English Oaks Convalescent & Rehabilitation Hospita
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 2633 West Rumble Rd, Modesto, California 95350
- CMS Provider Number
- 555190
- Inspections on file
- 28
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at English Oaks Convalescent & Rehabilitation Hospita during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment reported that a male CNA attempted to sexually assault him at night, describing that the CNA pulled down his pants, exposed himself, and tried to climb on top of him before the resident pushed him away and called for help. The resident disclosed the allegation to a CNA using a notepad with the word “rape,” and this CNA reported it to an LN, who then notified another nurse, after which the ADM and DON were informed. Although leadership stated that CDPH was notified the same day, they could not provide evidence of the time of notification, and the SOC 341 related to the allegation was not received by CDPH until the following day. The ADM later acknowledged knowing that such allegations must be reported to CDPH within two hours, but the facility could not document that this requirement was met, despite a policy requiring abuse allegations to be reported within federal timeframes.
A resident admitted under Medicare Part A did not receive the required initial comprehensive visit from a physician; instead, a nurse practitioner performed the assessment and admission orders. Facility staff confirmed that the physician did not personally conduct the initial assessment, which is mandated by federal regulations and facility policy.
A resident with a history of aggressive behavior physically struck another resident, causing injury and distress, after staff failed to provide adequate monitoring and supervision. The aggressive resident was known to require close observation due to behavioral disturbances, but lapses in hourly monitoring and reduced staff presence during lunchtime allowed the incident to occur in an unsupervised hallway.
A resident with hemiplegia and hemiparesis was transferred using a mechanical lift by only one CNA, despite assessment and facility policy requiring two staff for such transfers. The resident slipped from the sling and fell, resulting in a large intramuscular hematoma and fractures. Staff interviews confirmed the failure to follow policy led to the resident's injuries.
A resident with a history of cancer, anxiety disorder, and failure to thrive was found outside in a neighboring parking lot late at night after being unaccounted for in her room. Staff were unable to monitor or ensure her safety during this time, and the resident sustained two skin tears to her right knee. Facility leadership confirmed the incident and acknowledged the risk of more serious injury due to the lack of supervision.
A facility failed to assess a resident's use of a partial denture and hearing aids, leading to staff being unaware of these needs. The resident's partial denture was lost and found cracked, and hearing aids were misplaced, contributing to weight loss and confusion. The facility did not maintain an accurate inventory or care plan for these items, as acknowledged by the DON and Administrator.
A facility failed to implement a comprehensive care plan for a resident's partial denture and hearing aids, leading to staff unawareness and inadequate care. The resident experienced confusion and a 15-pound weight loss. Clinical records did not assess these needs, and the denture was lost and damaged, while hearing aids were misplaced. Staff interviews revealed non-compliance with care planning policies.
A resident with hemiplegia and hemiparesis following a stroke did not receive the ordered RNA therapy for a week, as there was no documentation in the EHR. The facility's policy requires documentation of all services provided, which was not followed, leading to a deficiency in care.
The facility failed to maintain sanitary conditions for food storage and handling. Dirty serving scoops were found with clean utensils, and thawed healthshakes were improperly stored. A dish machine pipe lacked an air gap, and ice machines were not cleaned per guidelines, with mold-like spots and debris observed. These issues were acknowledged by the Dietary Services Manager and Plant Operations Director.
A resident's Midodrine medication was not administered according to physician orders, leading to significant medication errors. The medication, intended to manage blood pressure, was either held or given outside the prescribed parameters on multiple occasions, potentially causing adverse effects. The facility's policy on medication administration was not adhered to, resulting in this deficiency.
The facility failed to ensure kitchen staff competency in food and nutrition services, leading to potential contamination risks. A dishwasher was unable to correctly test sanitizer levels, and a Diet Aide did not follow handwashing protocols after handling trash. Additionally, two Diet Aides were not trained in thermometer calibration. These deficiencies were acknowledged by the Dietary Services Manager and Registered Dietitian.
The facility failed to serve meals at a palatable temperature and flavor, affecting 145 residents. Observations revealed discrepancies in recipe adherence and food temperatures, with milk served warmer than policy standards and meals described as bland. Residents reported dissatisfaction with the food quality, and the RD did not conduct test trays to ensure palatability.
The facility failed to maintain the dish machine in safe operating condition, with sanitizer levels exceeding the recommended 50-100 ppm, reaching 200 ppm. The dishwasher was unaware of a water leak and incorrectly believed the sanitizer level was acceptable. The Dietary Services Manager confirmed the incorrect levels, and a vendor technician adjusted the chemicals. The Registered Dietitian expected compliance with manufacturer guidelines, which were not met.
A facility failed to coordinate specialized mental health services for a resident with bipolar disorder and schizophrenia by not responding to the state authority for PASRR Level II needs. The resident's PASRR Level II case was closed due to unresponsiveness, requiring a new Level I Screening to reopen the case. The facility's policy mandates PASRR completion for all residents to determine mental illness and specialized service needs.
Two residents in the facility experienced deficiencies in their care plans. One resident, requiring continuous oxygen therapy, frequently removed his nasal cannula, and the care plan lacked interventions to maintain his oxygen levels. Another resident, with a midline catheter for IV therapy, had a care plan that did not specify necessary maintenance and monitoring, leading to inadequate care. The facility's policies were not adequately followed, resulting in these deficiencies.
A resident in a LTC facility had a peripheral IV inserted by a licensed nurse without a physician order after accidentally dislodging a midline catheter. The resident was receiving IV antibiotics for a hip wound infection. The Assistant Director of Nurses and the medical doctor confirmed there was no physician order or notification regarding the peripheral IV placement, which was against the facility's IV therapy policy.
A resident, admitted with mobility issues and an intact cognitive status, did not receive scheduled showers for over a week while on COVID precautions. Despite being scheduled for showers twice a week, facility records and staff interviews confirmed the absence of showers during this period, contrary to the facility's policy requiring assistance with bathing.
A resident returned from an orthopedic appointment with a sling on her arm but no new orders. The licensed nurse was unable to contact the orthopedist and removed the sling without notifying the resident's primary doctor, contrary to facility policy. The resident experienced swelling and discomfort, and the lack of communication could have delayed necessary care.
A facility failed to monitor a wander guard for a resident with Parkinson's disease, leading to unsupervised wandering. Another resident with COPD and nicotine dependence was not assessed for safe smoking practices in a timely manner, delaying the identification of smoking risks.
A facility failed to monitor the effectiveness of Haldol for a resident with dementia and personality disorder, prescribed for agitation and aggressive behavior. Despite the care plan's requirement for monitoring each shift, the facility did not begin monitoring until mid-September, a month after the resident's admission. This oversight was confirmed by the ADON, highlighting a lapse in following the facility's policy on antipsychotic medication use.
The facility failed to ensure safe medication storage practices, with expired and undated medications found in three of nine medication carts. An expired multi-dose inhaler and a single-dose hydralazine tablet were found, along with an undated Ozempic injection pen. The ADON confirmed that medications should be marked with open and expiration dates, and discharged resident medications should be promptly removed to prevent errors.
A facility failed to properly store and reheat food brought in for a resident, leading to the meal becoming inedible. The resident, with multiple health conditions, received food from family due to dissatisfaction with facility meals. Staff provided inconsistent information about storage and reheating policies, revealing a lack of knowledge and training on the facility's procedures.
The facility failed to maintain infection control practices for two residents. A nurse did not change gloves or perform hand hygiene during wound care for a resident with a gastrostomy tube, contrary to facility policy. Additionally, another resident's urinal was not labeled, risking cross-contamination. These actions did not adhere to the facility's infection prevention standards.
A resident with a history of congestive heart failure, depression, and anxiety experienced a fall, and the facility failed to accurately document the presence of a fall mat. The interdisciplinary team had recommended a fall mat, but records incorrectly indicated it was already in place. This led to potential miscommunication among healthcare providers.
A resident with osteoarthritis experienced severe pain due to the facility's failure to timely order and administer Norco. Despite requests and attempts to contact the physician, a prescription error delayed medication administration. Additionally, the facility ran out of the resident's pain medication, and the reorder process was not completed promptly, leading to further pain management issues.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after becoming aware of the allegation. A resident with a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment, reported that a male CNA attempted to have sex with him during the night, pulled down his pants, exposed himself, and tried to climb on top of him. The resident stated he pushed the CNA away, screamed for help, and that his roommate heard the incident. On a later date, the resident identified the alleged perpetrator as a specific CNA. The allegation was first brought forward when the resident showed CNA 1 a notepad with the word “rape” written on it and stated that the male CNA on the night shift was raping him. CNA 1 reported the allegation to LN 3 the same day, and LN 3 stated she immediately notified LN 2. A progress note authored by LN 2 documented that the Administrator and DON were made aware of the allegation that afternoon. The Administrator reported being notified of the allegation that day and stated that CDPH was notified the same day, but she could not provide evidence of the exact time of notification. The DON similarly stated that CDPH was notified that day but could not provide documentation of the time. A SOC 341 form related to the allegation was received by CDPH via email the following day at 1:57 PM. The Administrator later acknowledged awareness that the alleged abuse should have been reported to CDPH within two hours and was unable to provide documentation confirming that this requirement was met, despite the facility’s Abuse Prevention Program policy requiring investigation and reporting of abuse allegations within federally required timeframes.
Initial Physician Assessment Not Completed for Medicare Part A Admission
Penalty
Summary
The facility failed to ensure that the initial comprehensive visit for a resident admitted under Medicare Part A was completed by a physician, as required by federal regulations. Instead, the initial assessment and admission orders for the resident were performed by a nurse practitioner. This was confirmed through interviews and record reviews with facility staff, including the LN, DON, and Administrator, all of whom acknowledged that the physician did not personally conduct the initial assessment. The facility's own policy and procedure, as well as CMS guidance, specify that the initial comprehensive visit in a skilled nursing facility (SNF) must be performed by a physician and cannot be delegated to a non-physician practitioner. The deficiency was identified for one of three sampled residents, with documentation showing that the nurse practitioner completed the initial assessment and 72-hour charting. Staff interviews further confirmed the importance of the physician's role in establishing a baseline, reviewing and reconciling medications, and developing the plan of care during the initial assessment. The facility is dually certified under Medicare and Medicaid, and the failure to have the physician personally complete the required initial visit was verified by the Administrator.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of aggressive behavior physically abused another resident. The aggressive resident, who had diagnoses including dementia with agitation and behavioral disturbance, was known by staff to exhibit combative and threatening behaviors, including striking out at staff and other residents. On the day of the incident, the aggressive resident approached another resident in a hallway, struck her on the hand, and attempted to kick her. The assaulted resident, who had normal cognitive function and required assistance with personal care and mobility, sustained a bruised right hand and reported feeling upset, uncomfortable, and unsafe following the incident. Staff interviews and record reviews revealed that the aggressive resident was supposed to be monitored hourly due to his known behaviors and tendency to wander. However, documentation showed that hourly monitoring was not consistently performed or recorded as expected. At the time of the incident, there were fewer staff available due to lunchtime coverage, and no staff were present in the hallway where the abuse occurred. The area where the incident took place was not visible from the nurses' station, further reducing the likelihood of timely staff intervention. Multiple staff members, including nurses and CNAs, confirmed that the aggressive resident required close supervision when out of his room to prevent harm to others. Despite this, the lack of adequate monitoring allowed the resident to approach and harm another resident without immediate staff intervention. The facility's own policy required protection of residents from abuse by anyone, including other residents, but this was not effectively implemented in this case.
Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers due to hemiplegia, hemiparesis, and aphasia following a stroke, was transferred using a mechanical lift by a single CNA instead of the required two-person assist. The resident's Minimum Data Set assessment indicated a need for two or more staff members for transfers, and facility policy mandated at least two nursing assistants for safe use of a mechanical lift. Despite these requirements, the CNA attempted the transfer alone, resulting in the resident slipping from the sling and falling to the floor. As a result of this incident, the resident sustained a large intramuscular hematoma to the right pectoralis and minimally displaced fractures of the right proximal tibia and fibula. Interviews with facility staff, including the MDS Coordinator, Licensed Nurse, and DON, confirmed that the resident required two-person assistance and that the CNA did not follow established policy and procedures. The DON acknowledged that the resident's injuries were acquired due to the fall caused by the failure to implement the required two-person assist during the transfer.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was found outside the facility in the parking lot of a neighboring apartment complex at approximately 10:00 p.m. The resident was not in her room at 9:30 p.m., prompting a search of the building, and was located outside around 9:45 p.m. Upon assessment, the resident was found to have two skin tears on her right knee and was unable to recall the events that led to her being outside. The resident's clinical record indicated diagnoses including malignant neoplasm of the kidney, anxiety disorder, and failure to thrive. Staff interviews confirmed that the resident had eloped from the facility and that staff were unable to ensure her safety or monitor her when she was not in the building or accounted for. The administrator acknowledged that the resident was assessed and treated for her injuries after being found outside and stated there was potential for more serious injury due to the lack of supervision while the resident was outside the facility.
Failure to Assess Resident's Use of Dentures and Hearing Aids
Penalty
Summary
The facility failed to accurately assess a resident for the use of a partial denture and hearing aids, which led to staff being unaware of the resident's needs. Upon admission, the Licensed Nurse did not assess the resident's use of these items, and the Minimum Data Set (MDS) nurse incorrectly indicated that the resident did not use hearing aids. This lack of assessment resulted in the absence of a care plan for the resident's hearing aids and partial dentures. The resident's partial denture was lost and later found cracked, rendering it unusable for over three weeks, during which the resident experienced weight loss. The resident's hearing aids were also misplaced for a few days. Interviews with staff and family members revealed that the facility did not maintain an accurate inventory of the resident's possessions, and there was no consistent care for the resident's partial denture and hearing aids. The Director of Nursing and Administrator acknowledged that the Licensed Nurse should have reassessed the resident's dental and hearing status, which would have generated appropriate care plans. The facility's policy and procedure for resident assessment and care plan coordination were not followed, as confirmed by the Director of Nursing during a review of the facility's policy.
Failure to Implement Comprehensive Care Plan for Resident's Denture and Hearing Aids
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was in place for a resident, specifically addressing the use of a partial denture and hearing aids. This oversight resulted in the nursing staff's lack of awareness regarding the resident's need for these aids, leading to inadequate care and management of the partial denture and hearing aids. The resident experienced confusion and a significant weight loss of 15 pounds during their stay at the facility. The resident's clinical records, including the Admission Record and the Nursing Admission Data Collection and Baseline Care Plan Tool, did not assess or document the use of a partial denture and hearing aids. Despite the Registered Dietitian noting the presence of dentures in a Nutritional Comprehensive Assessment, the lack of a formal care plan meant that these needs were not systematically addressed. The resident's partial denture was lost and found damaged, and the hearing aids were misplaced for a few days, further complicating the resident's care. Interviews with facility staff, family members, and the resident revealed that the facility did not follow its policies and procedures for comprehensive, person-centered care planning. The Director of Nursing and Administrator acknowledged that the Licensed Nurse should have reassessed the resident's dental and hearing needs, which would have generated the necessary care plans. The failure to reassess and document these needs led to the absence of a care plan that could have mitigated the resident's confusion and weight loss.
Failure to Provide and Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing treatment and services for a resident, identified as Resident 2, who did not receive her ordered RNA therapy for a specific week. Resident 2 was admitted with diagnoses including difficulty in walking, hemiplegia, and hemiparesis following a cerebral infarction affecting the left side. The physician had ordered RNA therapy two times a week for upper extremity active range of motion (AROM) and transfer training, which was later increased to three times a week. However, there was no documentation of RNA services being provided to Resident 2 during the week of September 23rd, as confirmed by the Restorative Nurse Assistants and the Director of Rehabilitation. Interviews and record reviews revealed that the RNA services were not documented in Resident 2's electronic health record (EHR) for the specified week, and there was no paper documentation available either. The Director of Rehabilitation and the Assistant Administrator confirmed the absence of documentation, indicating a lapse in the provision of RNA services. Resident 2 and a family member also stated that RNA services began the following week. The facility's policy on restorative nursing services and documentation requires that all services provided be documented in the resident's medical record, which was not adhered to in this case.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage and handling, as observed during a survey. Dirty serving scoops with green and brown crusted substances were found stored with clean utensils in a cook's undercounter drawer. The Dietary Services Manager (DSM) acknowledged the oversight, noting that the scoops should have been clean and checked by the cooks. Additionally, eleven cases of thawed and soft mighty healthshakes were improperly stored in the walk-in refrigerator, with some past their use-by date. The DSM confirmed the shakes were heavily used in the facility and acknowledged the improper storage. Further inspection revealed a pipe from the dish machine extended directly into a floor sink drain without an air gap, which is a violation of the 2022 Federal FDA Food Code. The DSM and Plant Operations Director (POD) were unaware of this issue, and the POD admitted the pipe needed to be raised. Additionally, two ice machines were not cleaned and maintained according to the manufacturer's instructions. The ice machine in the dining room had small brownish pink spots and black, grayish mold-like spots on the baffle, which the POD acknowledged as missed during cleaning. The main ice machine also had thick debris and buildup inside the ice spout, which the POD admitted could have been scrubbed more thoroughly. The facility's policies and procedures were reviewed, indicating that equipment should be maintained and cleaned regularly. However, the observations during the survey showed that these procedures were not followed, leading to unsanitary conditions that could potentially expose residents to harmful substances. The Registered Dietitian (RD) expressed expectations for the ice machines to be clean, following the manufacturer's guidelines, without any residue or debris.
Medication Administration Error
Penalty
Summary
The facility failed to protect a resident from significant medication errors when Midodrine, a medication used to manage blood pressure, was not administered according to physician orders. The resident, who had a history of aphasia following a cerebral infarction, was prescribed Midodrine to be given three times a day via PEG-Tube for hypotension, with specific instructions to hold the medication if the systolic blood pressure exceeded 130. However, the medication was either held or administered outside of these parameters on multiple occasions in August and September 2024. The Assistant Director of Nursing confirmed that the medication was not administered correctly, with instances of Midodrine being held when it should have been given, and vice versa. This included specific dates where the medication was either held or administered incorrectly, potentially leading to adverse effects such as hypotension or hypertension. The facility's policy on administering medications, which mandates that medications be given safely and timely as prescribed, was not followed, resulting in this deficiency.
Deficiencies in Kitchen Staff Competency and Sanitation Practices
Penalty
Summary
The facility failed to ensure that the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice. During an observation, a dishwasher (DSW) was unable to correctly test the dish machine sanitizer or identify the safe temperatures and sanitizer levels for the 3-compartment sink. The DSW incorrectly recorded the sanitizer level as 200 ppm, which was too high, and did not know the correct temperature levels for the 3-compartment sink. The Dietary Services Manager (DSM) acknowledged these errors and stated that the correct sanitizer level should be 50-100 ppm. Additionally, a Diet Aide (DA) failed to wash his hands after disposing of trash outside on two occasions, which is a violation of proper food safety and sanitation practices. The DA admitted that he should have washed his hands and worn a disposable apron to prevent cross-contamination. The DSM confirmed that the DA did not follow the correct procedures, which could lead to contamination. Furthermore, two Diet Aides were unable to demonstrate how to calibrate a thermometer correctly. One DA stated she had never been trained on this procedure, while another DA recalled some information from a previous job but was unsure of the correct process. The DSM acknowledged that the DAs should know how to calibrate a thermometer correctly. The Registered Dietitian (RD) expected the kitchen staff to perform these tasks correctly and stated that monthly in-services and quarterly kitchen sanitation checks were conducted, but some staff members did not attend the relevant training sessions.
Deficiency in Meal Temperature and Flavor
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature and flavor, as per their policy, affecting 145 out of 155 residents. During a kitchen observation, it was noted that the cook was unsure if the regular recipe for pasta with garlic and herbs was fully followed, and the pureed chicken cacciatore sauce did not match the regular version, potentially altering the flavor. During a trayline service observation, test trays revealed that the milk was served at 52 degrees Fahrenheit, which was warmer than the facility's policy of 41 degrees Fahrenheit. The pureed salad was described as watery and bland, and the pureed chicken cacciatore lacked flavor until the sauce was added. The regular meal pasta was also found to be buttery and bland due to missing garlic and herb seasoning. During a resident council meeting, multiple residents anonymously reported that the food was not tasty, often served cold, and was bland and overcooked. The Registered Dietitian (RD) admitted to not conducting test trays to check food temperatures and palatability, although she personally liked the facility food. The RD acknowledged that the food should be served at an appealing temperature to encourage residents to eat. The facility's policies emphasized the importance of serving meals at appropriate temperatures and using approved recipes to ensure nutritional needs are met, but these were not adhered to, leading to the deficiency.
Dish Machine Sanitizer Levels Exceeded Safe Limits
Penalty
Summary
The facility failed to maintain the dish machine in safe operating condition, as observed during a kitchen tour. The dish machine sanitizer exceeded safe levels, with test strips showing a dark purple color indicating 200 parts per million (ppm), which is above the recommended 50-100 ppm. The dishwasher was unaware of the water leak beneath the machine and incorrectly believed the sanitizer level was acceptable. The dish machine sanitizer testing log consistently recorded 200 ppm from September 1 through 17, which was initialed by the dishwasher. The Dietary Services Manager (DSM) acknowledged the incorrect sanitizer levels and the water leak, confirming that the appropriate level should be 50-100 ppm. A vendor technician adjusted the chemical levels to the correct range, noting that excessive chemicals could contaminate dishes and food. The Registered Dietitian (RD) expected the dish machine to function according to manufacturer guidelines, which were not met. The facility's policies required proper maintenance and regular checks of the dish machine, which were not adhered to, leading to the deficiency.
Failure to Coordinate Specialized Mental Health Services
Penalty
Summary
The facility failed to ensure coordination of specialized mental health services for a resident with serious mental illness diagnoses, including bipolar disorder and schizophrenia. The deficiency occurred when the facility did not respond to the state-designated authority for further PASRR Level II needs, which is a tool used to ensure residents with certain mental illnesses receive the necessary care in the most appropriate setting. The resident was admitted in August 2024, and the PASRR Level II letter dated 8/21/24 indicated that facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. As a result of the facility's inaction, the PASRR Level II case was closed, and the facility was required to resubmit a new Level I Screening to reopen the case. The Minimum Data Set Case Manager (MDSCM) confirmed that the PASRR Level II was closed due to the agency's inability to contact anyone at the facility. A new PASRR Level I screening was completed on 9/18/24, which indicated the resident had serious mental illness diagnoses and required a PASRR Level II Screening. The facility's policy on PASRR indicated that all residents entering the facility should have a PASRR completed to determine if they are mentally ill and whether they need specialized services.
Deficiencies in Resident Care Plans for Oxygen and IV Therapy
Penalty
Summary
The facility failed to provide a resident-centered care plan for two residents, leading to deficiencies in their care. Resident 76, who was admitted with conditions including hepatic encephalopathy, COPD, CHF, and anxiety disorder, required continuous oxygen therapy. However, the care plan did not include interventions to ensure his oxygen levels remained above 90%. Observations revealed that Resident 76 frequently removed his nasal cannula, and staff were not consistently monitoring or reminding him to wear it, resulting in his oxygen saturation dropping below the desired level. Resident 104, admitted with an infection and inflammatory reaction due to a hip prosthesis, required intravenous therapy through a midline catheter. The care plan for Resident 104 was not specific to the midline catheter, lacking details on maintenance, dressing changes, and signs of complications. This oversight was evident when Resident 104 accidentally pulled out her midline catheter, and the care plan did not provide guidance on managing such incidents or the specific care required for her IV access. The facility's policies on oxygen administration and care planning were not adequately followed, as evidenced by the lack of specific interventions and monitoring for both residents. The Assistant Director of Nurses acknowledged the deficiencies in the care plans, noting the absence of necessary interventions and monitoring for Resident 76's oxygen therapy and the lack of specificity in Resident 104's IV therapy care plan.
Peripheral IV Inserted Without Physician Order
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident when a licensed nurse inserted a peripheral IV without a physician order. The resident was admitted with a diagnosis of infection and inflammatory reaction due to an internal left hip prosthesis and a surgical complication. The resident was receiving intravenous antibiotics for a hip wound dehiscence. On a specific date, the resident accidentally pulled out her midline catheter, and the licensed nurse inserted a peripheral IV cannula in the right arm without obtaining a physician order. The Assistant Director of Nurses confirmed that there was no physician order for the peripheral line and no nursing progress note indicating that the resident's medical doctor was informed about the dislodgement of the midline catheter. The medical doctor also confirmed that there was no record of being notified about the need for a peripheral line and did not place an order for it. The facility's policy on IV therapy requires verbal consent for placement and specifies that peripheral catheters are for short-term therapies, typically less than one week.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to provide weekly showers to a resident, identified as Resident 48, as per their preference and schedule. Resident 48, who was admitted in March 2022 with diagnoses including abnormalities of gait and mobility, had an intact cognitive status with a BIMS score of 15. The resident required substantial assistance for personal hygiene and preferred showers over bed baths. Despite being on COVID precautions since early September, the resident expressed concern about not receiving showers, with the last shower documented over a week prior to the interview. The facility's records and interviews with staff, including the Director of Staff Development and a Certified Nursing Assistant, confirmed that Resident 48 was scheduled for showers twice a week but did not receive them between early and mid-September. The Assistant Director of Nursing acknowledged that showers should have been provided according to the schedule, even for residents on COVID precautions, emphasizing the importance of showers for hygiene and infection prevention. The facility's policy required staff to assist residents with bathing as necessary, but documentation showed that showers were not provided as scheduled during the specified period.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to meet professional standards of care for a resident who returned from an orthopedic appointment with a sling on her right arm but without new medical orders. The licensed nurse attempted to contact the orthopedist for further instructions but did not receive a response. Consequently, the sling was removed from the resident's arm due to the absence of a formal order. This action was taken without notifying the resident's primary medical doctor, which was against the facility's policy for handling changes in a resident's condition. The resident, who had been readmitted to the facility earlier in the year, reported significant swelling, limited movement, and discomfort in her right arm. The facility's Assistant Director of Nurses confirmed that there was no documentation indicating that the primary medical doctor had been informed of the situation, which could have led to delayed care. The facility's policy requires prompt notification of the attending physician in the event of significant changes in a resident's condition, which was not adhered to in this case.
Failure to Monitor Wander Guard and Timely Smoking Assessment
Penalty
Summary
The facility failed to implement measures to minimize accidents for two residents, leading to potential safety risks. Resident 122, diagnosed with Parkinson's disease and at high risk for elopement, was not properly monitored with a wander guard device. Despite being identified as having impulsive behavior and poor safety awareness, the wander guard was not consistently checked for placement and functionality. On one occasion, Resident 122 was observed outside the facility without staff knowledge, and it was noted that the resident was not wearing the wander guard wristband. The facility's policy required monitoring of residents at risk for elopement, but this was not adhered to, increasing the risk of unsupervised wandering. Additionally, Resident 296, who was admitted with COPD and nicotine dependence, was not assessed for safe smoking practices in a timely manner. The Smoking Risk assessment was completed 12 days after admission, which delayed the identification of the resident's smoking habits and potential risks, especially given the resident's dependence on supplemental oxygen. The facility's policy required an evaluation upon admission to determine smoking status and ability to smoke safely, but this was not conducted promptly, potentially putting the resident and others at risk.
Failure to Monitor Antipsychotic Medication Effectiveness
Penalty
Summary
The facility failed to ensure safe medication use for a resident on antipsychotic medication, specifically Haldol, by not monitoring its effectiveness. The resident, who was admitted in August 2024 with diagnoses including dementia and personality disorder, was prescribed Haldol for agitation manifested by aggressive behavior. However, the facility did not monitor the resident's aggressive behavior as an indication for Haldol use until mid-September 2024, despite the care plan requiring monitoring each shift. The Assistant Director of Nursing confirmed that behavior monitoring for Haldol was not conducted in August 2024 and only began in September 2024. The facility's policy on antipsychotic medication use required staff to observe, document, and report the effectiveness of interventions, including antipsychotic medications, to the attending physician. This lapse in monitoring placed the resident at risk for inadequate symptom relief and/or adverse effects from the use of the antipsychotic medication.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage practices in three of nine medication carts. An expired multi-dose inhaler, Wilexa Inhub, was found in the medication cart for a resident, with the date indicating it should have been discarded a month after opening. The licensed nurse confirmed the medication was not discarded as per the manufacturer's instructions. Additionally, a multi-dose injection pen of Ozempic was found without a date opened label, which is necessary to determine its expiration. The Assistant Director of Nursing confirmed that medications should be marked with the open date and expiration date to ensure effectiveness. Furthermore, a single-dose package of hydralazine, a blood pressure medication, was found expired and stored in the medication cart for a discharged resident. The medication was not stored with other resident medications, and the licensed nurse was unsure why it was in the drawer. The Assistant Director of Nursing stated that medications for discharged residents should be removed from the cart within a day or two to prevent the risk of administering the wrong medication. The facility's policies on medication storage and disposal were not adhered to, contributing to these deficiencies.
Failure to Store and Reheat Resident's Outside Food
Penalty
Summary
The facility failed to ensure that food brought in from outside for Resident 85 was stored and reheated according to regulatory standards and facility policy. Resident 85, who was admitted with diagnoses including congestive heart failure, type 2 diabetes, iron deficiency anemia, and vitamin D deficiency, expressed dissatisfaction with the facility's food due to its saltiness. As a result, her granddaughter occasionally brought her meals from a nearby steak restaurant. On one occasion, the resident received a meal that included steak, mashed potatoes, and a dinner roll, but was informed by the nursing staff that they could not store or reheat her food, leading to it becoming cold and soggy after sitting out for several hours. Interviews with various nursing staff revealed inconsistencies and a lack of knowledge regarding the facility's policy on storing and reheating food brought in from outside. Licensed nurses provided conflicting information about the storage duration and reheating procedures, with some stating that food could not be stored due to lack of space, while others were unaware of the reheating policy. The Assistant Director of Nursing acknowledged the need for staff training on the policy, which required perishable foods to be labeled and stored appropriately, and reheated by kitchen staff, though specific reheating guidelines were unclear. The facility's policy indicated that discussions about outside food should be documented, and perishable foods discarded after an appropriate time, but these procedures were not followed in this instance.
Infection Control Deficiencies in Wound Care and Urinal Labeling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. For Resident 56, a licensed nurse did not change gloves or perform hand hygiene during wound care. The nurse administered medication via a gastrostomy tube and changed the dressing on the stoma site without changing gloves or washing hands between handling soiled and clean dressings. This was contrary to the facility's policy, which requires hand hygiene and glove changes during dressing changes to prevent infection. The Assistant Director of Nurses confirmed that the standard of care was not maintained, putting the resident at risk of infection. For Resident 246, the facility failed to label the resident's urinal with a name or room number. During an observation, a certified nursing assistant confirmed that the urinal was unlabeled, which could lead to the risk of infection if used by another resident. The facility's infection prevention and control program policy emphasizes the importance of labeling personal items to prevent the transmission of infections. The lack of labeling was identified as a failure to adhere to these infection control standards.
Documentation Errors in Fall Incident
Penalty
Summary
The facility failed to ensure the medical record accurately reflected a fall incident for a resident. Licensed staff did not document whether the resident's fall mat was present when the resident fell out of bed. The interdisciplinary team had recommended the use of a fall mat for the resident, but the care plan and other records incorrectly indicated that this intervention was already in place. This discrepancy in documentation had the potential to cause miscommunication and confusion among healthcare providers regarding the resident's fall. The resident was admitted to the facility in 2021 with diagnoses including congestive heart failure, depression, and anxiety. On the day of the incident, a licensed nurse was called to assess the resident after a fall and found the resident sitting on the floor next to the bed. The bed was in the lowest position, and the call light was within reach. During interviews, both the Director of Nursing and the licensed nurses involved acknowledged the documentation errors regarding the presence of the fall mat.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident diagnosed with osteoarthritis, leading to the resident experiencing severe pain. The resident was admitted in May 2024 and requested Norco for pain relief on May 18, 2024, as Tylenol was ineffective. Despite multiple attempts to contact the physician, including faxing and calling, the prescription was not corrected in a timely manner due to an error in the date, delaying the administration of the medication until May 20, 2024. Further issues arose when the resident's pain medication ran out on July 4, 2024, and the facility did not have the medication available. The nursing staff failed to reorder the medication in a timely manner, and the physician's order was not signed until July 5, 2024. The Director of Nurses acknowledged that medications should be reordered when there are approximately seven doses left, and urgent needs should be addressed within an hour. The facility's policy required medications to be reordered at least three days before the last dose to ensure availability.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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