Extended Care Hospital Of Riverside
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8171 Magnolia Avenue, Riverside, California 92504
- CMS Provider Number
- 056162
- Inspections on file
- 36
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Extended Care Hospital Of Riverside during CMS and state inspections, most recent first.
The facility failed to prevent accident hazards and ensure adequate supervision and assistive devices for three residents. A resident who smoked was allowed to keep cigarettes and a lighter at bedside despite documented safety concerns and a policy requiring smoking materials to be maintained by staff, with no evidence of an IDT review or care plan addressing this. Another resident with impaired gait, no decision-making capacity, and identified fall risk required supervised transfers but had a known history of attempting independent transfers that CNAs did not report, and the care plan was not revised before the resident sustained an unwitnessed fall with facial injuries. A third resident with frequent falls and no decision-making capacity was found in bed yelling for help with the call light hanging out of reach, contrary to the care plan and facility policy requiring call lights to be accessible.
Two residents were involved in an incident where one flicked the other on the head, which was documented by staff but not reported to the state agency within the required two-hour timeframe. The delay in reporting was confirmed by the DON, and interviews revealed that some staff were unaware of the reporting requirements. The facility's policy required immediate reporting, but this protocol was not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
A resident with impaired immunity and a history of UTI exhibited behavioral changes and refused medications and a physician-ordered urinalysis. Staff did not notify the physician of these changes or the treatment refusal until several days later, contrary to facility policy requiring prompt notification of significant changes in condition.
A resident with moderate cognitive impairment reported being scratched and having his arm twisted by his roommate, resulting in visible injuries. Although an LVN was informed of the incident and relayed it to the RN Supervisor, the allegation of abuse was not reported to CDPH within the required two-hour timeframe, as facility policy mandates. The Social Service Director became aware of the incident approximately eleven hours after it occurred, resulting in a delay in reporting.
A resident with documented bipolar and anxiety disorders was admitted after a PASARR Level I screening incorrectly indicated no serious mental illness. MDS nurses confirmed the mental health diagnoses were missed during the screening, which should have triggered a Level II evaluation prior to admission.
A resident with a history of a leg fracture and diabetes was discharged after improvement, but required post-discharge follow-up calls were not documented in the medical record. Interviews with the SSD and DON confirmed that facility policy mandates follow-up calls within 72 hours and again between 14-28 days post-discharge, but there was no evidence these were completed or recorded for the resident.
A facility failed to notify the LTC Ombudsman in a timely manner regarding a resident's discharge. The resident, diagnosed with esophageal cancer, was discharged to another facility with verbal consent. However, the required notice to the Ombudsman was sent four days late, contrary to the facility's policy that mandates prompt notification. This delay could potentially impact the resident's rights and discharge safety.
The facility failed to communicate decisions and rationales regarding issues raised by the Resident Council, leading to a deficiency in honoring residents' rights. Residents reported the dining room was closed at night, limiting access to the patio and vending machine. Staff interviews confirmed the closure, and the Administrator admitted solutions were not shared with the council, violating facility policy.
A resident with moderate cognitive impairment and a history of atelectasis was not assessed for self-administration of medication, despite expressing a desire to do so. The resident had a bottle of Robitussin, not ordered by the facility, visible on their nightstand. Staff interviews revealed a lack of awareness and action regarding the medication, and the facility's policy on self-administration was not followed.
A facility failed to update the PASARR for a resident after new diagnoses of depression and schizoaffective disorder. Initially, the resident had no active psychiatric disorders, but later assessments showed these new conditions. Despite the facility's policy requiring a new PASARR for newly diagnosed mental disorders, no additional screening was completed.
A resident was admitted with bipolar disorder and depression, but the PASARR Level I screening did not reflect these diagnoses, resulting in a negative screening and no Level II evaluation. The DON acknowledged the error, and the Administrator expected adherence to PASARR policy.
A resident with moderate cognitive impairment and physical limitations was not provided with necessary grooming and nail care assistance by the facility staff. Despite policies requiring routine grooming, the resident was observed with long toenails, fingernails, and facial hair. CNAs admitted to not having enough time to perform these tasks, and the DON and Administrator acknowledged the deficiency in care.
A resident with dysphagia was ordered to receive Isosource 1.5 tube feeding, but staff administered Fibersource HN instead, which has a lower caloric content. The LVN relied on a formula exchange sheet and previous day's formula bag, rather than verifying current orders. The RD confirmed the substitution was inappropriate, and the DON and Administrator expected staff to follow physician's orders.
A facility failed to properly store a nebulizer mask between uses for a resident, leading to a deficiency in respiratory care. The facility's policy requires nebulizer equipment to be cleaned, air-dried, and stored in a bag. However, observations revealed the mask was not stored in a bag as required. The resident, with a history of pneumonia, was receiving nebulizer treatments for shortness of breath. Interviews with staff confirmed the expectation to follow the facility's policy.
A resident with a history of low back pain and other conditions did not receive prescribed PRN pain medication despite requesting it before dialysis. The CNA informed the LVN of the request, but the LVN did not administer the medication, and there was no documentation of the medication being given. The facility's pain management policy was not followed.
The facility failed to ensure staff wore required PPE during care for residents on EBP. A resident with a gastrostomy tube and history of ESBL was cared for by an LVN who did not wear a gown during medication administration. Another resident with an ostomy and ESBL history received care from a CNA who did not wear a gown during bed linen changes and a bed bath. Both staff members acknowledged the oversight, and the DON confirmed the expectation for appropriate PPE use.
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit, affecting 46 residents. During an unannounced visit, temperatures in several rooms were observed to be between 82 and 85 degrees. A resident recovering from surgery and another with serious health conditions expressed discomfort due to the heat. The Maintenance Director reported a breaker fuse issue, and the facility's policy on temperature maintenance was not followed.
A facility failed to consistently monitor the weights of two residents upon admission, leading to significant weight changes without proper documentation or intervention. One resident experienced weight fluctuations with no record for the third week, while another resident had a significant weight loss with no documentation after the initial assessment. The registered dietician confirmed the lack of adherence to the facility's weight management policy, which required weekly monitoring and documentation for significant weight changes.
A resident reported that the hot water in his restroom took too long to heat, resulting in cold washcloths during bed baths. Multiple temperature checks confirmed that the water temperature did not reach the required range of 105 to 120 degrees Fahrenheit within a reasonable time frame. Interviews with staff corroborated the issue, and the facility's policy and relevant regulations highlighted the deficiency.
Failure to Prevent Accident Hazards, Falls, and Inaccessible Call Light
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and assistive devices for three residents. One resident who smoked was observed with cigarettes and a lighter at bedside, despite a smoking assessment documenting safety concerns such as burns to skin, clothing, furniture, and dropping ashes on self, with a recommendation to smoke only with supervision. Facility policy required smoking materials to be maintained by designated staff, and both an LVN and the ADON stated residents were not allowed to keep smoking paraphernalia at bedside without an IDT meeting, physician notification, and care plan in place. There was no documented evidence that such an IDT meeting, physician notification, or care plan had been completed for this resident, and staff were unaware the resident had cigarettes and a lighter at bedside. Another deficiency involved a resident at risk for falls who did not receive adequate supervision and effective fall prevention interventions. This resident had diagnoses including abnormalities of gait and mobility, was assessed as lacking capacity to understand and make decisions, and was identified as at risk for falls. The MDS indicated the resident required supervision or touching assistance for transfers. The resident experienced an unwitnessed fall while attempting to transfer, resulting in facial injuries and hospital transfer. CNAs reported the resident had a history of attempting to transfer independently from wheelchair to bed or toilet, that staff were aware of this behavior, and that one CNA had observed such behavior previously but did not report it to the licensed nurse. The ADON stated CNAs were expected to report unsupervised transfer attempts so that a fall risk assessment and care plan updates could be completed, but the care plan contained no revisions addressing the resident’s behavior of attempting to transfer independently prior to the fall. A third deficiency involved a resident at risk for falls whose call light was not within reach. The resident, who had diagnoses including frequent falls and lacked capacity to understand and make decisions, was heard yelling from her room and was found in bed with the call light hanging to the side of the bed and not within reach. The resident stated she wanted her bedside table moved and was unable to locate her call light. The resident’s care plan documented that the call light should be placed within reach and that the resident needed a prompt response to all requests for assistance. During observation and interview, an LVN confirmed the call light was not within reach and acknowledged that if the call light was not within reach, the resident would be unable to request assistance, including during an emergency. Facility policy required staff to ensure the call light is within reach of the resident and secured as needed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of physical abuse involving two residents to the State survey agency within the required two-hour timeframe. One resident, who had dementia and was not capable of making decisions, was flicked on the head by another resident who had chronic obstructive pulmonary disease, polyneuropathy, and depression. The incident was documented in the progress notes, with the aggressor admitting to flicking the other resident on the head to quiet him. There were no witnesses to the event, and the resident who was flicked did not sustain any injuries. Despite the documentation of the incident in the medical record, there was no evidence that the alleged abuse was reported to the California Department of Public Health within two hours as required. The Director of Nursing confirmed that the incident was not reported until seven days after it occurred, after being notified by the Social Service Director who discovered the documentation during a routine review. Interviews with nursing staff revealed a lack of awareness regarding the two-hour reporting requirement for allegations of abuse. The facility's policy required immediate reporting of all alleged violations to the appropriate agencies, specifying a two-hour window in cases of serious bodily injury. However, the staff involved did not follow this protocol, resulting in a delay in notifying the authorities about the incident. The failure to report the allegation in a timely manner was confirmed through interviews, record reviews, and observation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Notify Physician of Resident's Change in Condition and Treatment Refusal
Penalty
Summary
The facility failed to notify the physician of a significant change in condition and refusal of treatment for one resident. The resident, who had diagnoses including toxic encephalopathy and a urinary tract infection (UTI), exhibited behavioral changes and refused medications, blood sugar checks, and a physician-ordered urinalysis. Documentation shows that on June 16, the resident refused care and displayed aggressive behaviors, but there was no evidence that the physician was notified of these changes or the refusal to complete the urinalysis at that time. Physician notification did not occur until four days later, despite ongoing noncompliance and worsening behavior. Facility staff interviews confirmed that the refusal and behavioral changes should have been reported to the physician and documented in the medical record, in accordance with facility policy. The lack of timely physician notification and documentation was identified through observation, interview, and record review.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. A resident with moderate cognitive impairment and a history of osteomyelitis reported an altercation with his roommate, during which he claimed his arm was twisted and he was scratched, resulting in visible scabbed marks above his wrist. The incident was documented in a social service progress note, and the resident expressed feeling unsafe that night. The roommate confirmed there was a heated exchange but denied physical contact, while a Licensed Vocational Nurse (LVN) stated she was informed by the resident that he had been scratched and reported this to the RN Supervisor, instructing her to notify the DON. Despite the facility's policy requiring all alleged violations to be reported immediately, but no later than two hours after the allegation is made, the Social Service Director became aware of the incident approximately eleven hours after it occurred. The administrator confirmed that abuse allegations should be reported to CDPH within two hours, but this protocol was not followed in this case. The delay in reporting the incident constituted a failure to comply with regulatory requirements for timely reporting of suspected abuse.
PASARR Screening Failed to Identify Resident's Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for a resident. Specifically, a resident was admitted with diagnoses including bipolar disorder and anxiety disorder, but the PASARR Level I screening was marked as negative for serious mental illness (SMI). The screening form incorrectly indicated that the resident did not have a serious diagnosed mental disorder, despite documentation of such diagnoses in the admission record. During interviews and record reviews, it was confirmed by two Minimum Data Set Nurses (MDSNs) that the mental health diagnoses were missed during the PASARR screening process. One nurse acknowledged that the question regarding serious mental illness should have been answered affirmatively, and both nurses recognized that this error could have changed the PASARR result from Level I Negative to Level I Positive, which would have required further evaluation prior to admission. The facility's policy states that a positive Level I screen necessitates a Level II evaluation before admission.
Failure to Document Post-Discharge Follow-Up
Penalty
Summary
The facility failed to ensure that a post-discharge follow-up was conducted and documented in the medical record for one resident. The resident, who had a history of a left tibia fracture and type 2 diabetes mellitus, was admitted to the facility and later discharged after his health improved. Documentation review showed that there was no evidence of a follow-up call or contact with the resident after discharge, as required by facility policy. The Social Service Director confirmed that follow-up calls should be made within 72 hours post-discharge and that records of such calls are maintained, but was unable to confirm whether the case manager completed this for the resident in question. Further interviews with the Director of Nursing revealed that both social services and case management are responsible for conducting and documenting follow-up calls at specific intervals after discharge. Review of facility policies confirmed the requirement for timely follow-up calls and accurate documentation in the medical record. However, there was no documentation indicating that the required post-discharge follow-up was completed for the resident, resulting in a deficiency related to discharge planning and documentation.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure timely notification to the Office of the State Long-Term Care Ombudsman regarding the proposed transfer or discharge of a resident. Specifically, the facility did not notify the Ombudsman until four days after the resident had been discharged. The resident, who had been admitted with a diagnosis of esophageal cancer, was discharged to another facility. Although the resident had given verbal consent to the discharge plan, the Social Services Director (SSD) did not send the required notice to the Ombudsman on the day the resident received the discharge notice. The facility's policy requires that the notice of transfer or discharge be provided to the resident and the LTC Ombudsman as soon as practicable before the transfer or discharge. However, the SSD admitted to not following this protocol, as there was no evidence that the Ombudsman was notified on the appropriate date. This oversight could potentially result in the resident lacking an advocate to protect their rights and ensure an appropriate and safe discharge plan.
Failure to Communicate Resident Council Decisions
Penalty
Summary
The facility failed to ensure that staff discussed decisions and rationales regarding issues raised by the Resident Council, which led to a deficiency in honoring residents' rights to organize and participate in resident/family groups. Interviews with residents revealed that the dining room, which provides access to the patio and vending machine, was closed at night, limiting their ability to socialize, relax, and access amenities. Despite residents expressing concerns about the dining room's closure during Resident Council meetings, the facility did not communicate the solutions or their rationale to the council. Interviews with staff, including a CNA, Dietary Service Supervisor, and the Registered Nurse Supervisor, confirmed the dining room was locked at night, contrary to the Assistant Director of Nursing's statement that it should only be closed. The Administrator acknowledged that while solutions were developed to address the issue, they were not shared with the Resident Council. The facility's policy requires that decisions be communicated to the council, which was not adhered to in this case. The residents involved were capable of making decisions, as indicated by their medical records.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, despite the resident expressing a desire to do so. The facility's policy supports residents' rights to self-administer medications, contingent upon an interdisciplinary team assessment to ensure safety. However, the resident, who had a moderate cognitive impairment and a medical history of atelectasis, was not assessed for self-administration. The resident had a bottle of Robitussin, brought by a family member, visible on their nightstand, which was not ordered by the facility and was not included in the resident's medication orders. Interviews with staff revealed a lack of awareness and action regarding the presence of the medication at the resident's bedside. CNAs and an LVN were unaware of the medication, and the LVN confirmed that no assessment for self-administration had been conducted. The Director of Nursing and the Administrator both stated that no residents were approved for self-administration of medications, and the presence of the medication should have been reported and assessed according to facility policy. The oversight resulted in a failure to adhere to the facility's policy on medication self-administration.
Failure to Update PASARR Following New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASARR) for a resident following the diagnosis of new mental disorders. The resident was admitted with no active psychiatric or mood disorders, as indicated by the initial PASARR Level I screening. However, subsequent assessments revealed the resident was diagnosed with depression and schizoaffective disorder. Despite these new diagnoses, the facility did not complete an additional PASARR Level I screening as required by their policy. Interviews with the Director of Nursing and the Administrator confirmed that a new PASARR should have been completed following the resident's new mental health diagnoses. The facility's policy mandates that any resident exhibiting a newly evident or possible serious mental disorder should be referred for a Level II resident review. The failure to adhere to this policy resulted in the deficiency noted in the report.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I screening accurately reflected the presence of diagnosed mental disorders for a resident. The resident was admitted with a medical history that included unspecified bipolar disorder and depression, but the PASARR Level I screening completed by a local hospital did not reflect these diagnoses. As a result, the screening was marked as negative, and a Level II evaluation was not conducted. Interviews with facility staff revealed that the MDS Coordinator and the Director of Nursing (DON) were responsible for reviewing PASARR screenings for accuracy. The DON acknowledged that the PASARR for the resident was inaccurate and should have been corrected. The Administrator expected staff to adhere to the facility's policy for PASARRs, which was not followed in this instance, leading to the deficiency.
Failure to Assist Resident with Grooming and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required substantial assistance due to moderate cognitive impairment and physical limitations following a stroke. The resident, who had hemiplegia and hemiparesis affecting one side of the body, was observed with long toenails, fingernails, and facial hair, indicating a lack of grooming and nail care. Despite the facility's policies requiring routine grooming and nail care, the staff did not assist the resident adequately, leaving the resident with untrimmed nails and unshaven facial hair. Interviews with Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) revealed that the CNAs were responsible for grooming tasks, but they failed to perform these duties due to time constraints. The CNAs admitted to not having enough time to shave the resident or trim their nails, and one CNA did not report the resident's long toenails to anyone. The Director of Nursing (DON) and the Administrator confirmed that it was unacceptable for staff to neglect these tasks and expected residents to be groomed as needed. The resident expressed discomfort due to the condition of their toenails, further highlighting the deficiency in care provided by the facility.
Failure to Administer Correct Tube Feeding Formula
Penalty
Summary
The facility failed to provide the correct tube feeding formula as ordered for a resident, leading to a potential nutritional deficiency. The resident, who had a history of dysphagia following a stroke and was receiving nutrition via a feeding tube, was ordered to receive Isosource 1.5 at a rate of 60 mL per hour for 16 hours daily. However, staff provided Fibersource HN instead, which has a lower caloric content, potentially leading to insufficient caloric intake. Observations revealed that the incorrect formula was administered on multiple occasions, and the staff responsible for the resident's care did not follow the updated physician's orders. The Licensed Vocational Nurse (LVN) involved relied on a formula exchange sheet and the previous day's formula bag, rather than verifying the current orders. The Registered Dietitian (RD) confirmed that the substitution was not appropriate and that she had not been consulted about the change. Interviews with the Director of Nursing (DON) and the Administrator indicated that staff were expected to follow physician's orders and consult the RD or physician if the ordered formula was unavailable. Despite these expectations, the LVN did not verify the updated orders, leading to the administration of an incorrect formula, which was not a comparable exchange for the ordered Isosource 1.5.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly store a nebulizer mask between uses for a resident, leading to a deficiency in respiratory care. The facility's policy on nebulizer therapy, revised in February 2024, specifies that nebulizer equipment should be cleaned after each use, disassembled, rinsed with sterile or distilled water, air-dried, and stored in a storage bag once completely dry. However, observations on December 16 and 17, 2024, revealed that the nebulizer mask for Resident #7 was not stored in a bag as required by the policy. Instead, it was found lying on top of the resident's dresser. Resident #7, who was admitted to the facility in November 2024, had a medical history that included pneumonia and was receiving as-needed nebulizer treatments for shortness of breath related to a cough. The resident's care plan included the administration of DuoNeb as ordered. Interviews with LVN #3 and the Director of Nursing confirmed that the nebulizer mask should be stored in a bag when not in use, aligning with the facility's policy. The Administrator also expressed the expectation that staff follow the facility's policy regarding the cleaning and storage of nebulizer masks.
Failure to Administer PRN Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #210, who had a medical history of low back pain, personal history of malignant neoplasm of the breast, and acute kidney failure. The resident was admitted on 12/11/2024 and had orders for Tylenol and Norco for pain management. On 12/16/2024, the resident reported a pain level of 7 out of 10 and requested pain medication before going to dialysis. Despite this request, there was no documented evidence that the resident received the prescribed PRN Tylenol or Norco on that day. The deficiency occurred when CNA #6, after being informed by the resident about the need for pain medication, communicated this to LVN #7. However, LVN #7 could not recall if he was informed about the request and admitted to not administering the pain medication before the resident's dialysis session. The facility's policy on pain management, which requires recognizing and managing pain consistent with the resident's care plan and preferences, was not followed, as confirmed by the Administrator's statement that the medication should have been given upon the resident's complaint of pain.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore all required personal protective equipment (PPE) during the provision of care for residents on enhanced barrier precautions (EBP). This deficiency was observed in the care of Resident #18, who had a history of extended-spectrum beta-lactamase (ESBL) and utilized a gastrostomy tube. During a medication administration task, a Licensed Vocational Nurse (LVN) checked the resident's vital signs and administered medications via the feeding tube while wearing gloves but not a gown, contrary to the facility's policy. The LVN admitted to not knowing that a gown was required for such procedures. Similarly, the facility's failure to adhere to EBP was noted in the care of Resident #5, who also had a history of ESBL and an ostomy. A Certified Nursing Assistant (CNA) changed the resident's bed linens and provided a bed bath while wearing a mask and gloves but no gown. The CNA acknowledged that a gown should have been worn due to the resident's EBP status. The Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including gowns, when providing care to residents on EBP.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents by not ensuring room temperatures were kept between 71 and 81 degrees Fahrenheit. During an unannounced visit, it was observed that the temperatures in several rooms ranged from 82 to 85 degrees Fahrenheit, affecting 46 out of 96 residents. The Maintenance Director reported that a breaker fuse had gone bad, causing the generator power to activate, and they had been working on replacing the fuse throughout the day. Two residents were interviewed during the visit. One resident, who was recovering from surgery, was observed perspiring and expressed discomfort due to the heat. Another resident, who had multiple serious health conditions including acute respiratory failure and chronic congestive heart failure, also expressed discomfort and dissatisfaction with the situation. The facility's policy on maintaining temperatures within the specified range was not adhered to, leading to the substantiated complaint of an uncomfortable environment for the residents.
Failure to Monitor Resident Weights Consistently
Penalty
Summary
The facility failed to weigh two residents, Resident A and Resident B, on admission and weekly for the first four weeks as required to establish a baseline weight. This failure was identified during an unannounced visit on June 10, 2024, for an allegation of quality of care and treatment. Resident A, who was admitted with diagnoses including Type II Diabetes Mellitus, Sepsis, and Alzheimer's, experienced significant weight fluctuations without consistent monitoring. Initial weight was recorded at 173 pounds, followed by a loss to 166 pounds and then 160 pounds, with no weight documented for the third week. The registered dietician (RD) confirmed that the policy required weekly weights for the first four weeks and noted that a 5% weight change in a week is significant and requires closer monitoring. Resident B, admitted with a history of falls and a heart attack, also experienced significant weight loss without consistent monitoring. Initial weight was 118 pounds, dropping to 109 pounds within a week, and further to 103 pounds over the following weeks. The RD noted that a nutritional assessment should be completed within the first two weeks of admission, and progress notes should be added for any weight changes. However, there was no documentation of weight or nutritional progress notes for Resident B after February 7, 2024, despite continued weight loss. The facility's policy on weight management, dated December 19, 2022, outlined the need for a systematic approach to optimize residents' nutritional status, including weekly weight monitoring for newly admitted residents. The policy also required the RD to document weight change notes for significant weight changes. The RD acknowledged the lack of documentation and monitoring for both residents, which was inconsistent with the facility's policy and professional standards of practice.
Failure to Maintain Appropriate Water Temperatures
Penalty
Summary
The facility failed to ensure that the resident's water temperatures were maintained at a comfortable level, as evidenced by the complaint from Resident 1 and subsequent observations. Resident 1, who has a medical history including malignant neoplasm of the lung, secondary malignant neoplasm of the brain, type 2 diabetes mellitus, and atrial fibrillation, reported that the hot water in his restroom took too long to heat, resulting in cold washcloths during bed baths. Multiple temperature checks confirmed that the water temperature in Resident 1's restroom did not reach the required range of 105 to 120 degrees Fahrenheit within a reasonable time frame, with temperatures recorded at 85, 95, 89.5, and 100.6 degrees Fahrenheit at various times during the surveyor's visit. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Maintenance Director (MD), corroborated the issue, with the MD acknowledging that the water temperature should not take more than five minutes to heat up. The Director of Nursing (DON) also confirmed that the hot water was taking an unusually long time to reach the appropriate temperature. A review of the facility's policy on safe water temperatures and relevant California Code Regulations further highlighted the deficiency, as the facility failed to maintain hot water temperatures within the required range for resident care areas.
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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