Healthcare Centre Of Fresno
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 1665 M Street, Fresno, California 93721
- CMS Provider Number
- 055626
- Inspections on file
- 28
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Healthcare Centre Of Fresno during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care planning and coordination when staff failed to develop a care plan for one resident’s repeated refusals of showers and bed baths and did not arrange transportation for another resident’s scheduled urology appointment to evaluate urinary catheter removal for discharge. Nursing staff and the DON confirmed that the resident who frequently refused bathing had no care plan addressing these refusals, despite multiple documented shower refusals and partially completed shower review forms lacking nurse assessment and interventions. Social Services staff acknowledged that a urology appointment for another resident was known at admission but was never entered on the transportation calendar, resulting in a missed appointment and no care plan addressing transportation needs, contrary to facility policies on person-centered care planning, referrals to outside services, and resident rights.
Surveyors found that three cognitively impaired residents with hemiplegia, mobility limitations, and dependence on staff for ADLs did not receive consistent oral hygiene and grooming assistance as required by their care plans and facility policy. Observations showed long, dirty fingernails, facial hair, and teeth with visible buildup and foul odor, while residents reported that staff did not routinely offer tooth brushing or grooming and sometimes cited lack of time. ADL records either conflicted with the residents’ observed condition or lacked any oral care documentation, despite staff, including CNAs, an LVN, the DON, and the DSD, stating that daily oral care and personal hygiene before breakfast were expected for all residents. Residents reported feeling dirty and experiencing oral pain associated with inadequate tooth brushing.
The facility failed to secure medication destruction bins (MDBs) in two medication rooms, leading to potential drug diversion risks. Observations revealed that the MDB lids were loose, allowing access to discarded medications, including narcotics. The Nurse Supervisor, LVN, Pharmacy Consultant, and Infection Preventionist all acknowledged the issue, highlighting the risk of drug diversion and infection control concerns. The Director of Nursing confirmed that facility policies for medication storage and disposal were not followed.
The facility failed to store drugs safely in two medication rooms, where seven unidentifiable pills were found on the floor. Staff members, including an NS, LVN, PC, IP, and DON, acknowledged the potential for drug diversion and the failure to adhere to the facility's medication storage policy.
The facility failed to serve meals according to the menu for first-floor residents, as the kitchen ran out of spinach bake and other items, leading to alternate foods being served. Residents expressed dissatisfaction, noting that they often received different meals than those listed on the menu. The CDM and RRD were unaware of these issues, but acknowledged that the kitchen should not run out of food. Substitution lists confirmed the discrepancies between planned and served meals.
The facility failed to serve meals at regular times, with lunch and dinner being served significantly later than scheduled, affecting all sampled residents. Interviews with residents and staff confirmed the consistent delay, with meals being served as late as 8:00 p.m. The Director of Nursing acknowledged the lack of a formal audit system to monitor meal distribution, and resident grievances highlighted dissatisfaction with cold and late meals.
A facility failed to implement comprehensive care plans for two residents, leading to potential health risks. One resident with a chronic indwelling catheter was not properly monitored for infection signs, while another resident with PTSD did not have a timely care plan addressing their condition. Staff admitted to not following care plans and lacking training in trauma-informed care, resulting in potential risks to residents' well-being.
The facility failed to update care plans for several residents, including one who fell and was hospitalized, another with a progressing pressure ulcer, and a resident with significant weight loss. Care plans for medication and infection precautions were also delayed, potentially impacting resident care.
The facility failed to properly assess and document changes in condition for several residents, including a resident with worsening pressure ulcers and another with significant weight loss. Additionally, a resident's oxygen order was not followed, and activities documentation was compromised by improper use of credentials. These deficiencies indicate lapses in communication and adherence to care standards.
The facility failed to serve food at appropriate temperatures, leading to resident complaints about cold, undercooked, and flavorless meals. Observations and interviews revealed that food items were often below the required temperature, and the facility's policy for food temperatures was not consistently followed. A lunch test tray audit confirmed that several food items were under temperature, and a resident grievance report highlighted issues with reheated meals. These deficiencies in food service practices resulted in resident dissatisfaction and potential health risks.
The facility failed to provide a safe and comfortable environment, with non-functional blinds compromising privacy, a hole with exposed wiring posing safety risks, and inadequate lighting in a resident's room. The DOM acknowledged these issues, but they were not recorded in the maintenance log, and staff were unaware until the survey.
The facility failed to maintain the dignity and privacy of two residents by leaving their urinary catheter bags uncovered and visible. One resident with severe cognitive deficits had their catheter bag on the mattress, while another resident's bag was on the floor. Staff interviews confirmed that the bags should have been covered and hung on the bed, as per facility policy.
A resident with asthma was not assessed for the ability to self-administer her albuterol inhaler, despite being her own responsible party and having no cognitive impairment. Staff were unaware of the policy allowing self-administration with a prescriber's order. The facility's policy permitted bedside medication storage for capable residents, but no assessment or order was made for this resident.
A resident developed a facility-acquired Stage 3 pressure ulcer on the left buttock, but the facility failed to complete a Significant Change of Condition Assessment as required by the Minimum Data Set (MDS). The resident's medical history included hypertensive heart disease, morbid obesity, quadriplegia, and spinal stenosis. Despite the worsening of the pressure ulcer from Stage 2 to Stage 3, no change of condition assessment was documented, which is necessary to monitor wound progress and prevent further decline.
A facility failed to update the PASRR for a readmitted resident with depressive disorder and psychosis. The PASRR from the acute care hospital did not reflect the resident's mental health conditions or the use of psychotropic medications. The MDSN did not review or update the PASRR, despite the facility's policy requiring a new assessment upon significant changes in condition.
A resident with paraplegia and hand contractures experienced pain and potential infection risk due to untrimmed fingernails curling into his palms. Despite being cognitively intact and expressing discomfort, staff failed to document or address the issue, and the DON was unaware of the situation. The facility did not follow its grooming policy, leading to inadequate nail care.
A resident with muscle weakness and dementia experienced pain due to long, jagged toenails, which the facility failed to address. Despite the resident's requests and staff observations, toenail care was not provided, and a podiatry referral was delayed. The facility's policy on nail care was not followed, leading to the deficiency.
A resident with a documented lactose allergy was served milk, despite her preferences being noted in her records. The facility staff, including CNAs and dietary management, failed to ensure her dietary needs were met, as her allergy was not listed on her Meal Ticket. This oversight was contrary to the facility's policy requiring resident preferences to be reflected in medical records and tray cards.
A resident was not provided with the prescribed mechanical soft diet, receiving whole kernel corn instead, despite having no teeth and being at risk for choking. The Registered Dietician confirmed the error, and the Director of Nursing acknowledged the responsibility of the nursing staff to ensure dietary compliance.
A resident's POLST form was found incomplete, missing critical information such as physician signature and date, risking the resident's end-of-life wishes not being honored. The resident, with severe cognitive impairment and multiple medical conditions, was listed as DNR, but the incomplete form could lead to confusion in emergencies. Facility staff acknowledged the oversight, noting the form should have been completed within 72 hours of admission.
A resident with COPD and asthma had their oxygen nasal cannula and nebulizer mask improperly stored on a nightstand without protective bags, contrary to infection control practices. Staff interviews confirmed the expectation to store these items in labeled bags to prevent infection, but the facility's policy lacked guidance on storage, leading to this oversight.
A resident with a history of falls and requiring assistance with personal care was left unsupervised outside the facility, leading to an accident. Despite being cognitively intact, the resident left the premises unsupervised and was involved in an auto versus pedestrian accident, resulting in severe injuries. Interviews revealed a lack of clarity in monitoring processes, with no staff assigned to supervise residents outside before the receptionist's arrival.
A resident with a dependency on supplemental oxygen did not receive the prescribed oxygen levels due to LVNs administering 2 liters per minute instead of the ordered 3 liters per minute. This occurred over several days, with missing documentation in the Treatment Administration Record. The DON and ADON were informed of the issue but failed to ensure compliance with physician orders, leading to a deficiency in care.
Two residents were subjected to involuntary seclusion when an LVN closed their room door, leaving their basic care needs unmet. One resident felt sad and angry due to the inability to leave the room, while the other was yelling. Communication barriers with staff prevented the residents' needs from being addressed, despite available resources like a language line.
A resident with a history of mental health disorders jumped from a second-story window after expressing suicidal ideations, which were not reported by a CNA. The facility failed to ensure window screws were secure, allowing the resident to open the window and jump, resulting in severe injuries.
A resident with a complex medical history, including major depressive disorder and PTSD, removed a loose window screw and jumped from the second floor, resulting in serious injuries. The facility failed to ensure window screws were secure, as maintenance checks were undocumented, and the fire marshal had advised against using screws to secure windows.
A severe roach infestation was found in the kitchen's dishwashing area, with roaches observed in the sink, on walls, and in the dishwasher. Staff and residents were aware of the issue, but it was not addressed effectively. Pest control reports indicated ongoing problems, and the facility failed to maintain proper sanitation, leading to an unsanitary environment.
A resident with multiple medical conditions did not receive prescribed pain medication for three days after returning from a hospital stay. Despite a physician's order for Ibuprofen, the medication was not recorded or administered, leading to unmanaged pain. Staff interviews revealed a lack of communication and documentation regarding the medication order, which was not clarified with the resident's physician upon return.
A resident with severe cognitive impairment and dependency on staff for care fell out of bed and sustained significant injuries when a CNA provided care without the required assistance from another staff member. The care plan and visual indicators for two-person assistance were not followed, leading to the fall and injuries.
Failure to Care Plan for Bathing Refusals and Coordinate Transportation for Outside Urology Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered care plans and follow policies related to resident refusals of care and referrals to outside services. For one resident with progressive neuropathy, type 2 diabetes mellitus, and congestive heart failure, the facility did not create a care plan addressing repeated refusals of showers and bed baths. Documentation on Skin Monitoring Comprehensive CNA Shower Review forms from late January through late February showed that the resident refused all nine offered showers and accepted only three bed baths, with several additional partial bed baths documented due to shower refusals. Despite these repeated refusals, the sections on the forms for charge nurse assessment, interventions, and forwarding to the DON were left blank, and the DON, RN, and LVN all confirmed there was no care plan in place for the resident’s ongoing refusal of bathing. Staff interviews further confirmed that the resident frequently refused showers and bed baths and that the facility’s expectation was that residents receive bathing at least twice a week. LVN 1 stated that all residents should receive two showers or baths weekly and that a care plan should be started if a resident refused. RN 1 similarly stated that a care plan should have been developed for the resident’s repeated refusals. The DON reviewed the resident’s care plans and shower documentation and acknowledged that the resident had no care plan, past or present, addressing the refusal of showers, even though the facility’s policy on comprehensive person-centered care planning requires care plans to include services to be furnished and services not provided due to a resident’s exercise of the right to refuse treatment. The deficiency also includes the facility’s failure to coordinate transportation for another resident’s outside urology appointment, as required by the facility’s policies on referrals to outside services and resident rights. This resident, who had a history of cerebral infarction with hemiplegia and hemiparesis, type 2 diabetes mellitus, major depressive disorder, urinary retention, anxiety disorder, and UTI, had a scheduled follow-up urology appointment to assess removal of a urinary catheter in preparation for discharge to an assisted living facility. The Social Service Director stated that the process for arranging transportation required nurses to place appointments on a calendar that Social Services used each morning to set up transportation. However, the Social Service staff member responsible for the calendar admitted that, although she was informed of the urology appointment at admission and told the nurse she would put it on the calendar, she forgot to do so. As a result, the resident did not have transportation and missed the appointment. The DON confirmed that the resident missed the appointment because transportation was not provided and that there was no care plan addressing transportation to outside appointments or ensuring the resident attended those appointments, despite facility policies stating that the Director of Social Services coordinates referrals to outside services and that the facility assists residents in exercising their rights, including arranging transportation and supporting participation in treatment decisions. A professional reference from the American Nurses Association regarding the nursing process was also cited, stating that nursing care is implemented according to the care plan, that continuity of care must be assured, and that both the patient’s status and the effectiveness of nursing care must be continuously evaluated with the care plan modified as needed. This reference underscores that the facility’s failure to develop and implement appropriate care plans for the resident refusing showers and for the resident requiring transportation to an outside urology appointment was inconsistent with professional standards of nursing practice and the facility’s own policies on comprehensive person-centered care planning, referrals to outside services, and resident rights.
Failure to Provide Daily Oral Hygiene and Grooming Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically oral hygiene and grooming, to three residents who required staff support. Resident 1, admitted with hemiplegia affecting the left side, multiple contractures, muscle weakness, and moderate cognitive impairment (BIMS score 10/15), was observed with long fingernails containing brown substance, visible white buildup on teeth, foul breath, and long facial hair. Resident 1 reported not remembering the last time his teeth were brushed or nails trimmed, stated he had a history of refusing showers but not oral care, shaving, or nail care, and said staff did not offer daily tooth brushing or grooming and that he had not received grooming assistance from any staff at the time of the interview. CNA 1 and RN 1 both observed that Resident 1’s appearance suggested personal hygiene had not been completed for more than a few days, with RN 1 noting the resident appeared not to have been shaved for a few weeks and that nails were dirty, long, and uncut, despite ADL documentation indicating recent nail care, oral hygiene, and shaving. Resident 2, admitted with visuospatial deficit, hemiplegia affecting the left side, muscle weakness, GERD, and a need for assistance with personal care, also had moderate cognitive impairment (BIMS 12/15). Resident 2 stated she had been in the facility for a few months and that tooth brushing and grooming were part of her care plan but were not offered. She reported that her teeth were not brushed often because staff had previously said they did not have time, and she expressed a desire to have her teeth brushed every morning and night as part of her routine. She stated she felt dirty and believed the lack of tooth brushing had caused tooth pain because her teeth were dirty. During a later interaction in the hallway, Resident 2 stated she had not had her teeth brushed and was unable to open her mouth due to oral pain. ADL documentation for Resident 2 indicated oral hygiene was recorded as completed on two consecutive days in the review month. Resident 3, admitted with spastic hemiplegia affecting the left side, arthritis, muscle weakness, and wheelchair dependence, also had moderate cognitive impairment (BIMS 12/15). During observation and interview, Resident 3’s teeth showed white and yellow buildup and foul breath. Resident 3 stated he had not been offered supplies or staff assistance to brush his teeth daily, and that tooth brushing was part of his care that should have been completed without him having to request it. He reported feeling dirty and being able to smell a foul odor on himself, and stated he wanted help brushing his teeth every day. Review of Resident 3’s ADL documentation showed no entries for oral hygiene since admission. Staff interviews with a CNA, LVN 1, the DON, the administrator, and the DSD consistently described the facility’s expectation that CNAs complete all personal hygiene and ADLs daily, including tooth brushing, grooming, shaving, and nail care, generally before breakfast unless residents requested otherwise. Facility policies on Resident Rights, Oral Care, Grooming Care of Fingernails and Toenails, and Showering and Bathing stated that residents should receive daily oral care, nail care, and personal care consistent with their preferences and care plans, but the observed conditions and resident reports demonstrated that these services were not consistently provided to the three residents. The failure to provide daily oral care and grooming as required by the residents’ care plans and facility policies resulted in the three residents feeling unclean and, as stated by LVN 1 and the DON, placed them at risk for tooth decay, oral and respiratory infections, skin infections, skin breakdown, and other preventable issues. The discrepancy between the ADL documentation and the observed condition of Resident 1, as well as the absence of oral hygiene documentation for Resident 3, further demonstrated that the documented provision of care did not match the actual care delivered. The residents’ own statements that they were not offered oral care or grooming, combined with staff acknowledgments that these tasks had not been completed and that residents should not have to request such basic care, directly contributed to the identified deficiency in providing necessary services for ADLs to maintain personal and oral hygiene.
Unsecured Medication Destruction Bins Pose Risk of Drug Diversion
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding medication storage and disposal, specifically concerning the secure sealing of medication destruction bins (MDBs) in two medication rooms. During observations and interviews, it was noted that the MDB lids were loose and not properly sealed, which could allow staff to access discarded medications, including narcotics and other controlled substances. This was confirmed by the Nurse Supervisor and a Licensed Vocational Nurse, who both acknowledged the potential for drug diversion due to the unsecured bins. Further interviews with the Pharmacy Consultant and the Infection Preventionist highlighted the risks associated with the unsecured MDBs. The Pharmacy Consultant emphasized that the best practice would be to have the MDBs sealed to prevent unauthorized access to discarded medications, including those in powder form. The Infection Preventionist also noted that the unsecured bins posed an infection control issue and reiterated the potential for drug diversion, as anyone with access to the medication rooms could potentially take medications from the bins. The Director of Nursing confirmed that the facility's policies and procedures for medication storage and disposal were not followed, as the MDB lids were not properly secured in both medication rooms. The facility's policy, dated 2019, requires medications to be stored safely and securely, and controlled medications to be disposed of in a designated waste container. The unsecured MDBs were in violation of these policies, as well as federal regulations that require collection receptacles to be securely locked and maintained in a secured area.
Unsafe Medication Storage in Facility
Penalty
Summary
The facility failed to store drugs safely in two medication rooms, where a total of seven unidentifiable pills were found on the floor. In the second-floor medication room, five different pills were observed on the floor during an interview with the Nurse Supervisor, who confirmed that the pills were unidentifiable and could potentially be narcotics. Similarly, in the third-floor medication room, two different pills were found on the floor during an interview with an LVN, who acknowledged that the pills were random and should not have been on the floor. Both staff members expressed concerns about the safety and potential for drug diversion due to the presence of these unaccounted pills. Interviews with the Pharmacy Consultant, Infection Preventionist, and Director of Nursing further highlighted the failure to adhere to the facility's policy and procedure for medication storage. The Pharmacy Consultant noted the risk of staff or residents picking up the pills, while the Infection Preventionist emphasized the potential for drug diversion and the safety issues posed by the unsecured medications. The Director of Nursing confirmed that the medications were not secured and acknowledged the potential for drug diversion, indicating that the facility's policy and procedure for medication storage was not followed.
Meal Service Discrepancies on First Floor
Penalty
Summary
The facility failed to ensure that the meals served to residents on the first floor matched the menu items, as observed on January 7, 2025. Specifically, the kitchen ran out of spinach bake, which was supposed to be served to 49 out of 54 residents on that floor, and instead served green beans as an alternative. This discrepancy was noted during observations and interviews with residents and staff, revealing that the first-floor residents often received alternate meals when the kitchen ran out of menu items. Interviews with residents indicated dissatisfaction with the meal service, as they frequently did not receive the food items listed on the menu. Resident 48 reported that dessert options were unavailable because the kitchen prioritized serving other floors first, and mentioned that the facility ran out of food three times a week. Resident 78 corroborated this, stating that the first-floor residents were served last and often received alternate foods. Resident 112 expressed frustration when served a bun with cheese instead of the turkey burger listed on the menu, as the kitchen had run out of meat. The Certified Dietary Manager (CDM) and the Regional Registered Dietician (RRD) were unaware of the incidents of running out of food, but acknowledged that the kitchen should not run out of food. The CDM admitted that the cook did not prepare enough burgers, despite having more in the freezer. The facility's substitution lists and diet spreadsheet menus confirmed the discrepancies between the planned and served meals, highlighting a pattern of insufficient food preparation and substitution without proper adherence to the menu.
Late Meal Service in LTC Facility
Penalty
Summary
The facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident requests and preferences. On specific dates, lunch and dinner were served significantly later than the scheduled times, affecting all 141 sampled residents. Observations and interviews with residents and staff revealed that meals were consistently served late, with lunch being served as late as 2:00 p.m. and dinner as late as 8:00 p.m. This delay in meal service was corroborated by multiple residents who expressed dissatisfaction and frustration with the timing of their meals. Interviews with staff, including Licensed Vocational Nurses and Certified Nurse Assistants, confirmed the late meal service, with meals being delivered to different floors at staggered times, often much later than the posted schedules. The Director of Nursing acknowledged the issue, noting that while meal schedules were posted, there was no formal audit system in place to track and monitor meal distribution. The Certified Dietary Manager also noted that meals should be delivered within 15 to 30 minutes of the scheduled time to avoid affecting medication administration and resident satisfaction. Resident grievances further highlighted the issue, with complaints about meals being served cold and late, sometimes as late as 10:00 p.m. The facility's policy and procedure for meal service emphasized the importance of timely meal delivery, yet the facility failed to adhere to these guidelines. The deficiency in meal service timing had the potential to impact residents' nutritional and hydration needs, as well as their overall satisfaction and well-being.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential health risks. For Resident 94, who was admitted with paraplegia and neuromuscular dysfunction of the bladder, the care plan included monitoring for signs of urinary tract infections due to a chronic indwelling catheter. However, licensed nurses did not follow the care plan, as evidenced by observations of cloudy and sediment-filled catheter tubing, which was not properly assessed or reported to a physician. This oversight was acknowledged by the Licensed Vocational Nurse (LVN) and the Wound Nurse (WN), who admitted to not conducting accurate assessments or notifying the physician, potentially exposing Resident 94 to infection risks. Resident 63, diagnosed with Post Traumatic Stress Disorder (PTSD), did not have a comprehensive care plan addressing this condition. Despite the resident's expressed discomfort with loud noises due to PTSD, the care plan was not developed until months after admission. The Social Services Director (SSD) acknowledged that a PTSD care plan should have been initiated earlier to address the resident's needs. Interviews with staff, including the LVN and the Director of Nursing (DON), revealed a lack of awareness and training regarding trauma-informed care, which contributed to the delay in developing an appropriate care plan for Resident 63. The facility's policies and procedures for comprehensive person-centered care planning were not adhered to, as evidenced by the lack of timely and accurate care plans for both residents. The DON and other staff members recognized the importance of following these procedures to ensure residents' health and safety. The failure to implement these care plans as required by the facility's policies resulted in potential risks to the residents' physical and mental well-being.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to follow its policy and procedure to ensure care plans were reviewed and revised for five of 23 sampled residents. Resident 45's care plan was not updated after a fall and subsequent hospitalization, which increased the risk of further falls. The Licensed Vocational Nurse (LVN) acknowledged the oversight and emphasized the importance of care plans in notifying staff about residents' conditions and necessary preventative measures. Resident 67's care plan was not updated when a pressure ulcer progressed to a stage III wound. The Wound Nurse noted that the care plan for the pressure ulcer was not initiated upon identification, which could delay care and treatment. The Director of Nursing (DON) stated that care plans must be developed and updated to prevent worsening of wounds. Resident 74 experienced significant weight loss, but the care plan was not revised to reflect this change. The Registered Dietitian confirmed the weight loss and the need for the care plan to be updated. Additionally, Resident 74's care plan was not updated after a fall, and the DON stated that care plans should be revised after each fall to prevent further incidents. Resident 76's care plan was not updated upon returning from the hospital with a pressure ulcer, and Resident 392's care plans for apixaban and Enhanced Barrier Precaution were not initiated in a timely manner, which could have led to inadequate monitoring and care.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to meet professional standards of quality care for several residents, as evidenced by the lack of proper assessment and documentation of changes in their conditions. Resident 67, who was admitted with multiple diagnoses including hypertensive heart disease and quadriplegia, developed facility-acquired pressure ulcers that were not properly assessed or documented. Despite the worsening of a Stage 2 pressure ulcer to Stage 3, there was no change of condition assessment or interdisciplinary team (IDT) note completed, which is crucial for monitoring and preventing further deterioration of the wounds. Resident 74 experienced significant weight loss, exceeding five percent in one month, which was not documented or addressed by the facility's staff. The resident, who had a history of diabetes mellitus and cirrhosis of the liver, reported an inability to tolerate the facility's food, yet no change of condition assessment or IDT note was completed. This oversight in communication and documentation could have led to further weight loss, as the necessary interventions were not implemented. Additionally, Resident 55's prescribed oxygen order was not followed, as the resident was observed receiving a higher oxygen level than ordered without a documented change in condition or emergency situation. Furthermore, the Activities Director allowed assistants to document resident activities using her credentials, compromising the accuracy of records. These deficiencies highlight a pattern of inadequate documentation and communication within the facility, potentially impacting the quality of care provided to residents.
Facility Fails to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable and served at an appetizing temperature, as evidenced by complaints from five residents about cold, undercooked, and flavorless meals. Residents reported that the food was often served cold, and when reheated, it did not improve in quality. One resident mentioned that the food was so unappealing that it caused weight loss, and another resident described the food as being colder than ice cream. These issues were corroborated by staff interviews, where a CNA acknowledged that residents frequently complained about the food's lack of taste and temperature. Observations and interviews revealed that the facility's food service practices were inadequate. A lunch test tray audit conducted by the Regional Registered Dietician showed that the temperatures of the food items were below the facility's policy requirements, with the beef patty and roasted potatoes being particularly under temperature. The facility's policy stated that hot food should be served above 145 degrees Fahrenheit, but the audit found that the beef patty was only 119.8 degrees, and the potatoes were 108 degrees. Additionally, the Dietary Quality Control Review audits consistently indicated that the standard for serving food at appropriate temperatures was not met. The facility's failure to maintain proper food temperatures was further highlighted by a resident grievance report, where a resident received a cold and soggy dinner. The investigation into this complaint revealed that the grilled cheese sandwich served was not freshly made but reheated from the lunch shift. The Registered Dietitian confirmed that food served under temperature could lead to foodborne illnesses and impact resident satisfaction and intake. Despite these findings, the facility's policy and procedure for food temperatures were not adhered to, resulting in ongoing resident dissatisfaction and potential health risks.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents, staff, and the public, as evidenced by several deficiencies observed during a survey. In five out of 23 residents' rooms on the first floor, vertical blinds were found to be non-functional, lacking handles, missing slats, or stuck, which compromised the residents' privacy. Resident 31 expressed concerns about feeling unsafe due to the inability to properly close the blinds, which allowed people from outside to look into her room. The Director of Maintenance (DOM) acknowledged that the majority of the blinds on the first floor were not working properly, yet there was no record of these issues in the maintenance log. In another instance, a hole with exposed wiring was observed in Resident 103's room, posing a potential safety hazard. The DOM confirmed the presence of the hole and expressed concerns about the possibility of pest infestation and the risk of electrocution if the wires were live. Despite the potential dangers, there was no prior report of this issue, and the Licensed Vocational Nurse (LVN) was only made aware of it during the survey. The administrator acknowledged the risks associated with the hole and emphasized the importance of maintenance rounds to ensure safety. Additionally, Resident 55's room was found to have inadequate lighting due to missing light bulbs in both the ceiling fixture and the overhead light. This lack of proper lighting resulted in decreased visibility and eye strain for the resident, who had to go to the lobby to read. The DOM was aware of the issue but had not yet resolved it, and the LVN highlighted the importance of adequate lighting for providing quality care. The administrator reiterated the expectation for the maintenance department to address lighting issues promptly.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents by not covering their urinary catheter bags, which were left visible to other residents and visitors. Resident 69, who has severe cognitive deficits and quadriplegia, was observed with an uncovered urinary catheter bag placed on top of the mattress. Resident 191, who has no cognitive impairment, expressed a preference for his catheter to be covered, yet it was found on the floor under the bed. Both instances were not in accordance with the facility's policy and procedure, which requires catheter bags to be covered and hung on the side of the bed. Interviews with facility staff, including CNAs, a Nurse Supervisor, an Infection Preventionist, and the Director of Nursing, confirmed that the urinary catheter bags should have been placed in privacy bags and hung appropriately to maintain dignity and prevent infection. The facility's policy on indwelling catheters and resident rights emphasizes the importance of covering catheter bags to protect residents' privacy and dignity. The failure to adhere to these policies resulted in a violation of the residents' rights to privacy and dignity.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to uphold a resident's right to self-administer medication, specifically for Resident 92, who was not assessed for her ability to keep her albuterol inhaler at bedside and self-administer it as needed. Resident 92, who was her own responsible party and had no cognitive impairment, expressed a desire to keep her inhaler at bedside for her asthma condition. However, staff members, including CNAs and an RN, indicated that residents were not allowed to keep medications at bedside or self-administer them, and they were unaware that nurses could permit this. The facility's policy allowed for bedside medication storage for residents capable of self-administration upon a prescriber's written order and the interdisciplinary team's judgment. Despite this, Resident 92's Order Summary Report showed no orders for self-administration, and LVN 1 acknowledged that Resident 92 was a good candidate for self-administration. The Director of Nursing confirmed that residents had the right to self-administer medication and that an assessment should have been conducted for Resident 92. The failure to assess and provide the necessary order for self-administration potentially compromised Resident 92's ability to manage her asthma effectively.
Failure to Complete Significant Change of Condition Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to complete a Significant Change of Condition Assessment for a resident who developed a facility-acquired Stage 3 pressure ulcer on the left buttock. This assessment is part of the Minimum Data Set (MDS), a federally mandated resident assessment tool. The deficiency was identified during an observation and interview with the resident, who was alert and oriented, and confirmed the presence of a wound being treated by nurses. The resident's medical history included hypertensive heart disease with heart failure, morbid obesity, quadriplegia, and spinal stenosis. The Wound Doctor assessed the resident's wounds and diagnosed a Stage 3 pressure ulcer on the left buttock and a Stage 2 pressure ulcer on the right thigh. The Wound Nurse confirmed that the pressure ulcer on the left buttock had worsened from Stage 2 to Stage 3, but no change of condition assessment was documented. The Nurse Supervisor and Registered Nurse also reviewed the resident's records and confirmed the absence of a change of condition assessment, which is required to monitor the progress of wounds and prevent further decline. The Director of Nursing and the Minimum Data Set Nurse both stated that a new change of condition assessment should have been completed when the wound worsened from Stage 2 to Stage 3. The facility's policy and procedures require a new MDS assessment within 14 days if there is a significant change in condition. The failure to document the change of condition assessment could have resulted in a delay in care and treatment, potentially worsening the resident's wounds.
Failure to Update PASRR for Readmitted Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Level I Preadmission Screening and Resident Review (PASRR) for a resident who was readmitted to the facility. The resident, who had diagnoses of depressive disorder and psychosis, was readmitted without an updated PASRR assessment reflecting these mental health conditions and the use of psychotropic medications. The PASRR completed at the general acute care hospital did not indicate a diagnosis of mental illness, which was inaccurate given the resident's condition upon readmission. The Minimum Data Set Nurse (MDSN) did not review the PASRR assessment, which was dated prior to the resident's readmission, and failed to update it to reflect the resident's current mental health diagnoses and treatment. The Director of Nursing (DON) confirmed that it was the responsibility of the MDSN to review and update the PASRR as needed upon readmission. The facility's policy required a new PASRR to be completed if there was a significant change in the resident's condition, which was not adhered to in this case.
Failure to Provide Adequate Nail Care for Resident with Contractures
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, specifically in the grooming of fingernails, as per the facility's policy and procedure. The resident, who was admitted with paraplegia and contractures in both hands, had long fingernails that were curling into his palms, causing pain and potential for infection. Despite the resident's cognitive intactness and his complaints about the discomfort caused by his nails, the staff did not trim them. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) were aware of the issue but did not document the resident's refusal of care or the condition of his nails, and the Director of Nursing (DON) was not informed of the situation. The Infection Preventionist highlighted the importance of regular nail care, especially for residents with contractures, to prevent potential infections. However, the facility's records, including skin assessments and shower reviews, did not accurately reflect the resident's condition. The Social Services Assistant was also not informed of the issue, which could have warranted external medical intervention. The facility's failure to adhere to its grooming policy resulted in the resident's nails not being trimmed, which could have led to wounds or infections.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for Resident 40, who was admitted with diagnoses including muscle weakness and unspecified dementia. The resident's toenails were observed to be long and jagged, causing pain during ambulation. Despite the resident expressing a desire for his toenails to be cut, the facility did not provide this service. The resident's Brief Interview for Mental Status (BIMS) score indicated moderate cognitive impairment, which may have affected his ability to consistently communicate his needs. Licensed Vocational Nurse (LVN) 3 acknowledged that Resident 40's toenails should have been cut and that Certified Nursing Assistants (CNAs) were responsible for evaluating toenails during showers. However, the toenails were not addressed, and LVN 3 admitted to not having assessed the resident's toes. The Social Services Assistant (SSA) received a podiatry referral form for the resident but had not arranged for a podiatrist visit. CNA 14, who had showered the resident, noted the long and thick toenails but did not perform nail care, misunderstanding the documentation requirements for abnormal findings. The Director of Nursing (DON) was unaware of the issue and stated that the staff should have escalated the need for toenail care. LVN 8 also observed the overgrown toenails and submitted a referral for podiatry, but did not cut the nails due to their thickness. The Medical Doctor of Podiatry confirmed that the toenails should have been trimmed every two months to prevent infection and injury. The facility's policy on grooming care of fingernails and toenails was not followed, contributing to the deficiency.
Failure to Accommodate Resident's Dietary Allergies and Preferences
Penalty
Summary
The facility failed to provide food that accommodated the allergies and preferences of a resident, identified as Resident 92, who had a documented allergy to lactose. Despite this, Resident 92 was served milk with her lunch, which she stated she did not want and was given daily. The resident's Admission Record indicated an allergy to lactose, and her Minimum Data Set showed no cognitive impairment, suggesting she was capable of communicating her needs. During an observation and interview, it was confirmed that her Meal Ticket listed a dislike for lactose, but her allergy was not noted, leading to the inappropriate serving of milk. Interviews with facility staff, including a CNA, the Certified Dietary Manager, the Director of Staff Development, and the Director of Nursing, revealed a breakdown in communication and procedure adherence. The CNA acknowledged that kitchen staff should have noticed the resident's allergies and preferences, and the CDM admitted that the allergies were not indicated on the Meal Ticket. The DSD and DON both confirmed that CNAs were trained to check meal trays for accuracy, and the DON stated that the kitchen staff should have ensured the resident received her preferred meal. The facility's policy required that resident preferences be reflected in the medical record and tray card, which was not followed in this instance.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a mechanical soft diet as prescribed by the attending physician for Resident 83, who was one of the 32 sampled residents. Resident 83, who had been at the facility for three years, was observed to have been served whole kernel corn instead of the prescribed mechanical soft diet. This was despite the resident's admission record indicating a need for a mechanical soft diet due to her medical conditions, including cerebral infarction, Type 2 Diabetes Mellitus, protein-calorie malnutrition, dementia, major depressive disorder, muscle weakness, and a history of falling. The resident, who was moderately cognitively impaired and had no teeth, reported that the facility often provided food she could not chew, such as whole kernel corn, which she had to swallow whole. The Registered Dietician confirmed that Resident 83 should have been served creamed corn instead of whole kernel corn, acknowledging that the latter was not acceptable and increased the risk of choking. The Director of Nursing stated that it was the nurse's responsibility to ensure the resident's meal matched the dietary requirements, and any discrepancies should have been addressed by consulting the Certified Dietary Manager. The failure to adhere to the prescribed mechanical soft diet placed Resident 83 at risk for choking and aspiration.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one of the sampled residents, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST) form. The POLST form for Resident 137 was found to be incomplete, missing critical information such as artificially administered nutrition, physician signature, physician license, physician phone number, and date. This deficiency was identified during a review of the resident's records and interviews with facility staff, including a Licensed Vocational Nurse (LVN), Nursing Supervisor (NS), Medical Records Coordinator (MR), and the Director of Nursing (DON). Resident 137 was admitted to the facility with several medical conditions, including pneumonia, pleural effusion, cognitive communication deficit, dysphagia, failure to thrive, and dementia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of seven out of 15. Despite the resident being listed as Do Not Resuscitate (DNR) in the computer system, the incomplete POLST form posed a risk of not honoring the resident's end-of-life wishes in an emergency situation. Interviews with facility staff revealed that the POLST form should have been completed within 72 hours of admission, but it remained incomplete from December to the date of the survey. The staff acknowledged the importance of a completed POLST to ensure the resident's treatment preferences are respected. The facility's policy and professional standards require that all fields in the POLST form be filled out and signed by a physician to be valid, which was not adhered to in this case.
Infection Control Deficiency Due to Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of infections for a resident with chronic respiratory conditions. The resident's oxygen nasal cannula and nebulizer mask were found lying on the nightstand without being stored in a protective bag, which is against the facility's infection control practices. The resident, who has Chronic Obstructive Pulmonary Disease (COPD) and asthma, uses these devices daily as part of their treatment. During observations and interviews, it was noted that the oxygen concentrator and nebulizer were not stored properly, posing a risk of bacterial contamination. Interviews with various staff members, including a CNA, Wound Nurse, Nursing Supervisor, Infection Preventionist, and the Director of Nursing, confirmed that the standard practice was to store oxygen and nebulizer tubing in labeled protective bags to prevent infection. The facility's policy on oxygen therapy, however, did not address the storage of these items, which contributed to the oversight. The staff acknowledged that leaving the tubing unprotected was an infection control issue, and the expectation was to follow the standard of practice to ensure sanitary conditions.
Lack of Supervision Leads to Resident Accident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who had a history of falls and required assistance with personal care. Despite the resident's known preference to sit outside and engage in daily exercises around the facility perimeter, staff did not provide supervision while the resident was outside. On the morning of the incident, the resident left the facility premises unsupervised and was involved in an auto versus pedestrian accident, resulting in multiple severe injuries. The resident, who was considered cognitively intact with a BIMS score of 13 out of 15, had a complex medical history including hypertensive heart and kidney disease, peripheral vascular disease, end-stage renal disease, and a history of falls. The resident's care plan indicated a need for supervision during activities of daily living, including toileting and transfers. However, the facility's staff, including the receptionist and nursing staff, were not specifically assigned to monitor residents outside, leading to a lack of awareness of the resident's departure from the facility. Interviews with facility staff revealed a lack of clarity and consistency in the monitoring process for residents who were outside. The receptionist, who was responsible for identifying elopement risks, was not present before 8:00 a.m., and no staff were assigned to monitor residents outside during this time. The facility's policies on leave of absence and resident safety were not effectively implemented, contributing to the resident's unsupervised departure and subsequent accident.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide services that met professional standards of quality for a resident when Licensed Vocational Nurses (LVNs) did not administer oxygen as per the physician's order. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Adult Failure to Thrive, Shortness of Breath, Hypoxemia, and Dependence on Supplemental Oxygen, was prescribed oxygen at 3 liters per minute via nasal cannula to maintain oxygen saturation at or above 93%. However, the LVNs administered only 2 liters per minute on multiple occasions, and there were several days with no documentation of oxygen administration in the Treatment Administration Record (TAR). Interviews and record reviews revealed that the physician's order was not followed for numerous days across May, June, and July, with the resident receiving less oxygen than prescribed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the failure to follow physician orders and the lack of oversight in ensuring compliance. The Medical Records Director (MRD) had informed the DON and ADON about the missing documentation, but no follow-up actions were taken to address the issue. The facility's policies and procedures for oxygen therapy and physician orders emphasize the importance of administering oxygen as prescribed and verifying the completeness and accuracy of physician orders. Despite these guidelines, the LVNs did not adhere to the physician's orders, and the DON admitted to not providing the necessary oversight. This deficiency in care had the potential to impact the resident's health and well-being, as the resident was dependent on supplemental oxygen.
Failure to Prevent Involuntary Seclusion
Penalty
Summary
The facility failed to protect two residents from involuntary seclusion, which was not required to treat their medical symptoms. This deficiency occurred when an LVN closed the door to the room shared by the two residents, leaving them isolated and with unmet basic care needs. One resident expressed feelings of sadness, anger, and being unheard when she was unable to leave her room to a quieter area of her choice, while the other resident was yelling with the door closed. The incident was observed and reported by the first resident, who recalled the events of a particular night when the second resident was yelling, preventing her from sleeping. Despite using the call light to request assistance, communication barriers with the CNA and LVN led to the resident's needs being unmet. The LVN exited the room without addressing the resident's concerns and closed the door, leaving the resident to attempt to crawl to the door to seek help. Interviews with staff members revealed that the facility had resources, such as a language line, to assist in communication with residents who spoke different languages. However, these resources were not utilized in this instance. The facility's policy on abuse prevention and resident rights emphasized the importance of treating residents with dignity and ensuring their rights are respected, which was not adhered to in this case.
Resident Jumps from Second Story Due to Inadequate Supervision and Window Security
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for a resident who removed a window screw, opened the window, and jumped from the second story, resulting in severe injuries. The resident, who had a history of mental health disorders including major depressive disorder and borderline personality disorder, expressed suicidal ideations to a Certified Nursing Assistant (CNA) but the CNA did not report these changes to the licensed staff. The resident was found outside by the sidewalk with multiple fractures and other injuries. The CNA, who was familiar with the resident's care, noted a change in the resident's demeanor and heard her expressing that she was done with everything. Despite these observations, the CNA did not report the change in behavior to the charge nurse, believing the resident was preparing to leave the facility for personal reasons. The facility's process required CNAs to report any changes in residents' behavior to the charge nurse immediately, which was not followed in this case. Additionally, the facility's maintenance department failed to ensure that window screws were securely in place, as evidenced by the observation of loose window screws in multiple rooms. The maintenance supervisor claimed that window screws were checked daily, but there was no documentation to support this. The facility's policy required the maintenance department to maintain the building in a safe and operable manner, which was not adhered to, contributing to the resident's ability to open the window and jump out.
Unsafe Window Conditions Lead to Resident Injury
Penalty
Summary
The facility failed to provide a safe environment for 28 of 134 residents due to loose window screws in 15 resident rooms on the second and third floors. This deficiency was highlighted when a resident, identified as Resident 1, was able to remove a protective screw from her window, push out the screen, and jump from the second floor, resulting in serious injuries. The resident was found outside by facility staff and was transferred to an acute hospital for further evaluation. Resident 1 had a complex medical history, including systemic lupus erythematosus, neuropathy, spinal stenosis, major depressive disorder, borderline personality disorder, anorexia, muscle weakness, PTSD, adult failure to thrive, homelessness, and noncompliance with medical treatment. Despite these conditions, Resident 1 was assessed as cognitively intact with a BIMS score of 14 out of 15. The resident reported suicidal ideations and attributed her actions to the treatment she received at the facility, although she could not specify the treatment. Interviews with facility staff, including CNAs, RNs, and the maintenance supervisor, revealed that the maintenance department was responsible for ensuring window screws were secure. However, there was no documentation of regular checks on window screws, and the maintenance supervisor admitted that while it was implied windows were checked during rounds, there was no specific record of this. The facility's administrator acknowledged that the screws should not have been easily removable and that the fire marshal had informed the facility that using screws to secure windows was not allowed.
Severe Roach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of roaches in the dishwashing area of the kitchen. On the day of the survey, roaches were observed crawling in the sink with dirty dishes, on the walls, and in the dishwasher, with some even swimming in the sanitizing water. The infestation was so severe that roaches were nesting in the corners of the dishwashing room and crawling into dish racks on the floor. This unsanitary condition was acknowledged by the dietary aide and the dietary services supervisor, who admitted to having seen roaches previously but did not recognize the extent of the infestation. Interviews with various staff members, including the administrator, dietary aides, and the infection preventionist, revealed that the presence of roaches in the kitchen was a known issue. The administrator and dietary supervisor were aware of roaches being seen in the kitchen but did not consider it an infestation. The infection preventionist incorrectly stated that roaches are sanitary and do not spread infections, despite acknowledging their presence in the kitchen. Residents also reported seeing roaches in the hallways and dining areas, indicating that the infestation was not limited to the kitchen. The facility's pest control service reports from previous months indicated ongoing issues with roaches, with recommendations for improved sanitation and sealing of cracks and crevices. Despite these recommendations, the facility failed to implement effective measures to control the pest problem. The pest control representative confirmed that sanitation plays a crucial role in keeping roaches away, as they thrive in cluttered and dirty environments with food debris. The facility's failure to address these issues led to an unsanitary environment that posed a risk of cross-contamination and potential harm to residents.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide necessary care according to professional standards for a resident who did not receive prescribed pain medication for three days. The resident, who was admitted with conditions including hemiplegia, aphasia, major depressive disorder, facial weakness, and type 2 diabetes, was observed in pain and guarding her abdomen. Despite a physician's order for Ibuprofen 800 mg every six hours as needed for pain, this medication was not administered following the resident's return from an acute care hospital. The resident had been discharged from the hospital with a prescription for pain management, but the order was not recorded in the facility's medication administration records. Interviews with staff, including a CNA and an LVN, revealed that the resident had returned from a leave of absence complaining of abdominal pain after an alleged attack. The LVN acknowledged that the medication order was not completed or added to the resident's orders, which was crucial for managing the resident's pain. The Director of Nursing confirmed that the order for Ibuprofen was not clarified with the resident's physician upon her return to the facility. The facility's policy required licensed nurses to ensure physician orders are clear and documented, but this was not followed. The administrator also stated that it was expected for nurses to clarify and input new orders into the resident's medication records, which did not occur in this case.
Failure to Provide Adequate Supervision and Assistance During Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident who fell out of bed during care provided by a CNA without the required assistance from another staff member. The resident, who had severe cognitive impairment and was dependent on staff for various activities, sustained significant injuries including a fractured occipital condyle, a laceration to the nose, and swelling to the left eye. The resident's care plan clearly indicated the need for two-person assistance during care, which was not followed by the CNA, leading to the fall and subsequent injuries. The incident occurred when the CNA attempted to change the resident's brief alone, despite the care plan and visual indicators (a picture of two hands shaking) outside the resident's room that signified the need for two-person assistance. The CNA admitted to not following the care plan, resulting in the resident rolling out of bed and falling to the floor. The resident was found face down, bleeding, and in pain, and was subsequently diagnosed with a fractured occipital condyle at the hospital. Interviews with various staff members, including the ADON, DON, and other CNAs, confirmed that the resident required two-person assistance for care and that the failure to follow this protocol directly led to the fall and injuries. The facility's policies on fall management and resident safety were not adhered to, as the CNA did not follow the established care plan designed to prevent such accidents and ensure the resident's safety.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
