Greenfield Care Center Of Fillmore, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fillmore, California.
- Location
- 118 B Street, Fillmore, California 93015
- CMS Provider Number
- 555066
- Inspections on file
- 33
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Greenfield Care Center Of Fillmore, Llc during CMS and state inspections, most recent first.
The facility failed to create individualized care plans for three residents, leading to unmet needs. A resident who speaks only Spanish was not provided with an interpreter, another with dementia and fall risks had no care plan for alarm use, and a quadriplegic resident had an inappropriate call light. These oversights were acknowledged by the DON and were not in line with facility policies.
The facility failed to adhere to professional standards in medication administration and documentation, including administering oxygen without a physician's order, not providing Acetylcysteine as scheduled, and failing to follow insulin sliding scale orders for residents with respiratory and diabetic conditions.
The facility failed to follow its policies for sharps disposal, timely replacement of E-Kits, and medication administration. Syringes were improperly disposed of, E-Kits were not replaced within 72 hours, and expired medications were found. Medication nurses administered drugs outside the prescribed time window due to workload issues, and medications were not immediately documented in the MAR.
A facility was found to have a medication error rate of 17.7%, exceeding the acceptable threshold. Errors included an LVN crushing a delayed-release medication, failing to administer prescribed medications, and incorrect dosages of topical treatments. These observations were made during medication passes involving multiple residents.
The facility improperly installed and maintained portable air conditioning units (PACUs) in 12 rooms. Exhaust hoses were duct taped to window frames, making windows inoperable, and air filters were not cleaned as per manufacturer's guidelines. The Maintenance Supervisor was unaware of the correct cleaning frequency and the presence of two filters per unit.
A facility failed to ensure an IDT assessed a resident's ability to self-administer medication, leading to the resident having unauthorized access to DuoNeb vials. The resident stated he administered the medication himself, but the LN confirmed he was not allowed to do so. The DON acknowledged that no IDT meeting had occurred to authorize self-administration, contrary to the facility's policy.
The facility did not maintain the most current survey results in the survey results binder accessible to the public. The binder, located at the facility's main entrance, contained outdated survey results, missing updates from August 2024 to February 2025. The DON acknowledged the oversight, which was contrary to the facility's policy requiring the most recent survey documents to be available in a common area.
The facility inaccurately assessed two residents using the MDS, leading to incorrect data reporting to CMS. One resident's language needs were misrepresented, indicating no need for an interpreter despite their primary language being Spanish. Another resident's functional status was inaccurately recorded as having no impairments, despite an OT assessment indicating otherwise. These errors were acknowledged by the MDS Coordinator and DON.
The facility failed to document and maintain medication refrigerator temperatures within the required range. On one occasion, the temperature was recorded below the policy range, and on another, there was no documentation of the temperature, indicating a deficiency in proper storage conditions for drugs and biologicals.
The facility failed to follow its policies for labeling and dating food items, risking foodborne illnesses. Observations revealed bins of rice, beans, and pasta with incomplete date information, and a box of mixed vegetables with non-specific delivery dates. The Kitchen Manager and Dietician acknowledged the labeling issues.
The facility failed to adhere to infection control practices, including improper storage of respiratory equipment for two residents and lack of PPE availability outside rooms with contact precautions. Equipment was not stored in plastic bags as required, and PPE was not accessible before room entry, posing a risk of cross-contamination.
The facility failed to document responses to recurring complaints from residents about untimely call light responses during Resident Council Meetings. In December and January, residents reported long wait times and inadequate assistance, with no documented resolution or communication of outcomes. The assistant director of nursing confirmed the lack of documentation, despite facility policy requiring a response form to track and resolve issues.
A resident, totally dependent on staff for repositioning, developed a new stage 3 pressure ulcer on the right buttock due to the facility's failure to consistently reposition the resident every two hours as required. Despite being at risk for skin breakdown, the resident's care plan was not followed, leading to the deterioration of a stage 2 ulcer to stage 3. Interviews confirmed the lack of consistent repositioning, contrary to the facility's policy.
The facility failed to implement comprehensive RNA care plans for fourteen residents, resulting in missed RNA services and lack of documentation. Interviews and record reviews confirmed that RNA exercises were not provided as ordered, and no replacements were arranged when the assigned RNA was unavailable.
A resident with a history of falls and multiple medical conditions fell and sustained a right distal femur fracture due to the facility's failure to ensure a bed alarm was in place. The facility did not follow its policies on fall risk and injury prevention, nor did it conduct a neurological evaluation following the unwitnessed fall.
A resident admitted with a history of hemi-glossectomy, post tracheostomy, and a left arm grafted site experienced deficiencies in care. The facility failed to follow up on a discharge order for the arm wrap, leading to a delayed wound consultation and graft failure. Sutures were removed without a physician's order, and skin assessments were inadequately documented, missing significant skin damage.
A facility failed to accurately document a resident's tracheostomy site condition, as noted in the Admission Nursing Assessment and skilled charting, which showed redness around the stoma. However, the Respiratory Orders Administration Record indicated no signs of infection during the same period. This discrepancy was acknowledged by the DON, highlighting inaccuracies in the resident's clinical record.
A resident with end-stage Huntington's disease and other conditions exhibited new symptoms of right leg redness and swelling. Despite these observations, the facility failed to develop and implement a comprehensive care plan. The DON confirmed the absence of a care plan during a review of the resident's medical record.
A facility failed to implement a smoking care plan and ensure adequate supervision for a resident with a history of traumatic brain injury and muscle weakness. The resident fell from a wheelchair while smoking unsupervised, resulting in an acute fracture of the left humerus. The care plan and facility policies for fall risk and smoking supervision were not followed.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for three residents, leading to unmet needs. Resident 35, whose preferred language is Spanish, was not provided with a Spanish-speaking interpreter for communication with healthcare staff, despite expressing a desire for one. The MDS Coordinator confirmed the absence of a care plan addressing this communication need, and the Director of Nursing acknowledged the oversight. Resident 11, who has dementia and a history of repeated falls, was observed with tab alarms on his wheelchair and bed. However, there was no documented care plan addressing the use of these alarms. The Director of Nursing confirmed the lack of a care plan for the alarms, which is contrary to the facility's policy on managing falls and fall risks. Resident 47, who is quadriplegic and has multiple medical conditions, was found with a push button call light that was not within reach and inappropriate for his condition. The Director of Nursing acknowledged that a more suitable call light, such as a pad alarm, should have been assessed and provided during the admission process. This oversight was not in line with the facility's policy on ensuring accessible call lights for residents.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to meet professional standards of quality care in several instances, as observed through a combination of interviews, record reviews, and direct observations. One significant deficiency involved the administration of supplemental oxygen to a resident without a physician's order. The resident, who was admitted with COVID-19 and an acute cough, was observed receiving oxygen therapy, yet there was no documented physician order for this treatment. This oversight was acknowledged by the Assistant Director of Nursing during a review of the resident's medication records. Another deficiency was noted in the administration of Acetylcysteine for a resident with acute and chronic respiratory failure. The resident reported not receiving the medication as scheduled, and the respiratory therapist confirmed that the medication was unavailable due to a delay in pharmacy delivery. Additionally, the therapist admitted to documenting the administration of the medication at a time different from when it was actually given, to avoid alert flags in the medical record system. This practice was contrary to the facility's policy, which requires medications to be administered and documented according to the physician's orders. Furthermore, the facility failed to administer insulin according to the physician's sliding scale orders for a resident with type 2 diabetes. The resident's medication administration records showed multiple instances where insulin was either not given or administered outside the prescribed time frame. The Assistant Director of Nursing confirmed these discrepancies, which were not reported to the physician as required by the facility's policy. These failures in medication administration and documentation highlight significant lapses in adhering to professional standards and physician orders, potentially impacting resident care and safety.
Pharmaceutical Services Deficiencies in Medication Management
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding pharmaceutical services, leading to several deficiencies. During an inspection of the medication storage room on Unit 3, it was found that sharps waste was not disposed of according to the facility's policy. Specifically, syringes with needles attached were improperly placed in non-controlled waste containers that were open and not sealed. The facility's Infection Prevention Nurse confirmed that this was against the policy, which requires used syringes and needles to be disposed of in puncture-resistant containers with lids. Additionally, the facility did not replace Emergency Drug supplies (E-Kits) within the required timeframe. An Antibiotic E-Kit had been opened and not replaced for eight days, and a Narcotic E-Kit had been opened for twelve days without replacement, both exceeding the 72-hour replacement policy. Furthermore, expired medications were found in the Director of Nursing's medication storage room, including Ceftazidime vials that were eight months past their expiration date. The facility also failed to administer medications in accordance with its policies. Medication nurses were administering medications outside the prescribed time window due to workload issues, such as handling admissions and resident falls, which led to early medication passes. This practice was contrary to the policy that requires medications to be administered within one hour of the scheduled time. Additionally, medications were not immediately documented in the Medication Administration Record (MAR) after administration, as nurses were entering data after completing their rounds to avoid system flags for early administration entries.
High Medication Error Rate Observed
Penalty
Summary
The facility was found to have a medication error rate of 17.7%, significantly exceeding the acceptable threshold of 5%. This was determined through observations of medication passes conducted by two LVNs, where 8 errors were identified out of 45 opportunities. One notable error involved an LVN administering Divalproex DR 250 mg to a resident by crushing the tablet, despite the manufacturer's instructions indicating that the delayed-release formulation should be swallowed whole. This alteration in the medication's delivery method constituted a medication error. Additional errors were observed during medication passes involving other residents. One LVN failed to administer five prescribed medications to a resident, as confirmed during an interview where the nurse could not recall giving these medications. Another error involved the incorrect administration of Testosterone Gel and Diclofenac Sodium cream to a resident, where the dosage did not match the physician's orders. These errors contributed to the high medication error rate observed at the facility.
Improper Installation and Maintenance of PACUs
Penalty
Summary
The facility failed to ensure the proper installation and maintenance of portable air conditioning units (PACUs) in 12 rooms. Observations revealed that the exhaust hoses of the PACUs were duct taped to window frames, rendering the windows inoperable. The slider kits provided with the PACUs were too short for the facility's window size, leading to the use of cardboard to fill gaps and duct tape to secure the installation. This improper installation could prevent windows from being opened in emergencies, such as a fire. Additionally, the facility did not adhere to the manufacturer's guidelines for cleaning the air filters of the PACUs. The Maintenance Supervisor (MS) admitted to cleaning the air filters every three months, contrary to the manufacturer's instructions, which required cleaning every two weeks. The MS was unaware that each PACU had two filters and lacked documentation or a tracking method for filter maintenance. This oversight could lead to poor air quality due to dust accumulation, affecting the performance of the air conditioning units.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) assessed a resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate. This deficiency was identified for one of the twenty sampled residents, referred to as Resident 51. During an observation and interview, it was found that Resident 51 had two vials of DuoNeb, a medication used for breathing treatments, in his drawer and stated that he administered the medication himself. However, the Licensed Nurse (LN 1) confirmed that the resident was not allowed to self-administer the medication, indicating a lapse in the facility's protocol. The Director of Nursing (DON) confirmed that an IDT meeting is required to authorize a resident to self-administer medications, along with a physician's order. It was acknowledged that no such meeting had taken place for Resident 51. The facility's policy and procedure on self-administration of medications, revised in February 2021, mandates that the IDT assess each resident's cognitive and physical abilities to determine the safety and appropriateness of self-administration. The failure to conduct this assessment for Resident 51 led to the resident having unauthorized access to medication, which could result in incorrect medication administration.
Failure to Update Survey Results Binder
Penalty
Summary
The facility failed to maintain the most current survey results in the survey results binder accessible to the public. During an observation and interview with the Director of Nursing (DON) at the facility's main entrance, it was found that the most recent survey results available in the binder were from May 22, 2024. The binder lacked survey results from August 8, 2024, through February 19, 2025. The DON acknowledged that the survey results binder was not up-to-date. According to the facility's policy and procedure titled 'Survey Results, Examination of,' a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, and state-approved plans of correction for noted deficiencies, should be maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room hallway.
Inaccurate MDS Assessments for Language and Functional Status
Penalty
Summary
The facility failed to accurately assess two residents using the Minimum Data Set (MDS), leading to the reporting of inaccurate data to the Centers for Medicare & Medicaid Services (CMS). Resident 35's language assessment was incorrect, as the MDS indicated no need for an interpreter, despite the resident's primary language being Spanish and their expressed desire for an interpreter to discuss their care plan. This discrepancy was acknowledged by both the MDS Coordinator and the Director of Nursing during interviews. Resident 39's functional status assessment was also inaccurate. The MDS coded no impairment in the resident's upper and lower extremities, contrary to an occupational therapist's assessment indicating impairments. This error was similarly acknowledged by the MDS Coordinator and the Director of Nursing. The facility's policy requires the interdisciplinary team to gather accurate data for the MDS, but this was not adhered to in these cases.
Medication Refrigerator Temperature Documentation Deficiency
Penalty
Summary
The facility failed to ensure that the medication refrigerator temperatures were documented and maintained within the required range as per the facility's policy. During an inspection of the medication refrigerator temperature logs for station 3, it was found that on December 4, 2024, the refrigerator temperature was recorded at 35 degrees Fahrenheit, which is below the facility's policy range of 36 to 46 degrees Fahrenheit. Additionally, on February 19, 2025, there was no documentation of the refrigerator temperature, leaving the facility unable to verify the actual temperature on that date. This lack of documentation and deviation from the required temperature range constitutes a deficiency in maintaining proper storage conditions for drugs and biologicals.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to adhere to its policies and procedures for labeling and dating food items, which could potentially lead to foodborne illnesses. During an observation, it was noted that six large bins containing various food items such as rice, pinto beans, and split peas had different dates but lacked information on the received date, opened date, or expiry date. Additionally, a bin labeled pasta had a date of 9/18/24 but did not indicate an expiry or open date, and contained two packs of pasta with different dates. A box containing mixed vegetables and beans had labeled delivery dates that were not specific to the packaged produce. In an interview, the Kitchen Manager and Dietician acknowledged that the labeling was not specific and should include the expiry date and/or opened date. A review of the facility's Policies and Procedures on labeling and dating foods indicated that newly opened food items should be closed and labeled with an open date and used by date according to storage guidelines.
Infection Control Deficiencies in Equipment Storage and PPE Availability
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. In Resident 4's room, a nebulizer with an attached nose mask and tubing was left exposed on a nightstand, contrary to the facility's policy that requires such equipment to be stored in a plastic bag with the resident's name when not in use. The assistant director of nursing confirmed that the nebulizer mask was not stored appropriately. Resident 4 had multiple diagnoses, including gastrostomy, dysphagia, type 2 diabetes mellitus, and hemiplegia. In Resident 27's room, oxygen tubing was found wrapped around a portable oxygen tank without a label or date, and it was not stored in a plastic bag as required by the facility's policy. The licensed nurse acknowledged the oversight. Resident 27 had acute and chronic respiratory failure, pseudomonas, chronic obstructive pulmonary disease, and a tracheostomy. Additionally, in the sub-acute unit, contact precaution signs were posted outside certain rooms, but no personal protective equipment (PPE) was available outside the rooms for use before entry, as required by the facility's Enhanced Barrier Precautions Policy.
Failure to Address Resident Council Complaints on Call Light Response
Penalty
Summary
The facility failed to document its response and resolution to recurring complaints raised by residents during Resident Council Meetings regarding the untimely answering of call lights. In December 2024, residents expressed concerns about long wait times for call lights to be answered, with reports of waits up to an hour and lights being turned off during the night shift. In January 2025, similar complaints were raised, including instances where staff attended to residents who did not use the call light and a resident having to hold her bladder longer due to delayed assistance. During a review of the Resident Council meeting minutes for December 2024 and January 2025, it was found that there was no documentation indicating that the issues raised were addressed or resolved, nor was there any record of informing residents of the outcomes. The assistant director of nursing confirmed that the minutes did not reflect any actions taken to address the concerns. The facility's policy and procedure on Resident Council, revised in November 2023, requires the use of a Resident Council Response Form to track issues and their resolution, which was not adhered to in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident who was totally dependent on staff for all activities of daily living, including repositioning, resulting in the development of a new stage 3 pressure ulcer on the resident's right buttock. The resident, who had a history of respiratory failure, tracheostomy, quadriplegia, epilepsy, and diabetes, was admitted with a stage 3 pressure ulcer on the sacrococcyx but no other pressure ulcers. However, a subsequent medical record indicated the development of a stage 2 pressure ulcer on the right hip, which later deteriorated to a stage 3 ulcer. The care plan for the resident, dated shortly after admission, identified the resident as being at risk for skin breakdown and specified that the resident should be turned and repositioned every two hours. Despite this, there was no evidence in the records that the resident was repositioned as required throughout August, and there were missing documentation for September and October. Interviews with the wound care nurse and a registered nurse confirmed that the resident was not consistently repositioned every two hours, as per the facility's policy and procedure for the prevention of pressure ulcers.
Failure to Implement Comprehensive RNA Care Plans
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for fourteen residents regarding the Restorative Nursing Assistant (RNA) program. The deficiency was identified through observation, interview, and record review, revealing that the RNA exercises were not provided as ordered for the residents. This failure was particularly evident for Resident 1, who reported that RNA exercises had not been provided since the RNA went on vacation. The review of Resident 1's RNA Flow Sheet confirmed the absence of documentation for the RNA services from 05/09/2024 to 05/21/2024, despite physician orders indicating the need for these services three times a week. Similar deficiencies were found for other residents, including Residents 4 through 16. Each resident had specific physician orders for RNA programs to maintain or improve their physical function, such as ambulation with a walker, assisted active range of motion (AAROM), and passive range of motion (PROM). However, the RNA Flow Sheets for these residents showed no evidence of the required RNA services being provided during the specified dates. For instance, Resident 4's RNA Flow Sheet lacked documentation of RNA services from 05/07/2024 to 05/21/2024, and Resident 5's RNA Flow Sheet showed no RNA services from 05/09/2024 to 05/21/2024. Interviews with facility staff, including the Director of Staff Development Assistant (DSDA) and the Director of Nurses (DON), confirmed the lack of RNA services and documentation. The DSDA mentioned that a Certified Nursing Assistant (CNA) trained as an RNA was reassigned to CNA duties on several dates, and no replacement was arranged to continue the RNA program. The facility's policies and procedures emphasized the importance of the Restorative Program in maintaining residents' optimal physical, mental, and psychological functioning, but these were not adhered to, leading to the identified deficiencies.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, resulting in an avoidable accident and injury. The resident, who had a history of falling, unspecified dementia, hemiplegia, hemiparesis, muscle weakness, and epilepsy, was supposed to have a bed alarm as part of their fall prevention strategy. However, during an observation, it was noted that the resident did not have a bed alarm in place. The resident fell and sustained a right distal femur fracture. Interviews with staff confirmed that the bed alarm was not in use at the time of the fall, and the facility's policy on fall risk and injury prevention was not followed. The resident's care plan, which included interventions such as frequent visual checks and the use of a bed alarm, was not adhered to. The facility's policy on neurological evaluations following an unwitnessed fall was also not followed. The administrator acknowledged that the bed alarm was not in use and that the facility's policies and procedures were not followed, leading to the resident's fall and subsequent injury.
Failure to Follow Physician Orders and Conduct Accurate Skin Assessments
Penalty
Summary
The facility failed to ensure nursing professional standards of care for a resident who was admitted with a history of hemi-glossectomy, post tracheostomy, and a left arm grafted site. Upon admission, the facility did not follow up with the admitting physician regarding the discharge order for the left arm wrap, which was supposed to be maintained and replaced in an outpatient clinic. This oversight led to a delay in wound consultation and eventually resulted in the failure of the skin graft, as noted by the wound doctor. Additionally, the facility did not obtain a physician's order for the removal of sutures from the resident's post-tracheostomy site. The respiratory therapist removed the sutures based on a signal from nursing staff without verifying the presence of a physician's order, which was against the facility's policy requiring written approval from the attending physician for such procedures. Furthermore, the facility did not conduct accurate skin assessments upon the resident's admission. The clinical records lacked detailed documentation of the resident's skin condition, particularly the sacro coccyx area, which was later found to have significant moisture-associated skin damage at the hospital. The absence of comprehensive skin integrity assessments and documentation contributed to the oversight of the resident's skin condition.
Inaccurate Documentation of Tracheostomy Site
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's tracheostomy site skin condition, which could lead to unmanaged skin conditions and delayed treatment. The facility's policy on surgical wound care requires assessment of surgical wound sites for signs of infection, such as skin irritation, swelling, redness, and drainage. However, the Admission Nursing Assessment noted redness around the tracheostomy stoma upon admission, and subsequent skilled charting consistently indicated redness at the stoma site. Despite this, the Respiratory Orders Administration Record showed no signs of infection from the trach site during the same period. This discrepancy in documentation was acknowledged by the Director of Nursing during an interview, highlighting the inaccuracy in the resident's clinical record. The failure to accurately document the resident's condition could potentially lead to unmanaged skin conditions and delayed treatment.
Failure to Develop and Implement Care Plan for New Symptoms
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a new onset of right leg redness and swelling requiring medical treatment. The resident, who was admitted with diagnoses including end-stage Huntington's disease, severe depression, dementia, and muscle wasting, exhibited symptoms of redness, swelling, and warmth in the right leg as noted in the Nursing Progress Notes dated 4/3/24. Despite these observations, the facility did not create or implement a care plan to address these new symptoms. During an interview with the Director of Nursing (DON) and a concurrent review of the resident's medical record on 4/16/24, the DON acknowledged the new symptoms and confirmed that no care plan had been developed or implemented. The facility's policy and procedure on care planning, dated June 2012, mandates that a plan of care should be formulated based on a comprehensive assessment of the resident within 7 days of admission and updated as needed. The failure to create a care plan for the resident's new symptoms had the potential for the resident's care needs to go unmet.
Failure to Implement Smoking Care Plan and Supervision
Penalty
Summary
The facility failed to implement the interventions of a smoking care plan and ensure adequate supervision and assistance for a resident. This resident, who had a history of traumatic brain injury, generalized muscle weakness, and flaccid hemiplegia, was found smoking by himself off the facility premises. The resident fell from his wheelchair while attempting to step up on a curb, resulting in an acute fracture of the left humerus. The resident's care plan included multiple interventions for fall risk and smoking supervision, but these were not followed, leading to the incident. During the incident, the resident was found face down with a soft helmet on, and the wheelchair was off to the side. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident should have been supervised while smoking, as per the care plan. The facility's policy and procedure for managing falls and fall risk were also not followed, as the resident was not in a supervised area when the fall occurred. The clinical records and interviews with staff highlighted the lack of adherence to the care plan and facility policies, contributing to the resident's injury.
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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