Gilroy Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gilroy, California.
- Location
- 8170 Murray Avenue, Gilroy, California 95020
- CMS Provider Number
- 055797
- Inspections on file
- 34
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 24 (1 serious)
Citation history
Health deficiencies cited at Gilroy Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognitive function was asked by a CNA to sign an arbitration agreement related to new facility ownership. The CNA, who had not received training on the agreement, provided only a minimal explanation, stating the resident could not sue the facility, and did not answer further questions. The resident signed the agreement without understanding its contents, contrary to facility policy requiring clear explanation.
A resident with quadriplegia and contractures in both upper and lower extremities was observed to have significant limitations in movement, as confirmed by therapy and medical documentation. However, the MDS assessment was inaccurately coded to indicate no impairment in range of motion, contrary to direct observations and staff interviews.
A systemic failure occurred when all residents receiving Levaquin or Metformin did not have required Black Box Warning (BBW) monitoring or care plans documented, and many lacked appropriate indications for antibiotic use. Nursing staff inconsistently documented BBW monitoring, with only day shift nurses seeing alerts, and evening and night shifts not consistently involved. The Infection Preventionist and Consultant Pharmacist did not identify or report these irregularities, resulting in widespread noncompliance with facility policy and regulatory requirements.
Six residents had POLST forms with the advance directive section left blank, despite facility policy requiring all sections to be completed. The DON confirmed that nursing staff did not complete these sections as required by policy.
Multiple residents did not have required care plans developed or implemented for conditions such as nebulizer therapy, epilepsy, helmet use, respiratory issues, infection, and anticoagulant therapy. Staff confirmed that care plans were missing despite physician orders and clinical needs, and one resident's call bell system was not assessed or adapted to their physical limitations.
Surveyors observed multiple medication administration errors, including failure to prime an insulin pen before injection, incorrect dosing of a nasal spray, and combining multiple crushed medications for G-tube administration instead of administering them separately with flushing. These actions were not in accordance with facility policies and physician orders.
Multiple residents reported that meals were bland, repetitive, and unappetizing, with specific complaints about tasteless and dry eggs served daily. During a test tray evaluation, surveyors, the RD, and the DM found the green beans to be overcooked, lacking flavor, and visually unappealing. Job descriptions for dietary staff required them to ensure food was appealing and to monitor food acceptance, but these standards were not met.
Surveyors found that metal pans used for food preparation and service were stacked and stored while still wet, rather than being air dried as required by professional standards. The dietary manager confirmed the improper storage, which had the potential to affect nearly all residents receiving food from the kitchen.
Surveyors identified multiple infection control deficiencies, including improper cleaning and disinfection of glucometers and medication trays, failure to wear required PPE during enteral medication administration, and improper storage and labeling of nebulizer kits, nasal cannulas, and basins. Additional lapses included soiled linen left on the floor, missing Enhanced Barrier Precautions signage for a resident with a pressure ulcer, and urinary catheter drainage bags touching the floor, all contrary to facility policy.
Six residents received antibiotics without meeting Loeb's criteria, with antibiotics prescribed for symptoms such as confusion, knee pain, or abdominal pain, and in some cases, without documented assessment or appropriate clinical indications. Antibiotics were started before culture results were available, and some prescribed antibiotics were not effective against the identified bacteria. The facility's antibiotic stewardship protocols and interdisciplinary oversight were not consistently followed.
Three residents with significant physical and cognitive impairments did not have accessible or appropriate call light systems, as their call light buttons were found on the floor and out of reach, and one resident was not provided with a suitable alternative call system despite being bedbound and unable to use the standard device. Staff confirmed the deficiencies, and facility policy required call lights to be accessible and tailored to individual needs.
The facility did not ensure that residents could easily access or were informed about the location of the latest State survey results. Multiple residents reported not knowing where to find the survey results, and staff interviews and observations confirmed that the required binder was not available in the designated area, contrary to facility policy.
Surveyors found that a resident's Foley catheter drainage bag was left uncovered and visible from the hallway, and two residents had personal care instructions posted openly in their rooms, making sensitive information visible to others. Staff confirmed these actions did not comply with facility policies requiring privacy and confidentiality.
The facility did not ensure that psychotropic medications were used only when necessary, as evidenced by two residents receiving antipsychotic and antidepressant medications without proper documentation of behavioral symptoms or attempts at non-drug interventions, and another resident receiving PRN lorazepam without a required stop date or physician reassessment. Staff and DON interviews confirmed the lack of documentation and adherence to facility policy regarding psychotropic medication use.
The facility did not accurately complete MDS assessments for two residents, resulting in incorrect documentation of discharge status, injectable medication use, and fall history. One resident was incorrectly coded as discharged to a hospital instead of home, while another had missing documentation of weekly SQ injections for diabetes and inaccurate fall reporting. These errors were confirmed by the MDS staff and DON during record reviews and interviews.
A resident with a right outer ankle pressure ulcer was found in bed without a dressing on the wound and without a Prevalon heel protector boot in place, despite physician orders for both. Staff confirmed the omission during observation, and records showed the required treatments and devices were not applied as ordered, resulting in a deficiency in pressure ulcer care.
Nursing staff did not consistently document the administration of PRN controlled medications on the MAR after signing them out from the CDR for three residents with physician orders for narcotic pain medications. This resulted in incomplete records and inaccurate accountability of controlled substances, as confirmed by the DON and ADON during record review and interviews.
A resident with type 2 diabetes had two similar orders for Dilaudid (hydromorphone) and a Fentanyl patch, but the Consultant Pharmacist did not identify or report the duplicate opioid orders during the monthly medication regimen review. The duplicate orders were confirmed by nursing staff, and records showed the resident received more than the maximum allowed dose of hydromorphone in one day.
Failure to Adequately Explain Arbitration Agreement Prior to Resident Signature
Penalty
Summary
The facility failed to ensure that a resident was provided with an adequate explanation of an arbitration agreement in a form and manner the resident could understand prior to obtaining her signature. A certified nursing assistant (CNA) approached the resident and requested her electronic signature for the arbitration agreement, which was related to a change in facility ownership. When the resident asked for clarification, the CNA only stated that signing meant she could not sue the facility and did not provide further explanation. The CNA also admitted to not having received any education or training from the facility regarding the arbitration agreement or how to explain it to residents. The resident, who had diagnoses including depression, hypertension, and type 2 diabetes, was assessed as having intact memory and full mental capacity at the time of the incident. Documentation confirmed that the resident was alert and oriented, and her medical records indicated she was capable of understanding information presented to her. Despite this, the resident signed the agreement without understanding its contents, as the explanation provided was insufficient. Facility policy required that such agreements be explained in a manner understood by the resident or their representative, but this was not followed in this instance.
Inaccurate MDS Coding for Range of Motion with Contractures
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with significant contractures and quadriplegia. Observations revealed that the resident had curled fingers on the right hand, contractures in the left wrist, and both ankles, and was unable to move both hands and legs. Interviews with the resident confirmed the inability to open fingers or hold objects due to joint restrictions, and no movement in both legs. The resident's medical history included quadriplegia and cerebrovascular disease, with occupational therapy notes and physician documentation confirming impaired range of motion (ROM) in both upper and lower extremities due to contractures. Despite this, the resident's MDS assessment indicated no impairment for upper or lower extremity ROM. Interviews with the Director of Rehabilitation and the MDS Coordinator confirmed the presence of contractures and impaired ROM, and acknowledged that the MDS assessment was inaccurately coded. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, but this was not followed in this case, resulting in an inaccurate MDS assessment for ROM.
Systemic Failure to Monitor and Document Black Box Warning Medications
Penalty
Summary
Surveyors identified a systemic failure in the facility's management of medications with FDA Black Box Warnings (BBW), specifically Levaquin (levofloxacin) and Metformin, affecting all residents who received these drugs. For 54 residents who received Levaquin and 19 residents who received Metformin, there was no documentation that BBW monitoring was performed, and no care plans were developed addressing the BBW risks associated with these medications. Additionally, 30 residents who received Levaquin did not have an appropriate indication or diagnosis documented for its use. Six residents received both Levaquin and Metformin without proper BBW monitoring or care plans. These failures were confirmed through record reviews, interviews with staff, and examination of the facility's policies and procedures. Interviews with nursing staff, the Infection Preventionist (IP), and the Director of Nursing (DON) revealed inconsistencies and gaps in understanding and implementing BBW monitoring. While the facility's policy required nursing progress notes to reflect monitoring and resident response to BBW medications, staff interviews indicated that only the day shift nurse administering the medication would see the BBW alert, and documentation in progress notes was inconsistent or absent. Evening and night shift nurses were not consistently alerted or documenting BBW monitoring. Multiple resident records reviewed showed no evidence of BBW monitoring in either the Medication Administration Record (MAR) or nursing progress notes, despite ongoing or recent administration of Levaquin or Metformin. The facility's Infection Preventionist and Consultant Pharmacist failed to identify and report irregularities related to frequent Levaquin use, missed BBW monitoring, inappropriate antibiotic indications, and lack of care plans during their respective reviews. The deficiency was observed across all shifts and affected all residents prescribed these medications during the review period. The lack of monitoring and documentation was confirmed for multiple residents with complex medical histories, including those with kidney disease, diabetes, infections, and other serious conditions, as evidenced by detailed record reviews and staff interviews.
Incomplete POLST Forms for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms were fully completed for six out of eight sampled residents. Specifically, the section regarding advance directives (AD) was left blank on the POLST forms for these residents. Record reviews showed that, despite the residents' admissions and the preparation of their POLST forms, the required section for documenting advance directives was not filled out. This omission was confirmed during a concurrent record review and interview with the Director of Nursing (DON), who acknowledged that nursing staff should have completed all sections of the POLST forms. Facility policies and procedures require that a completed and fully executed POLST form is a legal physician order and must be immediately actionable. Additionally, the policies state that any decision-making regarding a resident's choices should be documented in the medical record and communicated. The failure to complete the advance directive section on the POLST forms for these residents represents noncompliance with these established policies.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for nine out of 26 sampled residents, as required by policy and professional standards. Specific deficiencies included the absence of care plans for residents receiving nebulization therapy, those with a diagnosis of epilepsy and prescribed anti-seizure medication, and residents requiring the use of a craniotomy helmet, including documentation of non-compliance with helmet use. Additionally, care plans were missing for residents experiencing wheezing or shortness of breath, those with active infections, and residents prescribed blood thinners such as Eliquis and Warfarin. Surveyors observed and confirmed through interviews and record reviews that these omissions occurred despite clear evidence in the residents' clinical records and physician orders indicating the need for such care plans. For example, residents with new or ongoing respiratory issues were receiving nebulizer treatments or inhaled medications without corresponding care plans. Similarly, residents with significant neurological or cardiovascular diagnoses, such as epilepsy or atrial fibrillation, were prescribed critical medications without individualized care plans addressing their conditions or the use of these medications. Further, the facility did not assess or document appropriate call bell system needs for a resident with significant physical limitations, resulting in the call light being inaccessible and not tailored to the resident's abilities. Staff interviews confirmed that care plans were not initiated or updated in a timely manner, and that the responsibility for care planning was not consistently fulfilled by the nursing staff, including the MDS nurse, ADON, and DON. Facility policies required comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not developed or implemented for the affected residents.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility was found to have a medication error rate of 18.18% during medication administration observations, with 6 errors identified out of 33 opportunities involving three residents. For one resident with diabetes, an LVN failed to prime the insulin pen before administering a 40-unit dose of insulin degludec, despite facility policy and manufacturer instructions requiring priming to ensure accurate dosing. The LVN acknowledged the omission during an interview, and both the DON and consultant pharmacist confirmed that priming is required before each use. Another resident was prescribed fluticasone nasal spray with instructions to administer two sprays in each nostril daily. During observation, an LVN administered only one spray per nostril. Upon review of the physician's order and facility policy, the LVN confirmed the error and acknowledged the correct dose should have been given as ordered. A third resident, who received medications via a gastrostomy tube, was administered four different crushed medications combined together in a single dose, contrary to facility policy. The RN responsible for the administration admitted that each medication should have been crushed and administered separately with appropriate flushing between medications. The DON and consultant pharmacist both confirmed that medications should not be mixed together for enteral administration, and the facility's policy requires separate administration and flushing.
Failure to Provide Palatable and Attractive Food to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and met expectations for taste and presentation. Multiple residents reported dissatisfaction with the meals, describing them as bland, lacking flavor, repetitive, and unappetizing. Specific complaints included breakfast being tasteless and monotonous, with eggs served daily that were described as dry and flavorless. These concerns were voiced by several residents during interviews conducted on the same morning. In response to these complaints, a test tray evaluation was conducted during a lunch service, with participation from the registered dietician (RD), dietary manager (DM), and surveyors. The green beans served as an alternate vegetable were found by surveyors to be unappealing in appearance, lacking color, overcooked, and without flavor. Both the DM and RD agreed with these assessments, with the DM noting the green beans were mushy and flavorless, and the RD stating they did not look appetizing enough to taste. Review of job descriptions for the cook and RD confirmed their responsibilities included ensuring appealing food presentation and monitoring food acceptance, which were not met in this instance.
Wet Stacking of Food Preparation Pans
Penalty
Summary
During a kitchen tour, surveyors observed 11 metal pans of various sizes stored under the steam table, stacked upside down inside one another while still wet on both the inside and outside surfaces. The dietary manager confirmed that the pans were wet and acknowledged that they should have been air dried before being stacked and stored. This practice did not comply with the 2022 FDA Food Code, which requires equipment and utensils to be air-dried after cleaning and sanitizing, and to be stored in a self-draining position that allows air drying. The failure to properly air dry and store the pans had the potential to affect 117 of 118 residents who received food from the kitchen.
Multiple Infection Control Deficiencies Observed
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. One nurse was seen using a glucometer on multiple residents without properly cleaning and disinfecting it according to manufacturer and facility policy. The nurse wrapped the glucometer in a disinfectant wipe without wiping it down first, and did not ensure the required wet contact time. Additionally, the same nurse failed to disinfect a medication tray between uses for different residents, despite facility policy requiring all reusable items to be cleaned between uses. Another nurse did not wear a gown during enteral tube medication administration, contrary to the facility's Enhanced Barrier Precautions policy, which requires both gloves and gowns for such procedures. Further deficiencies were noted in the handling and storage of resident care equipment. Used nebulizer kits, masks, and tubing were found unlabeled, undated, and improperly stored among residents' personal belongings or in plastic bags on nightstands. Staff interviews revealed inconsistent knowledge of cleaning, labeling, and replacement protocols for these items, with some staff unsure of the correct procedures or frequency of changes. Similar issues were observed with nasal cannulas, which were left uncovered, undated, and not stored in plastic bags when not in use. Used basins were also found unlabeled and stored inappropriately in shared bathrooms, and a bag of soiled towels was left on the floor outside the soiled linen room, both in violation of facility policy. Additional infection control lapses included the absence of Enhanced Barrier Precautions signage for a resident with a stage 3 pressure ulcer, and urinary catheter drainage bags observed touching the floor in two separate resident rooms. Staff confirmed that these practices did not align with facility policies, which require catheter bags to be kept off the floor and signage to be posted for residents requiring enhanced precautions. These observed failures were corroborated by staff interviews and a review of facility policies, all of which outlined proper procedures that were not followed during the survey period.
Failure to Follow Antibiotic Stewardship Program and Loeb's Criteria
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program by administering antibiotics to six residents who did not meet the Loeb's criteria for initiating antibiotic therapy. In multiple cases, antibiotics were prescribed and administered based on symptoms that did not align with established clinical guidelines, such as confusion, knee pain, or abdominal pain, without the presence of fever, dysuria, or other specific signs of infection. Documentation revealed that antibiotics were started before culture results were available, and in some instances, the prescribed antibiotics were not effective against the identified microorganisms, as shown by culture results indicating resistance. For example, one resident with Alzheimer's disease and a history of UTI was given levofloxacin for suspected UTI despite only exhibiting knee pain and increased confusion, with no fever or urinary symptoms. Another resident with paralysis of the vocal cords and diabetes received levofloxacin for pharyngitis based solely on a fever and sore throat, without further documented assessment or additional symptoms. Additional residents received antibiotics for confusion, abdominal pain, or asymptomatic bacteriuria, again without meeting the minimum clinical criteria for antibiotic initiation. Interviews with the Infection Preventionist (IP) and review of records confirmed that the facility's antibiotic stewardship meetings were infrequent, and there was a lack of consistent interdisciplinary oversight. The IP acknowledged awareness of the inappropriate antibiotic use but deferred to physician decisions, and the medical director confirmed a practice of prescribing antibiotics preemptively while awaiting culture results. The facility's policy required adherence to evidence-based criteria and monitoring of antibiotic use, but these protocols were not consistently followed, as evidenced by the findings.
Failure to Ensure Accessible and Appropriate Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the needs and preferences of three residents were reasonably accommodated, specifically regarding the accessibility and appropriateness of call light systems. For two residents with significant cognitive and physical impairments, the call light buttons were observed on the floor and out of reach while the residents were in bed. One resident, who had a history of spinal fracture and moderate cognitive impairment, was unable to access his call light and stated he did not know how long it had been on the floor. Another resident, with severe cognitive impairment and right-sided hemiplegia, was also unable to locate his call light, which was confirmed by staff to be on the floor. Staff interviews revealed that there should have been clips to secure the call lights within reach, and facility policy required call lights to be accessible to residents at all times. A third resident, who was bedbound with left-sided hemiplegia and aphasia following a stroke, was found to have a call light button hanging from urinary catheter tubing and resting on the floor, making it inaccessible. Staff confirmed that this resident never used the standard call light button and acknowledged that a different call system would have been more appropriate given the resident's limited movement and high dependency. Facility policy required that residents be evaluated for unique needs and that special accommodations, such as alternative call systems, be provided and documented in the care plan. These failures were identified through direct observation, resident and staff interviews, and record reviews. The lack of accessible and appropriate call systems for these residents had the potential to delay staff response and did not meet the residents' needs as required by facility policy and procedure.
Failure to Make State Survey Results Readily Available to Residents
Penalty
Summary
The facility failed to ensure that residents were made aware of the location of the latest State inspection results, including the Statement of Deficiencies and any subsequent survey findings. During a Resident Council meeting, six residents stated they were not aware of where to find the survey results and had not been informed by facility staff. Observations in the front lobby and at multiple nurse stations revealed that the State inspection results were not posted or available in the designated areas, and the binders present did not contain or indicate the survey results. Interviews with staff, including the activities supervisor, administrator, unit clerk, registered nurse, certified nursing assistant, and DON, confirmed that the survey results binder was not available in the lobby as required by facility policy. Staff members were either unaware of the binder's location or unable to provide clear information about its whereabouts. The facility's policy stated that the survey binder should be located in the main lobby and available for review, but this was not being followed at the time of the survey.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of three residents' personal and medical information. For one resident with muscle weakness and benign prostatic hyperplasia, surveyors observed that the resident's Foley catheter drainage bag was left uncovered on two separate occasions, making the contents visible from the hallway. The privacy curtains were open, and the drainage bag, containing yellow urine, was not concealed with a privacy bag as required by facility policy. Staff confirmed that the catheter bag should have been covered to protect the resident's privacy and dignity. Additionally, two other residents had personal care instructions posted openly in their shared rooms, making sensitive information visible to roommates and visitors. One resident had a large sign above the head of the bed instructing staff to remove and replace dentures, while another had two signs regarding the use of a neck brace and caution during care. Both residents were aware of the postings, and staff confirmed that such instructions should be covered or placed in a manner that maintains privacy. Facility policies reviewed by surveyors emphasized the importance of protecting residents' privacy and confidentiality in these situations.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications for multiple residents. One resident with Alzheimer's disease and dementia was administered a high dose of quetiapine (Seroquel) for reported auditory hallucinations, but there was no documentation in the clinical record specifying the nature of these hallucinations or evidence that they caused harm or significant distress. Observations and interviews with staff and the resident's family indicated that while the family reported past behavioral symptoms, there was no current documentation or monitoring of such symptoms in the facility records to justify the ongoing use of the medication. Another resident with bipolar disorder and depression was prescribed both Seroquel and fluoxetine, but the clinical record lacked evidence that non-drug interventions were attempted prior to administering these psychotropic medications. The Director of Nursing confirmed that nursing staff did not document any non-pharmacological approaches before medication administration, as required by facility policy. A third resident with depression received PRN lorazepam without a stop date, and the clinical record did not show that a physician had reassessed the need for continued use of the medication after 14 days, as required. The DON acknowledged the absence of physician re-evaluation and documentation for the ongoing PRN order. Facility policies require non-pharmacological interventions to be attempted and PRN psychotropic orders to be time-limited unless properly justified, but these procedures were not followed for the residents involved.
Inaccurate MDS Assessments for Discharge, Medication, and Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of discharge status, medication administration, and fall history. For one resident, the discharge MDS was coded as a transfer to an acute hospital, despite physician orders and staff confirmation that the resident was discharged home with medications and home health services. This discrepancy was verified during a record review and interview with the Minimum Data Set Manager, who acknowledged the error and confirmed the resident was not discharged to a hospital as recorded. For another resident, the MDS assessment failed to document the use of injectable medication, despite physician orders and electronic medication administration records showing weekly subcutaneous injections for diabetes. Additionally, the MDS inaccurately recorded the resident's fall history, listing both a fall with no injury and a fall with injury, when only a fall with no injury was documented in the incident reports. These inaccuracies were confirmed by the Minimum Data Set Coordinator Manager and the Director of Nursing during interviews and record reviews, who both stated that the MDS assessments should have been completed accurately according to facility policy and the RAI Manual.
Failure to Provide Ordered Pressure Ulcer Care and Preventive Devices
Penalty
Summary
A deficiency occurred when a resident with a right outer ankle pressure injury was observed in bed without a dressing on the wound and without a Prevalon heel protector boot on the right foot. Certified nursing assistant (CNA) and registered nurse (RN) both confirmed during separate observations that the resident's pressure injury was not covered as ordered, and the heel protector boot was not in use, despite being present on the nightstand. The CNA acknowledged forgetting to verify and apply the boot, while the RN confirmed that the dressing had not been applied to the pressure injury at the time of observation. Record review showed that there were physician orders in place for daily cleansing and dressing of the pressure ulcer, as well as for the use of a Prevalon heel protector boot to the right foot. The facility's policy required redistribution of pressure and evidence-based treatments for residents with pressure injuries. The failure to follow these orders and policies resulted in the resident not receiving necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.
Failure to Document Administration of Controlled Medications
Penalty
Summary
Nursing staff failed to accurately document the administration of controlled medications for three out of seven sampled residents. In each case, staff signed out controlled medications such as hydrocodone-acetaminophen and oxycodone from the Controlled Drugs Records (CDR), but did not record the administration on the Medication Administration Record (MAR). This discrepancy was identified during a review of the CDRs and MARs for residents who had physician orders for as-needed (PRN) narcotic pain medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the medications were signed out but not documented as administered on the MAR, and acknowledged that this documentation was required by facility policy. The facility's policies require that nursing staff sign the MAR after administering medications and maintain accurate controlled substance records, including the date, time, and signature of the person administering the medication. The DON stated that staff sometimes become busy and forget to document on the MAR, but confirmed that all controlled medications must be accounted for on the MAR. The failure to document these administrations resulted in inaccurate accountability of controlled substances for the affected residents.
Failure to Identify and Report Duplicate Opioid Orders During Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities during the monthly medication regimen review for one resident. Specifically, the resident was admitted with a diagnosis of type 2 diabetes mellitus and had two similar physician orders for Dilaudid (hydromorphone), both prescribed at the same dose and frequency, as well as an order for a Fentanyl patch. The orders included Dilaudid 2 mg, 4 tablets by mouth every 3 hours as needed for pain, and hydromorphone 8 mg, 1 tablet by mouth every 3 hours as needed for pain, with a maximum of 4 tablets per day. The duplicate orders were not identified or reported as irregularities in the medication regimen review conducted by the CP. Interviews and record reviews confirmed that the duplicate orders existed and were not addressed in the MRR. The CP acknowledged during an interview that the duplicate order was missed and should have been recommended for discontinuation. Additionally, a review of the controlled drug records showed that the resident received hydromorphone 8 mg five times in one day, exceeding the maximum ordered dose. The facility's policy required a thorough evaluation of the medication regimen to prevent, identify, report, and resolve medication-related problems, which was not followed in this instance.
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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