Horizon Health & Subacute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 3034 E Herndon, Fresno, California 93720
- CMS Provider Number
- 055199
- Inspections on file
- 31
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Horizon Health & Subacute Center during CMS and state inspections, most recent first.
The facility failed to follow its own policies and professional standards by sending Activity Aides into a behavioral health STP unit to perform activity assessments and revise care plans without ensuring they had completed required behavioral health training, despite staff requests for such training and internal records showing incomplete or absent training documentation. The facility also did not conduct the required annual review of its mechanical ventilation weaning policy, which had not been updated for several years despite a written policy mandating at least annual review by QAPI. Additionally, for a ventilator-dependent resident admitted for vent weaning with orders to wean as tolerated, RTs could not locate required follow-up assessments, were unfamiliar with or unable to access the facility’s vent weaning policy, and did not develop or document the multidisciplinary weaning plan with specific parameters (start time, mode, duration, monitoring, and rest periods) as required by that policy.
The facility failed to ensure adequate nursing staffing and did not adjust staffing based on resident acuity, leading to delayed care for multiple residents. A high-acuity resident with chronic behavioral issues and a preference for lengthy nighttime bed baths routinely occupied CNAs for one to three hours, while other residents reported waiting extended periods for assistance, including one ventilator-dependent resident who waited about three hours for a brief change and another who waited 20–30 minutes on the commode. The facility also reduced PM shift CNA coverage on the sub-acute unit from two CNAs to one without an acuity assessment, despite most residents requiring two-person assistance, and staff and residents repeatedly reported that needs were not being met under this staffing pattern.
The facility failed to ensure that staff had required behavioral health competencies and ready access to policies and procedures. Activity assistants assigned to a behavioral health Special Treatment Program entered the unit to assess residents and revise care plans without documented completion of the facility’s required ProACT behavioral health training, despite a policy mandating such training for all staff performing direct care or daily duties on behavioral health units. In addition, multiple CNAs, LVNs, a RT, and unit managers were unable to locate or identify key facility policies, including those for ventilator weaning and resident showers, and reported relying on others or personal experience rather than written P&P. A professional reference cited in the report emphasized that policies must be reviewed, updated, and accessible to guide staff actions and protect resident rights.
Surveyors found that a popcorn machine used to serve residents was visibly soiled, with black and brown residue on the kettle lid, rim, and exterior, and a popcorn fragment left on the lid. Activity staff reported they were solely responsible for cleaning the machine and described using only water and disposable napkins or a sponge after use, acknowledging that residue likely remained. The dietary manager assistant and IP stated the machine should be cleaned after each use per the manufacturer’s instructions, which outline specific cleaning and advanced kettle-cleaning steps. Facility policies and job descriptions required that food service equipment be sanitized according to guidelines and manufacturer recommendations, but these were not followed, resulting in contaminated food-contact surfaces for residents.
The facility failed to maintain an effective infection prevention and control program when it did not promptly report an initial confirmed scabies case and subsequent cases in a short‑term unit to the LPHD and CDPH. A confirmed case occurred in late December, followed by multiple additional resident cases and two affected staff members, yet reporting to public health authorities was delayed. Facility policies defined an outbreak and assigned responsibility for reporting to the Administrator, and professional guidance from CDPH and CDC required reporting scabies outbreaks in healthcare settings. Despite these standards, delayed reporting contributed to ongoing transmission and an outbreak involving nine residents in the short‑term unit.
A resident's room had its HVAC supply vent covered with rubber material, with two pieces hanging loose due to a missing screw. This modification, made years earlier to address cold air complaints, was found to be a fire hazard and did not meet facility standards for a safe, clean, and homelike environment. The resident had multiple medical conditions and was fully dependent on staff for ADLs.
A resident with severe mobility limitations and a history of DVT missed a scheduled CT scan because the facility failed to inform the outside agency that a mechanical lift was required for transfers. The outside agency was unable to complete the scan due to lack of appropriate equipment, resulting in delayed care for the resident.
Surveyors identified multiple infection control deficiencies, including a resident's nebulizer tubing left on the floor instead of being stored in a bag, a washing machine with visible white buildup and unclear cleaning responsibilities, and an LPN not fully following disinfection protocols for a glucometer after use on a diabetic resident. Staff interviews and facility policies confirmed these actions did not meet infection prevention standards.
Four residents did not have complete or accurate care plans for their prescribed medications, including missing or incorrect interventions and lack of documented behaviors to monitor. Staff and nursing leadership confirmed that care plans were incomplete or not individualized, and facility policy requires comprehensive, person-centered care plans with ongoing assessment and monitoring.
Three CNAs did not receive required annual performance evaluations or competency checks, as confirmed by record review and staff interviews. The DSD, DON, and Administrator acknowledged that these evaluations and trainings were not completed as required, resulting in missed opportunities to monitor and improve staff performance.
Three residents received unnecessary medications due to the facility's failure to monitor lab values for those on valproic acid and improper administration of oxycodone-acetaminophen for pain levels not indicated in the physician's order. Staff did not follow pharmacy recommendations or facility policy, resulting in medication errors and lack of appropriate monitoring.
Surveyors identified a medication error rate of 14.81% due to four errors involving two residents. Errors included not instructing a resident to rinse her mouth after inhaler use, administering a diuretic over an hour late, giving a beta-blocker without food as ordered, and mixing a nutritional supplement in an unmeasured amount of water. Nurses confirmed these deviations from prescriber orders and facility policy, and the DON acknowledged that such failures could pose a safety risk.
Surveyors found that multiple medication carts contained liquid medications and eye drops that were not properly labeled with open dates or resident information. Nursing staff confirmed that open dates and resident labels were missing from several multiuse bottles and eye drop containers, despite facility policy requiring this information. Residents with various medical conditions, including cognitive deficits, were dependent on staff for correct medication administration, but labeling practices were not consistently followed.
Surveyors identified several food safety and storage deficiencies, including failure to monitor and record cooling temperatures for prepared tuna salad, improper use of beard nets by kitchen staff, wet storage of food processing equipment, improper storage of utensils and food items, and lack of labeling and dating for resident snacks brought from home. A resident was found with an unlabeled, expired snack in their room, and staff interviews confirmed lapses in following facility policies for food safety and labeling.
Surveyors found that several residents' POLST forms were incomplete or missing preparation dates, with some lacking required sections or signatures. Staff interviews confirmed that these omissions made the forms invalid as medical orders, and the facility's process for auditing and completing POLST forms failed to ensure accuracy and completeness. The deficiency affected residents with both intact and impaired cognition, and staff acknowledged that incomplete POLST forms could result in care not aligning with residents' wishes.
Two residents were fed lunch by CNAs who stood over them instead of sitting at eye level, contrary to facility policy and care plans. Both residents, one with severe cognitive impairment and another with quadriplegia, required meal assistance. Staff interviews confirmed that standing while feeding could make residents feel uncomfortable and disrespected, and that proper in-service training on feeding techniques was lacking.
A resident with multiple chronic conditions and intact cognition was not allowed to change his scheduled shower day from Friday to Saturday, despite repeated requests and documentation of his preference. Staff continued to offer showers on Fridays, which the resident refused due to post-dialysis fatigue, leading to red, dry, and itchy skin with self-inflicted scratches. Interviews confirmed that resident choice should have been honored, but the facility did not adjust the schedule, resulting in unmet hygiene needs.
A resident with severe cognitive impairment and multiple medical conditions was left feeling cold and uncomfortable in bed due to cold air blowing directly onto his face from a vent. Despite repeated complaints from the resident, his caretaker, and a CNA, and documentation in the maintenance log, the issue was not corrected by the maintenance department, resulting in ongoing discomfort and a failure to provide a homelike environment.
Two residents receiving tube feedings did not have their feeding bags labeled with the required date and/or time when the bags were hung. Nursing staff and the DON confirmed that labeling is necessary for safe administration and infection prevention, but observations showed this was not done as required.
A resident with a history of depression and anxiety experienced prolonged pain and discomfort due to ill-fitting dentures and an untreated bone spur after the facility failed to coordinate and follow up on recommended dental care. Despite documented dental evaluations and care plan interventions, the resident went without necessary dental services for over a year, and staff did not ensure timely referral or reestablishment of dental care after a hospital discharge.
Two kitchen staff members lacked proper competency and did not follow established portion control procedures, resulting in incorrect serving sizes for chopped meat and sandwich fillings. The facility did not provide clear portion size guidance for certain diets, and required training and competency evaluations were not completed or documented for the staff involved.
A resident's room was found cluttered with clothing and personal items stacked on mobility equipment, blocking access to the window and creating a safety and fire hazard. Staff interviews confirmed awareness of the ongoing issue and acknowledged that the area was not kept clear or organized, contrary to facility policy. The resident had multiple medical conditions and moderately impaired cognition, and the cluttered environment posed risks for falls and did not meet standards for a clean, home-like setting.
A resident in a persistent vegetative state, requiring total care, fell out of bed when a CNA attempted to turn them alone, despite the care plan requiring a two-person assist. The CNA cited the unavailability of another staff member, leading to the resident's fall. The facility's policies on fall prevention and resident safety were not followed, resulting in the incident.
A resident with a closed fracture of the left humerus was not reported to the police or Ombudsman by the LTC facility, despite the injury being of unknown origin. The facility's staff believed the injury was not caused by abuse, based on the resident's inconsistent responses and their own assessment. This failure to report was against the facility's policy, which mandates reporting all injuries of unknown origin to local, state, and federal agencies.
A resident with schizophrenia and anxiety disorder experienced neglect and verbal abuse from an LVN who used profane language and instructed staff not to assist the resident after a fall. The incident was corroborated by a mental health worker, while other staff provided varying accounts. The facility's policies emphasize treating residents with dignity and respect, and the investigation substantiated the abuse allegation against the LVN.
The facility failed to prevent the transmission of infections by storing expired COVID-19 test kits in the clean utility supply room. The Infection Preventionist and Central Supply staff did not ensure the kits were within their extended expiration dates, risking inaccurate test results.
A resident with mental health issues was physically abused by a Mental Health Worker (MHW) who pushed him during an attempt to de-escalate an agitated situation. The resident, who was yelling in his bathroom, pushed the MHW, who then responded by shoving the resident backward, causing mental anguish. The incident was witnessed by staff, and the MHW's actions were inconsistent with de-escalation training, violating the facility's abuse prevention policy.
The facility failed to conduct reference checks for a Mental Health Worker (MHW) before employment, leading to an incident where the MHW improperly handled a resident during a de-escalation attempt. The MHW's file lacked completed references, contrary to the facility's policy requiring reference checks for new hires.
The facility failed to report the findings of an abuse investigation to the Department within the required five-day period. A resident was involved in an incident where a Mental Health Worker attempted to de-escalate a situation, resulting in the resident being pushed and stumbling back. The facility's policy mandates reporting within five days, but the Administrator confirmed no follow-up report was submitted.
A resident with quadriplegia and stage four pressure ulcers experienced severe pain and bladder distension due to a malfunctioning catheter. The facility staff did not promptly address the resident's pain, resulting in significant discomfort for over two hours. Additionally, the resident's pressure ulcers were left uncovered, leading to urine leakage onto the wounds. The staff did not adhere to physician orders and facility policies regarding wound care and catheter management, including the failure to change compression dressings and monitor urinary output as directed. These actions compromised the quality of care and posed immediate jeopardy to the resident's well-being.
A resident admitted with acute respiratory failure and other conditions had an incomplete physician order for CPAP settings. Nursing staff did not verify the order, and the Director of Nursing and Administrator confirmed that the order should have included the PEEP settings.
The facility failed to maintain complete and accurate documentation for three residents who required turning and repositioning every two hours. Instead, records only showed repositioning every shift, contrary to the facility's policy and professional standards. Interviews with staff confirmed the necessity of the two-hour repositioning to prevent further skin breakdown and promote healing, yet the documentation did not reflect this standard of care.
Failure to Provide Behavioral Health Training, Review Policies Annually, and Implement Multidisciplinary Vent Weaning Plan
Penalty
Summary
The facility failed to follow its policy requiring behavioral health training for all staff working in the Special Treatment Program (STP) behavioral health unit. An anonymous complainant reported that Activity Assistants were being sent into the STP to assess residents’ activity needs without the required behavioral health training. The STP Director confirmed that all employees working in the STP were required to have behavioral health training for their safety and the safety of residents. The Director of Staff Development’s review of the behavioral health training records showed that two Activity Assistants were not listed as having completed the training, and he was unsure whether Activity Assistants were required to have it. During interviews, three Activity Assistants stated they were required to go into the STP unit to perform activity assessments and revise residents’ activity care plans; two of them reported they had requested behavioral health training due to safety concerns but had not received it. The Administrator later confirmed that only one Activity Assistant was documented as having any behavioral health training, and certificates showed partial training for two Activity Assistants and no training documentation for two others. The facility also failed to follow its own policy requiring annual review of policies and procedures. During review with the DON and Administrator, the facility’s policy titled “Ventilation, Weaning a Patient from Mechanical,” last dated 7/31/2017, was found to have no documented review since that date. The Administrator acknowledged that policies and procedures should be reviewed annually. Another facility policy titled “Facility Policy and Procedures – Annual Reviews,” last revised 10/2018, stated that policies and procedures are to be reviewed as needed and at least annually, with revisions made as necessary to reflect current operations, regulatory requirements, and accepted standards of care, and that the QAPI committee reviews and revises policies at least annually. In addition, the facility did not implement its ventilator weaning policy for a resident admitted for ventilator weaning. A complainant reported that this resident had been admitted nine months earlier for ventilator weaning, that weaning trials had stopped, and that neither the resident nor the complainant could obtain information on the facility’s ventilator weaning policy from Respiratory Therapists (RTs). Physician orders directed ventilator weaning “as tolerated” with documentation of tolerance and hours, and noted the resident’s Guillain-Barré Syndrome and the need for patience in weaning. RT documentation on one date indicated that cool mist was paused to wean off the ventilator until the following week for reevaluation, but the RT could not locate the required follow-up reassessment. One RT could not state the facility’s current ventilator weaning policy or how to access it and reported relying on personal experience. Another RT, when reviewing the written policy, stated she was unfamiliar with the requirement to develop a multidisciplinary weaning plan and had not used one. The policy required a multidisciplinary plan specifying start time, mode, duration of weaning trials, and monitoring and rest periods, but the resident’s ventilator weaning order entered by an RT lacked these specific elements and did not document the multidisciplinary participants.
Failure to Adjust Staffing for High-Acuity Resident and Sub-Acute Unit Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and appropriate staffing adjustments to meet all residents’ needs, particularly in the sub-acute unit and in relation to a high-acuity resident. The facility did not adjust staffing levels or care approaches despite longstanding knowledge that one resident required extensive staff time due to chronic behavioral issues and specific care preferences, such as lengthy nighttime bed baths and refusal to use the shower room. Care plans and staff interviews documented that this resident frequently raised her voice, verbally abused staff, used racial slurs, threw items, made false accusations, and demanded significant attention, including bed baths on shower days and hair washing at the sink. Multiple residents and staff reported that CNAs often spent one to three hours in this resident’s room, which reduced the time available to respond to other residents’ needs. The facility also reduced PM shift CNA staffing on the sub-acute unit from two CNAs to one without conducting or documenting an assessment of resident acuity or monitoring the impact of this change. The administrator stated the reduction was based on a census decrease from 23 to 17 residents and a determination that CNA hours had previously exceeded requirements while nursing hours were slightly below required levels. However, the unit manager and CNAs reported that most residents on the sub-acute unit required two-person assistance for care, and that the single CNA on PM shift struggled to meet all residents’ needs. Although the administrator stated an additional LVN was scheduled on PM shifts solely to assist with ADLs and documentation and not assigned direct nursing responsibilities, the LVN interviewed reported assisting with both CNA-type care and nursing duties, including toileting, charting, and assessments. These staffing decisions and lack of acuity-based adjustment led to specific delays in care for multiple residents. One ventilator-dependent resident with Guillain-Barré syndrome, chronic respiratory failure, tracheostomy, major depressive disorder, and anxiety, who was completely dependent for all ADLs and cognitively intact, reported waiting approximately three hours on two separate evenings for a CNA to respond to his call light and change a soiled brief. He stated that the CNA apologized and explained she had been busy with other residents. Another resident reported that nighttime bed baths for the high-acuity resident often caused her own bedtime to be delayed from her preferred 8:30 p.m. to around 10:00 p.m. A third resident stated she had to wait 20 to 30 minutes on the commode for assistance to get off because CNAs were occupied with the high-acuity resident, and she reported raising this issue multiple times in resident council. Resident council minutes documented complaints that another peer resident was taking too much CNA time and playing the TV too loudly. Staff, including the MDS coordinator, medical records director, and social services director, acknowledged hearing repeated complaints that other residents’ needs were not being met because of the time staff spent with the high-acuity resident, yet no documented staffing adjustment or systematic follow-up was made in response.
Failure to Ensure Behavioral Health Training and Staff Access to Policies and Procedures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff working in the behavioral health Special Treatment Program (STP) had the required behavioral health training, and that clinical and direct care staff could locate and reference facility policies and procedures. A complainant reported that Activity Assistants (AAs) were required to enter the STP to assess residents’ activity needs without having the required behavioral health training. The STP Director stated that all employees who worked in the STP were required to complete behavioral health training to ensure staff and resident safety. Review of the facility’s behavioral health training record with the Director of Staff Development showed that AA 1 and AA 3 were not listed as having completed the training, and AA 2 had only participated in the first day of a two‑day behavioral health training program. AA 1, AA 2, and AA 3 confirmed they were required to enter the STP for activity assessments and care plan revisions; AA 1 and AA 3 reported they had requested behavioral health training due to safety concerns but had not received it, despite having worked at the facility from several months to over two years. Further review of training documentation with the DON and Administrator confirmed that only AA 2 appeared on the training list, and that AA 1 and AA 2 had completed only day one of the behavioral health training, with no evidence of completion of day two. There was no documentation of any behavioral health training for AA 3 or AA 4. The facility’s policy titled “ProACT Training & Certification,” dated 8/28/2025, stated that Generations Healthcare provides Professional Assault Crisis Training (ProACT) to all staff involved in direct patient care within behavioral health units, including program staff, nursing staff (RN, LVN, CNA), STP staff, and ancillary staff responsible for daily job duties on behavioral health units where they may interact with behavioral health residents. The policy required all applicable staff providing direct patient care or completing daily job duties on behavioral health units to complete ProACT de‑escalation and restraint training within 90 days of hire. The deficiency also includes the inability of multiple staff members to locate or identify facility policies and procedures (P&P), including those related to ventilator weaning and resident showers. A Unit Manager stated that P&P could be found on the computer but was unable to locate a ventilator weaning policy. A Respiratory Therapist reported not knowing where facility P&P were kept, stated that P&P used to be in a binder whose location he did not know, and was unable to state the current ventilator weaning policy, relying instead on personal experience. Several CNAs and LVNs reported they did not know where P&P were stored and indicated they would ask a nurse or manager if they had questions. Another Unit Manager stated she could ask medical records for P&P. A professional reference from the American Association of Post‑Acute Care Nursing, cited in the report, described that policies should be reviewed annually, revised as regulations change, and stored with documentation of review dates and revision histories, and that policies ensure regulatory expectations are met, resident rights are protected, and staff actions are guided with clarity and consistency.
Improper Cleaning and Sanitation of Popcorn Machine Used for Resident Food Service
Penalty
Summary
Surveyors identified a deficiency related to food service sanitation when a popcorn machine used for residents was found visibly soiled and not properly cleaned and sanitized. During observation in the malt shop, the machine’s kettle lid was darkened with uneven black and brown residue, a popcorn fragment was present on the lid, the rim under the lid was stained with patchy black and brown residue, and the exterior of the kettle was covered with similar buildup. The popcorn cart was locked, and activity staff reported they were responsible for cleaning the machine after each use, stating it was cleaned with a sponge and water before being locked. Both the activity assistant and the activity director acknowledged during the observation that the popcorn machine was not clean due to the visible popcorn piece and residue. Additional staff interviews confirmed inconsistent and inadequate cleaning practices. One activity assistant stated they cleaned the popcorn machine after every use with water and a brown disposable napkin, wiping the kettle and lid but believing chemicals would be needed to remove the oily residue and that residue likely remained without thorough scrubbing. The dietary manager assistant and the infection preventionist each stated the popcorn machine should be cleaned after every use, per manufacturer’s guidelines, and that an unclean machine could pose an infection risk and make residents ill. Review of the manufacturer’s instructions showed specific cleaning and advanced kettle cleaning steps, and facility policies and job descriptions for the activity director and infection preventionist required that equipment be maintained in a clean, sanitary manner and that food service equipment be sanitized according to guidelines and manufacturer’s recommendations. The failure to follow these established procedures resulted in the popcorn machine remaining soiled while being used to prepare food for residents.
Failure to Timely Report and Control Scabies Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when it did not timely report an initial confirmed case of scabies and subsequent cases to the Local Public Health Department (LPHD) and the California Department of Public Health (CDPH). The Infection Preventionist’s (IP) Scabies Case/Contact Line List documented the first confirmed resident case with onset on 12/25/25, followed by additional resident cases with onset dates of 1/9/26, 1/12/26, 1/14/26, 1/20/26, 1/21/26, 1/29/26, 1/30/26, and 2/1/26, all occurring in the short‑term unit. The IP stated she did not report the scabies incidents to the LPHD until 1/12/26 and did not report the outbreak to CDPH until 2/6/26, despite the first confirmed case having been identified in December. The Administrator confirmed that the facility experienced a scabies outbreak in the short‑term unit. The DON stated that the first case occurred on 12/25/25 and that no additional cases were identified until 1/9/26, and also reported that two staff members assigned to the affected unit tested positive for scabies. Review of the facility’s policies showed that an outbreak is defined as one case of a highly communicable infection or three or more cases of the same infection over a specified period in a defined area, and that the Administrator is responsible for communicating data about reportable diseases to the health department. Professional references from the California Department of Public Health and CDC indicated that scabies outbreaks in healthcare settings should be reported to the local health officer and CDPH, and that multiple cases in such settings constitute an outbreak for reporting purposes. Despite these policies and guidelines, the facility did not report the initial confirmed case when it was identified, which allowed ongoing transmission and resulted in a scabies outbreak affecting nine residents in the short‑term unit.
Fire Hazard Created by Improper Vent Covering in Resident Room
Penalty
Summary
A deficiency was identified when the supply ventilation duct in a resident's room was found to be covered with three pieces of rubber material, two of which were loose and hanging from the ceiling. This modification was made by the facility three years prior in response to the resident's complaint of cold air coming through the vent. During the observation, it was noted that one screw was missing, causing the material to hang loosely. The maintenance assistant confirmed the material was rubber and was unaware if it posed a fire hazard. Both the director of maintenance and the administrator later acknowledged that the use of rubber material in this manner was a fire hazard and unacceptable. The resident involved had significant medical conditions, including rheumatoid arthritis, functional quadriplegia, a colostomy, muscle wasting and atrophy in both thighs, and atrial fibrillation. The resident was dependent on staff for all activities of daily living and had minimal to no cognitive impairment. The facility's policy required a safe, clean, and homelike environment, but the presence of the rubber material over the HVAC vent, especially with pieces hanging loose, failed to meet these standards and created a fire hazard as confirmed by professional references.
Failure to Communicate Resident's Mechanical Lift Requirement Led to Missed Diagnostic Appointment
Penalty
Summary
The facility failed to meet professional standards of quality for one resident when it did not adequately communicate the need for a mechanical lift to an outside agency prior to a scheduled CT scan appointment. The resident, who had a history of Rheumatoid Arthritis, functional quadriplegia, and was completely dependent for activities of daily living, required a mechanical lift for all transfers. Despite this, the referral sent to the outside agency did not specify the need for a mechanical lift, resulting in the outside agency being unprepared to safely transfer the resident from her Geri Chair for the CT scan. On the day of the appointment, the resident was transported to the outside agency, but the staff there were unable to complete the CT scan because they did not have a mechanical lift or staff trained to use such equipment. As a result, the CT scan was canceled, and the resident was returned to the facility without receiving the scheduled imaging. This led to a delay in the assessment and management of the resident's deep vein thrombosis (DVT) in her right leg. Interviews with facility staff, including the Unit Manager, Director of Social Services, Director of Nursing, and Administrator, confirmed that it was standard practice to communicate all pertinent information, including required transfer devices, to outside agencies when arranging appointments. Review of the resident's care plan and medical records further documented her total dependence and need for a mechanical lift. The facility's policy also required coordination and communication of such needs, but this was not followed in this instance, directly resulting in the missed appointment and delayed care.
Infection Control Failures in Equipment Handling and Cleaning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in several instances. In one case, a resident with a tracheostomy and chronic respiratory failure was found with nebulizer tubing on the floor of their room, rather than stored in a bag as required by facility policy. Multiple staff members, including nursing and restorative staff, confirmed that the tubing should not have been on the floor and that this presented a risk of cross-contamination. Facility policies and job descriptions reviewed also indicated that equipment should be kept off the floor and stored properly to prevent infection. In another instance, the facility's laundry area was observed to have a white substance buildup on and around the front-loading door and handle of a washing machine. Laundry and maintenance staff were unsure of the nature of the buildup or when the machines were last serviced or cleaned. The maintenance director acknowledged the importance of cleaning the machines for infection control, and the housekeeping director noted the potential for cross-contamination if the buildup came into contact with residents' clothes. No maintenance logs for the washing machines were provided during the survey, and facility documents indicated that cleaning and inspection of laundry equipment were required. Additionally, a licensed vocational nurse did not properly clean and disinfect a glucometer after use on a resident with diabetes. The nurse cleaned the device with a bleach wipe and allowed it to dry, but did not follow the full disinfection protocol as described by other staff and the infection preventionist, which included wrapping the device in a bleach wipe for a specified dwell time. Facility policy and manufacturer guidelines required thorough cleaning and disinfection between resident uses to prevent the spread of infection. Interviews with other nursing staff and the infection preventionist confirmed the correct procedure and the importance of adhering to it.
Failure to Develop and Implement Comprehensive Medication Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, resulting in incomplete or inaccurate documentation and monitoring of medication administration and associated behaviors. For one resident prescribed divalproex sodium for schizophrenia, the care plan incorrectly included interventions for lithium instead of divalproex sodium, omitting necessary monitoring for side effects such as weight loss, loose stools, and drowsiness. Both the LVN and DON confirmed that the care plan should have been individualized and specific to the medication being administered. Another resident receiving escitalopram for depression and anxiety did not have documented behaviors to be monitored in the care plan. The care plan lacked details on what behaviors staff should observe, which was acknowledged by the LVN as an important omission for effective monitoring and updating of care. Similarly, a resident on olanzapine for psychosis and other mental health conditions had a care plan that was missing specific behaviors to monitor, with both LVNs and the DON confirming that the absence of target behaviors rendered the care plan incomplete and insufficient for guiding staff in monitoring the medication's effectiveness. Additionally, a resident prescribed apixaban for DVT prophylaxis did not have a care plan addressing the need to monitor for side effects such as bleeding, bruising, or lightheadedness. The LVN and DON both stated that a care plan was required for all residents on anticoagulants and should include monitoring parameters. The facility's policies and procedures require comprehensive, individualized care plans with measurable objectives and ongoing assessments, but these requirements were not met for the residents identified in the report.
Failure to Complete Annual CNA Performance Evaluations and Competency Checks
Penalty
Summary
The facility failed to ensure that three out of five sampled Certified Nursing Assistants (CNAs) received their required annual performance evaluations and competency checks. Record reviews and interviews with the Director of Staff Development (DSD) revealed that CNAs did not have documented performance evaluations for the year 2024, with the last evaluations and skills competency checks occurring more than a year prior. The DSD confirmed that annual evaluations and trainings were not completed as required, and that it was their responsibility to ensure these were done. The DSD also acknowledged that annual in-services and performance evaluations are necessary to identify areas for improvement and to maintain staff competency. Further interviews with the Director of Nursing (DON) and the Administrator confirmed that annual evaluations for job performance and competency were not being conducted as expected. Both acknowledged that without these evaluations, the facility would not be able to monitor staff performance, identify weaknesses, or ensure staff competency. Review of the facility's policy indicated that competency requirements and training for nursing staff should be regularly monitored and gaps in education addressed, but this was not being followed.
Failure to Monitor and Administer Medications Appropriately
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, as evidenced by the lack of appropriate monitoring and administration of medications for three out of seven sampled residents. Two residents who were prescribed valproic acid did not have liver function tests (LFTs) ordered or monitored as required. Despite recommendations from the consultant pharmacist and facility policy, there were no documented LFTs for these residents, and staff did not act on pharmacy recommendations to initiate this monitoring. Interviews with nursing staff and the Director of Nursing confirmed that LFTs should have been ordered and monitored to detect potential adverse effects of valproic acid, but this was not done. For one resident, the medication administration record showed that oxycodone-acetaminophen, which was ordered for moderate to severe pain, was administered for mild pain and even when the resident reported no pain. The nurse administering the medication acknowledged that the drug should not have been given for pain levels of 0-3, and that this constituted a medication error. The Director of Nursing also confirmed that the medication was not administered according to the physician's order and that staff failed to follow the prescribed protocol for pain management. The facility's own policies and procedures required monitoring for adverse consequences of psychotropic medications and adherence to prescriber orders for medication administration. However, these protocols were not followed in the cases reviewed. The lack of appropriate lab monitoring for residents on valproic acid and the improper administration of pain medication resulted in residents receiving unnecessary drugs and medication errors, as documented by staff interviews, record reviews, and policy references.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with surveyors identifying a rate of 14.81 percent based on 27 observed opportunities and four medication errors involving two residents. One resident with chronic obstructive pulmonary disease, sleep apnea, and mild persistent asthma was administered a fluticasone propionate and salmeterol inhaler but was not instructed to rinse her mouth afterward, as required by the prescriber order. The nurse present did not prompt the resident to rinse, and later acknowledged that failing to do so could result in white patches in the mouth and potential respiratory tract infection. Another resident with diagnoses including congestive heart failure, morbid obesity, chronic ulcer, and hypertension experienced three medication errors. This resident received Bumetanide over an hour later than the scheduled administration time, contrary to the prescriber order specifying an 8:00 a.m. dose. The same resident was also given Carvedilol without food, despite the order to administer it with food, and was provided a nutritional supplement mixed in an unmeasured amount of water rather than the prescribed four ounces. The nurse involved confirmed these deviations from the orders and explained the importance of adhering to the specified administration instructions. Facility policy and job descriptions reviewed by surveyors indicated that medications are to be administered according to prescriber orders, within one hour of the scheduled time, and with proper verification of the five rights of medication administration. The Director of Nursing stated that the expectation is for nurses to follow these policies and procedures, and acknowledged that failure to do so could pose a safety risk.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications in the facility. In two of six medication carts, several liquid medications, including multiuse bottles of acetaminophen, lactulose, and nystatin, were found without open dates. This was confirmed during observations with nursing staff, who acknowledged the importance of dating multiuse bottles to prevent administration of expired medications. Review of medication orders for several residents confirmed that these undated medications were actively prescribed and in use. Additionally, five of eleven eye drop bottles in one medication cart lacked patient-specific labels, and in another cart, three open bottles of eye drops for three different residents were not labeled with resident information or open dates. In these cases, the medication boxes were labeled, but the bottles themselves were not, raising concerns about the potential for misidentification if the bottles became separated from their boxes. Interviews with nursing staff and the DON confirmed that facility policy requires both the box and bottle to be labeled with resident information and open dates, and that failure to do so could result in medication errors. Resident interviews revealed that some residents were unaware of the specific medications they were receiving and relied on nursing staff for correct administration. Documentation showed that these residents had various medical conditions, including severe cognitive deficits, heart failure, diabetes, and chronic pain, which increased their dependence on staff for safe medication administration. Facility policy and procedures reviewed by surveyors further confirmed the requirement for proper labeling and dating of all medications, which was not consistently followed in these instances.
Multiple Food Safety and Storage Deficiencies Identified
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards, as evidenced by multiple observations and staff interviews. Kitchen staff did not monitor or record the temperature during the cooling process after preparing tuna salad from ingredients at room temperature. The tuna salad was placed in the refrigerator without temperature checks, and subsequent temperature readings showed it was above the recommended safe temperature. The facility's policies required monitoring of time and temperature for potentially hazardous foods, but staff were not following these procedures for items like tuna salad prepared from ambient ingredients. Additional deficiencies were observed in food safety practices among kitchen staff. Staff members preparing and handling food did not wear beard nets, leaving facial hair exposed while pouring juice and handling equipment. Equipment such as robot coupes were stored wet, with pooled water and condensation, contrary to expectations for air drying. A serving scoop was found stored inside a dry storage bin containing thickener, and a box of hash brown potatoes was stored directly on the floor of the walk-in freezer, both in violation of facility policy and FDA Food Code requirements for utensil and food storage. There was also a failure to properly label and date food items brought in by family members for residents. An opened box of crackers was found in a resident's room without a name or open date, and the resident reported the item had been there for over three months. Staff interviews confirmed that snacks should be labeled with the resident's name and date to prevent expired or incorrect food from being consumed. The facility's policy required clear labeling and storage of food brought by visitors, but this was not followed in the observed case.
Incomplete and Undated POLST Forms Compromise Medical Record Accuracy
Penalty
Summary
The facility failed to ensure that Physician Orders for Life-Sustaining Treatment (POLST) forms were accurate and complete for seven of twelve sampled residents. Surveyors found that multiple POLST forms were missing critical information, such as the date the form was prepared, physician or responsible party signatures, and completion of required sections. These omissions were identified during record reviews and interviews with staff, including the Admissions Nurse (AN) and Minimum Data Set Nurse (MDSN), who both acknowledged that the missing information rendered the POLST forms incomplete and invalid as medical orders. Specific examples included residents with intact cognitive function, such as those with schizoaffective disorder and chronic illnesses, whose POLST forms lacked preparation dates despite having resident signatures. Other residents with severe cognitive impairment or in persistent vegetative states also had undated or incomplete POLST forms, with some missing both the preparation date and required sections indicating the level of medical intervention desired. Staff interviews confirmed that the AN was responsible for completing the POLST forms upon admission, and that medical records were supposed to audit these forms for completeness, but this process failed to ensure all required fields were filled. Nursing staff, including LVNs and the DON, stated that the POLST forms are essential for guiding care during emergencies and that incomplete forms could result in staff not knowing the resident's wishes regarding life-sustaining treatment. The facility's own policy indicated that if a POLST or DNR order was not properly completed and signed, residents would be treated as Full Code. The surveyors' findings demonstrated that the facility did not maintain medical records in accordance with accepted professional standards, as required.
Failure to Provide Dignified Dining Experience During Meal Assistance
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide a dignified dining experience for two residents by standing while feeding them during lunch, rather than sitting at eye level as required by facility policy. Observations showed that one CNA stood over a resident with severe cognitive impairment and multiple neurological diagnoses, speaking to the resident while feeding her, and another CNA stood while feeding a resident with quadriplegia and contractures, who was cognitively intact. Both CNAs acknowledged during interviews that they should have sat at eye level and recognized that standing could make residents feel uncomfortable, rushed, or disrespected. Resident interviews confirmed these concerns, with one resident expressing discomfort and a sense of disrespect when staff stood while feeding her. The CNAs involved were unsure of the last time they received in-service training on proper feeding techniques. The residents' care plans indicated the need for assistance with meals, and the facility's policy specified that residents should be assisted with meals in a manner that ensures safety, comfort, and dignity, explicitly stating not to stand over residents while feeding them. Interviews with nursing staff and the Director of Nursing further confirmed that sitting at eye level during meal assistance is necessary to maintain resident dignity and comfort. Staff acknowledged that standing over residents during feeding could negatively impact their psychosocial well-being and diminish the sense of human connection and compassion. The failure to follow these practices resulted in a violation of the residents' rights to dignity and respect during mealtimes.
Failure to Honor Resident's Shower Day Preference Resulting in Skin Issues
Penalty
Summary
The facility failed to honor a resident's right to make choices about aspects of his life, specifically regarding his preferred shower schedule. The resident, who had diagnoses including end stage renal disease, diabetes mellitus, heart failure, hypertensive heart disease, pain, and a history of falls, was cognitively intact and expressed a clear preference for showers on days that did not coincide with his dialysis treatments. Despite his requests to have showers on Saturdays instead of Fridays, the facility continued to schedule his showers on Fridays, which he consistently refused due to fatigue from dialysis. Documentation in the resident's care plan indicated that his wishes regarding shower days should be honored, and staff interviews confirmed that residents have the right to choose their shower days. However, progress notes repeatedly documented the resident's refusals of showers and bed baths on Fridays, with staff offering alternatives but not addressing the underlying issue of the resident's preferred schedule. The resident reported notifying CNAs and nurses about his preference, but no changes were made to accommodate his request. As a result of not receiving showers on his preferred days, the resident developed red, dry, and itchy skin on his upper chest and arms, leading to self-inflicted scratches and open skin. Staff interviews acknowledged the importance of honoring resident choices and the potential for skin issues when hygiene needs are not met, but there was a lack of follow-through in modifying the shower schedule to align with the resident's wishes, as required by facility policy and resident rights.
Failure to Address Resident Discomfort from Air Vent
Penalty
Summary
A deficiency occurred when the facility failed to provide a comfortable and homelike environment for a resident with severe cognitive impairment and multiple medical conditions, including encephalopathy, dysphagia, Parkinson's disease, anemia, and a thyroid neoplasm. The resident repeatedly experienced discomfort due to cold air blowing directly onto his face from a vent above his bed. Observations confirmed that the air from the vent caused visible movement of objects near the resident's bed, and both the resident's caretaker and a CNA reported that the issue had been ongoing and unresolved, despite being reported to maintenance. The maintenance department was aware of the problem, as documented in the facility's deficiency report and maintenance log, but no corrective action had been taken to address the resident's complaint. The Maintenance Director acknowledged that the vent could be easily adjusted to prevent air from blowing on the resident and expressed that the current situation did not meet expectations for a homelike environment. The facility's own policy emphasized the importance of person-centered care and maintaining comfortable and safe temperatures, which was not upheld in this instance.
Failure to Label Tube Feeding Bags with Date and Time
Penalty
Summary
The facility failed to meet professional standards of practice for two residents receiving tube feedings. For one resident, the tube feeding (TF) bag was not labeled with the date it was hung, and for another resident, the TF bag was not labeled with the time it was hung. These omissions were observed during routine checks in the residents' rooms, where the TF bags lacked the required labeling, and staff confirmed that the bags should have been marked with both date and time when set up. Interviews with nursing staff revealed that the TF bags are required to be changed every 24 hours and should be labeled to indicate when they were last changed. Staff acknowledged that without proper labeling, it would be unclear when the TF was started or if it had been in use for too long. The Director of Nursing also confirmed that labeling the TF bags with date and time is a safe practice, aligns with manufacturer guidelines, and is necessary for infection prevention. Both residents involved had significant medical histories, including severe cognitive impairment, respiratory failure, and conditions requiring enteral nutrition via tube feeding. The facility's policy and procedure for enteral nutrition required nurses to confirm complete orders and follow administration instructions, but the observed lack of labeling on the TF bags indicated a failure to adhere to these professional standards.
Failure to Provide Routine Dental Services and Timely Follow-Up
Penalty
Summary
The facility failed to provide routine dental services to meet the needs of a resident who had treatment recommendations for removal of a bone spur and a new set of dentures. Despite documented dental evaluations and recommendations from the contracted dental office, no action was taken by the facility for over 17 months, leaving the resident without necessary dental intervention. The resident repeatedly reported discomfort and pain due to ill-fitting dentures and a bone spur, and staff were informed of these issues. The resident, who has a history of major depressive and anxiety disorders, expressed a desire to wear dentures for improved self-esteem but was unable to do so due to pain and improper fit. The care plan identified the risk for gum irritation and difficulty chewing, with interventions to monitor and refer to dental services as needed. However, the facility did not follow through with these interventions, and the resident continued to experience discomfort and dissatisfaction with her dental condition. Interviews with facility staff revealed that the resident was discharged from the dental provider's census following an acute hospital visit and was not readmitted to dental services upon return to the facility. The Social Services Director acknowledged responsibility for coordinating dental care and reviewing dental notes but failed to ensure follow-up on the resident's dental needs. The facility's policy required timely referral and documentation for dental issues, but these procedures were not followed, resulting in prolonged lack of dental care for the resident.
Failure to Ensure Food Service Staff Competency and Portion Control
Penalty
Summary
The facility failed to ensure that two kitchen staff members had the appropriate competencies and skill sets to safely and effectively carry out the functions of the food and nutrition service. One staff member used a #12 scoop (2.67 ounces) to portion chopped hamburger meat for residents on prescribed chopped diets, despite the menu not specifying portion sizes for chopped meat. The Dietary Services Supervisor later confirmed that the correct portion for a regular chopped hamburger should have been 3 ounces, which would require a #10 scoop. The staff member had been employed for eight years, but there was no evidence of completed job competency evaluations in her personnel file. The Registered Dietitian stated that staff were expected to follow recipes and portion sizes, and that regular chopped diets should match regular diet portions. However, there was no documentation of training or competency checks for this staff member. Another staff member prepared tuna and egg salad sandwiches using a plastic spoon to measure the filling, resulting in inconsistent portion sizes. The Dietary Services Supervisor indicated that a #8 scoop (1/2 cup) should have been used, as per facility policy and posted recipes. The staff member had not received the relevant in-service training, and there was no job competency documentation in her personnel file. The facility's policy required periodic training and competency-based assessments for food and nutrition services staff, but these were not completed for the staff involved. These failures were observed during meal service and through interviews and record reviews. The lack of clear portion size guidance for chopped diets, absence of documented training and competency evaluations, and failure to follow established portion control procedures led to the deficiency. The Registered Dietitian and Dietary Services Supervisor both acknowledged gaps in staff training and documentation.
Cluttered Resident Room Creates Safety and Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for one resident when a bag of adult diapers, multiple t-shirts, sweaters, and jackets were stacked on top of a walker and wheelchair at the foot of the hospital bed, blocking access to the window. Observations confirmed that the resident's room was cluttered, with additional clothing hanging on a doorknob and loose adult diapers present. Interviews with staff, including the Director of Social Services, CNA, LVN, and DON, revealed that the resident had a history of accumulating items, and staff were aware of the ongoing issue but did not ensure the area was kept clear and organized as required by facility policy. The resident involved had a history of chronic kidney disease, pain, hypertension, anxiety, depressive disorder, and hyperlipidemia, and was assessed as having moderately impaired cognition. Staff interviews acknowledged that the cluttered area posed a safety risk, including the potential for falls and fire hazards, and did not provide a home-like environment. The facility's policy required a clean, sanitary, and orderly environment, but staff did not follow these procedures, resulting in a cluttered and unsafe resident area.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who required a two-person assist for turning and repositioning. During a brief change, a CNA attempted to turn the resident alone, resulting in the resident falling out of bed. The resident, who was in a persistent vegetative state and required total care, was dependent on staff for all activities of daily living, including bed mobility. The resident's care plan clearly indicated the need for two staff members to assist with turning and repositioning due to the resident's condition and risk of falling. Despite this, the CNA proceeded without assistance, citing the unavailability of another staff member. This action was contrary to the facility's policy and the resident's care plan, which emphasized the necessity of two-person assistance to prevent accidents. The incident was reviewed by the facility's interdisciplinary team, which identified the root cause as the CNA's failure to follow the care plan. The facility's policies on fall prevention and resident safety were not adhered to, leading to the resident's fall. The resident was subsequently evaluated in the emergency department and found to be stable, with no acute medical emergencies identified.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy regarding the reporting of injuries of unknown origin, as evidenced by the case of a non-verbal and non-mobile resident who sustained a closed fracture of the left humerus. The injury was not reported to the Police Department or Ombudsman within the required timeframe, as mandated by law. This oversight was discovered during interviews and record reviews, revealing that the facility did not follow its own procedures for reporting such incidents to all relevant local and state authorities. The resident in question, who is non-verbal and non-mobile, was found with a fracture in the upper left arm. Despite the resident's limited ability to communicate, it was noted that he could respond to yes or no questions using his right index finger. During an interview, the resident indicated fear of the Director of Nursing (DON) but denied any physical harm. The facility's staff, including the DON and Administrator, believed the injury was not caused by abuse, based on the resident's inconsistent responses and their own assessment, and thus did not report it to the police or Ombudsman. The facility's policy, as reviewed, clearly states that all reports of resident abuse, including injuries of unknown origin, must be reported to local, state, and federal agencies. However, the facility failed to implement this policy, resulting in a delay in investigation by outside agencies. This failure had the potential to result in undiscovered resident abuse, thereby putting all residents at risk. The DON later acknowledged that the injury should have been reported to the police and Ombudsman, as per the facility's policy.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse, neglect, and exploitation when an LVN used profane language towards the resident and instructed staff not to assist the resident after an unwitnessed fall. The resident, who had a history of schizophrenia and anxiety disorder, reported slipping onto the floor and expressed that the LVN was mean and yelled at him. The incident was corroborated by a mental health worker who witnessed the LVN using vulgar language and diminishing the resident, instructing another LVN not to document the incident as a fall. Interviews with various staff members revealed differing accounts of the incident. A CNA stated that the resident was verbally abusive towards staff, while another CNA confirmed that the LVN used inappropriate language and instructed staff not to assist the resident further. The LVN denied using profane language but admitted to instructing the CNAs not to assist the resident further, citing the resident's manipulative behaviors. The LVN reported the incident to another LVN, who did not assess the resident for a fall and marked the behavior as attention-seeking. The facility's policies and procedures emphasize the importance of treating residents with dignity, respect, and compassion, and prohibit the use of profanity or derogatory language in the workplace. The facility's investigation substantiated the allegation of abuse against the LVN, highlighting a failure to adhere to the standards of conduct and resident rights policies. The incident underscores the need for staff to maintain professionalism and provide appropriate care, regardless of a resident's behavior.
Expired COVID-19 Test Kits Found in Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections. During an observation and interview, it was found that two boxes of [brand name] Covid-19 self-test kits, each containing 48 tests, were expired in the clean utility supply room. The expiration date on the boxes had passed, and although the FDA had extended the expiration date for these kits, the extended date had also passed. This oversight had the potential to produce inaccurate Covid-19 test results. The Infection Preventionist (IP) acknowledged that the Central Supply staff was responsible for checking the expiration dates before storing the kits for use. The Director of Nursing (DON) confirmed that it was the IP's responsibility to ensure the kits were not expired to guarantee accurate results. The facility's job description for the IP and its policy on infection prevention and control measures emphasized the importance of following guidelines to prevent the transmission of COVID-19. However, the failure to adhere to these guidelines resulted in the presence of expired test kits in the facility.
Resident Abused by Mental Health Worker
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Mental Health Worker (MHW) placed his hands on the resident's shoulders and shoved him backward. This incident occurred after the resident, who was in an agitated state, was yelling in his bathroom. The MHW attempted to de-escalate the situation but ended up pushing the resident after being pushed himself. This action caused the resident to stumble backward, resulting in mental anguish, including feelings of intimidation, threat, and increased agitation. The resident involved had a history of mental health issues, including Schizoaffective Disorder, Obsessive-Compulsive Disorder, restlessness, agitation, and an anxiety disorder. These conditions contributed to the resident's behavior, which included yelling and pushing the MHW. The incident was witnessed by other staff members, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), who confirmed the sequence of events and the inappropriate response by the MHW. The facility's policy on abuse prevention emphasizes providing an environment free from abuse and retaliation. However, the MHW's actions violated this policy, as he engaged with the resident in a manner inconsistent with de-escalation training. The MHW's behavior was deemed unprofessional and intimidating, leading to the resident's increased agitation and subsequent aggressive behavior towards other staff members.
Failure to Conduct Reference Checks for MHW
Penalty
Summary
The facility failed to check the references of a Mental Health Worker (MHW) prior to employment, which resulted in the potential for an unqualified employee to provide care to residents. This deficiency was identified during a review of the facility's records and interviews with staff. The MHW was involved in an incident where they attempted to de-escalate a resident who was yelling in the bathroom. During the interaction, the resident pushed the MHW, who then responded by pushing the resident back, causing the resident to stumble. This incident was documented in a report of suspected elder abuse submitted to the Department. Further investigation revealed that the MHW's employee file contained two Pre-Employment Reference Check (PERC) documents with names and telephone numbers of former employers, but the references were not completed. The Director of Staff Development and the Staffing Coordinator confirmed that the references were missing and acknowledged that it was the facility's policy to conduct reference checks on new hires. The facility's policy and procedure on background checks required obtaining two references after interviewing a candidate, which was not followed in this case.
Failure to Report Abuse Investigation Findings Timely
Penalty
Summary
The facility failed to report the findings of an investigation of an abuse allegation to the Department within the required five-day period. The incident involved a resident who was observed yelling in his bathroom, and a Mental Health Worker (MHW) attempted to de-escalate the situation. During the interaction, the resident pushed the MHW, who then responded by pushing the resident with two hands on each shoulder, causing the resident to stumble back. The facility's policy and procedure require that a completed copy of all investigation findings and documentation forms be provided to the Administrator and other officials within five working days of the incident. However, during an interview, the Administrator admitted that there was no five-day follow-up report submitted, indicating a failure to comply with the facility's reporting policy.
Deficiencies in Pain Management, Urinary Output Monitoring, and Wound Care
Penalty
Summary
The facility failed to provide appropriate treatment and care to Resident #1 in accordance with physician orders, resident preferences, and facility policies. The deficiencies identified included the failure to monitor urinary output as ordered, delayed response to Resident #1's complaint of severe pain, and inadequate treatment of the resident's stage four pressure ulcers. Resident #1, admitted with diagnoses including quadriplegia and stage four pressure ulcers, experienced severe pain and bladder distension due to a malfunctioning catheter. Staff did not address the resident's pain promptly, leading to significant discomfort for over two hours. The resident's pressure ulcers were left uncovered, resulting in leakage of urine onto the wounds, potentially causing serious clinical complications. The deficiency was further exacerbated by the lack of adherence to physician orders and facility policies regarding wound care and catheter management. Despite clear directives in the resident's care plan and order summary report, staff failed to change the resident's compression dressings as ordered by the physician. The facility's policies on wound care and catheter management were not followed, as evidenced by the inadequate monitoring of urinary output, delayed response to pain complaints, and failure to cover the resident's pressure ulcers as directed. These deviations from established protocols and physician orders compromised the quality of care provided to Resident #1, leading to potential harm and serious injury. The deficiencies identified in the facility's care of Resident #1 were deemed to pose immediate jeopardy to the resident's well-being, as outlined in the State Operations Manual. The failure to address the resident's pain promptly, monitor urinary output, and provide appropriate treatment for pressure ulcers not only violated regulatory requirements but also put Resident #1 at risk of harm, impairment, or even death. The facility's non-compliance with essential care standards highlights critical gaps in staff training, communication, and adherence to established protocols, underscoring the need for comprehensive corrective actions to prevent similar deficiencies in the future.
Incomplete Physician Order for CPAP Settings
Penalty
Summary
Resident #304 was admitted to the facility on 02/23/2024 with diagnoses including acute respiratory failure with hypoxia, asthma, and morbid obesity. The resident's care plan indicated the use of a CPAP device at bedtime, but the physician's order dated 02/24/2024 did not specify the PEEP setting for the CPAP/APAP device. Licensed Vocational Nurse #7 acknowledged that staff did not verify the completeness of the physician's order. The Respiratory Therapist stated that it was the nursing staff's responsibility to ensure the order was complete. The Director of Nursing confirmed that the CPAP/APAP PEEP settings were not adjusted by nurses and emphasized that the physician's order should include these settings. The Administrator also stated that nurses should verify the physician-ordered PEEP setting before applying the CPAP to the resident.
Failure to Document Required Turning and Repositioning
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible documentation of records for three residents who required turning and repositioning every two hours. The deficiency was identified through observation, interview, and record review, revealing that the facility was unable to provide documentation of the required turning and repositioning for Residents 1, 2, and 3. Instead, the facility only had documentation indicating that the residents were turned and repositioned every shift, which is every eight hours, contrary to the facility's policy and professional standards that mandate every two-hour intervals to prevent pressure ulcers (PUs). Resident 1 was admitted with multiple severe conditions, including respiratory failure, subarachnoid hemorrhage, cerebral aneurysm, cerebral edema, tracheostomy, gastrostomy, and a stage 4 pressure ulcer on the sacral region. Despite the care plan and medical orders requiring turning and repositioning every two hours, the facility's records only showed repositioning every shift. Interviews with the LVN, MD, and CNAs confirmed the necessity of the two-hour repositioning to prevent further skin breakdown and promote healing, yet the documentation did not reflect this standard of care. Similarly, Resident 2, with a history of Alzheimer's, diabetes, Parkinsonism, end-stage renal disease, and a stage 4 pressure ulcer, also required turning and repositioning every two hours. However, the facility's documentation only indicated repositioning every shift. Resident 3, who had a history of nontraumatic intracerebral hemorrhage, chronic respiratory failure, tracheostomy, dependence on a respirator, and a persistent vegetative state, faced the same issue. The Director of Nursing and the Administrator acknowledged the lack of proper documentation, admitting that the facility did not maintain medical records that were complete, accurate, and readily accessible for the required two-hour turning and repositioning.
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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