Hi-desert Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Joshua Tree, California.
- Location
- 6601 White Feather Rd, Joshua Tree, California 92252
- CMS Provider Number
- 555443
- Inspections on file
- 47
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Hi-desert Medical Center D/p Snf during CMS and state inspections, most recent first.
A resident with paraplegia and multiple sclerosis, who was cognitively intact, was noted in nursing documentation to be acting impaired after returning from smoking, prompting a physician order for a UA and drug screen that later returned positive for cannabis. The resident reported occasional, non-prescribed marijuana use in the designated smoking area and stated staff were unaware of this use. Despite a corporate policy requiring investigation of illegal substance use to determine who brought the substance into the facility and whether patients used or had access to it, the facility, as confirmed by the DON, did not investigate or search the resident’s room after the positive drug test.
Two cognitively intact residents reported that an RN responded to a resident’s question about the timeliness of pain medication by yelling, speaking aggressively, and stating she did not have to deal with his medication at that time. One resident described withdrawing, hearing the RN bad-mouthing him in the hall, and feeling anxious and distressed, while another resident went to calm him. A third resident, about four doors away, reported clearly hearing the RN yelling, described her behavior as unprofessional and disrespectful, and later felt anxious about interacting with her. CNAs relayed these reports to the DON, and Social Services staff confirmed that residents described the RN’s tone as loud, dismissive, and lacking composure, consistent with the facility’s policy definition of verbal abuse based on tone of voice.
An allegation of psychological/mental abuse toward a resident was identified but not reported to the Ombudsman and CDPH within the required 24-hour timeframe. Instead, the concern was initially documented as a grievance by a Dietary Supervisor and handed to a social worker, who placed it in the DON’s mailbox while the DON was out of town. The DON later reviewed the grievance, recognized it as an abuse allegation, and filed the SOC 341 several days after the incident, contrary to facility policy and mandated reporter requirements.
A resident with a tracheostomy and PEG tube, documented as comatose and with a history of multiple cerebral infarctions, had a physician’s order for continuous enteral nutrition at a set rate via PEG. For approximately 48 hours, only water was infused through the PEG tube instead of the ordered tube feeding, as later identified in nursing documentation and staff interviews. Although the RN, LVN, and unit monitoring practices required verification of correct formula, labeling, infusion status, and intake at specific times each shift, these checks did not prevent or detect that the pump was continually flushing with water rather than delivering formula. Weight records showed a small weight loss over the review period, and the DON acknowledged that the facility’s enteral nutrition management policy, which required formula at goal rate when appropriate, was not followed.
A resident with multiple medical conditions, including a tracheostomy and recent fractures, was left soiled and did not receive timely assistance with activities of daily living when an RN failed to respond appropriately to the call light and did not notify a CNA or provide care, as confirmed by interviews, record review, and observation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a history of depression and paraplegia reported being hit by a CNA during care. The DON confirmed that, during the subsequent abuse investigation, the care plan was not updated and enhanced monitoring was not implemented, contrary to facility policy.
A resident with a history of neurological and cognitive conditions exhibited increased aggressive behaviors, but staff failed to update the care plan or document these changes as required by facility policy. Staff interviews confirmed that documentation and care plan updates were not completed despite clear changes in the resident's condition.
The facility failed to develop and implement comprehensive care plans for four residents, lacking measurable objectives and timeframes. A resident on a ventilator with a sacral wound had no re-evaluated care plan. Two residents with contractures lacked care plans for prescribed Passive Range of Motion exercises. Another resident only had a nutritional care plan, with other necessary plans discontinued. The DON confirmed these deficiencies, which contradicted the facility's care planning policy.
A long-term care facility failed to administer medications as ordered for 23 residents, with nursing staff not notifying physicians or pharmacists of missed doses. Additionally, a resident with a PEG tube received medications through the tube without verifying the route with a physician. These actions violated the facility's medication administration policies, leading to unsafe practices.
A resident with complex medical needs was transferred to a hospital for a suprapubic catheter exchange without notifying their family, as required by facility policy. The absence of documentation confirming family notification was confirmed by the DON, highlighting a lapse in communication between the healthcare team and the resident's family.
The facility failed to provide and document Passive Range of Motion (PROM) services for two residents with contractures, as ordered by their physicians. Despite orders for PROM every Monday, Wednesday, and Friday, there was no evidence of these services being performed. Interviews with staff revealed that neither the Restorative Nurse Assistant nor the Certified Nurse Assistant provided the services, with the CNA stating she was not certified to perform ROM. The Director of Nursing confirmed the lack of documentation and service provision.
The facility failed to respond to call lights in a timely manner for two residents with significant health needs. One resident with paraplegia reported delays of up to two hours, while another with metastatic lung cancer experienced variable response times. Both residents were found to be fully dependent on staff for assistance. The facility lacked a specific policy on call light response times.
The facility failed to ensure accurate controlled medication verification for 17 residents, missing a second nurse's signature on drug count records over several days. Interviews revealed that the policy required two nurses to verify controlled drugs, but records showed only one signature on some occasions.
A resident's controlled medication was improperly removed and destroyed by an LVN, violating facility policies. The LVN took Norco from the medication cart without permission, leading to a discrepancy noted during verification. The facility's policies prohibit such actions, which resulted in the unauthorized diversion of medication.
Failure to Investigate Resident’s Positive Drug Screen for Marijuana
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to investigate and monitor the use of illegal substances after a resident tested positive for marijuana. The resident was admitted with diagnoses including paraplegia and multiple sclerosis, and had a BIMS score of 15, indicating intact cognition. A nurse’s note documented that the resident was acting impaired after returning from smoking, and a physician ordered a urinalysis with drug screen via straight catheter. Laboratory results from that testing showed the resident was positive for cannabis. Despite the positive drug screen and the facility’s corporate policy defining illegal substances and requiring an investigation to identify who brought the substance into the facility and whether a patient used or had access to it, no investigation was conducted. In an interview, the resident stated she occasionally used non-prescribed marijuana and had smoked it in the designated smoking area without staff awareness. During a subsequent interview and record review, the DON confirmed that no search of the resident’s room or investigation for illegal substances had been performed, and acknowledged that, per policy, an investigation should have occurred after the positive drug test.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from verbal abuse by a registered nurse (RN 1). One resident with multiple sclerosis and chronic pain due to trigeminal neuralgia, and another resident admitted after an accident with bone fractures, both had Brief Interview for Mental Status (BIMS) scores of 15, indicating normal cognition. According to interviews, when the resident with multiple sclerosis questioned RN 1 about the timeliness of his medications for chronic pain, RN 1 began yelling and “freaking out.” The resident reported withdrawing from the area, hearing RN 1 “bad mouthing” him in the hallway, and then blocking it out by putting on headphones. He stated that the interaction made him feel “like shit,” “crazy,” and anxious because he needed his pain medication. Another resident reported that RN 1 was yelling at the first resident, saying she did not have to deal with administering his medication at that time and that she was already late, and described RN 1 as aggressive and yelling, which upset the first resident enough that the second resident went to calm him down. A third resident, located approximately 40 feet and four doors down from the first resident’s room, reported overhearing the incident and stated that RN 1 was yelling at the first resident about the timing of his pain medication, describing RN 1 as very unprofessional and disrespectful. This resident emphasized that RN 1’s yelling was audible from his room and reported feeling anxiety about any potential interactions with her afterward. Social Services staff, after meeting with the involved residents, stated that the residents reported RN 1’s tone as loud, that she may not have maintained her composure in a stressful situation, and that she was loud talking and dismissive toward the first resident. The DON reported that CNAs 1 and 2 had brought forward the incident, and the DON characterized the behavior as verbal abuse based on yelling that could be heard down the hallway. CNAs 1 and 2 confirmed that the third resident reported RN 1 was irritated and yelling at the first resident about medication, and one CNA noted having previously heard RN 1 talk “a little loud” toward others. The facility’s abuse policy defines verbal abuse to include use of a tone of voice that causes a resident to feel frightened or threatened, and notes behavioral indicators such as fear, withdrawal, anger, and anxiety.
Failure to Timely Report Allegation of Psychological Abuse
Penalty
Summary
The facility failed to timely report an allegation of psychological/mental abuse toward one resident within the required 24-hour timeframe. Review of a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) dated January 21, 2026, showed that the allegation of psychological/mental abuse was identified on January 13, 2026, but was not reported to the Ombudsman and the California Department of Public Health (CDPH) until January 21, 2026, eight days after the incident. The SOC 341 documented that the allegation involved psychological/mental (mind, emotion, and behavior) abuse toward the resident. During an interview, the DON stated they had been out of town when the incident was initially documented. The DON explained that the Dietary Supervisor wrote the concern as a grievance and gave it to the Social Worker, who then placed it in the DON’s mailbox. The DON reported that on January 21, 2026, they read the grievance, recognized it should have been treated as an allegation of abuse, and then filed the SOC 341. The DON acknowledged there was a delay in reporting and stated that the facility’s policy, "Resident Abuse, Neglect Prevention, Investigation and reporting," requires all mandated reporters to report any allegation of abuse, and that all allegations of abuse not resulting in serious bodily injury must be reported within 24 hours to the facility administrator, CDPH, and the Ombudsman. The DON stated the policy was not followed because mandated reporters did not report the suspected abuse within 24 hours as required.
Failure to Administer Ordered PEG Tube Feeding for 48 Hours
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via PEG tube was provided tube feeding according to the physician’s order. The resident was admitted with a tracheostomy and PEG tube and had a history of hypertension, hyperlipidemia, and multiple cerebral infarctions. The MDS documented the resident as comatose with no discernible consciousness. Physician orders dated January 19, 2026, directed continuous tube feeding at 60 ml/hr via PEG tube. However, the resident did not receive the ordered enteral formula for approximately 48 hours, during which only water was infused through the PEG tube instead of the prescribed tube feeding. Interviews with staff described how tube feedings were expected to be managed and monitored. RN 1 stated that RNs and LVNs were responsible for managing tube feedings, including checking them at the start of each shift, during designated shut-off times, and at the end of the shift to document intake. The Clinical Coordinator reported that tube feedings were to be monitored during rounds to verify the correct formula, proper labeling, and that the feeding was infusing, and that feeding and water were to be changed every 24 hours. Despite these stated practices, the nursing narrative documented that when the resident was reconnected to enteral feeding, it was discovered that only water had been running through the system and that the pump appeared to be continually flushing with water instead of delivering the ordered formula. Further record review showed that the resident’s weights decreased from 87.2 kg to 85.4 kg over an 11-day period. The nursing narrative documented that the physician was notified that the resident’s tube feeding had not been administered for 48 hours and that only water had been infused via the PEG tube during that time. RN 1 acknowledged that nursing staff should have checked the feeding to ensure it was being administered as ordered and stated that it was important for residents to receive needed nutrition. Review of the facility’s policy, “Guidelines for Management of Enteral and Parenteral Nutrition,” indicated that enteral formula should be initiated at full strength at goal rate if there was no GI compromise. The DON stated that this policy was not followed and confirmed that it was important to meet each resident’s nutritional needs.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
A resident with a complex medical history, including blunt abdominal trauma, non-displaced C5 and C7 fractures, anxiety, a right upper arm partial thrombus, and a tracheostomy, was admitted to the facility. The resident was left soiled and their activities of daily living were not met in a timely manner. The incident occurred when a registered nurse failed to respond to the resident's call light and did not provide assistance when the resident attempted to communicate her needs. The nurse initially believed the call light was for another patient and, upon realizing it was for this resident, asked her to write down her request when she could not speak clearly. When the resident did not write down her needs, the nurse did not pursue further assistance and continued with other tasks until a respiratory therapist informed him that the resident needed to be changed. Interviews and record reviews confirmed that the nurse did not notify a CNA or provide timely care, resulting in the resident remaining soiled. The facility's policy requires that residents receive good personal hygiene and timely care to prevent bedsores and incontinence. The Director of Nursing acknowledged that there was no justification for the nurse's failure to assist or communicate the resident's needs to other staff. This lapse in care was identified through interviews, record reviews, and direct observation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that when an event involving suspected abuse, neglect, or theft occurred, the facility did not fulfill its obligation to promptly notify the appropriate authorities or provide the outcomes of its internal investigation as required.
Failure to Update Care Plan and Implement Monitoring During Abuse Investigation
Penalty
Summary
The facility failed to follow its policy and procedure for resident abuse in the case of one resident. After an allegation was made that a Certified Nurse Assistant (CNA) hit the resident on the buttocks and thighs while assisting with dressing, the resident expressed concern that the incident could recur if not reported. The Director of Nursing (DON) confirmed that, during the investigation, no interventions were added to the resident's care plan, and enhanced monitoring was not implemented as required by facility policy. Record review showed that the resident had a history of depression, paraplegia due to a self-inflicted gunshot wound, and left-sided weakness. The facility's policy stated that during an abuse investigation, actions such as assessment, care planning, supervision, staff assignment, and monitoring should be taken to ensure the resident's health and safety. The DON acknowledged that the care plan was not updated or revised following the incident, and the required monitoring was not put in place during the investigation process.
Failure to Update and Document Changes in Resident's Care Plan
Penalty
Summary
The facility failed to follow its policy and procedure for care plan documentation for one resident when the care plan was not updated to reflect changes in the resident's condition and behaviors. Specifically, a resident with a history of subdural hemorrhage, aphasia, and dementia exhibited increased aggressive behaviors, including yelling, slamming doors, and inappropriate interactions with another resident. Despite these changes, the care plan was not updated, and nursing staff did not document the resident's outbursts or aggressive behaviors as required by the facility's policy. The last documented update in the care plan was several weeks prior to the observed incidents. Interviews with staff confirmed that the resident's care plan should have been updated to reflect the recent behavioral changes, and that documentation of each outburst or aggressive behavior was not completed as per policy. The Director of Nursing acknowledged that the policy regarding care plan documentation was not followed, emphasizing the importance of timely updates and documentation to ensure effective communication among staff.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of five sampled residents, which included measurable objectives and timeframes to meet their medical, nursing, mental, and psychosocial needs. For Resident 24, who was on a ventilator and had a sacral wound, the care plan lacked measurable goals and timeframes, and there was no re-evaluation of the care plan since its initiation. The Director of Nursing confirmed that the care plan should have been initiated and re-evaluated as needed. Resident 61, who had anoxic brain injury and contractures, did not have a care plan developed for the prescribed Passive Range of Motion exercises. The Director of Nursing verified that a care plan should have been initiated the same day the physician order was received. Similarly, Resident 67, who also had contractures and required Passive Range of Motion exercises, did not have a care plan developed and implemented, as confirmed by the Director of Nursing. Resident 50, with a history of cerebral vascular accident and other conditions, only had an active care plan for nutritional status, while other necessary care plans were discontinued. The Director of Nursing was unable to provide documented evidence of the required care plans for Resident 50, confirming that the nursing staff should have documented the care plan. The facility's policy and procedure on care planning emphasized the need for documentation and consideration of individualized patient needs, which was not adhered to in these cases.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff administered medications as ordered for 23 out of 41 sampled residents. On December 1, 2024, medications were not administered to 22 residents, and the responsible physician or pharmacist was not notified of the missed doses. This included critical medications such as levetiracetam and apixaban, which are essential for managing conditions like seizures and preventing blood clots. The Director of Nursing confirmed that the facility's policy and procedure for medication administration were not followed, as the nursing staff did not report the medication omissions or notify the appropriate medical personnel. In a separate incident, a resident with a PEG tube was administered medications through the tube without verifying the route of administration with a physician. The resident had orders for oral medications, but due to their inability to swallow, the medications were given via the G tube. The registered nurse responsible for administering these medications did not notice the discrepancy in the route of administration, and the physician was not informed of the change in administration method. The Interim Director of Nursing acknowledged that the nursing staff failed to adhere to the facility's policy, which requires validation of the six rights of medication administration, including the right route. These failures in medication administration resulted in unsafe practices that could potentially lead to adverse health outcomes for the residents involved. The facility's policy and procedure for medication administration were not followed, leading to a lack of communication with physicians and pharmacists regarding missed doses and changes in medication administration routes. This oversight highlights significant deficiencies in the facility's medication management processes.
Failure to Notify Family of Resident Transfer
Penalty
Summary
The facility failed to notify the family or emergency contact of a resident before transferring them to an acute care hospital for a suprapubic catheter exchange. This deficiency was identified during a review of the resident's emergency department physician note and interviews with facility staff. The resident, a male with a history of quadriplegia, tracheostomy, ventilator dependency, neurogenic bladder, and suprapubic catheter dependency, was transferred from the long-term care facility without documented evidence of family notification. Interviews with a Licensed Vocational Nurse and the Director of Nursing revealed that the facility's policy requires family notification upon any transfer, which was not adhered to in this case. The Director of Nursing confirmed the absence of documentation regarding family notification in the resident's medical record. The facility's policy and procedure for transferring residents requiring emergency or acute care also mandates notifying the resident's primary contact, which was not followed, leading to a lack of communication between the resident's family and the healthcare team.
Failure to Provide and Document PROM Services
Penalty
Summary
The facility failed to provide Passive Range of Motion (PROM) services as ordered for two residents, leading to a deficiency in care. Resident 61, who was observed on the sub-acute unit, had bilateral upper extremities contractures and was supposed to receive PROM services every Monday, Wednesday, and Friday. However, there was no documented evidence that these services were provided on the specified dates. Interviews with the Restorative Nurse Assistant (RNA) and Certified Nurse Assistant (CNA) revealed that neither provided the PROM services, with the CNA stating she was not certified to perform ROM. Similarly, Resident 67, who also had contracted upper extremities and was breathing via tracheostomy, was not provided with the ordered PROM services. The physician's order for Resident 67 also indicated PROM every Monday, Wednesday, and Friday, but there was no documentation of these services being performed. The RNA and CNA both confirmed they did not provide the services, and the Director of Nursing (DON) verified the lack of documentation and service provision. The facility's policy and procedure on Wound Care Management Pressure Wounds required turning with range of motion every two hours and as needed, along with appropriate documentation. However, the failure to provide and document PROM services for Residents 61 and 67 indicates a lapse in following these procedures, as confirmed by the DON during the review of the residents' records.
Delayed Call Light Response for Clinically Compromised Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, affecting two residents who were clinically compromised. Resident 1, who has paraplegia and is totally dependent on staff for transfers, reported that it sometimes took up to two hours for staff to respond to calls for help. This was observed during an interview where Resident 1 was found seated in a wheelchair, indicating reliance on the wheelchair for mobility. Resident 1's clinical records confirmed a diagnosis of paraplegia and a Brief Interview for Mental Status (BIMS) score indicating no mental impairment. Similarly, Resident 2, who has lung cancer that has metastasized to the bone and is totally dependent on staff for assistance with activities such as using the commode, reported variable response times to call lights, ranging from prompt to delays of up to 45 minutes. During an interview, Resident 2 was found lying in her room, indicating reliance on staff for commode use. Resident 2's clinical records also showed a BIMS score indicating no mental impairment. Interviews with the Director of Nursing and the Administrator revealed that the facility lacked a specific policy on call light response times.
Controlled Medication Verification Deficiency
Penalty
Summary
The facility failed to maintain an accurate controlled medication verification process for 17 residents, as evidenced by missing signatures from two licensed nurses on the controlled drug count records. This deficiency was observed on seven out of 20 days between August 1, 2024, and August 20, 2024. The absence of a second nurse's signature was noted on specific shifts, including both AM and PM shifts on certain days. This lapse in procedure was identified during a review of the facility's control drug count records. Interviews conducted with the Director of Staff Development, the Pharmacist Consultant, and the Administrator revealed that the facility's policy required two nurses to verify controlled drugs at the beginning and end of each shift. However, the drug count sheets for August 2024 showed instances where only one nurse's signature was present. The Administrator acknowledged being recently informed of this issue. The facility's policy, dated March 15, 2017, mandates that high alert medications be checked by two licensed nurses, with both required to document the verification process in the Medication Administration Record (MAR).
Unauthorized Removal of Controlled Medication by LVN
Penalty
Summary
The facility failed to ensure the secure storage of controlled medications for a resident, leading to the wrongful use of the resident's belongings. A Licensed Vocational Nurse (LVN) took acetaminophen and hydrocodone (Norco) from the medication cart without permission, resulting in the diversion of controlled medication. This incident involved a resident who was admitted with a diagnosis of unspecified focal traumatic brain injury and had orders for Norco to be administered as needed for pain management. During a controlled medication verification, discrepancies were noted, and it was discovered that 18 tablets of Norco were missing. Interviews revealed that the LVN took the pill card and remaining medication home and destroyed them, admitting to the action but unable to explain the discrepancy. The facility's policies and procedures clearly state that controlled medications should not be surrendered to anyone other than specified parties, highlighting a breach in protocol. The incident was reported by a Registered Nurse (RN) who noticed the discrepancy and informed the facility's management. The LVN's actions resulted in the unauthorized removal and destruction of the resident's medication, violating the facility's medication storage policies.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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