Kingsburg Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsburg, California.
- Location
- 1101 Stroud Ave, Kingsburg, California 93631
- CMS Provider Number
- 055573
- Inspections on file
- 28
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Kingsburg Center during CMS and state inspections, most recent first.
A resident with a complex medical history, including TBI and a VP shunt, was found on an air loss mattress set to 245–285 lbs despite weighing 124.4 lbs. The NM confirmed the setting was incorrect and that no physician order for the mattress could be located. An LVN assigned to the resident acknowledged she did not know the correct settings, had not been checking weight settings, and later verified the resident’s actual weight in the record. The DSD stated staff were supposed to be trained on air loss mattress use and weight-based settings but could not produce training or in-service records for the LVN or the RN who had cared for the resident at the time of a prior fall. The ADM reported there was no facility policy for air loss mattress use, that staff were expected to follow the manufacturer’s instructions, and that the mattress settings used were not aligned with those instructions.
A resident with multiple comorbidities experienced leg discoloration and swelling, prompting a physician order for a vascular consult and leg elevation. Nursing staff failed to schedule the consult, did not complete required weekly assessments, and did not document changes in condition as required. These failures delayed appropriate care, resulting in the resident being hospitalized for a DVT and requiring surgical intervention.
A resident with dementia and moderate cognitive impairment eloped from the facility due to the failure to conduct a quarterly elopement assessment and implement necessary interventions. The resident was found outside in a confused state, highlighting inadequate supervision and the absence of a security bracelet, which was only applied after the incident.
A long-term care facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. A resident's oxygen tubing was improperly stored, increasing infection risk. Another resident's medication syringe was not cleaned properly, posing a bacterial infection risk. Additionally, a CNA did not wear appropriate PPE while caring for a resident on enhanced precautions. These actions were contrary to the facility's policies and professional guidelines.
The facility did not post the results of the most recent survey in an accessible location for residents and their representatives. The State Survey Binder, located near the DON's office, lacked the results of the last recertification survey. Both the ADM and DON confirmed the omission, acknowledging that the results should have been available. This failure potentially violated residents' rights to access survey results as per the facility's policy.
The facility failed to employ a full-time dietitian or qualified dietetic services supervisor, leading to inadequate oversight of food service operations. The Registered Dietitian provided limited consultation, primarily focusing on clinical work, and did not review or approve the facility menu. This lack of oversight resulted in issues with kitchen staff competency, menu adherence, and food preparation, placing residents at risk for compromised nutrition.
The facility failed to follow the planned menu, serving incorrect items and portions to residents, including serving steamed spinach instead of creamed spinach, using the wrong scoop size for mechanical diced ham, and providing fortified mashed potatoes instead of whipped sweet potatoes. A resident on a vegetarian diet was repeatedly served egg salad, contrary to the planned menu. The Registered Dietitian had not reviewed the menu, and the kitchen staff did not adhere to the expected guidelines.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. One resident, admitted with an indwelling urinary catheter, lacked a care plan for its management. Another resident, treated for a UTI, did not have a timely care plan to monitor their condition. The facility's policy required individualized care plans, but these were not implemented, resulting in potential unmet care needs.
A long-term care facility experienced a medication error rate of 6.9%, exceeding the acceptable threshold. One resident did not receive metformin due to unavailability, potentially affecting blood sugar levels. Another resident had a lidocaine patch applied for over 12 hours, contrary to physician orders, risking skin irritation. The facility's policies on medication administration and ordering were not adhered to, contributing to these deficiencies.
The facility failed to properly label and store medications, affecting three residents. Two residents' medications lacked expiration date labels, and a resident's insulin pen was missing a label, risking incorrect administration. Additionally, loose pills were found on the floor in a medication storage room, increasing the risk of medication errors.
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents. A resident was given escitalopram for depression without consent until late August, while another received sertraline without complete consent. A third resident was administered buspirone for anxiety without valid consent. The facility's policy requires informed consent before starting such medications, which was not followed.
The facility failed to maintain professional standards in medication management for two residents. One resident continued to be monitored for side effects of a discontinued anticoagulant, leading to inaccurate documentation. Another resident's medications were prepared by an LVN but administered by an IP, contrary to policy, risking medication errors. Both incidents highlight lapses in following established procedures.
Two residents in the facility were found with long, dirty fingernails, indicating a failure in personal hygiene care. Despite being cognitively intact, both residents could not recall when their nails were last trimmed. Interviews revealed that CNAs were responsible for daily nail care, while nurses handled diabetic residents' nails. The facility's policy required regular cleaning and trimming to prevent infections, but this was not followed, leading to the deficiency.
Two residents in an LTC facility did not receive the correct oxygen flow rates as per physician orders. One resident with COPD and asthma received four liters per minute instead of two, while another resident with multiple health issues received one liter per minute instead of two. These discrepancies were confirmed by LVNs and highlighted by the DON, emphasizing the importance of following physician orders to prevent adverse effects.
Two residents were found using bed rails without proper assessment, physician's orders, or informed consent. One resident had severe cognitive impairment and was on hospice care, while the other was cognitively intact. Staff acknowledged the lack of necessary documentation, which should have been completed within 24 hours of admission, as emphasized by the DON and DSD.
The facility failed to accommodate the food preferences of several residents, leading to potential nutritional deficiencies. Residents were served food items they disliked, such as sweet potatoes and ham, without being offered suitable alternatives. Additionally, a resident's preference for cold food was not documented, resulting in a period where he did not eat. Interviews with staff revealed a lack of communication and adherence to facility policies regarding meal preference updates.
The facility failed to maintain proper sanitation practices in food preparation areas. Observations revealed that a food service worker and a kitchen supervisor used sanitation solutions with insufficient concentration to clean food service equipment and areas. The facility's policy mandates maintaining cleanliness and sanitation in food preparation and service areas.
A resident did not receive the physician-prescribed double portion meal due to a failure in communication and documentation within the facility. The resident's meal ticket did not reflect the correct diet order, and the kitchen was not informed of the double portion requirement until days later. Staff interviews confirmed the oversight, and the facility's policy for reviewing dietary orders was not effectively implemented.
The facility failed to maintain a comfortable environment in the kitchen, with temperatures recorded between 89.4 and 93.6 degrees Fahrenheit. Staff confirmed the kitchen is usually warm, and a broken A/C remote controller prevented proper cooling. The facility's policy highlighted the need for ventilation, but the issue persisted, potentially increasing the risk of heat-related illnesses among staff.
A resident did not receive their metformin medication for two days because it was unavailable, as observed by an LVN. The facility's policy requires nurses to ensure medication availability and reorder in advance, but this was not followed. The DON confirmed the responsibility of nurses to contact the pharmacy for timely delivery.
A resident with severe cognitive deficits was not provided privacy during medical procedures by an LVN, who failed to close the privacy curtain or door while checking blood pressure and administering medication. This was observed and confirmed by staff interviews, highlighting a breach of the facility's policies on dignity and resident rights.
A resident with an indwelling urinary catheter was not accurately assessed in the MDS, as the diagnosis was not coded. Despite being admitted with the catheter, there was no order, diagnosis, or care plan documented. Facility staff, including an LVN, MDSN, and MRD, confirmed the oversight, and the DON acknowledged the failure to document the necessary information.
A facility failed to update a resident's care plan after discontinuing insulin medication, despite the resident's diagnoses of diabetes mellitus type 2, hypertension, end-stage renal disease, anemia, and pain. Staff interviews revealed that the care plan was not individualized to the resident's needs, as it continued to include insulin. The facility's policy required ongoing assessment and timely updates to care plans.
The facility failed to properly prepare pureed food, as a whole green bean was found in a pureed salad on a test tray. This was observed during a lunch meal service, and the CDM confirmed the error. The staff member used a handheld blender for preparation, contrary to the facility's guidelines requiring a smooth consistency. Despite completing an in-service on texture modification, the staff's competency was unclear.
The facility failed to ensure effective food and nutrition services, as a staff member did not follow menus and recipes, leading to incorrect meal preparation and failure to accommodate residents' dietary preferences. Several residents received meals that did not align with their dietary restrictions, and the facility's training and competency evaluation processes were inadequate.
The facility failed to create a care plan for a resident at risk of elopement, despite multiple assessments identifying the risk. Staff interviews revealed a lack of communication and adherence to policies, resulting in the resident successfully leaving a dialysis center against medical advice.
Improper Use of Air Loss Mattress and Lack of Staff Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an air loss mattress was used in accordance with the manufacturer’s instructions and that staff were trained and competent in its use for one resident. Surveyors found that the resident, who weighed 124.4 lbs, was lying on an air loss mattress with the weight setting dialed to 245–285 lbs. The Nurse Unit Manager (NM) confirmed during observation that the mattress was set at the maximum weight and acknowledged that this was not correct for the resident’s actual weight. The NM also stated that the mattress should be set according to the resident’s weight and that incorrect settings would affect the therapeutic effect of the mattress. The resident had a significant medical history, including traumatic brain injury, status post ventriculoperitoneal shunt placement, hypertension, and venous thromboembolism. He had been admitted to a hospital for diaphoresis, shortness of breath, and high blood pressure, and was then readmitted to the facility for acute rehabilitation. The resident had experienced a fall at the facility on a prior date while on an air loss mattress, and the NM reported that the facility’s review of that fall did not identify any issues with the mattress settings or functionality at that time. However, during the current survey, the NM was unable to locate a physician’s order for the use of an air loss mattress for this resident. When the LVN assigned to the resident was interviewed at the bedside, she confirmed that the mattress was set at 245–285 lbs and stated she was unsure what the settings should be for this resident. She indicated she did not know the resident’s current weight, only that he did not appear to weigh 245–285 lbs, and stated she believed she would need to check physician orders for the correct settings. Upon review of the medical record, the LVN verified the resident’s most recent weight of 124.4 lbs and acknowledged that setting the wrong weight on the air loss mattress was not acceptable and had the potential to cause pressure injuries and harm. She also stated she had not been aware that she should be checking the weight settings on the air loss mattress. The Director of Staffing Development (DSD) reported that she was responsible for staff training and stated that staff were trained on the use of air loss mattresses and that correct weight settings were important. She agreed that a 245–285 lb setting for a resident weighing 124.4 lbs was not safe and not aligned with the instructions for use. However, upon further review, the DSD confirmed that she could not find any training or in-service records indicating that the LVN assigned on the day of the survey or the RN assigned at the time of the resident’s fall had received training on air loss mattress use. The Administrator (ADM) stated that the facility did not have a policy for air loss mattress use and that staff were expected to follow the manufacturer’s instructions. He also confirmed that there were no training records for the nurses assigned to the resident at the time of the fall and on the survey date. Review of the manufacturer’s instructions for the air loss mattress showed that the mattress is intended for pressure injury treatment and prevention and that the dial should be set to the correct weight of the resident. The user manual warned that improper operation could cause injury and specified that only qualified personnel trained in the treatment and prevention of pressure injuries should operate the device. The ADM acknowledged that the resident’s mattress weight setting was not aligned with the instructions for use. The combination of an incorrectly set air loss mattress, lack of a physician order for its use, and absence of documented staff training or competency on air loss mattress operation constituted the deficiency identified by the surveyors.
Failure to Follow Physician Orders and Complete Required Assessments Leads to Delayed DVT Diagnosis
Penalty
Summary
A deficiency occurred when nursing staff failed to provide treatment and care in accordance with physician orders and professional standards for a resident who exhibited changes in her lower extremities, including discoloration and swelling. Despite the nurse's assessment and subsequent notification to the physician, which resulted in an order for a vascular consult and elevation of the resident's legs, the vascular consult was never scheduled. There was also no documentation of any attempts to obtain the consult, and the required weekly head-to-toe assessment was not completed as scheduled. Additionally, when changes in the resident's condition were observed, the required Change in Condition (CIC) documentation was not completed on multiple occasions. The resident involved had a medical history that included acute respiratory failure with hypoxia, COPD, hypertension, difficulty in walking, and abnormal posture. She was cognitively intact and able to communicate her needs. The initial change was noted when her legs became discolored and one leg was more swollen than the other. The physician was contacted and ordered a duplex scan, but the scan performed was an arterial ultrasound rather than a venous study, which would have been necessary to diagnose a DVT. The results indicated severe bilateral arterial disease and a possible occlusion, prompting the physician to order a vascular consult and leg elevation. However, the consult was not arranged, and the resident did not receive the ordered follow-up care. As a result of these failures, there was a delay in addressing the resident's symptoms, which led to an acute change in her condition, including increased pain and swelling. The resident was ultimately sent to the hospital, where she was diagnosed with a deep vein thrombosis (DVT) in her left leg and underwent a surgical thrombectomy. The lack of timely assessments, failure to complete required documentation, and not following physician orders contributed to the delay in treatment and escalation of the resident's condition.
Failure to Conduct Elopement Assessment and Implement Interventions
Penalty
Summary
The facility failed to conduct a quarterly elopement assessment for a resident, as required by their policy, and did not implement necessary interventions when the resident's risk factors for elopement increased significantly. The resident, who had dementia and was moderately cognitively impaired, was admitted in May 2024 and had expressed a desire to leave the facility on multiple occasions. Despite these indicators, the facility did not perform the required elopement assessment in November 2024, nor did they update the resident's care plan to address the increased risk. On the morning of January 23, 2025, the resident was found outside the facility in a confused state, having left without the staff's knowledge. The resident was seen by staff in bed at 4:40 a.m., but by 4:50 a.m., she was outside with a passerby who was calling 911. The resident was returned to the facility without injury, but the incident highlighted the lack of adequate supervision and preventive measures, such as a security bracelet, which was only applied after the incident. Interviews with facility staff, including the Director of Nursing and the Minimum Data Set Nurse, revealed that the resident's care plan regarding elopement risks was only created after the incident. The facility's policy required elopement risk assessments to be conducted quarterly and with any change in condition, but this was not adhered to, leading to the resident's unsupervised exit from the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One deficiency involved Resident 52, whose oxygen nasal cannula tubing was found on top of the oxygen concentrator without being stored in a protective plastic bag. This oversight was confirmed by multiple staff members, including a CNA, LVN, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, all of whom acknowledged that the tubing should have been bagged to prevent infection. The facility's policy and procedure on infection prevention and control, as well as professional guidelines, were not adhered to in this instance. Another deficiency was noted with Resident 48, whose medication syringe was stored in a wet plastic bag with an orange liquid at the tip. The LVN responsible for administering medication to Resident 48 did not rinse the syringe before or after use, which was contrary to infection control practices. The Infection Preventionist and the Director of Nursing both recognized this as an infection control issue, emphasizing the need for proper cleaning and storage of syringes to prevent bacterial growth. The facility's policy on administering medication and professional references on syringe cleaning were not followed. A third deficiency involved Resident 54, who was on Enhanced Standard/Barrier Precautions. CNA 7 provided personal care to Resident 54 without wearing a gown, despite the resident being on enhanced precautions due to an open dialysis port. Interviews with the Infection Preventionist, another CNA, and the Director of Nursing highlighted the requirement for staff to wear gowns and gloves when providing care to residents on such precautions. The facility's in-service training and policy on Enhanced Standard/Barrier Precautions were not implemented correctly in this case.
Failure to Post Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to all 83 residents, their families, and legal representatives. During an observation, it was noted that the State Survey Binder, located in the hallway near the Director of Nursing's office, did not contain the results of the last recertification survey conducted on July 14, 2023. This omission was confirmed during a review of the binder, which was undated, and through interviews with both the Administrator and the Director of Nursing. Both the Administrator and the Director of Nursing acknowledged that the survey results should have been included in the binder and made accessible to everyone. The facility's policy on Resident Rights, dated December 2021, guarantees residents the right to examine survey results, which was not upheld in this instance. The absence of the survey results in the binder potentially violated the rights of residents and their representatives to be informed of previous survey deficiencies and the facility's plan of correction.
Deficiency in Food Service Oversight and Dietitian Consultation
Penalty
Summary
The facility failed to comply with federal regulations regarding the oversight of food service operations by not employing a full-time dietitian or a qualified dietetic services supervisor (DSS) as required by the California Code, Health and Safety Code - HSC S 1265.4. The facility employed a Certified Dietary Manager (CDM) who worked only 32 hours a week and was not qualified as a full-time DSS. The CDM was also a district manager for a contract food service company, overseeing multiple facilities, and was not present full-time at the facility. The Kitchen Supervisor (KS) was in a manager-in-training program and was not yet qualified, with the CDMs providing only limited oversight. During the re-certification survey, several issues were identified, including kitchen staff competency, not following the planned menu, improper food preparation, and failure to accommodate resident food preferences. The Registered Dietitian (RD) was working remotely and had limited in-person presence, providing only 8 hours of consultation per week. The RD did not review or approve the facility menu and was primarily focused on clinical work rather than food service operations. The RD's contract did not include responsibilities for food service oversight or frequent consultation with the KS. Interviews with facility staff, including the Administrator and Regional Resource RD, revealed awareness of the RD's limited role and the lack of oversight in food service operations. The RD's contract and scope of work were limited, and there was no documentation to validate frequent consultation with the KS. The facility's failure to employ a qualified full-time DSS and ensure adequate RD consultation placed residents at risk for receiving incorrect food items and compromised nutrition.
Failure to Follow Planned Menus and Dietary Guidelines
Penalty
Summary
The facility failed to adhere to the planned menu for residents, leading to several discrepancies in meal preparation and service. On October 8, 2024, steamed spinach was served instead of the planned creamed spinach to 79 out of 81 residents. Additionally, the incorrect scoop size was used for serving mechanical diced ham to residents on dysphagia advanced and mechanical diets, which did not align with the dietary guidelines. Furthermore, fortified mashed potatoes were served instead of whipped sweet potatoes to residents on puree and dysphagia mechanical diets. Another significant issue involved Resident 133, who was on a vegetarian diet but was repeatedly served egg salad, which was not part of the planned menu. This resident expressed dissatisfaction with the lack of variety and the repetitive nature of the meals provided. The kitchen staff, under the direction of the Kitchen Supervisor, failed to follow the menu and recipes as outlined, leading to these discrepancies. Interviews with the Registered Dietitian and the Kitchen Supervisor revealed expectations for staff to follow menus and recipes, which were not met. The Registered Dietitian had not reviewed or approved the facility menu, which is a requirement according to the facility's policy. These failures in menu adherence had the potential to impact residents' nutritional needs and overall satisfaction with their meals.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 75, who was admitted with an indwelling urinary catheter due to acute kidney failure and other conditions, did not have a care plan for the catheter's use. Despite being in the facility for several weeks, no care plan was initiated to guide the nursing staff in managing the catheter, as confirmed by interviews with the LVN and MDS Nurse. The facility's policy required a comprehensive care plan to be developed within seven days of admission, but this was not done for Resident 75. Similarly, Resident 29, who was admitted with multiple diagnoses including diabetes and end-stage renal disease, did not have a timely care plan for a urinary tract infection (UTI). The resident was started on antibiotics following a positive test for E-coli and ESBL, but the care plan was only created several days later. Interviews with the LVN and Infection Preventionist revealed that the care plan should have been initiated when the change in condition was noted, to monitor the resident's response to treatment and update the care team. The Director of Nursing acknowledged that the care plans were not patient-centered and should have been updated promptly to reflect changes in the residents' conditions. The facility's policy emphasized the importance of individualized care plans to meet residents' medical, physical, mental, and psychosocial needs, but this was not adhered to in these cases, resulting in potential unmet care needs for the residents involved.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed rate of 6.9 percent. One incident involved a Licensed Vocational Nurse (LVN) who did not administer metformin to a resident during a medication pass because the medication was unavailable. The resident, who had a history of diabetes, hypertension, and unspecified multiple injuries, missed two doses of metformin, which could potentially lead to elevated blood sugar levels. The Director of Nursing (DON) acknowledged that the nurse should have ensured the medication was available and contacted the pharmacy when it was not. Another incident involved a resident who had a lidocaine patch applied for more than the recommended 12 hours. The patch was supposed to be removed at bedtime to prevent skin irritation and potential side effects. The resident, who was severely cognitively impaired, had been receiving the patch twice daily for the past two months. The Pharmacist Consultant confirmed that the patch should be removed every 12 hours, and the DON stated that the nurses should have followed the physician's order to remove the patch at night. The facility's policies and procedures were reviewed, indicating that medication errors should be reported and that medications should be administered according to prescriber orders. The policies also outlined the process for ordering and receiving medications from the pharmacy to ensure timely delivery. However, these procedures were not followed in the cases of the metformin and lidocaine patch, leading to the observed deficiencies.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored according to professional standards, affecting three residents. For two residents, medications such as Fluticasone Propionate and Albuterol Sulfate were not labeled with expiration dates, which was confirmed during an observation and interview with an LVN. The facility's policy required medications to be labeled with expiration dates, and the lack of labeling was acknowledged by the Infection Preventionist and the Director of Nursing, who emphasized the importance of labeling to prevent the use of expired medications. Another deficiency was observed with a resident's insulin pen, which was missing a label. The insulin pen was found in a medication cart with a bag that had a label, but the pen itself did not. This was confirmed by an RN, who stated the importance of labeling to ensure the correct medication is administered to the right resident. The Pharmacist Consultant and the Director of Nursing both confirmed that insulin pens should have labels on both the bag and the pen to prevent mix-ups and ensure resident safety. Additionally, four loose medication pills were found on the floor in a medication storage room, and one and a half pills were found in a red medication bin. An LVN confirmed that loose pills should not be on the floor and should be disposed of properly to prevent medication errors. The Pharmacist Consultant and the Director of Nursing reiterated that medications should be destroyed in designated bins and that loose pills on the floor were unacceptable.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for three residents, which is a requirement to ensure residents are fully informed about the risks and benefits of their treatments. Resident 3 was administered escitalopram oxalate for depression from June to August without informed consent being obtained until late August. This oversight was confirmed during an interview with a registered nurse who acknowledged that the medication was administered daily without the necessary consent. Similarly, Resident 13 was given sertraline for depression from August to mid-October without a complete informed consent. The registered nurse reviewing the case confirmed that the consent was incomplete and that the medication should not have been administered without it. The responsibility for ensuring informed consent was noted to lie with the licensed nurses. Resident 64 was administered buspirone for anxiety from late August to mid-October without an accurate informed consent. The registered nurse and the Director of Staff Development both confirmed that the consent was not valid, and the medication should not have been given. The facility's policy requires that informed consent be obtained by the prescriber before the initiation of psychotropic medications, which was not adhered to in these cases.
Medication Management and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure professional standards of quality in the care of two residents, leading to deficiencies in medication management and documentation. For Resident 29, licensed nurses continued to sign off on monitoring for side effects of an anticoagulant medication that had been discontinued. This resulted in inaccurate documentation and monitoring of the resident's medical symptoms, as the staff was checking for side effects of a medication that was no longer being administered. The oversight was acknowledged by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who confirmed that the physician's order should have been updated to reflect the discontinuation of the medication. In the case of Resident 55, a Licensed Vocational Nurse (LVN 1) prepared the resident's medications but did not administer them due to her pregnancy and the resident being on enhanced barrier precautions. Instead, the Infection Preventionist (IP) administered the medications prepared by LVN 1, which is against the facility's policy. This practice could lead to medication errors, as the person administering the medication did not prepare it. Both LVN 1 and the IP acknowledged that this was not an acceptable practice, and the DON confirmed that the facility's policy requires the same nurse to prepare and administer medications. The report highlights the importance of accurate documentation and adherence to medication administration protocols to ensure resident safety. The deficiencies observed in the care of Residents 29 and 55 demonstrate lapses in following established procedures, which could potentially lead to adverse outcomes for the residents involved.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for two residents, Resident 233 and Resident 32, as observed by surveyors. Both residents were found to have long fingernails with black particles underneath, indicating a lack of regular cleaning and trimming. Resident 233 expressed dissatisfaction with the condition of his nails and could not recall the last time they were cut. Interviews with the Director of Staff Development (DSD) and Certified Nursing Assistant (CNA) 8 revealed that CNAs were responsible for daily cleaning and trimming of fingernails, while nurses were tasked with cutting the nails of diabetic residents. Despite these responsibilities, the necessary care was not provided, leading to the potential risk of infections or skin injuries. Resident 233 was admitted with multiple diagnoses, including diabetes mellitus type 2, peripheral vascular disease, and hypertension, and was cognitively intact with a BIMS score of 15. Similarly, Resident 32, who also had diabetes mellitus type 2 among other conditions, was cognitively intact with a BIMS score of 14. The facility's policy on nail care, revised in 2018, emphasized the importance of daily cleaning and regular trimming to prevent infections and skin problems. However, the failure to adhere to this policy resulted in the observed deficiencies in nail care for these residents.
Failure to Administer Correct Oxygen Flow Rates
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 13 and Resident 33, by not administering oxygen at the flow rates ordered by their physicians. Resident 13, who was diagnosed with chronic obstructive pulmonary disease and unspecified asthma, was observed receiving oxygen at a flow rate of four liters per minute, contrary to the physician's order of two liters per minute. This discrepancy was confirmed by a Licensed Vocational Nurse (LVN) who was unsure why the flow rate was set incorrectly. The Director of Nursing (DON) emphasized that oxygen is considered a medication and should be administered as per the physician's order to avoid potential adverse effects such as oxygen toxicity. Resident 33, who had a history of hypertension, type 2 diabetes mellitus, pneumonia, and acute respiratory failure with hypercapnia, was also found to be receiving oxygen at an incorrect flow rate. The resident was observed with a flow rate of one liter per minute, while the physician's order specified two liters per minute. This error was noted during an assessment by an LVN, who acknowledged the potential for respiratory distress and hypoxia due to the decreased oxygen flow. The DON reiterated the importance of adhering to physician orders and checking oxygen settings at the beginning of each shift to prevent such issues. The facility's policies and procedures for medication administration and oxygen therapy were reviewed, highlighting the requirement for medications, including oxygen, to be administered as prescribed. The failure to follow these protocols resulted in both residents not receiving the necessary respiratory care, potentially leading to serious health complications.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for two residents, leading to a deficiency in care. Resident 48, who had severe cognitive impairment and was on hospice care, was observed with both side rails raised without a physician's order, care plan, or informed consent. The clinical record for Resident 48 indicated a previous safety evaluation recommended against the use of side rails, yet they were still in use. Licensed Vocational Nurse (LVN) 5 confirmed that necessary documentation and orders were not in place, which was crucial for ensuring resident safety. Similarly, Resident 133, who was cognitively intact, was also found using bed rails without the required physician's order, care plan, or safety evaluation. LVN 6 acknowledged the absence of necessary documentation and stated that such forms should be completed within 24 hours of admission. The Director of Nursing (DON) and Director of Staff Development (DSD) both emphasized the importance of obtaining physician's orders, care plans, safety assessments, and consents for the use of side rails to ensure they are used for their intended purpose. The facility's policy underscored the need for individualized patient assessments and documentation of risk-benefit assessments in the patient's medical chart.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of several residents, leading to potential nutritional deficiencies. During a lunch meal observation, it was noted that Resident 44, who was on a carbohydrate-controlled diet and disliked potatoes, was served sweet potatoes. Similarly, Resident 75, who was on a regular dysphagia mechanical diet and disliked ham and pork, was served ham. Resident 184, on a consistent carbohydrate, dysphagia advanced diet, also received ham despite disliking it. The kitchen supervisor confirmed these discrepancies and removed the ham from the trays of Residents 75 and 184, substituting it with egg salad. However, the facility's menu indicated Salisbury steak as the regular alternate entree, which was not provided. The facility also failed to provide alternate options for residents who disliked certain food groups. Resident 31, who disliked spinach, was not given an alternate vegetable, and Resident 39, who disliked spinach and sweet potatoes, was not provided with suitable alternatives. The kitchen staff did not prepare the alternate food items listed on the menu, such as the Capri vegetable blend, which was supposed to be available as an alternative to creamed spinach. Interviews with the kitchen supervisor and registered dietitian revealed that the expectation was for the kitchen staff to follow residents' likes and dislikes and offer alternate food items when necessary. Additionally, Resident 52's preference for cold food was not documented on his meal ticket, despite his severe cognitive impairment and the family's repeated requests for cold food alternatives. The resident's meal ticket did not reflect his preferences, leading to a two-week period where he did not eat because he was not provided with cold food. Interviews with staff, including a CNA, LVN, and the Director of Nursing, indicated that it was the responsibility of the nursing staff to communicate meal preference updates to the kitchen. The facility's policy required that food preferences be obtained within 72 hours of admission and updated as needed, but this was not adhered to in Resident 52's case.
Improper Sanitation Practices in Food Preparation
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety due to improper sanitation practices. During an observation in the kitchen, a food service worker used a sanitation solution with a concentration of zero parts per million (ppm) to wipe down a food service cart, which was below the required 200 ppm. The worker acknowledged the correct concentration and subsequently corrected the solution. In a separate observation, the kitchen supervisor used a similarly ineffective sanitation solution to clean around a food processor, with the test strip barely changing color, indicating insufficient concentration. The facility's policy requires all food preparation and service areas to be maintained in a clean and sanitary condition, with food contact surfaces cleaned and sanitized after each use.
Failure to Follow Physician-Prescribed Diets
Penalty
Summary
The facility failed to ensure that physician-prescribed diets were followed for Resident 6, who did not receive his ordered double portion meal for lunch on 10/8/24. This oversight was identified during an observation in the dining room where Resident 6 was served a regular portion instead of the prescribed double portion. A review of Resident 6's Meal Ticket revealed that it did not list the order for a double portion diet. Interviews with staff, including a CNA and LVN, confirmed that the meal ticket should reflect the prescribed diet, and the LVN acknowledged that Resident 6's diet order was for double portions, which was necessary due to his declining health. Further investigation revealed that the order for double portions was not communicated to the kitchen until 10/10/24, as stated by the Account Manager and Certified Dietary Manager. The Director of Nursing confirmed that the order for double portions should have been documented on the meal ticket and communicated to the kitchen staff. The facility's policy indicated that the Dietary Manager should review the attending physician's dietary order within 72 hours of admission, but this process was not effectively followed, leading to the deficiency.
Inadequate Kitchen Cooling Leads to Staff Discomfort
Penalty
Summary
The facility failed to provide a comfortable environment in the kitchen for staff, as evidenced by consistently high temperatures recorded during observations. On multiple occasions, the surveyor's thermometer recorded temperatures ranging from 89.4 to 93.6 degrees Fahrenheit in the kitchen. Interviews with staff confirmed that the kitchen is usually warm, and the Certified Dietary Manager (CDM) acknowledged that one of the air conditioning (A/C) units was not functioning due to a lack of a remote controller. The Facility Maintenance Director (FMD) confirmed that the A/C units had been in place for over eight years, and there was only one remote for both units, which was broken, preventing staff from verifying the A/C settings. The facility's policy and procedure, as well as a sanitation and food safety checklist, indicated the need for proper ventilation in the kitchen. However, the checklist noted that the kitchen office and emergency food room were hot, with a recommendation to install a wall A/C unit in the office. The high temperatures in the kitchen, combined with the lack of functional A/C units, created an environment that could potentially increase the risk of heat-related illnesses among staff. The facility's failure to address the broken remote controller and ensure adequate cooling in the kitchen contributed to the deficiency.
Failure to Administer Metformin Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the administration of medication to meet the needs of a resident, specifically Resident 48. Resident 48's metformin, a medication used to control high blood sugar, was not available for administration on two consecutive days. This lapse was observed during an interview with a Licensed Vocational Nurse (LVN) who confirmed that the medication was unavailable and acknowledged the potential for Resident 48's blood sugar to increase due to the missed doses. The facility's policy requires licensed nurses to ensure medications are available and to reorder them five days in advance. However, this procedure was not followed, as evidenced by the interviews with the LVNs and the Director of Nursing (DON), who stated that the nurse responsible for administering the last dose should have contacted the pharmacy to ensure timely delivery. The failure to administer metformin was documented in Resident 48's electronic medical administration record, which showed missed doses on two specific days.
Failure to Provide Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, specifically in maintaining privacy during medical procedures. A Licensed Vocational Nurse (LVN) checked the resident's blood pressure and administered medication without closing the privacy curtain or door, allowing staff, residents, and visitors to see inside the room. This lack of privacy was observed during two separate instances, one while checking blood pressure and another while administering medication. Interviews with the LVN and other staff, including the Infection Preventionist and Director of Nursing, confirmed that the LVN did not provide the necessary privacy, which is a right of the resident. The resident involved had a severe cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 4 out of 15, and was diagnosed with hemiplegia, hemiparesis, and aphasia. The facility's policies on dignity and resident rights emphasize the importance of maintaining privacy during care and treatment, which was not adhered to in this case. The failure to provide privacy was acknowledged by the LVN and other staff members, who stated that it was standard practice to ensure privacy during such procedures.
Inaccurate MDS Assessment for Resident with Urinary Catheter
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the diagnosis of an indwelling urinary catheter. During an observation and interview, it was noted that the resident had an indwelling urinary catheter, which was not coded in the MDS assessment. The resident was admitted with diagnoses including anxiety, kidney failure, and neuromuscular dysfunction, and had a moderate cognitive deficit. Despite the presence of the catheter, there was no corresponding order, diagnosis, or care plan documented in the resident's records. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Minimum Data Set Nurse (MDSN), and the Medical Records Director (MRD), revealed that the resident was admitted with the catheter, but the necessary documentation was missing. The LVN confirmed the absence of an order and diagnosis for the catheter, while the MDSN acknowledged that the catheter use was coded but not the diagnosis. The MRD, who was also a licensed nurse, was unaware of the catheter until reviewing the records and confirmed that the required documentation was only initiated days after the resident's admission. The Director of Nursing (DON) stated that the catheter was re-inserted after an unsuccessful attempt to discontinue it, due to the resident not voiding for eight hours. The DON admitted that the licensed nurse should have entered the order and obtained a diagnosis from the physician. The facility's policy on urinary catheters emphasized the need for valid medical justification and timely discontinuation, which was not adhered to in this case.
Failure to Update Care Plan After Insulin Discontinuation
Penalty
Summary
The facility failed to timely revise and implement a person-centered comprehensive care plan for a resident when the care plan was not updated to reflect the discontinuation of insulin medication. The resident, who was admitted with diagnoses including diabetes mellitus type 2, hypertension, end-stage renal disease, anemia, and pain, had their insulin medication discontinued on a specific date. However, the care plan was not updated to reflect this change, which was identified during a review of the resident's electronic Medication Administration Record (eMAR). Interviews with facility staff, including an LVN and the Director of Nursing (DON), revealed that the care plan should have been updated to match the resident's current needs and goals. The LVN acknowledged that the care plan needed to be individualized and that failing to update it could lead to missed issues for the resident. The DON confirmed that the care plan was not personalized or individualized to the resident's needs when it continued to include insulin after its discontinuation. The facility's policy and procedure on care plans emphasized the need for ongoing assessment and timely updates to reflect changes in the resident's condition.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared in the proper form, as evidenced by the presence of a whole green bean in a pureed salad served on a test tray. This incident was observed during a lunch meal service, where meals were being prepared and placed on trays in the kitchen. The surveyors ordered a regular and puree test tray, and upon inspection of the puree test tray, a whole green bean was found in the pureed salad. This was confirmed during an interview with the Certified Dietary Manager (CDM), who acknowledged that the presence of a whole green bean in the puree salad was not acceptable. Further investigation revealed that the staff member responsible for preparing the puree salad used a handheld blender to prepare the green bean salad with Italian dressing. A review of the facility's Corporate Recipe for Marinated Bean Salad indicated that for pureed diets, the ingredients should be blended until smooth. Additionally, the facility's Diet and Nutrition Care Manual specified that all foods for a Dysphagia Puree (Level 1 Diet) must be of a moist, pudding-like consistency without particles. Although the staff member had completed an online in-service on texture modification, the content and competency assessment of the in-service were unclear.
Deficiency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that support personnel effectively carried out the functions of food and nutrition services, as evidenced by the actions of a staff member, [NAME] 1, who did not follow menus and recipes. During a lunch meal observation, [NAME] 1 prepared spinach incorrectly, using only 10 pounds of frozen spinach instead of the required 16 pounds for 80 servings, leading to a shortage. Additionally, the tray line did not include alternate vegetables or entrees as specified in the menu, resulting in residents receiving meals that did not accommodate their dietary preferences or restrictions. Several residents were affected by these discrepancies. For instance, a resident who disliked spinach received a meal with spinach, and another resident who disliked the potato group received sweet potatoes. Furthermore, a resident on a dysphagia mechanical diet who disliked ham and pork was served ham. These actions were confirmed by the Kitchen Supervisor, who acknowledged the residents' dietary preferences and made adjustments by serving egg salad instead of ham. The facility's training and competency evaluation processes were also found lacking. Although [NAME] 1 had completed online in-services on texture modification and plate presentation, there was no documentation of in-services regarding following recipes or menu spreadsheets. The Registered Dietitian had offered to conduct in-services, but the kitchen staff had not requested them. The competency checklist for [NAME] 1 was signed off by the Kitchen Supervisor, but observations during the survey indicated concerns with [NAME] 1's competency in preparing mechanically altered foods and assembling resident meal trays correctly.
Failure to Create Care Plan for Elopement Risk
Penalty
Summary
The facility failed to create a care plan for a resident at risk of elopement, despite multiple indicators and assessments identifying the risk. The resident had a history of elopement from previous skilled nursing facilities and had attempted to leave against medical advice from a dialysis center. Despite these clear signs, no care plan was developed to address the resident's elopement risk, and the resident successfully left the dialysis center against medical advice on a subsequent occasion. Interviews with staff revealed a lack of communication and adherence to the facility's policies and procedures regarding elopement risk. The Social Service Director was aware of the resident's history but did not ensure a care plan was in place. The Licensed Vocational Nurse acknowledged that the resident often expressed a desire to leave and had documented an attempted elopement, but no care plan was created. The Minimum Data Set Coordinator and Director of Staff Development also confirmed that the resident was not included in the facility's Wander Risk Binder, and no interdisciplinary team meeting was held to address the risk. The facility's policy required an elopement risk assessment and the development of a person-centered care plan for residents identified as at risk. However, this policy was not followed. The Director of Nursing confirmed that no care plan was made, and there was no communication with the dialysis center to monitor the resident. The failure to create and implement a care plan for the resident's elopement risk led to the resident successfully leaving the dialysis center against medical advice.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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