Fortuna Rehabilitation And Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Fortuna, California.
- Location
- 2321 Newburg Road, Fortuna, California 95540
- CMS Provider Number
- 056361
- Inspections on file
- 39
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Fortuna Rehabilitation And Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with cognitive decline, gait abnormalities, and documented high fall risk experienced multiple falls while the facility failed to implement and document key fall risk and post-fall care plan interventions. Despite repeated falls and high fall risk scores, required measures such as q2h location checks, q2h toileting while awake, a documented root cause analysis of prior falls with education to the care team, and a PT eval ordered after a serious unwitnessed fall were not supported by documentation. The Administrator confirmed that records of these interventions could not be located, contrary to the facility’s person-centered care planning policy.
A resident with dementia, major depressive disorder, PTSD, and suicidal ideations, and a moderately impaired BIMS score, was struck twice in the shoulder by another resident, triggering a change in condition. Subsequent notes documented that the resident expressed uncertainty about being hurt versus upset and later reported ongoing distress and worry that the other resident would continue to bother him. Although a COC was initiated, the DON confirmed that 72-hour monitoring notes were not documented every shift as required, and completion of the monitoring could not be verified, contrary to facility policy requiring licensed nurse documentation each shift for at least 72 hours after a change in condition.
A resident receiving palliative care with CHF, muscle weakness, hearing loss, and a left below-knee amputation, and with slight memory impairment per MDS, was subjected to verbal abuse by a CNA during a shower. The CNA was overheard yelling and swearing at the resident, who was visibly bothered and later reported disliking how he was treated. The resident’s care plan documented that he was a victim of alleged abuse, with the CNA having called him a derogatory name, in violation of the facility’s abuse prevention policy that prohibits verbal abuse and the use of disparaging or derogatory terms toward residents.
A resident with palliative care needs, CHF, muscle weakness, hearing loss, and a left below-knee amputation was involved in an alleged abuse incident, but staff did not follow the facility’s abuse policy. The DON reported that LNs were expected to complete and document a change of condition assessment, notify the MD and family, update the care plan, and perform 72-hour monitoring with alert charting and psychosocial documentation, with Social Services also conducting daily psychosocial follow-up. Record review and interviews showed that no assessment, progress notes, or required 72-hour checks by nursing or Social Services were documented, despite written policies and lesson plans directing these actions.
A resident with chronic kidney disease had her call light and bed remote removed by an LN while in her room because she was repeatedly adjusting her bed and pressing the call light. The LN documented the removal in a nursing note, indicating an expectation that the behavior would stop. In an interview, the DON stated this action was inappropriate, affirmed that the call light and bed remote were considered the resident’s personal property, and identified the incident as a resident rights issue. Review of the facility’s Resident Rights policy showed staff are required to treat residents with kindness, respect, and dignity and to honor residents’ exercise of their rights, which did not occur in this case.
A resident with significant medical conditions reported severe pain and feeling abused during a treatment performed by a nurse, who did not stop when asked. The incident was documented and reported internally, but the facility failed to submit the required abuse report to authorities within the mandated two-hour window, as confirmed by staff interviews and policy review.
Three residents with mental health or developmental diagnoses did not receive appropriate PASRR evaluations. Despite documented histories of mental illness, cognitive impairment, or developmental delay, PASRR Level 1 screenings were either incorrectly completed or not properly reviewed, resulting in the absence of required Level II screenings. Facility staff acknowledged that errors in hospital-completed PASRRs were common and not always corrected, leading to incomplete assessments for these residents.
Three residents with complex medical conditions did not receive required in-person physician visits at least every 60 days, as only telehealth visits or no visits occurred during the review period. Staff interviews and record reviews confirmed the deficiency, and the facility's administrator acknowledged the issue with the prior contracted physician services.
Licensed nurses did not administer medications on time for two residents, including one receiving palliative care and another with epilepsy, due to severe staffing shortages. Medications were given more than an hour late on multiple occasions, exceeding the facility's policy window. Staff and the DON confirmed that high resident assignments per nurse and failure to meet state staffing requirements made timely medication administration impossible, and a resident reported anxiety and discomfort as a result.
The facility failed to provide adequate staffing to meet residents' wound care needs, resulting in missed treatments for several residents. Interviews and record reviews revealed that treatments were not documented as completed, indicating they were not performed. Staffing challenges, including the absence of a Treatment Nurse, contributed to this deficiency.
A resident with a history of falls and high fall risk was left unsupervised on the toilet by a CNA, resulting in a fall and fracture of the right distal fibula and tibia. The resident's medical history included conditions that increased her fall risk, and her care plan required supervision during toileting. Despite this, the CNA left the resident alone, leading to the incident. Interviews with staff confirmed the need for supervision, which was not provided, resulting in the injury.
The facility failed to report an abuse allegation within the required timeframe after a CNA witnessed a resident hitting another with a shoe. The incident was reported three days late, contrary to the facility's policy requiring a two-hour notification to the Department, Ombudsman, and Law Enforcement. This delay decreased the potential to ensure resident safety and caused a delayed response by enforcement agencies.
A resident fell and broke her arm due to an improperly positioned transition strip at a doorway, which created a trip hazard. The resident was walking without her walker and tripped on the uneven threshold, leading to a fall. Observations confirmed the hazardous condition, and the DON acknowledged the issue, assuming it had been repaired. The facility's safety policy was not effectively followed, contributing to the deficiency.
A resident with Type 2 Diabetes Mellitus and Essential Hypertension did not receive regular showers as scheduled, leading to a missed and infected wound on their shoulder, which developed into sepsis. Despite being dependent on staff for bathing, the resident only received two bed baths in July and none in early August. Facility staff confirmed the lack of documentation and care, acknowledging that shower refusals should be documented. The facility's policies on skin observation during bathing were not followed, contributing to the missed and infected wound.
A resident in a long-term care facility developed an infected wound on the shoulder due to inadequate skin assessments and irregular showering. Despite weekly checks, the wound was not documented or treated, leading to sepsis and hospitalization. Staff were unaware of the wound, and facility policies on skin care and hygiene were not followed.
A resident was administered an extra dose of Oxycodone HCL 5 mg without a physician's order, resulting in a significant medication error. The nurse claimed to have received a verbal order, which the physician could not recall. The facility's policy requires medications to be administered only upon a physician's order.
Failure to Implement and Document Fall Risk and Post-Fall Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document comprehensive, person-centered fall risk and post-fall care plan interventions for one resident. The resident was admitted with diagnoses including progressive cognitive decline with anxiety, generalized muscle weakness, insomnia, impaired communication, and gait and mobility abnormalities. An MDS dated 12/25/25 showed memory impairment on the BIMS and two or more falls since the prior assessment. SBAR forms dated 4/15/25, 4/28/25, 5/3/25, 7/24/25, 10/3/25, and 10/12/25 documented six fall incidents in 2025. Fall risk evaluations from 3/4/25 to 12/12/25 showed scores ranging from 10 to 20, confirming the resident was at high risk for falls. The resident’s care plan, initiated 3/5/25 for high fall risk, included specific interventions such as verifying and documenting the resident’s location every two hours, offering toileting every two hours while awake after a fall on 7/24/25, and performing a root cause analysis of past falls with documentation of possible root causes and education of the resident, family, caregivers, and IDT. Additional post-fall care plans initiated on 1/26/26 and 1/28/26 directed staff to continue fall-risk interventions and obtain a PT evaluation after an unwitnessed fall with serious injury. During interviews, the Administrator confirmed the facility could not produce documentation that the root cause analysis was performed, that the resident’s location was monitored and toileting was offered every two hours, or that a PT evaluation was completed as ordered in the care plan. The facility’s own person-centered care planning policy required development and implementation of a comprehensive care plan describing services to attain or maintain the resident’s well-being, but documentation of implementation of the specified interventions was absent.
Failure to Complete 72-Hour Change-in-Condition Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to complete required 72-hour monitoring and documentation following a change in condition for one resident after an altercation. The resident, who had dementia, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, was admitted with significant mental health diagnoses. His MDS dated 11/4/25 showed a BIMS score of 11, indicating moderately impaired cognition, and documented that he felt down, depressed, or hopeless nearly every day during the assessment period. On 1/11/26 at 3:45 p.m., a progress note documented that the resident was struck twice in the left front shoulder with a closed fist by another resident, constituting a change in condition that triggered the facility’s change in condition process. Subsequent documentation showed that on 1/12/26 at 1:19 p.m., an IDT note recorded the resident stating, "I don't know if I am hurt or just upset," and on 1/13/26 at 8:35 a.m., a progress note indicated he remained upset about the altercation and was very worried the other resident would continue to bother him. During an interview and record review on 2/26/26 at 11:45 a.m., the DON reviewed the resident’s documentation following the 1/11/26 altercation and acknowledged that although a change in condition had been initiated, continuous 72-hour monitoring notes were not charted for every shift after the incident, so completion of the monitoring could not be verified. This failure occurred despite the facility’s policy titled "Change in Condition," effective 8/25/22, which required a licensed nurse to document each shift for at least 72 hours when there is a change in a resident’s condition.
Failure to Protect a Resident From Verbal Abuse During Shower Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a certified nursing assistant (CNA) yelled and swore at the resident during care. The resident, who had been admitted with diagnoses including encounter for palliative care, acute chronic systolic (congestive) heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set indicating slight memory impairment. During a shower, CNA 1 was overheard yelling and swearing at the resident, and the resident was later described as visibly bothered when interviewed about the incident. In a subsequent interview, the resident reported that CNA 1 yelled and swore at him and that he did not like how he was treated. The resident’s care plan documented that he was a victim of alleged abuse related to CNA 1 yelling at him in the shower and calling him an "asshole." The facility’s Abuse Prevention and Management policy, effective 2024, stated that the facility does not condone any form of resident abuse, including verbal abuse, and defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms directed to a resident. The substantiated incident of yelling and use of derogatory language toward the resident constituted a failure to ensure the resident was free from abuse as required by facility policy.
Failure to Implement Abuse Assessment and 72-Hour Monitoring After Alleged Incident
Penalty
Summary
The facility failed to implement its abuse prevention and management policy for one resident following an alleged abuse incident. Resident 1, admitted in October 2025 with diagnoses including encounter for palliative care, acute chronic systolic congestive heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set dated 1/10/26 indicating slight memory impairment. After an allegation of abuse on 1/9/26, the DON stated she expected licensed nurses to complete and document a change of condition assessment, including a physical and psychosocial assessment, document when the physician and family were notified, update the resident’s care plan, and initiate 72-hour monitoring. However, record review and the DON’s concurrent interview confirmed there was no documented assessment or progress notes and that the required 72-hour monitoring and alert charting were not completed. The facility’s own Abuse Reporting and Documentation lesson plan directed licensed nurses to complete an assessment and skin assessment of the alleged victim, notify the MD, add the resident to alert charting for 72 hours with appropriate monitors for increased distress, and document psychosocial status every shift, with Social Services documenting psychosocial status daily and the IDT promptly reviewing allegations. The facility’s Abuse Prevention and Management policy, revised 5/30/24, required that the resident be assessed by a licensed nurse for any physical injuries or emotional distress and that the physician be notified and treatment provided as ordered. The DON confirmed that social services 72-hour checks were lacking and that there was no assessment documented or progress notes for Resident 1 following the alleged abuse incident.
Resident Rights Violated When Call Light and Bed Remote Removed
Penalty
Summary
A resident admitted in March 2023 with chronic kidney disease experienced a violation of resident rights when a licensed nurse (LN 1) removed her call light and bed remote while she was in her room. According to LN 1’s nursing note dated 11/30/25, the nurse took these items because the resident had been moving her bed up and down and repeatedly pressing her call light, and the nurse expected this behavior to stop. During an interview, the Director of Nursing stated that LN 1’s actions were inappropriate, acknowledged that the facility is the resident’s home, and considered the call light and bed remote to be the resident’s personal property and a resident rights issue. Review of the facility’s Resident Rights policy, revised 1/1/12, showed that employees are required to treat all residents with kindness, respect, and dignity and to honor the exercise of residents’ rights, which was not followed in this incident. This failure resulted in the resident not having access to her call light and bed remote as documented in the nursing note and confirmed by the DON, constituting a lack of respect for the resident’s dignity and self-determination as outlined in the facility’s own policy.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The incident involved an 81-year-old resident with multiple diagnoses, including heart failure and venous insufficiency, who reported that a nurse performed an incorrect treatment using scissors to debride thick dry skin on her legs, causing severe pain. The resident expressed multiple times for the nurse to stop due to 9/10 pain, but the nurse refused. The resident later stated that what happened was abuse and that she felt unsafe. This information was documented in a nurse's progress note and reported internally to the facility administrator. Despite the internal reporting, the facility did not submit the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the Department within the mandated two-hour timeframe. The report was received by the Department nearly two hours after the incident was identified during a chart review. Both the nurse and the administrator acknowledged during interviews that allegations of abuse must be reported to the Department within two hours, as required by facility policy and state regulations. The delay in reporting constituted a failure to comply with mandated reporting requirements.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health and Developmental Diagnoses
Penalty
Summary
The facility failed to ensure that three sampled residents received appropriate PASRR (Preadmission Screening and Resident Review) evaluations as required by federal regulations. For the first resident, documentation showed diagnoses including toxic encephalopathy, post-traumatic stress disorder, anxiety disorder, and chronic pain syndrome, with a BIMS score indicating moderate cognitive impairment. Despite these diagnoses and a history of mental health conditions, the PASRR Level 1 screening marked that the resident did not have a serious mental disorder, and no Level II screening was conducted, as confirmed by correspondence from the state agency. The second resident was admitted with diagnoses of toxic encephalopathy, cerebral palsy, depression, and developmental delay of scholastic skills, and also had a BIMS score indicating moderate cognitive impairment. Hospital records noted the need for coordination with the Regional Center due to developmental delay. The PASRR Level 1 screening indicated a developmental or intellectual disability and past Regional Center services, but did not identify a serious mental disorder, and no Level II PASRR was found in the resident's chart. The third resident had diagnoses of depression, hemiplegia and hemiparesis following cerebral infarction, and brain injuries, with a BIMS score indicating moderate cognitive impairment. Physician notes included toxic encephalopathy, anxiety disorder, and major depressive disorder. The PASRR Level 1 was positive for suspected mental illness, but the state agency determined no serious mental illness was present, and no Level II screening was conducted. Interviews with facility staff revealed that PASRR Level 1 screenings completed by acute hospitals were often incorrect, and the facility did not consistently review or correct these errors, resulting in missed Level II screenings for the affected residents.
Failure to Provide Required Face-to-Face Physician Visits
Penalty
Summary
The facility failed to ensure that residents received required face-to-face physician visits at least once every 60 days, as mandated by federal regulations. For three sampled residents, documentation and interviews confirmed that either the required in-person visits did not occur within the specified timeframes or that only telehealth/virtual visits were conducted instead of face-to-face encounters. Specifically, one resident did not have a face-to-face physician visit for an eight-month period, and for two other residents, all physician visits during the review period were conducted virtually. The residents affected had significant and complex medical histories, including acute respiratory failure, post-traumatic stress disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease, post laminectomy syndrome, toxic encephalopathy, quadriplegia, spastic cerebral palsy, depression, developmental disorder of scholastic skills, acute kidney failure, hemiplegia, hemiparesis, muscle weakness, and a history of falls. Their cognitive status ranged from moderately impaired to moderate cognitive impairment, as indicated by their BIMS scores. Interviews with facility staff, including a Registered Nurse Consultant and the MDS Nurse, confirmed that the required face-to-face physician visits were not provided, and that telehealth visits were used instead. The facility administrator acknowledged that the prior contracted physician services were terminated due to failure to provide agreed face-to-face services. Review of federal regulations and facility policy confirmed that in-person physician visits are required and that telehealth visits do not meet this requirement.
Failure to Administer Medications Timely Due to Staffing Shortages
Penalty
Summary
Licensed Nurses failed to administer medications to residents according to physician orders, resulting in multiple instances of late medication administration for two residents. For one resident with diagnoses including palliative care and malignant neoplasm of the skin, medications such as propranolol, methadone, and gabapentin were documented as being given significantly later than scheduled, with delays ranging from over an hour to more than four hours. Another resident with epilepsy experienced late administration of medications including ropinirole, levetiracetam, and aspirin, with delays of over an hour past the scheduled times. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but these instances exceeded that window. Interviews with nursing staff and the Director of Nursing revealed that the late administration was due to severe staffing shortages, with each nurse assigned to care for 28 to 34 residents per shift. Staff reported that the high number of resident assignments made it impossible to administer all medications on time. The Director of Nursing confirmed that the facility had not met state staffing requirements during the relevant periods. One resident reported experiencing anxiety and discomfort due to the late administration of medications. The facility's own documentation and staff interviews confirmed the pattern of late medication administration and the underlying staffing issues.
Inadequate Staffing Leads to Missed Wound Care Treatments
Penalty
Summary
The facility failed to ensure adequate staffing with appropriate competencies to meet the physical needs of the residents, specifically in providing wound care treatments as ordered by physicians. This deficiency was identified through interviews and record reviews, revealing that treatments for wound care were not provided as ordered for four of nine sampled residents. The lack of documentation for wound care treatments on specific dates for these residents indicated that the treatments were not performed, which could potentially delay wound healing and increase the risk of infection. Resident 1 had multiple orders for wound care, including treatments for a malignant breast wound and pressure ulcers on the coccyx and sacro-coccygeal areas. However, the Treatment Administration Record (TAR) showed that these treatments were not documented as completed on several occasions. Similarly, Resident 2's TAR indicated missed treatments for a pressure ulcer on the right below-knee amputation stump. Resident 3's TAR also showed incomplete documentation for pressure ulcer treatments on the coccyx and upper buttocks. Resident 4's TAR revealed missed treatments for wounds on the left calf and right leg. Interviews with facility staff, including the Infection Preventionist and licensed nurses, highlighted staffing challenges, such as the absence of a Treatment Nurse and the inability of other staff to consistently perform wound care treatments. The Infection Preventionist noted that several staff members, including the Treatment Nurse, had quit simultaneously, leaving the facility unable to schedule a nurse specifically for treatments. Licensed nurses reported being unable to complete all required dressings due to time constraints and lack of documentation, further contributing to the deficiency.
Failure to Supervise Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who was left unsupervised on the toilet by a Certified Nursing Assistant (CNA). The resident, who had a history of falls and was identified as high risk for falls, was left alone in the bathroom while the CNA attended to another resident. This lack of supervision resulted in the resident falling and sustaining a fracture of the right distal fibula and tibia. The resident's medical history included hemiplegia, hemiparesis, epilepsy, and memory deficits following a cerebral infarction, all of which contributed to her high fall risk. The resident's care plan and assessments consistently indicated the need for supervision during toileting due to her fall risk and history of noncompliance with using the call light. Despite these documented needs, the CNA left the resident unsupervised, leading to the fall. Interviews with facility staff, including the Director of Nursing and Licensed Nurse, confirmed that the resident required assistance and supervision in the bathroom. The facility's policy on fall management emphasized the need for supervision for residents at high risk of falls. However, the CNA's actions did not align with these guidelines, resulting in the resident's injury.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for two residents involved in an incident. A Certified Nursing Assistant (CNA) witnessed one resident hitting another resident on the face with a shoe. This incident occurred at approximately 11:30 p.m. on November 15, 2024. However, the facility did not report this allegation of abuse to the California Department of Public Health until November 18, 2024, which was three days after the incident. During interviews, the Director of Staff Development (DSD) and the Administrator confirmed that the facility's policy required allegations of abuse to be reported to the Department within two hours. The DSD and the Administrator acknowledged that the incident was not reported within this timeframe. The facility's policy, revised in March 2018, also indicated that the Administrator or a designated representative should notify the Department, the Ombudsman, and Law Enforcement by telephone within two hours, followed by a written report. The delay in reporting decreased the facility's potential to ensure resident safety and caused a delayed response by enforcement agencies.
Unsafe Flooring Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to maintain a safe and functional environment, as evidenced by the improper positioning of transition strips at two doorways, which resulted in a hazardous threshold. This deficiency was directly linked to an incident where a resident fell and broke her arm. The resident was ambulating without her walker and tripped on the uneven threshold strip while attempting to return to her room to retrieve her walker. The fall caused her to land on her right side, resulting in a fracture of the right arm. The incident was documented in the resident's medical records, and the facility's investigation report noted the need for repairs at the affected doorways. Observations conducted by surveyors confirmed the hazardous conditions at the doorways, with uneven flooring and inadequate repairs, such as the use of black tape that did not effectively smooth the transition between different flooring types. The Director of Nursing acknowledged the trip hazard and expressed an assumption that the maintenance staff had already addressed the issue. The facility's policy on resident safety, which mandates immediate reporting of unsafe conditions, was not effectively implemented in this case, contributing to the deficiency.
Failure to Provide Regular Showers Leads to Infected Wound and Sepsis
Penalty
Summary
The facility failed to regularly provide showers for a resident, which contributed to the development and infection of a wound on the resident's right shoulder. The resident, who was admitted with diagnoses of Type 2 Diabetes Mellitus and Essential Hypertension, was dependent on staff for activities of daily living, including bathing. Despite being scheduled for showers twice a week, the resident only received two bed baths in July and no documented showers or bed baths in early August. Interviews with facility staff, including licensed nurses and certified nursing assistants, confirmed that the resident was not receiving showers as scheduled. Staff acknowledged that shower refusals should be documented, and if care was not documented, it was not provided. The lack of regular showers and skin assessments led to the resident's wound being missed and subsequently becoming infected, resulting in sepsis. The facility's policies on skin and wound management and showering and bathing emphasized the importance of skin observation during bathing. However, these procedures were not followed, as evidenced by the lack of documentation and care provided to the resident. The Assistant Director of Nursing verified the discrepancies in shower documentation and acknowledged that the failure to provide regular showers and assess the resident's skin contributed to the missed and infected wound.
Failure in Skin Assessment and Hygiene Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure thorough and accurate skin assessments for a resident, leading to a missed wound on the resident's right shoulder. Despite weekly skin checks, the wound was not documented or treated, resulting in the wound becoming infected. The resident was eventually hospitalized with a diagnosis of sepsis secondary to cellulitis and a small abscess on the right shoulder. The treatment nurse admitted that the skin assessments were inaccurate and that the wound was acquired at the facility. Additionally, the facility did not provide regular showers as scheduled for the resident, which contributed to the missed identification of the wound. The resident was supposed to receive showers twice a week, but documentation showed that only two bed baths were given in a month, and no showers or bed baths were provided in the days leading up to the resident's hospitalization. This lack of regular hygiene care was a factor in the development and worsening of the wound. Interviews with staff revealed a lack of awareness about the resident's wound, with both a CNA and a licensed nurse expressing surprise upon discovering the wound. The assistant director of nursing confirmed that the infection likely started at the facility and was not treated, leading to the resident's hospitalization for sepsis. The facility's policies on skin and wound management and showering were not followed, contributing to the oversight and subsequent health issues for the resident.
Significant Medication Error Involving Oxycodone Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an extra dose of Oxycodone HCL 5 mg was administered without a physician's order. The resident had an order for Oxycodone HCL 5 mg to be given every 6 hours as needed for pain, only when non-narcotic options were ineffective. On the day of the incident, the resident was given Oxycodone HCL 5 mg at 6:30 a.m. and again at 10 a.m., with the latter dose being a one-time dose ordered on that day. However, the Individual Narcotic Record indicated that another dose was administered at 9:15 a.m. by a different nurse, Licensed Nurse A, who claimed to have received a verbal order from an on-call physician, which the physician later could not recall giving. During an interview, Licensed Nurse A stated that she administered the extra dose because the resident was in excruciating pain and claimed to have received a verbal order from Physician C. However, Physician C could not recall giving such an order. The Director of Nursing (DON) confirmed that the administration of the extra dose was a medication error and that Licensed Nurse A was terminated as a result. The resident's progress notes and an investigation by the Medical Director confirmed that the extra dose was given without a proper physician's order. The facility's policy on medication administration, dated January 1, 2012, states that medications should be administered by a licensed nurse upon the order of a physician or licensed independent practitioner. The failure to adhere to this policy resulted in the administration of an unscheduled dose of Oxycodone HCL 5 mg, which was determined to be a medication error. Although the error did not result in physical harm to the resident, it had the potential to affect the resident's health and safety.
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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