Evergreen Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 5265 East Huntington Avenue, Fresno, California 93727
- CMS Provider Number
- 555920
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Evergreen Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including ESRD, heart failure, and abnormal breathing, was discharged home without the physician-ordered medical equipment, including continuous oxygen, wheelchair, and shower chair. Although discharge documentation stated that medical equipment and oxygen supplies were delivered and explained, the SSD and family reported that no equipment was provided and that the oxygen concentrator was not available at the time of discharge. RN, SSD, DON, and ADM interviews confirmed that the facility’s discharge process requires ensuring all ordered equipment is in place before discharge and that this did not occur for this resident, resulting in an unsafe discharge contrary to facility policy.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Three residents experienced missed or delayed medical appointments due to inadequate transportation arrangements, lack of accommodation for transportation preferences, and poor communication between staff, residents, and responsible parties. Issues included late arrivals, inappropriate vehicles, and extended wait times after appointments, with incomplete documentation and unclear staff responsibilities contributing to the deficiencies.
A resident with a history of trauma was not provided with trauma-informed care upon admission to the facility. Despite disclosing her traumatic past and expressing fear of being around unfamiliar men, the facility did not implement effective interventions to avoid triggers. The resident was placed in a room near male residents, causing distress and anxiety. Staff were unaware of her traumatic history due to a lack of training, and her requests for room changes were not addressed, leading to feelings of isolation and fear.
The facility failed to employ a full-time DON from December 2024 to March 2025. A nursing consultant performed some DON duties part-time, but no full-time DON was designated. This absence potentially risked inadequate care planning and supervision, affecting residents' health and safety.
The facility failed to ensure privacy for two residents during health discussions, as the social services director's office was too small and residents' rooms did not provide adequate privacy. Both residents reported concerns about discussing personal health information due to the presence of roommates and staff. The facility's policy emphasized confidentiality, but the lack of a suitable private area led to potential breaches of privacy.
A facility failed to create a trauma-informed care plan for a resident with a history of trauma, despite identifying her trauma upon admission. The resident, who was cognitively intact and had multiple diagnoses, experienced triggers that caused her to relive past traumas. Staff interviews revealed a lack of awareness of the resident's trauma history and the importance of identifying triggers, contrary to the facility's policies on comprehensive care plans and trauma-informed care.
Two residents were denied the opportunity to reheat food brought by family after 7:00 p.m. due to the lack of a functioning microwave and the absence of dietary staff. Both residents, who were cognitively intact, expressed anger over this restriction, which did not respect their autonomy. The facility's policy allowed food from outside but did not accommodate reheating after dietary staff hours, impacting residents' rights to self-determination.
A resident with cognitive intactness and multiple medical conditions was abused by a CNA who hit them with a closed fist during personal care. The resident became aggressive, leading to the CNA's inappropriate response. Staff interviews confirmed the incident, which violated the facility's abuse prevention policies.
The facility failed to maintain food safety standards, as observed in three key areas: improper sanitizer concentration used by a kitchen staff member, failure to record food temperatures before serving, and storing kitchenware while still wet. These actions could potentially expose residents to foodborne illnesses due to bacterial growth.
Two residents were not provided privacy during medical procedures by an LVN, who checked vital signs and administered medications in public areas. Despite facility policies requiring privacy, these actions were conducted in view of others, compromising the residents' dignity and respect. Both residents had no cognitive deficits, highlighting the importance of adhering to privacy protocols.
The facility failed to complete dialysis communication forms for two residents undergoing hemodialysis, as observed through interviews and record reviews. One resident, admitted with end-stage kidney disease and a fractured femur, lacked documentation of post-dialysis assessments on multiple dates. Another resident had incomplete forms for several dates in May. Staff interviews revealed that charge nurses and medical records staff were responsible for ensuring form completion, which was not done, risking delayed detection of complications.
A resident was administered heparin for venous thromboembolism prophylaxis without a comprehensive care plan in place. Despite the resident's significant medical conditions, facility staff, including an LVN, the MDS Nurse, and the DON, confirmed the absence of a care plan to monitor the anticoagulant use. This oversight was contrary to the facility's policy requiring timely development of care plans.
A resident with Type 2 Diabetes Mellitus did not have their fasting blood sugar levels monitored as per physician's orders, which required daily checks. The DON confirmed the absence of records for these checks, and the LVN was unaware of the resident's diabetes diagnosis and monitoring order. The MDSN noted that prompts for blood sugar checks were missing in the MAR, and the Medical Records Staff acknowledged the need for more careful review of orders.
A resident's prescribed Lactulose medication for constipation was unavailable for administration due to a failure in reordering. An LVN discovered the unavailability during a medication pass, and the DON confirmed that nurses are responsible for ensuring timely medication orders. The facility's policy mandates timely delivery to prevent administration delays.
A resident with a history of cerebral infarction and dysphagia was not provided with the prescribed finger food diet, receiving whole pieces of chicken and other non-finger foods instead. The CNA did not verify the meal against the tray ticket, assuming it was already checked by the nurse. This oversight was confirmed by the RNA and MDSN, and the DSM acknowledged the error, highlighting a failure in the facility's process to ensure dietary orders are followed.
A resident reported and was observed to have fecal stains on the toilet in their bathroom, indicating a failure in maintaining a sanitary environment. The DON and IP confirmed the issue as an infection control problem, with potential risks of pathogen transmission. The facility's policies on cleanliness were not adhered to, as evidenced by the unclean bathroom.
The facility did not meet the required square footage per resident in 12 out of 19 rooms, as observed during a survey. Despite this, residents had adequate privacy, storage, and accessibility. The facility has requested a waiver continuance, claiming no adverse effects on resident health and safety.
Unsafe Discharge Without Required Medical Equipment and Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a cognitively intact resident who required specific medical equipment and services upon leaving the facility. The resident was admitted with multiple diagnoses including DM, bacterial infections, ESRD, hypertension, heart failure, and abnormalities of breathing. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. Physician discharge orders dated 2/19/26 specified that the resident was to be discharged home with post-discharge needs including home health nursing, home health PT and OT, a wheelchair, a shower chair, and oxygen. An existing order from 12/5/25 required continuous oxygen at 4 L/min via nasal cannula related to abnormalities of breathing. Despite these orders, the resident was discharged without the ordered medical equipment. The SSD confirmed that the resident was discharged with physician orders for home health, PT, OT, shower chair, walker, and oxygen concentrator, but no medical equipment was provided to the resident upon or prior to discharge. The discharge summary documentation stated that medical equipment was delivered at bedside and that all oxygen supply was handed over to home health, with explanations given on how to use the oxygen supply, but this conflicted with interviews and other record review indicating that the equipment was not actually provided. The SSD also stated that home health was contacted on the day of discharge and that the home health agency had notified her that the oxygen concentrator would not be available upon discharge, and that the resident’s medical equipment and oxygen concentrator were not delivered to the new residence prior to discharge. Interviews with facility staff further described the failure in the discharge process. RN 1 stated that the facility’s process for discharge was to ensure residents had all medications, education, and medical equipment needed for a safe discharge, and that the resident should not have been discharged without the physician-ordered medical equipment and oxygen concentrator. The SSD stated that the resident had been issued a notice of non-payment and had informed her of plans to rent a room from a friend, but acknowledged that the discharge was not safe and that the resident was not educated on the need for medical equipment or the potential consequences of not having it. The DON and the ADM both stated that facility process required ensuring all needed medical equipment was in place prior to discharge and acknowledged that the resident’s discharge without the ordered equipment was unsafe and not consistent with facility policy and procedure on transfer and discharge, which requires orientation and planning to ensure a safe and orderly transfer or discharge.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Ensure Timely and Appropriate Transportation for Medical Appointments
Penalty
Summary
The facility failed to adequately assist residents in arranging and coordinating transportation to and from medical appointments, resulting in missed or delayed appointments for three residents. One resident, who had a history of end stage renal disease and diabetes, experienced repeated issues with a specific transportation company, leading to missed appointments and the need to reschedule. The resident's preference for a different transportation provider was not accommodated, and when concerns were raised with the Social Services Designee (SSD), the resident was advised to contact their insurance rather than receiving direct assistance from the facility. Documentation showed that the resident was cognitively intact and had clearly communicated her transportation preferences and frustrations. Another resident, with a history of hemiplegia, cerebral edema, and mental health disorders, missed appointments due to transportation problems, including a vehicle with a flat tire and a van that could not accommodate his specialized wheelchair. The resident's responsible party reported poor communication from the facility regarding missed and rescheduled appointments, and there was no documentation of these communications in the resident's chart. The SSD confirmed that transportation issues had occurred and that communication with responsible parties was not consistently documented. A third resident, who was cognitively intact and had diagnoses including Alzheimer's disease and congestive heart failure, was left waiting for hours after a medical appointment because the scheduled transportation did not arrive. The resident ultimately had to arrange alternative transportation, resulting in significant distress. Facility staff interviews and record reviews revealed that the process for monitoring residents' departures and returns from appointments was inconsistent, with incomplete logs and unclear responsibilities among staff. The Director of Nursing and Administrator acknowledged gaps in communication, documentation, and staff training related to transportation arrangements and resident safety during off-site appointments.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who had a history of trauma due to past sexual and physical abuse. Upon admission, the resident disclosed her traumatic history and expressed fear of being around unfamiliar men. Despite this, the facility did not recognize the severity of her trauma and did not implement effective interventions to avoid triggers. The resident was placed in a room across from a male resident, which caused her significant distress, including sleeplessness and anxiety, as she feared male residents might enter her room at night. The resident's care plan did not include trauma-informed care, and staff were not aware of her traumatic history or the environmental triggers affecting her. Interviews with facility staff, including CNAs and LVNs, revealed a lack of training and awareness regarding trauma-informed care. The resident's requests to be moved to a different room were not addressed, and she felt isolated and unsupported by the facility staff, who reportedly dismissed her concerns. The facility's policy on trauma-informed care was not followed, as evidenced by the absence of a care plan addressing the resident's trauma and triggers. The resident's high score on the trauma evaluation was not acted upon, and her primary care physician was not notified. The lack of a trauma-informed care plan and staff training contributed to the resident's re-traumatization and feelings of isolation, depression, and fear.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate and employ a full-time Director of Nursing (DON) from December 2024 to March 2025. During this period, the facility did not have a DON assigned, as confirmed by interviews with the Administrator and Assistant Administrator. They stated that a DON was supposed to start working full-time but did not due to unforeseen circumstances. Instead, a nursing consultant completed some DON duties 1-2 times per week, but this was not sufficient to meet the full-time requirement. Registered Nurses were assigned as supervisors for the day but did not perform any DON duties. The clinical resource also confirmed that there was no DON employed at the facility, and she assisted with DON duties only 1-3 days a week, without being the interim DON or working full-time hours. The facility's policy and procedure indicated the intent to comply with RN staffing requirements, including designating a full-time DON. The job description for the DON outlined responsibilities such as planning, organizing, and directing the Nursing Service Department in accordance with standards and regulations. The absence of a full-time DON had the potential to result in inadequate care planning and supervision, placing residents' health and safety at risk.
Lack of Privacy for Resident Health Discussions
Penalty
Summary
The facility failed to protect and promote the rights of residents' privacy for two of nine sampled residents when it did not provide a private area for them to discuss their personal health information. Resident 1, who was admitted with diagnoses including Major Depressive Disorder, Morbid Obesity, Anxiety, insomnia, and alcohol abuse, expressed concerns about the lack of privacy during personal conversations and medical visits. Resident 1 reported that discussions with the social services director (SSD) were not private due to the presence of a roommate and staff entering and exiting the room. Additionally, the SSD's office was too small to accommodate private conversations. Resident 2, who was admitted with diagnoses of Morbid Obesity, Anxiety, and other stimulant abuse, also reported a lack of privacy for private conversations unless roommates were removed from the room. Resident 2 felt that the privacy curtain in her room was insufficient to keep her health information private from staff and other residents. The SSD confirmed that the office space provided was inadequate for private discussions and that she had been directed to conduct private health conversations in residents' rooms, which did not ensure privacy when other roommates or staff were present. The facility's policy and procedure on confidentiality of personal and medical records emphasized the right to secure and confidential records and stated that confidential information should not be discussed in public or semi-public areas. Despite this policy, the facility did not provide a suitable private area for residents to discuss their personal health information, leading to a potential breach of confidentiality and privacy for Residents 1 and 2.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for trauma-informed care for a resident who had a history of trauma. Upon admission, the admitting nurse and social services director identified the resident's history of trauma but did not create a care plan to recognize trauma and triggers that impacted the resident's care. This oversight resulted in the resident experiencing triggers that caused her to relive past traumas during her stay at the facility. The resident was admitted with diagnoses including Major Depressive Disorder, Morbid Obesity, Anxiety, Insomnia, and Alcohol Abuse. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan did not address her past trauma or associated triggers. Interviews with facility staff, including a CNA, LVN, and SSD, revealed that they were unaware of the resident's trauma history and the importance of identifying triggers to provide appropriate care. The facility's policies and procedures for comprehensive care plans and trauma-informed care emphasize the need for individualized interventions and collaboration with residents and their families to minimize triggers and avoid re-traumatization. However, these procedures were not followed in the case of the resident, as no care plan was created to address her trauma and triggers, even after a high score on the trauma evaluation. This lack of a care plan was acknowledged by various staff members, including the administrator and clinical resource, who recognized the importance of establishing a plan of care to prevent further trauma and triggers.
Facility Fails to Support Residents' Rights to Reheat Food
Penalty
Summary
The facility failed to uphold the rights of two residents by not allowing them to reheat food brought in by their families after 7:00 p.m. This was due to the absence of a functioning microwave for resident use and the facility's policy that only dietary staff, who were not available after 7:00 p.m., could reheat food. Both residents were cognitively intact and expressed anger and frustration over this restriction, which they felt did not respect their individuality and autonomy. Resident 1, who was admitted with diagnoses including Major Depressive Disorder, Morbid Obesity, Anxiety, and Bipolar Disorder, reported that the facility staff informed him they were not supposed to assist with reheating his food. Similarly, Resident 2, who had type 2 diabetes mellitus and anemia, was told that the microwave used for reheating resident food was broken and that staff were not allowed to assist in reheating food. Instead, Resident 2 was offered facility snacks, which did not meet his preference for consuming his own food. The facility's policy allowed food brought by family or visitors but required it to be handled safely and stored properly. However, the policy did not accommodate the residents' right to reheat their food after the dietary staff had left for the day. The assistant administrator and other staff confirmed that there was no microwave available for resident use and that the facility's process was to have dietary staff reheat food, which was not possible after 7:00 p.m. This led to a situation where residents' rights to self-determination and a homelike environment were not fully supported.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a certified nursing assistant (CNA) was observed hitting the resident with a closed fist. The incident involved a resident who was admitted with diagnoses including hemiplegia, epilepsy, morbid obesity, muscle weakness, and major depressive disorder. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. During an episode of personal hygiene care, the resident became aggressive, kicking and scratching the CNA, who then retaliated by hitting the resident on the right thigh. Interviews with staff and the resident confirmed the occurrence of the incident. The resident recalled being hit twice on the right hip by the CNA, which caused pain and mental trauma. Another CNA present during the incident corroborated the resident's account, stating that the resident was resisting care and that the CNA hit the resident multiple times. The facility's policy and procedure on abuse, neglect, and exploitation clearly prohibit such actions, defining abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. The facility's staff, including a Licensed Vocational Nurse and another CNA, acknowledged that the incident constituted abuse and was not in line with the facility's process for handling aggressive behaviors. The facility's policy emphasizes the importance of recognizing and managing resident behaviors appropriately, which includes stepping away and allowing the resident to calm down. Despite regular training on abuse prevention, the CNA involved in the incident failed to adhere to these guidelines, resulting in the abuse of the resident.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several instances. One kitchen staff member, identified as CK 2, was observed using a surface sanitizer with zero parts-per-million (ppm) concentration when wiping a food preparation table. This was contrary to the expected range of 50-100 ppm for chlorine solutions or 150-200 ppm for quaternary ammonium compounds, as per the facility's policy and professional standards. The Registered Dietician and Dietary Services Manager both acknowledged that such a low concentration was unacceptable and could lead to bacterial growth, potentially causing illness among residents. Another deficiency was noted when CK 1 did not take the temperature of food items after heating them in the microwave before serving them to a resident. The facility's policy requires that all hot and cold food temperatures be recorded before service to ensure safety. CK 1 admitted to not recording the temperature of the vegetarian patties, which should have been heated to 165 degrees Fahrenheit. The Dietary Services Manager confirmed that failing to check food temperatures is a safety and quality issue that could result in residents becoming ill. Additionally, the facility was found to be improperly storing kitchenware. Plates, plate holders, lids, and cooking pans were observed to be stacked and stored while still wet, which is against the facility's policy and FDA guidelines that mandate air drying to prevent microorganism growth. The Registered Dietician and Dietary Services Manager both stated that dishware should be completely dry before storage to avoid bacterial growth, which could lead to foodborne illnesses among residents.
Failure to Provide Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents during the administration of medications and the checking of vital signs. For Resident 146, the Licensed Vocational Nurse (LVN) 3 conducted these activities in a public hallway, where other residents and staff were present, thus not providing the necessary privacy. Resident 146, who had no cognitive deficits as indicated by a BIMS score of 14 out of 15, was exposed to a lack of privacy despite the facility's policy requiring such measures. Similarly, Resident 243 was not afforded privacy during the same procedures. LVN 3 checked vital signs and administered medication while the resident was in bed with the privacy curtain open, exposing the resident to others passing by. Resident 243 also had no cognitive deficits, with a BIMS score of 15 out of 15. The facility's policies clearly state the importance of providing privacy during such procedures, yet these guidelines were not followed, resulting in a breach of the residents' rights to dignity and respect.
Incomplete Dialysis Communication Forms for Residents
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed for two residents, Resident 142 and Resident 25, who were undergoing hemodialysis. This deficiency was identified through observations, interviews, and record reviews. Resident 142, who had been admitted with end-stage kidney disease and a fractured femur, was observed in her room and reported attending dialysis three times a week. However, there was no documentation of completed post-dialysis assessments of her access sites on multiple dates. Similarly, Resident 25, also diagnosed with end-stage renal disease, had incomplete dialysis communication forms for several dates in May 2024. Interviews with facility staff, including CNAs, LVNs, and the Director of Nursing, revealed that the responsibility for ensuring the completion of these forms lay with the charge nurse and medical records staff. The LVNs and medical records staff acknowledged the absence of completed forms and the importance of these documents in tracking new orders and updates from the dialysis center. The facility's policy on hemodialysis emphasized the need for timely communication and documentation, which was not adhered to in these cases, placing the residents at risk for delayed detection and management of complications from their dialysis access sites.
Failure to Implement Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was administered heparin as a prophylactic measure for venous thromboembolism. Despite the resident's admission with significant medical conditions, including a fracture of the right femur and end-stage renal disease, no care plan was initiated to address the use of anticoagulant medication. This oversight was identified during a review of the resident's clinical records, where it was noted that the heparin order was placed, but no corresponding care plan was documented. Interviews with facility staff, including an LVN, the MDS Nurse, and the DON, confirmed the absence of a care plan for the resident's anticoagulant use. Each staff member acknowledged the importance of a care plan in directing nursing care and monitoring for potential side effects of the medication. The facility's policy on care plans emphasized the need for a comprehensive, person-centered plan to be developed within a specified timeframe, which was not adhered to in this case.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to provide quality care and treatment in accordance with professional standards for a resident with Type 2 Diabetes Mellitus. The resident's fasting blood sugar levels were not monitored as per the physician's orders, which required daily checks at 6:00 a.m. This oversight was identified during an observation and interview with the resident, who confirmed that his blood sugar levels had not been checked. The Director of Nursing (DON) acknowledged the absence of records for blood sugar monitoring since the order was placed, attributing it to a mistake by the nursing staff who failed to follow the physician's orders. Further investigation revealed that the Licensed Vocational Nurse (LVN) responsible for the night shift was unaware of the resident's diabetes diagnosis and the order to check blood sugar levels. The Minimum Data Set Nurse (MDSN) also confirmed that the prompts for blood sugar checks were not appearing in the Medication Administration Record (MAR). The Medical Records Staff and the DON admitted that the orders should have been reviewed more carefully, emphasizing the importance of daily review of MD orders to prevent potential mistakes and harm. The facility's policy on diabetes management required monitoring and reporting of blood sugar levels, which was not adhered to in this case.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the administration of medication to meet the needs of a resident. Specifically, a resident's Lactulose medication, prescribed for constipation, was not available for administration on a particular day. During a medication pass observation, an LVN noted that the medication was unavailable and confirmed that the outgoing nurse did not mention the unavailability of the medication or whether the pharmacy had been notified. The resident had a history of constipation and muscle weakness, and the medication was part of their routine treatment. The Director of Nursing (DON) stated that licensed nurses were responsible for ordering medications in advance to ensure availability. The facility's policy required timely delivery of medications to prevent delays in administration. However, the medication was not reordered in time, leading to the missed dose.
Failure to Provide Correct Food Texture for Resident
Penalty
Summary
The facility failed to provide the appropriate food texture for a resident who required large portions of finger foods due to their inability to use utensils. During an observation, it was noted that the resident was served whole pieces of chicken breast, steamed rice, cut-up broccoli, and fruit cobbler, which did not align with the ordered finger food diet. The Certified Nursing Assistant (CNA) responsible for serving the meal did not verify the food consistency against the meal tray ticket, assuming the licensed nurse had already checked it. This oversight was confirmed by the Rehabilitative Nurse Assistant (RNA) and the Minimum Data Set Nurse (MDSN), who both acknowledged that the food served was not suitable for finger food consumption. The resident in question had a medical history of cerebral infarction, hemiplegia, hemiparesis, and dysphagia, which necessitated the finger food diet to accommodate their difficulty in using utensils. The Registered Dietitian (RD) and the Director of Nursing (DON) both emphasized the importance of adhering to the prescribed diet to prevent weight loss, as the resident was unable to feed themselves effectively with the incorrect food texture. The Dietary Services Manager (DSM) confirmed that the resident did not receive the correct diet consistency, highlighting a breakdown in the facility's process for ensuring dietary orders are followed, as outlined in their policy and procedure for Food and Nutrition Services.
Infection Control Deficiency Due to Unclean Bathroom
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for a resident, identified as Resident 34, when brown-colored fecal stains and remnants were found on the toilet and toilet seat in the resident's bathroom. This issue was identified during an interview and observation on May 13, 2024, where Resident 34 expressed discomfort using the bathroom due to its uncleanliness. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, suggesting full cognitive awareness of the situation. The Director of Nursing (DON) and the Infection Preventionist (IP) both confirmed the presence of fecal matter on the toilet and acknowledged it as an infection control issue. The facility's policies on infection prevention and control, safe and homelike environment, and routine cleaning and disinfection were reviewed, indicating that environmental cleaning and disinfection should be performed according to facility policy to prevent the transmission of communicable diseases. However, the presence of fecal matter on the toilet seat and bowl demonstrated a failure to adhere to these policies, posing a risk of cross-contamination and transmission of pathogens such as Clostridium difficile and Hepatitis C.
Facility Fails to Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to provide and maintain the minimum required square footage per resident in 12 out of 19 rooms during a survey conducted from May 13 to May 17, 2024. Specifically, rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19 did not meet the regulatory requirements of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. Despite this deficiency, the report notes that residents had a reasonable amount of privacy, adequate closets and storage spaces, available bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The facility has requested a continuance of a waiver, asserting that the waiver will not adversely affect the health and safety of the residents.
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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