Gateway Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 661 West Poplar, Porterville, California 93257
- CMS Provider Number
- 056423
- Inspections on file
- 24
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gateway Post Acute during CMS and state inspections, most recent first.
A resident who experienced a fall and reported increased pain had a STAT x-ray ordered for the left hip and shoulder, but the x-ray was not performed until approximately 19 hours after the order was placed. Both facility staff and the contracted x-ray provider indicated that STAT orders should be completed within 4-8 hours. The delay was confirmed through interviews and record reviews, and the x-ray ultimately revealed a left clavicle fracture.
A resident with a history of osteomyelitis and diabetic neuropathy experienced severe pain during a wound dressing change, as the Infection Preventionist failed to assess or manage the pain despite visible signs of distress. The resident, who had been prescribed Morphine, did not receive pain medication prior to the procedure, contrary to the facility's pain management policy.
A facility failed to implement proper infection control practices when an IP did not use appropriate PPE or perform hand hygiene during a procedure on a resident with an open wound. Additionally, the facility lacked effective infection control surveillance, as the IP did not conduct necessary observations or data analysis, and no documentation was provided.
The facility failed to implement an effective Antibiotic Stewardship program, lacking participation from key personnel and oversight. A resident was treated for a UTI without a positive urine culture, and another was treated indefinitely for Valley Fever without lab confirmation. The facility's policies on antibiotic use were not followed, leading to potential unnecessary medication use.
A facility failed to assess a resident's competency to self-administer eye drops, as required by policy. The resident had been self-administering the medication for over two months without a physician's order or IDT assessment. This oversight posed a potential risk for medication errors and health risks.
A facility failed to notify a physician about the discontinuation of restorative therapy for a resident with spinal cord injury and muscle weakness, and about another resident's toe wounds. The first resident's therapy was stopped due to refusal to participate, but no physician notification was documented. The second resident's toe was red, swollen, and had wounds, yet there was no nursing assessment or physician notification documented, despite facility policy requiring weekly skin assessments.
The facility failed to maintain a homelike environment for two residents, resulting in unkempt living conditions. A resident's toilet had a dark brown ring, and the Maintenance Supervisor and Housekeeping staff confirmed it was stained and needed replacement. Another resident's restroom had broken and missing tiles with a sticky black substance, which the Administrator and Maintenance Supervisor agreed required repair.
A facility failed to ensure the accuracy of a resident's assessment, specifically regarding dental status. The resident complained of tooth pain, but the MDS inaccurately indicated the resident had no natural teeth, while records showed some natural teeth were present. The facility's policy requires certification of assessment accuracy, which was not followed.
A facility failed to conduct a PASRR Level 2 evaluation and psychiatric assessment for a resident with serious mental disorders, despite a positive PASRR Level 1 screening. The resident, diagnosed with schizophrenia, anxiety disorder, and major depressive disorder, did not receive the necessary follow-up evaluations, as confirmed by the MDSC. This failure to comply with DHCS guidelines potentially affected the resident's placement and access to mental health treatment.
The facility failed to provide summaries of the baseline care plans to two newly admitted residents within 48 hours of admission. One resident, admitted with osteomyelitis and diabetes, underwent a transmetatarsal amputation, while another, admitted for aftercare following surgical amputation, had toes amputated. Both residents' baseline care plans were incomplete, and summaries were not provided, contrary to the facility's policy.
A facility failed to develop a hospice care plan for a resident admitted under hospice care, as required by their policy. The resident's records indicated hospice care, but no End of Life or Hospice care plan was created. The facility's policy mandates comprehensive care plans with measurable objectives and regular updates, especially after significant changes in a resident's condition.
A resident with hypertension was given AmLODPine Besylate despite having a systolic blood pressure below the prescribed threshold, contrary to physician orders. Additionally, HYDROcodone-Acetaminophen was administered for severe pain even when the resident's pain level was recorded as 0 or 2, below the severe pain threshold. LVNs showed discrepancies in following physician orders, contrary to the facility's medication administration policy.
A resident with major depressive disorder and Alzheimer's Disease was not provided with activities of her choice, despite expressing a desire to engage in group activities and enjoy fresh air. The facility failed to develop an activities care plan for her, and there was a lack of documentation regarding her participation or refusal of activities, contrary to facility policy.
A resident with hemiplegia and hemiparesis following a stroke did not receive a comprehensive pain management care plan, leading to unrelieved pain and isolation. The facility's incomplete pain assessment failed to trigger necessary physician notifications, and the resident's daily use of Oxycodone indicated insufficient pain management.
A facility failed to follow its repositioning policy for a resident with Alzheimer's, who was at risk for pressure ulcers. The resident's care plan required repositioning every two hours, but records showed multiple instances in August where this was not done. The RNC confirmed that documentation was inconsistent, and if not documented, repositioning was considered not done, contrary to the facility's policy.
A resident with dysphagia and missing teeth was served a regular textured meal despite recommendations for a mechanical soft diet. The resident, who pockets food, was at risk due to the facility's failure to adjust her diet according to the Speech Language Pathologist's evaluation. The Registered Dietician had not received updated recommendations, and the facility's policy on dysphagia management was not followed.
A facility failed to complete pre-dialysis and post-dialysis communication assessments for a resident with ESRD, missing several scheduled assessments. The DSD confirmed that these assessments were crucial for communication between the facility and the dialysis center regarding the resident's condition, as outlined in the facility's policy.
A facility failed to follow its bed safety and bed rail policy for a resident with encephalopathy, muscle weakness, and dysphasia. The Bed Rail and Entrapment Risk Observation/Assessment was incomplete, lacking documentation of the family's request for bed rails, and the Interdisciplinary Team was not involved in the review. Additionally, there was no physician's order or care plan for the use of bilateral bed rails, contrary to the facility's policy requiring interdisciplinary evaluation and informed consent.
The facility failed to employ a full-time DON for a 62-bed facility, leading to a lack of oversight in nursing services and quality of care. The DSD managed nursing staffing hours without review, and the IP lacked guidance in infection control, relying on external consultations.
An expired Advair Diskus Inhaler was found on a medication cart during an observation and interview with an LVN. The inhaler, which should have been discarded by its labeled discard date, was not removed, contrary to the facility's policy on medication storage. The LVN confirmed that it is the nurse's responsibility to check and dispose of expired medications.
A facility failed to maintain a medication error rate of 5% or less, resulting in an 8% error rate. An LVN administered an incorrect insulin dosage to a resident without a physician's order, and another LVN gave Tylenol two hours earlier than prescribed. The facility's policy requires medications to be administered as prescribed.
A resident received an incorrect insulin dosage due to a Licensed Vocational Nurse (LVN) administering an additional six units of Humalog insulin without a Physician's Order (PO). The LVN acted on the resident's request but failed to document the extra dosage, violating the facility's medication administration policy.
The facility did not ensure that two kitchen staff members followed the dress code policy, which required all facial hair to be covered by a beard restraint. Observations revealed that their mustaches were exposed, contrary to the policy. The Dietary Service Supervisor incorrectly believed that trimmed mustaches could be left uncovered, leading to a potential risk of food contamination.
A facility failed to monitor the intake and output of a resident on a fluid restriction, as required by their policy. The resident had a fluid restriction order of 1.8 liters per 24 hours, but monitoring ceased after the first 30 days post-admission. This lapse was confirmed by the Director of Staff Development, who could not provide documentation of ongoing monitoring, despite the facility's policy requiring it.
Delay in STAT X-ray Completion Following Resident Fall
Penalty
Summary
A deficiency occurred when a STAT x-ray ordered for a resident following a fall was not completed in a timely manner. The resident, who had fallen from her bed and was experiencing increased pain, had a physician's order placed for a STAT x-ray of the left hip and left shoulder. Despite the order being labeled as STAT, the x-ray was not performed until approximately 19 hours after the order was obtained. Both the LVN and DON confirmed that the facility's practice is for STAT orders to be completed within 4-6 hours, and the x-ray company's agreement indicated STAT orders should be completed within 6-8 hours. The delay was confirmed through interviews and record reviews. The resident was observed lying in bed with her left arm immobilized and reported that her arm was broken. The x-ray results later confirmed a left clavicle fracture. The facility's policy and procedures also stated that urgent radiological requests labeled as STAT should be carried out in a timely manner according to the contracted agency's policy. The failure to obtain the STAT x-ray within the expected timeframe constituted a deficiency in meeting the resident's needs for timely diagnostic services.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 51 during a wound dressing change, as observed by a surveyor. Resident 51, who was admitted with acute osteomyelitis, Type 2 diabetes mellitus with diabetic neuropathy, and other skin ulcers, exhibited signs of severe pain during the procedure. The Infection Preventionist (IP) conducted the dressing change on the resident's amputated left big toe and a vascular wound on the left ankle without assessing or addressing the resident's pain, despite visible signs of distress such as facial grimacing and a reported pain level of nine out of ten. During the procedure, the IP continued to flush and clean the wounds with Daikin and betadine solutions, ignoring the resident's verbal and non-verbal expressions of pain. The IP informed the resident that pain medication would be administered after the treatment, but did not pause the procedure to manage the pain. The resident had been prescribed Morphine, a narcotic pain medication, but it was not administered prior to the dressing change, resulting in unnecessary suffering. The facility's policy on pain assessment and management requires assessing pain before, during, and after treatment, and intervening as needed. However, this protocol was not followed, as evidenced by the lack of pain assessment and management during the dressing change. The resident's care plan also indicated the need for pain management, but the IP failed to adhere to these guidelines, leading to the deficiency noted in the report.
Inadequate Infection Control Practices and Surveillance
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during an incident involving the Infection Preventionist (IP) and a resident with an open wound. The IP did not adhere to the facility's policies on personal protective equipment (PPE) and hand hygiene. Specifically, the IP did not wear a face shield or goggles during a procedure with potential for splash, did not change gloves, and failed to perform hand hygiene after dressing changes. The IP also handled clean dressings and medication cart keys without removing gloves or washing hands, and exited the resident's room carrying a trash bag without performing hand hygiene. Additionally, the facility did not conduct effective infection control surveillance activities. The IP admitted to not performing surveillance on cleaning blood glucose meters and only observing day shift staff due to not working nights. The IP lacked knowledge on conducting infection control surveillance, had no previous data collected, and did not analyze or track hand hygiene surveillance results. The facility's infection control policies required ongoing surveillance for healthcare-associated infections, but no documentation of such activities was provided by the IP.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship program, as evidenced by the lack of participation from key personnel such as the pharmacist, medical director, and director of nursing in the program. The Infection Preventionist (IP) was responsible for the program but admitted that there were no antibiotic stewardship meetings and could not provide documentation that antibiotic stewardship was part of the infection control committee agenda. This lack of oversight led to instances where antibiotics were prescribed without proper justification or documentation, such as in the case of a resident who was treated for a urinary tract infection without a positive urine culture, contrary to the McGreer Criteria guidelines. Additionally, another resident was treated indefinitely with fluconazole for a diagnosis of Valley Fever without laboratory confirmation or physician documentation. The resident's history and physical did not mention Valley Fever, and there was no evidence of reevaluation or referral to an infectious disease specialist. The facility's policies and procedures on antibiotic stewardship, which require review and surveillance of antibiotic use, were not followed, leading to potential unnecessary medication use and lack of proper medical oversight.
Failure to Assess Resident's Competency for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed and determined to be competent to self-administer medication, specifically eye drops. During an observation and interview, it was noted that a bottle of eye drops was left on the bedside table of the resident, who stated that the nurse leaves them there for self-administration. The resident mentioned having the eye drops in the room for over two months, indicating a prolonged period without proper assessment or authorization for self-administration. Further investigation revealed that there was no documentation of a physician's order or interdisciplinary team (IDT) assessment regarding the resident's ability to self-administer the medication. The facility's policy requires an IDT evaluation to determine if self-administration is clinically appropriate and safe, but this process was not followed. The lack of documentation and assessment posed a potential risk for medication administration errors and serious health risks to the resident.
Failure to Notify Physician of Therapy Discontinuation and Wound Condition
Penalty
Summary
The facility failed to notify the physician regarding the discontinuation of restorative therapy for a resident diagnosed with post-laminectomy syndrome, cord compression, and muscle weakness. The resident, who required staff assistance due to spinal cord injury and muscle weakness, was initially placed on a restorative nursing assistant (RNA) program. However, due to the resident's refusal to participate, the therapy was discontinued without notifying the physician. The Director of Rehabilitation Services and the Director of Staff Development were unable to provide documentation of physician notification or any subsequent therapy or range of motion exercises for the resident. Additionally, the facility did not notify the physician about a resident's left big toe, which was observed to be red, swollen, purplish, and with wounds. A Certified Nursing Assistant reported the skin abnormalities to a nurse, but there was no documentation of a nursing assessment or physician notification regarding the wounds. The facility's policy required weekly skin assessments, but the assessments did not indicate any evaluation of the wounds. The facility was unable to provide a policy on physician notification.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, resulting in them living in an unkempt environment. For Resident 162, a dark brown ring was observed on the inside of the toilet bowl during an observation and interview. The resident was unaware of the last time the toilet had been cleaned. The Maintenance Supervisor and Housekeeping staff confirmed the presence of the stain and stated that the toilet was stained and should be replaced. The Administrator also confirmed the toilet's condition and agreed it should be replaced. In the case of Resident 46, during an observation and interview, broken and missing tiles with a sticky black substance were found in the corner entrance of the restroom. The Administrator acknowledged that the area looked unfinished and should have been fixed, while the Maintenance Supervisor agreed that the restroom should not have broken and missing tiles and needed repair. The facility's policy and procedure on maintaining a homelike environment emphasized providing a clean, sanitary, and orderly environment, which was not upheld in these instances.
Inaccurate Resident Assessment Regarding Dental Status
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the accuracy of resident assessments, specifically for one resident. During an observation and interview, the resident pointed to his upper tooth and complained of pain. A subsequent review of the resident's Minimum Data Set (MDS) revealed inaccuracies in Section K, which indicated the resident had broken or loosely fitting dentures and no natural teeth, contrary to the resident's actual condition of having some natural teeth with some missing. The facility's policy requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion, which was not done correctly in this case.
Failure to Conduct PASRR Level 2 Evaluation and Psychiatric Assessment
Penalty
Summary
The facility failed to ensure that a resident received a psychiatric evaluation and a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation after a PASRR Level 1 screening indicated the need for further evaluation of the resident's mental disorder. The resident's PASRR Level 1 screening, dated January 15, 2024, was positive for serious mental disorders, including schizophrenia, anxiety disorder, and major depressive disorder. Despite this, the resident did not receive a psychiatric evaluation or a PASRR Level 2 follow-up, as confirmed by the Minimum Data Set Coordinator (MDSC) during interviews and record reviews. The MDSC was unable to find documentation of a physician's referral to a psychiatrist or any physician progress notes regarding a psychiatric evaluation for the resident. The Department of Health Care Services (DHCS) guidelines state that a positive Level 1 screening should be followed by a PASRR Level 2 evaluation to determine the most appropriate placement and whether specialized services are needed. The lack of a PASRR Level 2 evaluation and psychiatric assessment for the resident indicates a failure to comply with these guidelines, potentially affecting the resident's placement and access to necessary mental health treatment.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan (BCP) to two newly admitted residents, Resident 51 and Resident 109, within 48 hours of their admission. Resident 51 was admitted with acute osteomyelitis, Type 2 diabetes mellitus with diabetic neuropathy, and other skin ulcers. Following a transmetatarsal amputation of the left first toe due to gangrene, the BCP for Resident 51 was incomplete, and neither the resident nor their representative received a summary of the BCP for post-operative care. This was confirmed during an interview and record review with the Minimum Data Set Coordinator (MDSC) 1. Similarly, Resident 109 was admitted with aftercare following surgical amputation, diabetes mellitus with diabetic neuropathy, and cellulitis of the left upper limb. After undergoing an amputation of the third, fourth, and fifth toes at the transmetatarsal level, the BCP for Resident 109 was also incomplete, and no summary was provided to the resident or their representative. The facility's policy and procedure, dated 2001, requires that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative. This policy was not adhered to in these cases, as confirmed by MDSC 1 during the review.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for developing comprehensive, person-centered care plans for one of the sampled residents, identified as Resident 22. Upon review of Resident 22's records, it was found that the resident was admitted under hospice care, as indicated in the Order Listing Report and the Minimum Data Set. However, during an interview and record review with the MDS Consultant, it was revealed that there was no End of Life or Hospice care plan developed for Resident 22, which should have been created following the resident's admission to hospice care. The facility's policy requires that care plans include measurable objectives and timetables to address the resident's needs and be reviewed and updated when there is a significant change in the resident's condition or at least quarterly. This oversight had the potential to not meet Resident 22's physical, psychosocial, and functional needs.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to administer medications to a resident according to physician orders, which could potentially lead to adverse medication outcomes. The resident, who had a history of hypertension, was given AmLODPine Besylate despite having a systolic blood pressure of 103, which was below the prescribed threshold of 110 for withholding the medication. This action was contrary to the physician's order, which specified holding the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Additionally, the resident was administered HYDROcodone-Acetaminophen for severe pain, even when the pain level was recorded as 0 or 2, which is below the severe pain threshold of 7-10 as per the care plan. Interviews with LVNs revealed discrepancies in understanding and following the physician's orders, with one LVN stating she would administer severe pain medication for a pain level less than seven if it was scheduled and requested by the patient, while another LVN acknowledged that administering the medication for a pain level less than seven would not be in accordance with the physician's order. The facility's policy on medication administration emphasized that medications should be administered as prescribed, highlighting a failure in adherence to this policy.
Failure to Provide Resident with Person-Centered Activities
Penalty
Summary
The facility failed to provide a resident with activities of her choice, resulting in her not participating in person-centered activities. The resident, who was admitted with diagnoses including major depressive disorder and Alzheimer's Disease, expressed a desire to engage in group activities, enjoy fresh air, and participate in her favorite pastimes such as knitting and needlepoint. Despite these preferences being documented in her assessments, the resident reported that she only left her room for therapy or showers and wished staff would take her outside or to the activities room. The facility's Director of Activities acknowledged that there was no activities care plan for the resident, which should have been developed to reflect her preferences and refusals. The facility's policy required a comprehensive, person-centered care plan to be developed within a specific timeframe, but this was not done for the resident. Additionally, there was a lack of documentation regarding the resident's participation or refusal of activities, which was contrary to the facility's policy on maintaining appropriate departmental documentation.
Failure to Develop Pain Management Care Plan
Penalty
Summary
The facility failed to provide quality care to Patient 15, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke. Despite the patient's capacity to understand and make decisions, a care plan for pain management was not developed. This oversight was identified during a review of the patient's care plan, where it was noted that the interdisciplinary team had not created a comprehensive, person-centered care plan for pain management within the required timeframe. Additionally, the admission Nursing - Pain Observation and Assessment (NPOA) for Patient 15 was incomplete. The assessment lacked critical details such as the type, duration, frequency, and pattern of the pain, as well as its impact on activities of daily living. The incomplete assessment failed to trigger necessary notifications to the physician for potential new orders to address the patient's pain more effectively. Patient 15 experienced unrelieved pain, which was documented as moderate but was severe enough to prevent the patient from engaging in desired activities, such as going outside. The patient's Medication Administration Record indicated daily use of Oxycodone for pain rated between seven and nine on the pain scale, suggesting that the current pain management strategies were insufficient. The facility's policies on pain assessment and management were not adequately followed, contributing to the patient's ongoing pain and isolation.
Failure to Reposition Resident as Per Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding repositioning for a resident, identified as Resident 22, who was at risk for developing pressure ulcers due to Alzheimer's disease. The care plan for Resident 22, dated October 7, 2020, indicated the need for monitoring, reminding, and assistance to turn and reposition at least every two hours. However, a review of the resident's turning and repositioning records revealed multiple instances where the resident was not repositioned during both day and night shifts in August 2024. Specifically, the records showed that on several dates, the resident was not turned or repositioned as required by the facility's policy. During an interview and record review with the Registered Nurse Coordinator (RNC 2), it was confirmed that the documentation of turning and repositioning was inconsistent with the facility's repositioning policy. The RNC 2 acknowledged that if the repositioning is not documented, it is considered not done. The facility's policy, revised in May 2013, emphasized the importance of repositioning as a critical intervention for preventing skin breakdown and promoting circulation, especially for residents who are immobile or dependent on staff for repositioning. The failure to consistently document and perform the required repositioning placed Resident 22 at risk for developing pressure ulcers.
Failure to Provide Appropriate Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide an appropriate diet texture for a resident diagnosed with dysphagia and feeding difficulties. The resident, who was missing most of her top teeth and did not wear dentures due to the risk of swallowing them, was observed being served a regular textured meatball sandwich. Despite the resident's tendency to pocket food and hold onto large pieces, her diet was not adjusted to accommodate her swallowing difficulties. The resident's care plan indicated a risk for weight loss, dehydration, skin breakdown, and altered nutritional status related to her medical condition. The Speech Language Pathologist (SLP) evaluated the resident and recommended a mechanical soft diet due to moderate oropharyngeal dysphagia and a mild aspiration risk. However, the resident continued to receive a regular textured diet. The Registered Dietician (RD) stated that she follows the speech therapist's recommendations but had not received any new recommendations to change the resident's diet. The facility's policy on dysphagia management included obtaining a physician's order for modified consistency diets, but this was not implemented for the resident.
Incomplete Dialysis Communication Assessments for Resident with ESRD
Penalty
Summary
The facility failed to ensure complete pre-dialysis and post-dialysis communication assessments for a resident with end-stage renal disease (ESRD) who was dependent on renal dialysis. The resident was admitted with a diagnosis of ESRD and had scheduled dialysis treatments on Mondays, Wednesdays, and Fridays. However, the facility did not complete the required pre-dialysis assessments on several occasions, including 10/2, 10/4, 10/9, 10/11, 10/14, and 10/16. Additionally, the post-dialysis assessments from the dialysis center were not completed and returned to the facility on multiple dates, including 10/2, 10/4, 10/7, 10/9, 10/11, 10/14, and 10/16. The Director of Staff Development (DSD) confirmed that the facility's protocol required pre-dialysis assessments to be completed and sent with the resident to the dialysis center, and post-dialysis assessments to be obtained from the dialysis center and placed in the resident's medical record. These assessments were crucial for ensuring communication between the facility and the dialysis center regarding the resident's condition, including level of consciousness, skin issues, medications, and vital signs. The facility's policy and procedure for caring for residents with ESRD emphasized the importance of agreements with the dialysis center to manage the resident's care and exchange information effectively.
Failure to Follow Bed Rail Policy and Procedure
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding bed safety and bed rails for a resident, resulting in several deficiencies. The resident, who was admitted with diagnoses including encephalopathy, muscle weakness, and dysphasia, was observed with bilateral bed rails up and foam wedges between the resident and the bed rails. However, the Bed Rail and Entrapment Risk Observation/Assessment (BEAR) was found to be inaccurate and incomplete, lacking documentation of the reason for the family's request for bed rails. Additionally, the Interdisciplinary Team (IDT) was not involved in the review of the use of bed rails, as evidenced by the absence of documentation of IDT members and physician consultation in the BEAR. Furthermore, there was no physician's order for the continuous use of bilateral bed rails, nor was there a care plan for their use. The facility's policy requires that the use of bed rails be based on an interdisciplinary evaluation, resident assessment, and informed consent, with alternatives attempted first. The lack of a physician's order and care plan indicates a failure to meet these criteria, potentially putting the resident's safety and health at risk.
Absence of Director of Nursing Leads to Oversight Deficiencies
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) for a 62-bed facility, resulting in a lack of oversight on nursing services and quality of care. During an entrance conference, the Administrator confirmed the absence of a DON. The Director of Staff Development (DSD) revealed that there had been no DON for over a year, and she was responsible for calculating and submitting nursing staffing hours to the Payroll Based Journal (PBJ) without oversight or review from the Administrator or Registered Nurse Consultant (RNC). Additionally, the Infection Preventionist (IP) reported a lack of guidance and direction in managing the infection control program, particularly in antibiotic stewardship, due to the absence of a DON. The IP had to seek consultation from external sources like the County Health Department Nurse and the Infection Control Consultant (ICC).
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to ensure that one of three medication carts did not contain expired medication, specifically an Advair Diskus Inhaler, which was labeled with a discard date of 10/8/24. During an observation and interview with an LVN at Medication Cart 3, it was confirmed that the inhaler should have been discarded by the specified date. The LVN stated that it is the responsibility of the nurse assigned to the medication cart to check expiration dates and dispose of any expired medications or supplies. A review of the facility's policy and procedure on medication storage indicated that outdated, contaminated, or deteriorated medications should be immediately removed from stock and disposed of according to the facility's procedures for medication disposal.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in an observed error rate of 8%. This was due to two specific incidents. In the first incident, a Licensed Vocational Nurse (LVN) administered an incorrect dosage of insulin to a resident. The resident's blood sugar level was 236 mg/dl, and according to the sliding scale, they were to receive four units of Humalog insulin. However, the LVN administered an additional six units of insulin based on the resident's request, despite there being no physician's order for this additional dosage. The LVN did not document the administration of the extra six units, and the Director of Staff Development (DSD) confirmed that it was not acceptable to administer medication without a physician's order. In the second incident, another LVN administered Tylenol to a resident two hours earlier than prescribed. The resident's order entry indicated that Tylenol should be given every six hours for pain, but the medication was administered only four hours after the previous dose. The facility's policy on administering medication requires that medications be given in a safe and timely manner, as prescribed. The DSD confirmed that the early administration of Tylenol was not in accordance with the prescribed orders.
Medication Error Due to Unauthorized Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. A Licensed Vocational Nurse (LVN) administered an incorrect dosage of insulin to a resident, identified as Resident 109. The LVN prepared and administered 10 units of Humalog insulin based on a sliding scale order for the resident's blood sugar level of 236 mg/dl. However, the LVN included an additional six units of insulin that were not prescribed in the resident's Physician's Orders (PO). This additional dosage was given at the resident's request, but without a valid PO, and was not documented by the LVN. Further review of Resident 109's POs confirmed the absence of an order for the additional six units of Humalog insulin before meals. The Director of Staff Development (DSD) confirmed that it was against standard practice to administer medication without a PO, emphasizing that excessive insulin could lead to hypoglycemia. The facility's policy on administering medication, dated April 2019, mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in this instance.
Non-compliance with Dress Code Policy in Kitchen
Penalty
Summary
The facility failed to ensure that two kitchen staff members, the Dietary Service Supervisor (DSS) and a kitchen cook (KC), adhered to the facility's policy and procedures regarding dress code in the Food & Nutrition Department. During an observation, both DSS and KC were noted to have facial hair, specifically beards and mustaches, with their mustaches left uncovered by the beard restraint they were wearing. This was contrary to the facility's policy, which required all facial hair, including mustaches, to be covered by a beard restraint. During an interview, the DSS incorrectly stated that exposed mustaches were permissible if trimmed, which was not in alignment with the written policy from 2018. This oversight had the potential to lead to food contamination.
Failure to Monitor Fluid Intake and Output for Resident on Fluid Restriction
Penalty
Summary
The facility failed to monitor the intake and output of a resident who was on a fluid restriction, as required. The resident had a fluid restriction order of 1.8 liters per 24 hours, which was documented in their Order Summary Report. Despite this, the facility did not continue to monitor the resident's fluid intake and output beyond the first 30 days after admission. This oversight was confirmed during an interview with the Director of Staff Development, who acknowledged the lack of ongoing monitoring documentation. The facility's policy on restricting fluids, which mandates recording the amount of fluid consumed, was not adhered to in this case.
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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