Fresno Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 1233 A Street, Fresno, California 93706
- CMS Provider Number
- 555426
- Inspections on file
- 27
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Fresno Postacute Care during CMS and state inspections, most recent first.
The facility failed to maintain a full-time RN DON or appoint an acting DON after the previous DON resigned, despite having a census of 71 residents. The administrator and multiple staff members, including RNs, LVNs, and the MDS coordinator, confirmed that there was no DON or interim DON in place and that staff instead relied on shift RNs, an LVN DSD, and a corporate RN available by phone and occasional visits for clinical and staffing issues. Facility policy and professional references reviewed by surveyors required that nursing services be under the direct supervision of a full-time RN DON responsible for managing nursing services, overseeing licensed nurse schedules, and ensuring care and documentation follow resident assessments and care plans, and staff acknowledged that the absence of a DON could lead to potential medication errors, improper assessments, and non-compliance with policies and procedures.
A nurse completed an admission assessment for a resident with hypertension and Parkinson’s disease that contained multiple errors, including contradictory fall risk information and incorrect documentation that the resident did not have hypertension, did not take antihypertensive medication, and did not have Parkinson’s disease, despite active physician orders for metoprolol and ropinirole. These inaccuracies affected the data used to develop the resident’s fall risk care plan. In a separate incident, an LVN applied medicated cream to another resident’s peri-area for MASD without wearing gloves, as confirmed by the LVN, a CNA witness, and a police officer’s interview. The DON stated that gloves are required for any contact with the vagina and cited facility policy requiring appropriate PPE and protection of resident privacy, dignity, health, and safety during clinical procedures.
A CNA failed to provide adequate incontinent care for three residents during a night shift, resulting in neglect. Two residents received only one brief change, while a third resident was not changed at all, leading to feelings of anger, frustration, and loss of dignity. The facility's investigation confirmed the neglect, and the Director of Nursing acknowledged the findings.
A LTC facility failed to meet professional standards in medication administration and bed rail use. A resident received Metformin without food, risking stomach upset. Another resident's medication was left unattended, accessible to others. Two residents had incorrect bed rail setups, contrary to physician orders, posing safety risks.
The facility failed to follow prescribed menus and portion sizes for residents on various therapeutic diets, leading to incorrect servings during a lunch meal. Residents on Consistent Carbohydrate, mechanical soft, puree, large portion, and renal diets received inappropriate portions, and pureed coleslaw was not measured. Additionally, cappuccino mousse was not served, and chocolate pudding was inconsistently portioned. Corn was missing from the corn coleslaw, and the facility's Resident Council Minutes indicated ongoing issues with portion sizes and food preferences.
A CNA failed to perform hand hygiene after handling soiled linen, potentially contaminating a linen cart and causing cross-contamination. Interviews with staff confirmed the importance of hand hygiene in preventing infection spread, as outlined in the facility's policy.
A facility failed to maintain accurate and complete POLST forms for three residents, leading to potential confusion and risk regarding their healthcare decisions. One resident's POLST form had a misspelled last name, another's was missing a necessary signature, and a third's had an inaccurate date. Staff interviews confirmed the importance of accurate documentation for these critical medical records.
The facility failed to maintain an effective pest control program, resulting in cockroach sightings in the kitchen and hallway. A Dietary Aide and a resident confirmed frequent cockroach issues, and the Pest Control Technician noted unaddressed recommendations to seal cracks. The facility's pest control policy was not effectively implemented.
The facility failed to provide palatable and flavorful meals, as evidenced by resident complaints and observations of undercooked peas, dry chicken, and bland rice. The Certified Dietary Manager confirmed these issues, and previous Resident Council concerns about food quality were not adequately addressed.
The facility failed to accommodate food preferences for several residents, leading to dissatisfaction and potential nutritional issues. Some residents received meals with items they disliked, such as chocolate pudding, without alternatives. Additionally, residents who disliked certain vegetables were not offered substitutes. One resident's specific preferences were not documented or honored, resulting in skipped meals. The facility's policy on food preferences was not followed, as confirmed by staff.
The facility failed to store medications securely and in accordance with professional standards. Medication carts were left unlocked and unattended, and some medications lacked visible expiration dates. Additionally, medications for multiple residents were not stored separately, increasing the risk of errors. Expired glucometer control solution was also found in a medication cart.
The facility failed to ensure food service staff were competent, resulting in incorrect portion sizes being served during meal service. Dietary aides used incorrect scoops and did not follow specific diet orders from meal tickets. Competency checks were not completed for the staff, and the Certified Dietary Manager could not provide documentation of necessary in-services. This oversight risked non-compliance with residents' diet orders and facility menus.
Three residents were not provided privacy during medication administration in a LTC facility. An RN administered medication to a resident in the hallway, while another RN gave an injection without closing the privacy curtain. An LVN also failed to close the privacy curtain or door during medication administration. All residents involved had no cognitive deficits, and staff acknowledged the importance of providing privacy.
The facility failed to uphold resident dignity and privacy for four residents. A resident was transported with their back exposed post-shower, another was spoon-fed while lying in bed, a third ate while lying flat, risking aspiration, and a fourth had an uncovered urinary catheter bag. Staff interviews confirmed these actions violated facility policies on dignity and resident rights.
The facility failed to accurately code the smoking habits of four residents in their MDS assessments, despite evidence from Smoking-Safety Screens and staff interviews confirming their tobacco use. This oversight involved residents with various medical conditions, including diabetes, hyperlipidemia, asthma, and hemiplegia, who smoked under supervision. The MDS Nurse acknowledged the errors, and the facility's policy required accurate certification of MDS assessments, which was not adhered to in these cases.
A resident's preference for female caregivers was not documented in her care plan, despite verbal communication among staff. This oversight could lead to male staff unknowingly providing care, potentially upsetting the resident. The facility's policies emphasize the importance of documenting personal preferences, but this was not reflected in the resident's care plan.
A resident with Vitamin D deficiency did not receive their prescribed Ergocalciferol medication because the RN did not verify a discrepancy between the medication bubble pack and the eMAR with the pharmacy. The DON stated that licensed nurses are responsible for ensuring timely medication administration, which was not adhered to in this instance.
A LTC facility reported a medication error rate of 10.34%, exceeding the acceptable limit. An RN administered metformin without food to a resident, contrary to instructions, and failed to fully dilute a therapeutic powder for another resident, leaving residue. Additionally, the RN did not administer a vitamin D supplement due to confusion over packaging, resulting in a missed dose. The DON confirmed these errors, emphasizing adherence to medication guidelines.
A resident was not provided with a sippy cup, as required for safe drinking, due to a shortage in the kitchen. Despite the resident's meal ticket and order summary indicating the need for a sippy cup, regular cups were used instead. Staff interviews revealed a lack of awareness and communication about the resident's needs, and the facility's policy on self-feeding devices was not followed.
The facility did not ensure pureed meat maintained its shape for several residents on pureed diets. During an observation, the Certified Dietary Manager confirmed that the pureed curry chicken was spread across the plate and did not hold its form. The facility's diet manual requires pureed food to be smooth, moist, and able to hold its shape, which was not followed.
The facility did not provide the required minimum square footage per resident in 17 rooms, each housing two residents. Although the Maintenance Supervisor noted adequate privacy and space for care, the rooms did not meet the regulatory requirement of at least 80 square feet per resident, potentially affecting residents' comfort and privacy.
A persistent strong odor of urine was noted in a resident room and hallway, affecting four residents. Despite cleaning efforts, the smell remained, causing discomfort. The residents had various medical conditions, including muscle weakness and cognitive impairments. Staff confirmed the odor, which violated the facility's policy on maintaining a homelike environment.
Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The deficiency involves the facility’s failure to have a full-time Registered Nurse (RN) designated as the Director of Nursing (DON), as required by federal and state regulations and the facility’s own policy. Interviews with the administrator and multiple nursing staff confirmed that the previous DON, an RN, resigned and her last day was 3/6/26, and no interim or acting DON had been appointed since that time. The administrator, who had been in the role for eight days, acknowledged that the facility did not have a DON or interim DON, that the DON position was only posted and they were actively recruiting, and that it is a regulatory requirement to have a full-time DON onsite. The facility census at the time was 71 residents. Multiple staff members, including RNs, LVNs, and the MDS Coordinator, consistently reported that there was no DON or acting DON in place. Staff described relying on RNs on their shifts, a corporate RN available by phone and visiting intermittently, and an LVN Director of Staff Development for staffing and clinical questions, but none of these individuals were designated as DON. One LVN reported that there were RNs on the day and evening shifts but no RN on the night shift. Review of the facility’s policy on Director of Nursing Services stated that nursing services are under the direct supervision of an RN DON employed full-time (40 hours per week) and responsible for managing nursing services, overseeing licensed nurse schedules, and ensuring care and documentation are in accordance with assessments and care plans. Professional references reviewed by surveyors confirmed the regulatory requirement for a full-time RN DON. The MDS Coordinator stated that without a DON or acting DON, there could be a potential risk of medication errors, improper resident assessment, and non-compliance with facility policies and procedures.
Inaccurate Admission Assessment and Failure to Use Gloves During Peri-Care
Penalty
Summary
The facility failed to ensure professional standards were met when a nurse inaccurately completed admission assessment data for a newly admitted female resident with diagnoses including muscle weakness, musculoskeletal problems, hypertension, and Parkinson’s disease. Review of the resident’s Nursing Admission Assessment dated 1/9/26 showed contradictory fall risk information, documenting that the resident ambulated without problems while also having balance and gait problems when standing or walking. The assessment also incorrectly indicated that the resident did not take an antihypertensive medication, despite a physician’s order for metoprolol tartrate for hypertension, and incorrectly documented that the resident did not have Parkinson’s disease, despite a diagnosis of Parkinson’s and an order for ropinirole. The RN interviewed confirmed these entries were errors and stated they contributed to inaccurate assessment data used to develop the resident’s fall risk care plan. The resident’s Medication Review Report dated 2/17/26 confirmed active physician’s orders for ropinirole for Parkinsonism and metoprolol tartrate for primary hypertension, both ordered on 1/9/26. These orders conflicted with the admission assessment entries that denied the presence of hypertension and Parkinson’s disease and the use of antihypertensive medication. The facility’s Falls and Fall Risk Managing policy, dated 11/17, stated that staff, with input from the attending physician, would identify appropriate interventions related to specific risks and causes to try to prevent residents from falling, indicating that accurate assessment data were required to identify appropriate fall risk interventions. The facility also failed to ensure professional standards were met when a nurse did not use appropriate personal protective equipment while performing peri-care on another female resident. The resident had an order for medicated cream to be applied to the peri-area for MASD, and a progress note documented treatment to the peri-area on 1/19/26 by an LVN. In interviews, a local police officer reported that the LVN admitted he was not using gloves while applying the cream, and the LVN himself stated that after applying the cream to the resident’s vaginal area and between her thighs and vagina, he noticed cream on his bare fingers and acknowledged his finger was exposed. A CNA who was present stated she stood shoulder to shoulder with the LVN and observed him apply the cream over the vaginal area and upper thighs without gloves. The DON stated that nurses should wear gloves for any contact with the vagina and that if a glove breaks, the procedure should be stopped and new gloves applied, and referenced the facility’s Standards for Clinical Practice policy, which requires appropriate PPE (gloves) and protection of privacy, dignity, health, and safety during clinical procedures.
Neglect of Incontinent Care by CNA
Penalty
Summary
The facility failed to ensure residents were free from neglect when a Certified Nursing Assistant (CNA) did not provide adequate incontinent care for three residents during a night shift. The CNA, identified as CNA 9, limited incontinent care to one change for two residents and did not provide any care for the third resident throughout the entire shift. This neglect resulted in the residents experiencing feelings of anger, frustration, loss of dignity, and disrespect. Resident 1 and Resident 2, both cognitively intact and requiring substantial assistance with toileting hygiene, expressed their dissatisfaction with the care they received. They reported that CNA 9 informed them of being short-staffed and only able to provide one brief change during the shift. Despite their requests for additional changes, they were left in soiled briefs for extended periods, leading to emotional distress. Resident 3, who was dependent on staff for toileting hygiene, was not changed at all during the shift, contrary to his preference to be changed before breakfast. The facility's investigation confirmed the neglect, and the Director of Nursing acknowledged the accuracy of the findings. The facility's policy on abuse prevention and neglect defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The report highlights the failure of the facility to meet the residents' needs, resulting in substantiated claims of neglect.
Medication and Bed Rail Deficiencies in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of practice in the administration of medication for several residents. A registered nurse administered Metformin to a resident without food, contrary to the medication's instructions, which could lead to stomach upset. The resident had a history of diabetes and quadriplegia, and the nurse acknowledged the potential for stomach irritation if the medication was not given with food. In another instance, a medication cup containing a tablet was left unattended on a resident's bedside table, accessible to other residents. The resident had dysphagia and muscle weakness, and the medication was a multivitamin. The licensed vocational nurse responsible admitted that it was against nursing practice to leave medications unattended, as it posed a risk of other residents ingesting the medication, potentially causing allergic reactions. Additionally, the facility did not adhere to physician orders regarding bed rails for two residents. One resident, with a history of convulsions and falls, had bed rails without the required padding, increasing the risk of injury during seizures. Another resident, under hospice care, had full bed rails instead of the ordered half rails, which was not in compliance with the physician's instructions. The facility's policy on the proper use of side rails was not followed, compromising resident safety.
Failure to Adhere to Prescribed Menus and Portion Sizes
Penalty
Summary
The facility failed to adhere to the planned menus for the lunch meal on August 12, 2024, resulting in incorrect portion sizes being served to residents on various therapeutic diets. Specifically, 20 residents on a Consistent Carbohydrate (CCHO) diet received 1/2 cup of sweet potato fries instead of the prescribed 1/4 cup. Additionally, eight residents on a mechanical soft diet were served 2 ounces of roast beef instead of the required 3.2 ounces, and seven residents on a puree diet received 2.67 ounces of pureed roast beef instead of 4 ounces. Furthermore, three residents on a large portion diet were given double portions of all food items, and two residents on a renal diet received sweet potato fries, which were not included in their prescribed menu. The facility also failed to measure pureed coleslaw when serving it to residents on a puree diet. During the meal preparation, the dietary aide poured the pureed coleslaw into bowls without measuring, contrary to the facility's Summer Menu, which specified a #12 scoop for portioning. Additionally, the facility did not serve cappuccino mousse as planned, and the chocolate pudding served as a substitute was inconsistently portioned, with some bowls not filled to the required amount. The facility's registered dietitian confirmed that the kitchen staff did not follow the portion sizes on the menu spreadsheet. Moreover, the facility did not include corn in the corn coleslaw served during the lunch meal, as specified in the Summer Menu. The dietary aide admitted that some ingredients were not available for the recipes. The facility's Resident Council Minutes from previous months indicated ongoing issues with portion sizes and food preferences, highlighting a pattern of non-compliance with menu planning and execution. These deficiencies had the potential to result in residents not meeting their physician-prescribed diet orders and nutritional needs.
Failure to Perform Hand Hygiene After Handling Soiled Linen
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the spread of communicable diseases and infections, as observed in the actions of a Certified Nursing Assistant (CNA) who did not perform hand hygiene after handling soiled linen. Specifically, CNA 1 exited the shared room of two residents, carrying a bag of soiled linen, and disposed of it without washing or disinfecting his hands. Subsequently, CNA 1 moved the linen cart without performing hand hygiene, which had the potential to contaminate the cart and cause cross-contamination of other surfaces. Interviews with various staff members, including CNA 1, CNA 5, the infection preventionist, the director of staff development, and the director of nursing, confirmed that the facility's policy required staff to perform hand hygiene after contact with potentially contaminated substances. The staff acknowledged the importance of hand hygiene in preventing the spread of infections and maintaining a clean environment. The facility's policy on handwashing emphasized the necessity of washing hands before and after direct resident care and after contact with potentially contaminated substances to prevent nosocomial infections.
Inaccurate and Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential confusion and risk regarding their healthcare decisions. For Resident 51, the Physician Order for Life Sustaining Treatment (POLST) form contained a misspelled last name, which was identified during a review of the resident's admission record. Interviews with staff, including a certified nursing assistant, registered nurse, medical records coordinator, and the director of nursing, confirmed the importance of accurate documentation, as the POLST is a critical medical record that guides end-of-life care decisions. Resident 2's POLST form was found to be incomplete, lacking a necessary signature from either the resident or a legally recognized decision-maker. This omission was discovered during a review of the resident's admission record, which noted diagnoses of convulsions and hyperlipidemia. The medical records person acknowledged the incomplete status of the POLST and indicated that the responsibility for ensuring completeness lay with the admission nurse and licensed nurses. For Resident 22, the POLST form was inaccurately dated, with a discrepancy between the completion date and the physician's signature date. This error was noted during a review of the resident's admission record, which included diagnoses of COPD, anemia, and chronic pain. The medical records person admitted to not checking the documents closely before scanning them into the computer system. The director of nursing and the administrator both emphasized the necessity of accurate and complete POLST forms before they are entered into the system.
Pest Control Deficiency: Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in the kitchen and hallway areas. During an observation and interview with a Dietary Aide, a cockroach was seen crawling on the wall in the dish machine area, and the aide confirmed previous issues with cockroaches in the kitchen. Further observations revealed cockroaches on the floor by the handwashing station and under the food preparation table near the three-compartment sink. The Certified Dietary Manager acknowledged being informed by the kitchen staff about the cockroach problem. Additionally, a resident in Station 2 hallway reported frequently seeing cockroaches in the facility, and a cockroach was observed crawling into a crack on the shower room floor. The Maintenance Supervisor noted the need to seal the crack. The Pest Control Technician, who services the facility, mentioned visiting twice in the past months and had recommended sealing cracks in the kitchen, but was unsure if the recommendations were implemented. The facility's pest control policy, dated January 2018, indicated an ongoing program to keep the building free of insects and rodents, which was not effectively maintained.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that the food served to residents was palatable and flavorful, as evidenced by multiple resident complaints and direct observations. Residents reported that the food was either overcooked or undercooked, with specific complaints about firm and undercooked peas, dry and bland chicken, and bland rice. Several residents expressed dissatisfaction with the taste and quality of the meals, describing them as dreadful, bland, and not appetizing. The facility's Summer Menus indicated a meal of curry lemon chicken, garlic rice, and peas with onions, but the actual food served did not meet these expectations. During a concurrent observation and interview, the Certified Dietary Manager confirmed that the peas were firm and undercooked, and the curry flavor was more pronounced in the pureed chicken than in the regular chicken. The facility's Resident Council had previously identified concerns about food quality, and responses from the Department Head indicated issues with staff not properly reading meal tickets. Despite these concerns being raised, the facility did not adequately address the issues, leading to continued dissatisfaction among residents regarding the quality and palatability of their meals.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate food preferences for several residents, leading to dissatisfaction and potential nutritional issues. Three residents, identified as Resident 12, Resident 23, and Resident 18, received meals that included items they had explicitly stated they disliked, such as chocolate pudding and pudding in general. Despite the dietary aides' acknowledgment of these preferences, the meals were not adjusted accordingly. The Certified Dietary Manager and Registered Dietitian both confirmed that residents with dislikes should have received alternatives, but this was not implemented. Additionally, the facility did not provide alternative options of similar nutritive value for residents who chose not to eat certain menu items. Three residents, identified as Resident 31, Resident 51, and Resident 34, were served meals containing vegetables they disliked, such as peas, without being offered alternative vegetables. The facility's policy stated that substitutes should be provided for disliked foods, but this was not adhered to, as confirmed by the Certified Dietary Manager and Registered Dietitian. Furthermore, the facility failed to document and provide for a resident's specific food preferences. Resident 29, who had no cognitive impairment, expressed a dislike for ham and a preference for potatoes, which was not documented or honored by the kitchen staff. Despite communicating these preferences, the resident's meal ticket was not updated, leading to dissatisfaction and the resident skipping meals. The Certified Dietary Manager admitted the oversight and acknowledged the importance of documenting meal preferences to ensure residents receive their desired food.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with accepted professional standards of practice. On multiple occasions, medication carts were left unlocked and unattended, making medications accessible to unauthorized individuals. Specifically, a medication cart in Station 1 was left unlocked by an RN while she washed her hands and used the restroom, and again when she entered a resident's room to administer medication. Similarly, another medication cart was found unlocked and unattended in a hallway outside a resident's room. These actions were acknowledged by the staff involved, who admitted that such lapses could lead to unauthorized access to medications by residents, staff, or visitors. Additionally, the facility did not ensure that all medications had visible expiration dates. Two bottles of Perampanel, a medication used to prevent seizures, were found without expiration dates on the labels. The LVN responsible for these medications admitted that the expiration dates should have been checked and clarified before administering the medication to residents. The absence of expiration dates could result in the administration of expired medications, which may have lost efficacy or could cause unwanted side effects. Furthermore, the facility failed to store medications in an orderly manner. Medication bubble packs for 12 of 19 sampled residents were not separated in the medication cart, increasing the risk of administering the wrong medication to residents. This lack of organization was noted by the LVN, who stated that medications should be stored separately as a safety measure. The facility's policies and procedures were not followed, as evidenced by the presence of expired glucometer control solution in a medication cart, which could lead to incorrect glucose readings and improper medication dosing.
Incompetence in Food Service Staff Leads to Incorrect Meal Portions
Penalty
Summary
The facility failed to ensure that three food service staff members were competent in carrying out the functions of food and nutrition services safely and effectively. During the lunch meal service and preparation, it was observed that incorrect portion sizes of food items were served. Specifically, the dietary aides used incorrect scoops for various food items, such as roast beef and sweet potato fries, which did not align with the facility's menu requirements. Additionally, one dietary aide did not call out specific diet orders, such as Consistent Carbohydrate (CCHO) and renal diets, from the meal tickets when instructing the cook. The facility's records revealed that the dietary aides did not have competency or skills checks completed, despite being employed for varying lengths of time. The Certified Dietary Manager confirmed the lack of competency checks and was unable to provide documentation of in-services regarding portion sizes, menu adherence, and therapeutic diets. The facility's policy required annual competency testing for food and nutrition services employees, which was not adhered to in this case. This oversight had the potential to result in residents' diet orders and facility menus not being followed.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during medication administration for three of the nine sampled residents. Registered Nurse (RN) 2 administered medication to Resident 20 in the hallway, where other residents, staff, and visitors were present, without providing privacy. Resident 20, who had no cognitive deficit, was exposed to a lack of privacy during this process. RN 2 acknowledged the mistake and stated that privacy should have been provided. Similarly, RN 1 administered an aspart injection to Resident 24 without closing the door or privacy curtain, exposing the resident's abdominal area. Resident 24, who also had no cognitive deficit, was not afforded the privacy they were entitled to during the medication administration. RN 1 admitted to not providing the necessary privacy and recognized the importance of respecting residents' rights to privacy. Licensed Vocational Nurse (LVN) 1 administered medication to Resident 40 in their room but failed to close the privacy curtain or door, leaving the resident exposed to others passing by. Resident 40, with no cognitive deficit, was not given the privacy required during medication administration. The Director of Nursing (DON) confirmed that the expectation was to provide privacy by closing curtains or doors and acknowledged that residents' rights to privacy were not upheld in these instances.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that four residents were treated with respect and dignity, as required by federal and state laws. Resident 30 was transported from the shower room with his back exposed, which violated his right to privacy. Interviews with staff, including CNAs and the Director of Nursing, confirmed that residents should be fully covered after showers to maintain their dignity. The facility's policy on dignity and resident rights emphasized the importance of treating residents with respect and ensuring their privacy. Resident 8 experienced a lack of dignity during meal assistance. A CNA stood over him while spoon-feeding him breakfast, rather than sitting at eye level, which would have provided a more respectful dining experience. The CNA acknowledged the mistake, and other staff members confirmed that the proper practice is to lower the bed and sit next to the resident during meals. The facility's policy on dignity supports the need for residents to be treated with respect and to have their self-esteem and self-worth maintained. Resident 57 was observed lying flat in bed while eating, unable to see her food, which posed a risk for aspiration and choking. Despite her refusal of assistance, staff should have ensured she was positioned correctly to prevent health risks and maintain her dignity. Additionally, Resident 65's urinary catheter bag was left uncovered, visible to others, which violated her privacy. Staff interviews confirmed that catheter bags should be covered to protect residents' dignity, as outlined in the facility's policies on resident rights and quality of life.
Inaccurate MDS Assessments for Resident Smoking Habits
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the smoking habits of four residents, leading to potential unmet care needs. Resident 14, who was admitted with diagnoses including pain, diabetes, and mobility issues, was identified as a smoker through a Smoking-Safety Screen, yet this was not coded in the MDS assessment. Similarly, Resident 29, with diagnoses of hyperlipidemia and diabetes, was also a smoker according to the Smoking-Safety Screen, but this information was omitted from the MDS assessment. Resident 34, who had muscle weakness and asthma, reported smoking and following a smoking schedule supervised by staff, yet her tobacco use was not recorded in the MDS assessment. Resident 38, with hyperlipidemia and hemiplegia, also smoked under supervision, but his smoking habit was not documented in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged the oversight in each case, stating that the residents should have been coded as smokers. Interviews with the Activity Assistant and the Director of Nursing highlighted the facility's expectation for accurate assessments, with the Director noting that inaccuracies could be considered falsification of records. The facility's policy required staff to certify the accuracy of MDS assessments, and the Resident Assessment Instrument manual specified that tobacco use should be recorded if used during the look-back period. Despite these guidelines, the smoking habits of the residents were not accurately captured in the MDS assessments.
Failure to Document Resident's Care Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident 66, who had specific preferences regarding the gender of the staff providing her care. Despite verbal communication among staff members about Resident 66's preference for female caregivers, this preference was not documented in her care plan. Interviews with multiple certified nursing assistants (CNAs) and a registered nurse (RN) revealed that the lack of documentation could lead to male staff members unknowingly entering Resident 66's room, which would upset her. The absence of a written care plan meant that new or temporary staff might not be informed of her preferences, potentially compromising her comfort and sense of safety. Resident 66 was admitted with diagnoses including heart failure, atrial fibrillation, and major depressive disorder. The facility's policy and job descriptions for licensed vocational nurses (LVNs) and registered nurses (RNs) emphasize the importance of incorporating residents' personal and cultural preferences into care plans. However, the review of Resident 66's care plan showed no mention of her preference for female staff, and interviews with the minimum data set coordinator (MDSC) and the director of nursing (DON) confirmed that this preference should have been documented to ensure all staff were aware of the necessary interventions to respect her wishes.
Failure to Administer Prescribed Medication Due to Verification Error
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the administration of medication to meet the needs of a resident diagnosed with Vitamin D deficiency and muscle wasting and atrophy. On a specific day, the resident did not receive their prescribed Ergocalciferol medication because the medication bubble pack had a different name than the order on the electronic Medication Administration Record (eMAR). The Registered Nurse (RN) responsible for administering the medication did not verify the discrepancy with the pharmacy but instead contacted the physician, resulting in the medication not being administered. The Director of Nursing (DON) acknowledged that licensed nurses are responsible for ordering medications and ensuring their timely administration. The facility's policy and procedure for medication administration require medications to be administered according to the physician's written orders and within a specified time frame. The failure to administer the medication as prescribed was not in accordance with the facility's policy, which emphasizes the importance of checking medications delivered from the pharmacy to ensure they are correct.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.34 percent. One incident involved a registered nurse (RN) administering metformin to a resident without food, contrary to the medication's instructions. The resident, who had been readmitted with diagnoses including diabetes and muscle spasms, was given the medication while lying in bed with a food tray nearby. The RN acknowledged the error, noting that the medication should have been given with food to prevent gastrointestinal upset. Another incident involved the same RN not fully diluting a therapeutic powder for a resident, leaving residue in the cup. This resident, admitted with conditions such as vitamin D deficiency and muscle wasting, did not receive the full dose of the therapeutic powder intended for wound healing. The RN admitted to not mixing the powder thoroughly, which was confirmed by the Director of Nursing (DON), who stated that the full dose was not administered due to the residue left in the cup. Additionally, the RN failed to administer a vitamin D supplement to the same resident because of confusion over the medication's packaging and order. The RN did not verify the medication with the pharmacy, resulting in the resident missing a dose. The DON emphasized the importance of ensuring routine medications are available and administered as prescribed. The facility's policy on medication errors highlights the need to follow clinical guidelines and physician orders to minimize adverse consequences.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment, specifically a sippy cup, for a resident who required it for safe and independent drinking. During an observation, it was noted that the resident's meal tray contained two regular cups without handles, despite the meal ticket indicating the need for a sippy cup. Interviews with dietary aides revealed that the kitchen lacked sufficient sippy cups, leading to the use of regular or disposable cups instead. The resident's order summary also specified the need for light-up utensils and a sippy cup to minimize spillage during meals. Further observations and interviews highlighted a lack of awareness and communication among staff regarding the resident's need for a sippy cup. A registered nurse confirmed the resident's requirement for a sippy cup or a cup with a handle due to seizure precautions, while a certified nursing assistant was unaware of any such order. The facility's policy stated that self-feeding devices should be kept in stock and provided with each meal, yet this was not adhered to, resulting in the deficiency.
Failure to Maintain Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed meat was prepared in a form that could hold its shape or form for seven residents who were on a pureed diet. During an observation and interview with the Certified Dietary Manager, it was noted that the pureed curry chicken was spread all over the plate and did not maintain its shape. The Certified Dietary Manager acknowledged this issue. A review of the facility's Diet Type Report indicated that the affected residents were on various types of pureed diets, including regular puree, fortified puree, and puree with specific liquid consistencies such as nectar thick and honey thick liquids. The facility's diet manual specified that the pureed diet should be smooth, moist, and able to hold its shape, which was not adhered to in this instance.
Failure to Meet Square Footage Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in 17 resident bedrooms, specifically Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21. Each of these rooms housed two residents but did not meet the regulatory requirement of at least 80 square feet per resident. During an observation and interview with the Maintenance Supervisor, it was confirmed that the rooms did not meet the square footage requirement. However, the Maintenance Supervisor noted that the room variations were in accordance with the particular needs of the residents, and that the residents had a reasonable amount of privacy, with adequate closets, storage space, and bedside stands. There was also sufficient room for nursing care and for residents to ambulate, with accessible wheelchairs and toilet facilities. Despite these accommodations, the failure to meet the square footage requirement had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort.
Persistent Urine Odor in Resident Room and Hallway
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for four residents, as evidenced by a persistent strong odor of urine in a specific room and the surrounding hallway. Observations made over several days noted the presence of the odor, which was confirmed by multiple staff members, including the Infection Preventionist, Activities Coordinator, and Maintenance Supervisor. Despite efforts to clean the room, the odor remained, leading to discomfort for the residents, one of whom reported experiencing a headache due to the smell. The residents affected by this deficiency included individuals with various medical conditions such as muscle weakness, chronic pain, heart failure, and cognitive impairments. The Minimum Data Set assessments indicated that two of the residents had no cognitive impairment, while the other two had moderate cognitive impairments. The facility's policy on maintaining a homelike environment, which includes ensuring pleasant and neutral scents, was not adhered to, contributing to the deficiency.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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