policy requires all kitchen areas and equipment to be clean and in good repair, which was not the case. Additionally, clean plates were found with food residue and a sugar packet, and steam table pans were stored wet, which could lead to bacterial growth. Hairnets were not consistently used by kitchen staff and visitors, increasing the risk of contamination. Food items were transported uncovered, and maintenance work was conducted over food production areas, both of which could lead to cross-contamination. The facility's policies and FDA Food Code require hair restraints and covering of food items to prevent contamination, but these standards were not met. These failures had the potential to lead to foodborne illness for the 125 residents consuming facility-prepared meals.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to required personal protective equipment (PPE) protocols. In one instance, a Certified Nurse Assistant (CNA) was observed changing the briefs of a resident on enhanced barrier precautions (EBP) without wearing a gown, despite signage indicating the necessity of both gloves and a gown for high-contact activities. Similarly, another CNA was seen transferring a resident on EBP without wearing a gown, contrary to the facility's policy and procedures. Additionally, the facility did not properly store and label respiratory equipment, increasing the risk of cross-contamination. A resident's nasal cannula was found uncovered and unlabeled on a bedside drawer, and another resident's nebulizer face mask was similarly stored without proper labeling. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that respiratory equipment should be stored in infection control pouches and labeled with the date of first use to ensure timely replacement. Further deficiencies were noted in the facility's handling of droplet isolation precautions and hand hygiene practices. A CNA entered a droplet isolation room wearing only a face mask, despite the requirement for full PPE, including an N95 mask, gloves, gown, and face shield. Additionally, a Licensed Nurse (LN) failed to perform hand hygiene between administering medications, and a nasal cannula found on the floor was placed back on a resident without being replaced, contrary to the facility's infection control policies.
Deficiencies in Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which could potentially lead to foodborne illness for the 125 residents consuming meals prepared by the facility. The deficiencies observed included ice build-up on the floor of the walk-in freezer due to a leak from the ice machine, which was not addressed promptly. Additionally, the ice machine itself was leaking, and a bucket was placed underneath to catch the water. A black, mold-like substance was observed on the pipe connected to the ice machine, indicating a lack of proper maintenance and cleaning. Further issues were identified with the dish machine, where the temperature gauge was not functioning, preventing the monitoring of water temperature necessary for proper sanitation. This led to the decision to use paper plates for serving meals. Additionally, the tray line rack used in food service was not holding its position and was temporarily secured with plastic wrap, resulting in a tray falling during meal service. These observations highlight the facility's failure to maintain equipment in good repair and in accordance with the Food and Drug Administration (FDA) Food Code 2022, which could compromise the safety and sanitation of food services provided to residents.
Inaccessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for four residents, which could prevent them from communicating their needs for assistance. Resident 41, who was admitted with hemiplegia and hemiparesis, had her call light button pinned to the top of the bed, out of reach. CNA 3 confirmed this observation and acknowledged that Resident 41 would not have been able to ask for help if needed. Similarly, Resident 11, with muscle weakness and reduced mobility, had her call light button pinned behind the bed, making it inaccessible. CNA 12 confirmed that Resident 11 could not reach it and would not have been able to call for help. Resident 52, who required assistance with personal care, had her call light button on the floor, which CNA 13 confirmed should have been within reach. Resident 20, with severe cognitive impairment and multiple physical limitations, was observed with his call light button hung on the wall and later on the floor, both out of reach. CNA 9 confirmed that the call light button should be accessible to Resident 20. The facility's policies and procedures require that each resident be provided with a means to call staff directly for assistance from their bed, and that the call light should be accessible when in bed. The Director of Nursing confirmed the expectation for call lights to always be within reach, acknowledging the potential for residents to be unable to call for assistance if the call lights are not accessible.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to uphold the rights of two residents to be treated with respect and dignity during meal assistance. Resident 8, who has chronic pain syndrome, weakness, contracture, and major depressive disorder, was observed being fed by a CNA who stood over her. This action caused Resident 8 to feel disrespected and emotionally distressed. The resident's care plan indicated the need for assistance with meals, but the manner in which the assistance was provided did not align with the facility's policy of treating residents with kindness, respect, and dignity. Similarly, Resident 20, who has hemiplegia, hemiparesis, dementia, and requires full assistance with meals, was also fed by a CNA standing over him. The CNA believed this was acceptable, despite the facility's policy stating that residents should be fed with attention to safety, comfort, and dignity. The Director of Nursing acknowledged that a more person-centered approach, such as sitting and facing the resident, should be used to maintain respect and dignity during meal assistance.
Inadequate Call Light System for Resident with Disabilities
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's needs when the call light system was not appropriate and not within reach. The resident, who was admitted in January 2025, had multiple diagnoses including hemiplegia, hemiparesis, dementia, contractures, and muscle weakness, and was dependent on assistance for personal care. Observations revealed that the resident's call light button was either hung on the wall next to the door or on the floor, making it inaccessible. The resident was unable to use the call light button due to hand contractures, and a soft touch pad, which would have been more suitable, was not provided. Interviews with staff confirmed that the resident was given a call light button despite being unable to use it. A Licensed Nurse and the Director of Nursing acknowledged the need for an alternative call system, such as a soft touch pad, but it was not implemented. The facility's policy required that an alternative means of communication be provided if a resident could not use the standard call system, but this was not documented in the care plan. The resident's progress notes indicated an inability to use the call light due to physical and cognitive limitations, highlighting the facility's failure to accommodate the resident's needs appropriately.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, Resident 24 and Resident 47, as part of their Activities of Daily Living (ADLs). Resident 24, who has multiple sclerosis and quadriplegia, was found with long and jagged nails on her left hand, which she confirmed were bothersome and could cause self-scratching. Similarly, Resident 47, who has hemiplegia and hemiparesis, was observed with long nails on both hands, which she stated were sharp and painful as they cut into her hand. Both residents' conditions were confirmed by licensed nurses, who acknowledged the potential for the nails to cause injury. The Director of Nursing (DON) stated that staff are expected to provide nail care as needed and check nails on residents' shower days. However, the care plans for both residents indicated that nail care should be performed on bath days and as necessary. The facility's policy and procedure on nail care emphasized the importance of regular trimming to prevent infections and injuries. Despite these guidelines, the facility did not ensure that the residents received the necessary assistance with nail care, leading to the deficiency.
Failure to Provide Resident-Centered Activities for Hearing-Impaired Resident
Penalty
Summary
The facility failed to provide resident-centered activities for one resident, identified as Resident 13, who was admitted with a diagnosis of senile degeneration of the brain. Observations and interviews revealed that Resident 13 expressed feelings of loneliness and a desire to communicate with others, but faced difficulties due to a hearing impairment. Despite requests for hearing assistance, no activity tools such as magazines, music players, or communication aids were present in the resident's room. The care plan for Resident 13 indicated the importance of having reading materials, yet these were not provided, and no accommodations for hearing loss were documented. Interviews with staff, including a Certified Nurse Assistant, Licensed Nurse, and the Social Services Director, highlighted a lack of communication tools and activities for Resident 13. The Activities Assistant noted that Resident 13 had not participated in group activities and no translation devices were used. The Director of Nursing acknowledged the expectation for residents' needs and preferences to be supported, but the facility's policy on activity programs was not effectively implemented for Resident 13. The absence of a care plan addressing communication strategies and the lack of engagement in activities contributed to the resident's isolation and unmet needs.
Inconsistent Monitoring of Low-Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that two residents, Resident 44 and Resident 59, received treatment and care in accordance with professional standards of practice and the facility's policy and procedure. Both residents had physician's orders for low-air loss mattresses (LALM) to aid in wound healing, with specific instructions to monitor the settings and functioning every shift. However, the monitoring was not consistently performed, as evidenced by gaps in the treatment administration records for both residents over several shifts in January and February 2025. Resident 44, who was admitted in April 2020, had diagnoses including dementia, major depressive disorder, weakness, and malnutrition. The resident was at risk of developing pressure ulcers and was using a pressure-reducing device for the bed. Despite the physician's order to check the LALM settings every shift, there were multiple instances where this was not done, potentially impacting the resident's wound healing process. The Assistant Director of Nursing (ADON) confirmed the inconsistency in monitoring during a record review. Similarly, Resident 59, admitted in July 2022, had diagnoses including rheumatoid arthritis, failure to thrive, major depressive disorder, and contracture. The resident had a Stage 4 pressure ulcer and was also using a LALM for wound healing. The treatment administration records showed that the LALM settings were not monitored consistently, as required by the physician's order. The ADON and the Director of Nursing (DON) both acknowledged the failure to adhere to the monitoring schedule, which was crucial for ensuring the proper functioning of the LALM and the residents' well-being.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper delivery of respiratory care for one resident, as the physician's order for oxygen therapy was not followed. The resident, who was admitted in April 2021, had diagnoses including respiratory failure, chronic obstructive pulmonary disease, weakness, and major depressive disorder. The resident's care plan required oxygen therapy as ordered by the physician, which was continuous oxygen at 3 liters per minute (LPM) via nasal cannula. However, observations on multiple occasions revealed that the oxygen concentrator was set at 1.5 LPM, contrary to the physician's order. Interviews with facility staff, including a Certified Nurse Assistant and the Director of Nursing, confirmed the discrepancy in oxygen delivery. The Director of Nursing acknowledged the risk of shortness of breath if oxygen is delivered at a lower setting than ordered and emphasized the importance of following the physician's order. The facility's policy on oxygen administration also required reviewing the physician's orders and the resident's care plan to assess any special needs, which was not adhered to in this case.
Failure to Follow Pain Medication Orders
Penalty
Summary
The facility failed to provide appropriate pain management services for one resident, identified as Resident 17, by not adhering to the physician's order for pain medication. Resident 17, who was admitted in May 2023, had diagnoses including diabetes mellitus, neuropathy, osteoarthritis, and low back pain. The resident's cognitive assessment indicated intact cognition. The physician's order, dated August 22, 2023, specified that Percocet should be administered only for severe pain levels of 7 to 10. However, the medication administration records for February 2025 showed that Percocet was given on multiple occasions when the resident's pain levels were recorded as moderate or mild, contrary to the physician's order. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the physician's order was not followed, and the DON acknowledged the risk of medication overdose if the order was not adhered to. The facility's policy on pain management, dated August 25, 2021, emphasized the need for pain management to be consistent with professional standards and the resident's care plan. The failure to follow the physician's order for pain medication administration had the potential to affect the resident's well-being.
Failure to Adhere to Prescribed NAS Diet for a Resident
Penalty
Summary
The facility failed to adhere to the physician's prescribed diet for Resident 16, who was on a No Added Salt (NAS) diet. During a lunch meal, Resident 16 received two packets of iodized salt on their meal tray, despite the meal ticket indicating an NAS diet. Resident 16, who has a history of dementia, malnutrition, hypokalemia, and hypertension, did not request the salt packets. The oversight was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the resident should not have been given additional salt. Interviews with the Dietary Manager and the Director of Nursing revealed that residents on an NAS diet should not receive salt packets, and staff are expected to follow diet orders to prevent adverse health effects. The facility's policy requires the Food Services Manager or supervisor to check trays for correct diets before transport, and nursing staff to verify the diet before serving. However, these procedures were not followed, leading to the dietary error for Resident 16.
Failure to Administer PRN Clonidine HCl as Ordered
Penalty
Summary
The facility failed to follow physician's orders for administering PRN Clonidine HCl to a resident with a history of hemiplegia, hemiparesis, chronic kidney disease, and hypertensive heart disease. The resident was admitted with an order for Clonidine HCl to be given as needed for systolic blood pressure (SBP) of 170 or greater. However, on two occasions, the resident's SBP exceeded 170, and the PRN medication was not administered as per the physician's order. The Medication Administration Record (MAR) for November 2024 showed no indication that the medication was given on these dates. Interviews and record reviews revealed that the Licensed Vocational Nurse (LVN) did not follow the protocol of administering the PRN medication after reassessing the blood pressure 30 minutes to an hour after giving routine blood pressure medications. The facility's policy on medication administration requires adherence to physician's written orders, which was not followed in this case. This oversight had the potential to negatively impact the resident's health condition and well-being.
Failure to Provide Timely Pain Management Due to Construction Delays
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, resulting in inadequate pain relief. The resident, who was admitted with diagnoses including depression, anxiety, lumbar intervertebral disc degeneration, and chronic pain syndrome, had a care plan that required anticipation of pain needs and immediate response to complaints of pain. However, on a specific night, the resident's request for pain medication was delayed due to ongoing construction work in the facility, which was cited as a reason for the nurse's inability to administer the medication promptly. The resident's pain was not assessed or managed in a timely manner, as evidenced by the delay in administering oxycodone, which was ordered to be given every four hours as needed for moderate to severe pain. The resident reported experiencing severe pain, rated 8 out of 10, and had to wait for nearly three hours before receiving the medication. The nurse on duty cited construction work as the reason for the delay, despite the facility's policy indicating that environmental situations should not hinder resident care. Interviews with staff, including the Director of Nursing and the Maintenance Director, confirmed that the construction should not have interfered with resident care. The facility's policies on pain management emphasized the importance of timely assessment and intervention based on professional standards and the resident's care plan. The failure to adhere to these policies resulted in the resident not attaining the highest possible level of comfort.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a resident with Alzheimer's disease, who had severely impaired memory and was not her own responsible party, was subjected to unwanted touching by another resident. The incident occurred when the resident was sitting in her wheelchair at the nurses' station, and another resident, who had no memory impairment, grabbed her hands, touched her left breast, and began to massage it. Staff quickly intervened and separated the residents. Interviews with facility staff, including a Certified Nursing Assistant and the Assistant Director of Nursing, confirmed the incident and acknowledged that the touching was non-consensual and constituted abuse. The Social Services Director noted that the resident had no recall of the incident and showed no change in mood or behavior afterward. The facility's policy on abuse prohibition clearly states that sexual abuse includes any non-consensual sexual contact with a resident.
Failure to Follow Oxygen Therapy Orders and Update Care Plans
Penalty
Summary
The facility failed to ensure proper delivery of respiratory care for two residents, Resident 4 and Resident 6, by not adhering to physician's orders for oxygen therapy and not including the therapy in their care plans. Resident 4, who was admitted with diagnoses including congestive heart failure, diabetes mellitus, and anemia, was observed using oxygen at 4.5 LPM, contrary to the physician's order of 2 LPM for shortness of breath and chest pain. The Assistant Director of Nursing (ADON) confirmed the discrepancy and acknowledged that Resident 4's oxygen therapy was not reflected in his care plan. Similarly, Resident 6, admitted with end-stage renal disease, dependence on renal dialysis, and anemia, was observed using oxygen at 1 LPM, while the physician's order specified 2 LPM for shortness of breath. The ADON confirmed that Resident 6's oxygen therapy was not accurately documented in the care plan, and the resident's attempt to wean off oxygen was also not reflected. This lack of documentation could lead to staff being unaware of the resident's current needs and treatment plan. The facility's policies and procedures for oxygen administration and comprehensive care planning were not followed, as evidenced by the failure to review and implement physician's orders and update care plans accordingly. The facility's policy required reviewing physician's orders and care plans to assess any special needs of the resident, which was not done in these cases, leading to the potential for unsafe delivery of oxygen therapy.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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