Lincoln Meadows Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, California.
- Location
- 1550 Third Street, Lincoln, California 95648
- CMS Provider Number
- 555333
- Inspections on file
- 45
- Latest survey
- May 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lincoln Meadows Care Center during CMS and state inspections, most recent first.
Two residents with moderate cognitive impairment and significant medical needs were found to have non-functioning call light systems in their room and bathroom. Staff, including the DON, DSD, and an RN, confirmed that the call lights did not activate as required, and attempts to repair or use the system were unsuccessful. Both residents reported delays in receiving assistance, and the facility's policy requiring a functional call system at all times was not met.
During a meal service, staff did not follow prescribed menus and portion controls for various therapeutic diets, resulting in residents receiving incorrect portion sizes and meal components. Residents on regular, CCHO, CCHO renal, small portion, fortified, and finger food diets were all affected, with issues such as oversized pasta servings, full desserts instead of half portions, missing fortified margarine, and lack of required garnishes. These discrepancies were confirmed by dietary staff and were not in accordance with facility policies or physician orders.
Surveyors identified multiple deficiencies in food safety and sanitation, including improperly cleaned and stored metal pans, unclean storage areas, a poorly maintained can opener, and dietary staff unable to correctly describe or perform manual dishwashing and sanitizing procedures. Additionally, staff failed to use proper hair restraints and did not consistently label, date, or discard resident food in the refrigerator, which was also found to be unclean. These failures were confirmed through observation, staff interviews, and review of facility policies.
Several residents with cognitive and mobility impairments experienced significant delays in receiving incontinence care or assistance to the bathroom, resulting in episodes of incontinence, emotional distress, and skin discomfort. Documentation showed that individualized care plans for incontinence were lacking for some residents, and staff interviews confirmed that timely care was not consistently provided.
The facility failed to ensure dietary staff were properly trained and competent in food safety procedures, including manual dishwashing, cleaning and sanitizing food contact surfaces, and preparing sanitizer solutions. Two dietary aides lacked required food handler certifications and demonstrated incorrect practices, placing the majority of residents at risk for foodborne illness.
Surveyors found that oxygen and catheter tubing for several residents were in contact with the floor, and enteral feeding tubing was left uncapped and open to air while disconnected. Staff and facility policies confirmed these practices were not in line with infection control standards, as the tubing should not touch the floor or be left open to air due to contamination risks.
A resident with muscle weakness, difficulty walking, and a history of falls did not have their call light within reach on multiple occasions, despite requiring partial to moderate assistance with ADLs. The resident was unable to request help, and staff confirmed the call light was not accessible. Facility policy requires call lights to be within easy reach, but this was not followed.
A resident with a stage 4 pressure ulcer and chronic pain did not receive appropriate pain management during wound care. The nurse did not assess pain using a standardized scale or administer pain medication prior to the procedure, despite the resident expressing significant discomfort. The procedure was further prolonged due to lack of preparation, causing the resident to remain in pain for an extended period. Facility policies and care plan expectations for pain management and wound care preparation were not followed.
A facility failed to follow infection control practices when a nurse did not wear a gown during wound care for a resident with chronic osteomyelitis and bacteremia. Despite Enhanced Barrier Precautions requiring gowns for high-contact care, the nurse confirmed the oversight. Interviews with the Infection Preventionist and DON highlighted the necessity of gowns to prevent infection spread, as per facility policy.
A facility failed to report an alleged abuse incident involving a resident with hemiplegia and hemiparesis. The resident reported being disrespected by a CNA, who pushed her fingers into his chest and made demeaning comments. Despite the grievance being documented, staff members did not perceive the incident as abuse and did not report it to the State Survey Agency or local law enforcement, contrary to the facility's policy.
A resident with memory issues and aphasia was transferred to the hospital due to aggressive behavior, but the facility failed to notify the resident's representative as required. The representative only learned of the transfer from the hospital, leading to feelings of astonishment and upset. Documentation discrepancies were noted in the timing of notifications.
The facility failed to provide appropriate respiratory care for three residents. Two residents received incorrect oxygen levels, and one resident was not provided with an incentive spirometer as ordered by the physician. These discrepancies were confirmed by staff and the Director of Nursing, indicating a failure to follow the facility's policies on oxygen administration and physician orders.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Controlled medications did not reconcile between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). The Director of Nursing confirmed that staff were expected to document on both records, as per facility policy.
The facility had a 10.42% medication error rate during a medication pass for two residents. Errors included not instructing a resident to rinse and spit after using an inhaler, not priming insulin pens, not swabbing a heparin vial, and administering insulin after a meal. The DON confirmed these actions were against the facility's policies.
A resident with left side hemiplegia and muscle weakness was not provided with a rocker knife, as required by her care plan, leading to her inability to cut food and subsequent weight loss. Staff confirmed the absence of the rocker knife and the facility's failure to notify appropriate personnel about its unavailability.
The facility failed to store food in a sanitary manner, with staff not using hair nets and beard guards, and several food items not labeled with open dates or expired. This included expired left-over roast beef that a Dietary Cook was about to reheat.
The facility failed to follow proper infection control practices when a dietary cook did not perform proper hand hygiene in the kitchen and a licensed nurse did not change gloves or perform hand hygiene during wound care for a resident with diabetes and a stage 4 pressure ulcer. These failures had the potential to spread infection within the facility.
A facility failed to ensure that a resident's self-administered albuterol inhaler was reviewed and approved by a physician. The inhaler, brought from the hospital, was found at the resident's bedside without a pharmacy label or physician's order. The Director of Nursing confirmed that a physician's order and proper storage were required for safe self-administration.
A resident with asthma and a left lower limb infection reported being unable to reach the call light while in her wheelchair because it was located on the other side of her bed. The DON confirmed that the call light should have been within reach, as per the facility's policy.
A resident with paraplegia and other medical conditions returned from the hospital to find her room cluttered with personal belongings. Despite her requests for assistance, staff did not help her unpack, leading to an unsafe and disorderly environment. The clutter prevented proper cleaning and created hazards, as the resident could not adjust her bed or use the call light. The facility failed to follow the care plan and policy for a homelike environment.
The facility failed to ensure accurate MDS assessments for three residents. One resident's vision impairment was not documented, another's feeding tube was not recorded, and a third resident's discharge status was incorrectly noted as hospitalization instead of home. These inaccuracies could impact care plans and interventions.
The facility failed to develop and provide a baseline care plan (BCP) and written summary for a resident within 48 hours after admission. The BCP was not completed until several days later, and the summary was not provided to the resident or her representative. The DON confirmed the oversight, which is against the facility's policy.
A facility failed to develop a comprehensive care plan for a resident with COPD, omitting physician's orders for an incentive spirometer and compression stockings. This was confirmed through interviews and record reviews, highlighting a lapse in following the facility's policy for timely care plan development.
A resident received an incorrect dose of heparin when a nurse failed to expel air from the syringe before administration. The nurse acknowledged the error, and the Director of Nursing confirmed that proper medication administration is a staff competency expectation.
The facility failed to assist a resident with the arrangement of an eye doctor consultation, despite the resident's repeated requests and documented need for vision care. The resident, who experienced headaches from provided reading glasses, had not seen an eye doctor since the request was made in August 2023.
A facility failed to follow a physician's treatment order for a stage 4 pressure ulcer on a resident's left posterior leg. The prescribed treatment included cleansing with normal saline, applying collagen, hydroferra blue, triad cream, and a silicone border foam dressing with skin prep. However, during an observation, a licensed nurse did not use skin prep and collagen as prescribed. This was confirmed by the nurse and the Director of Nursing.
A facility failed to properly check the functionality of a roam signal device for a resident with paranoid schizophrenia and Alzheimer's disease, leading to an increased risk of elopement. The current method involved taking the resident near the main door, which the DON acknowledged needed improvement for safety.
The facility failed to ensure routine care and dressing changes for a resident's midline catheter, leading to an increased risk of infection. The dressing was not changed for 21 days, and there were no orders or documentation for flushing and locking the catheter. The DON confirmed that nurses did not follow the facility's policies.
A nurse left a med cart unattended in the hallway with a bubble pack containing six hyoscyamine 0.125 mg tablets on top. The facility's policy stated that no medications should be kept on top of the cart.
The facility failed to ensure the competency of Food and Nutrition Services staff, specifically in the cooling down process for turkey and the proper procedures for pureeing food. Dietary Cook 1 did not follow correct procedures, use recipes, or measuring tools, which was confirmed by the Kitchen Dietary Manager and the Food Service Efficiency Consultant.
The facility failed to prepare food in a manner that conserves nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, vegetables, and starch. This deficiency was confirmed by the dietary cook and the Food Service Efficiency Consultant, and it had the potential to decrease the nutrients in the food served to five residents on a pureed diet.
The facility failed to post complete daily staffing information at the beginning of each shift for a census of 90 residents. The Staffing Coordinator posted incomplete staffing information in the afternoon, missing the total number and actual hours worked per shift for licensed and unlicensed staff. This was observed on multiple occasions, and the SC confirmed the deficiency.
Non-Functioning Call Light System in Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for two residents residing in the same room. Both residents had moderate cognitive impairment and required assistance due to their medical conditions, including a displaced comminuted fracture of the left patella and surgical aftercare following digestive system surgery. Observations and interviews revealed that the call light in their room did not activate the light above the door or register at the nurse's station, and one resident reported not being given a call bell. Both residents described significant delays in receiving assistance, with one stating she had to call out for help and the other reporting waits of up to two hours. Multiple staff members, including the DON, DSD, and an RN, confirmed through direct observation that the call light system was not working as intended. Attempts to replace the call light cord and activate the system were unsuccessful, and the emergency call light in the bathroom required excessive force to activate. The facility's policy required the call system to remain functional at all times, but this was not maintained, as confirmed by staff interviews and direct testing of the system.
Failure to Follow Therapeutic Diet Menus and Portion Controls
Penalty
Summary
The facility failed to ensure that planned menus were followed for therapeutic diets during a lunch meal service. Observations revealed that residents received incorrect portion sizes and meal components that did not align with their prescribed diets. Specifically, residents on regular diets received larger portions of pasta than indicated, those on consistent carbohydrate (CCHO) and CCHO renal diets received full servings of dessert and larger pasta portions instead of the prescribed reduced amounts, and residents on small portion diets were served full portions of dessert, pasta, and chicken rather than the smaller amounts required. Additionally, residents on fortified diets did not receive the extra margarine intended to increase caloric intake, and those on finger food diets did not have their desserts appropriately portioned for ease of handling. All residents who received meals from the facility kitchen did not receive the required garnish, which was specified in the menu to enhance meal presentation and potentially stimulate appetite. The discrepancies were confirmed through interviews with kitchen staff, the dietary manager, and the registered dietitian, who all acknowledged that the menu and portion guidelines were not followed during meal preparation and service. The facility's own menu spreadsheets and diet guidelines clearly outlined the correct portions and meal components for each therapeutic diet, but these were not adhered to during the observed meal service. A review of facility policies and job descriptions further confirmed that staff were expected to follow prepared menus, portion control guides, and special diet requirements accurately. The failure to do so resulted in residents receiving meals that did not meet their individualized nutritional needs as prescribed by their physicians and outlined in the facility's diet manual. These actions and inactions directly led to the deficiency cited in the report.
Multiple Food Safety and Sanitation Deficiencies Identified in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, and distributed in accordance with professional standards, as evidenced by multiple deficiencies observed during survey. Metal pans in the clean and ready-to-use storage areas were found stacked while still wet and with food particles present, indicating improper cleaning and drying procedures. The storage areas themselves were not clean, with food debris noted on surfaces. Additionally, the blade of the can opener was discolored and chipped, and the dietary staff did not consistently demonstrate or verbalize correct procedures for manual dishwashing, cleaning, sanitizing, or preparing and testing sanitizer solutions. For example, one dietary aide was unable to describe the full manual dishwashing process, omitting the sanitizing step, and another did not follow correct procedures for cleaning food contact surfaces or using sanitizer test strips. Further observations revealed that dietary staff did not always use proper hair restraints, with one aide's hair not fully covered by a cap or hairnet. The resident food refrigerator located at the nurse station was found to be unclean, with dry liquid spills and improperly labeled or outdated food items present in the freezer. Food items lacked resident names, received dates, or were past their expiration dates, and there was no set schedule for cleaning the refrigerator. Interviews with nursing and housekeeping staff revealed confusion over responsibilities for monitoring and cleaning the refrigerator, with inconsistent practices regarding labeling, dating, and discarding perishable foods. Facility policies and procedures reviewed during the survey supported the need for proper dishwashing, sanitation, maintenance of equipment, labeling and dating of resident food, and regular cleaning of storage and refrigeration areas. However, staff interviews and direct observations confirmed that these procedures were not consistently followed, leading to unsanitary conditions and potential food safety risks for all residents receiving food from the facility kitchen.
Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for four residents who required varying levels of support for toileting hygiene. Documentation and interviews revealed that these residents experienced delays in receiving help, resulting in episodes of incontinence and emotional distress. For example, one resident with a history of left femur fracture and moderate cognitive impairment reported being unable to access the restroom due to physical barriers and lack of staff response, leading to an incontinence episode. Another resident with spinal stenosis and impaired mobility stated that staff took a long time to assist her to the bathroom, despite her preference to use a commode or toilet rather than remain in a brief. Care plan reviews showed that some residents who were always or frequently incontinent did not have individualized care plans addressing their incontinence needs. For instance, residents with documented incontinence episodes throughout all shifts lacked specific interventions in their care plans to manage bladder incontinence. One resident with enterocolitis due to C. difficile, who was always incontinent with bowel movements, reported significant discomfort and skin irritation due to delays in incontinence care, stating it took hours to receive assistance after an episode of diarrhea. Staff interviews confirmed that the expectation was to provide incontinence care as soon as possible to maintain skin integrity and prevent irritation or infection. However, multiple residents described long wait times for assistance, leading to feelings of anger, distress, and being unvalued. Observations and interviews corroborated that the facility did not consistently provide timely and appropriate care for residents who were continent or incontinent of bowel/bladder, as required by facility policy.
Deficient Food and Nutrition Service Staff Training and Competency
Penalty
Summary
The facility failed to ensure that dietary staff had the appropriate skills and knowledge to safely perform food and nutrition service operations. Dietary Aide 1 was unable to correctly verbalize the manual dishwashing process using a 2-compartment sink, omitting the sanitizing step and not knowing the required sanitizer concentration. Facility policy required washing, rinsing, sanitizing at 200-400 ppm for at least 1 minute, and air drying, but DA 1 could not state these requirements. Additionally, DA 1 did not possess the required food handler's certificate as per the job description. Dietary Aide 2 was observed cleaning soiled food contact surfaces incorrectly by using a towel from a sanitizer bucket without first cleaning with soap and water, contrary to facility policy which mandates a two-step process of cleaning and then sanitizing. DA 2 also demonstrated improper technique in preparing and testing the sanitizer solution, including incorrect use of test strips and not adhering to the required solution temperature for accurate testing. The sanitizer solution was found to be below the recommended temperature range, and DA 2 did not have the required food handler's certificate, despite being listed as a cook in her employee file. Both DA 1 and DA 2 had documentation indicating competency in relevant procedures, and records showed they attended in-service trainings. However, there were no individualized lesson plans for the competency topics, and the Director of Food and Nutrition was responsible for training and ensuring compliance with infection control policies. These failures had the potential to place 88 out of 92 residents at risk for foodborne illness due to improper food handling and sanitation practices.
Infection Control Lapses: Tubing and Enteral Feeding Practices
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Oxygen tubing for three residents with respiratory conditions, including chronic obstructive pulmonary disease, acute respiratory failure, and asthma, was found lying on the floor while in use. Licensed nurses and the Director of Nursing confirmed during interviews that the tubing should not be in contact with the floor due to infection control and safety concerns. Facility policy requires respiratory therapy equipment to be free from all microorganisms, and staff acknowledged the tubing's improper placement. A resident with a Foley catheter for urinary drainage was seen wheeling herself in a wheelchair with the catheter tubing dragging on the floor. Both a licensed nurse and the Director of Nursing confirmed the tubing was in contact with the floor and stated this was against infection control expectations. The facility's policy on indwelling catheters specifies that catheter tubing and drainage bags must be kept off the floor, and the Infection Preventionist reiterated that floor contact increases the risk of contamination. Additionally, a resident receiving continuous enteral feeding via a feeding tube was observed returning from physical therapy with the feeding formula and tubing left uncapped and open to air while disconnected. A licensed nurse confirmed that the uncapped tubing could lead to contamination, especially for vulnerable residents. Facility policies on enteral feedings and cleaning of resident-care items require aseptic technique and prevention of contamination, which were not followed in this instance.
Call Light Not Within Reach for Resident Requiring Assistance
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including muscle weakness, difficulty walking, and a history of falls, did not have their call light within reach on multiple occasions. The resident required partial to moderate assistance with activities of daily living, as documented in their Minimum Data Set. During observations, the call light was found on the floor behind the bed and later dangling off the side of the bed, both times out of the resident's reach. The resident expressed frustration about not being able to use the call light to request assistance, such as lowering the television volume, and noted that the privacy curtain was usually drawn, making it difficult to see staff passing by. The resident also mentioned that their roommate kept the television volume high, making it unlikely that staff would hear them if they called out. Staff interviews confirmed the call light was not within reach during these observations. A licensed nurse and a certified nurse assistant both acknowledged the issue when it was pointed out. The Director of Nursing stated that the expectation was for all call lights to be within reach of residents. A review of the facility's policy on answering call lights indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Provide Appropriate Pain Management During Wound Care
Penalty
Summary
A resident with a history of chronic pain and a stage 4 sacral pressure ulcer was admitted to the facility and was under hospice care. The resident had physician orders for pain assessment every shift using a standardized pain scale and for administration of morphine or oxycodone as needed for moderate to severe pain. The resident's care plan specified that pain should be managed to a tolerable level, with relief expected after comfort measures or medication. During wound care, the resident expressed significant pain, stating her pain was 'a lot,' and was observed moaning and crying throughout the procedure. The nurse performing the wound care did not use a pain scale to assess the resident's pain, nor was there documentation of pain medication being administered prior to the treatment, despite the resident's clear expressions of discomfort. The nurse also prolonged the resident's pain episode by not having all necessary supplies at hand, resulting in multiple trips to the treatment cart and extending the time the resident had to remain in a painful position. The Director of Nursing confirmed that the facility's expectation was for nurses to pre-medicate residents for pain prior to wound care and to use a pain scale for assessment. Facility policies required pain assessment using a standardized approach and for wound care supplies to be prepared in advance and within reach. These protocols were not followed, resulting in unmanaged pain for the resident during wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident diagnosed with chronic osteomyelitis and bacteremia. The resident was under Enhanced Barrier Precautions (EBP) for activities such as wound care, which required the use of personal protective equipment (PPE) including gowns. However, during an observation, a licensed nurse performed wound care on the resident without donning a gown, which was confirmed by the nurse as a deviation from the required protocol. Interviews with the Infection Preventionist and the Director of Nursing further confirmed that gowns are mandatory during high-contact care activities like wound care under EBP. The facility's policy, effective April 2024, mandates the use of gowns and gloves during such activities to mitigate infection risks. The failure to follow these guidelines had the potential to increase the spread of infection, as noted in the report.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency and local law enforcement, and did not report the results of the investigation within the required five working days. The incident involved a resident who was admitted with medical diagnoses including hemiplegia and hemiparesis following a cerebral infarction. The resident, who had an intact cognitive status, reported that a Certified Nursing Assistant (CNA) disrespected him by pushing her fingers into his chest and making demeaning comments. This grievance was documented, but the facility did not follow through with the necessary reporting procedures. Interviews with various staff members revealed a lack of consensus on the severity of the incident. The Director of Staff Development acknowledged receiving the grievance but did not report it further, considering it a customer service issue rather than abuse. Similarly, other staff members, including a Licensed Nurse and the Social Services Director, did not perceive the incident as abuse and did not take further action. The facility's policy on abuse prevention requires investigation and reporting of all possible incidents of abuse, but this protocol was not followed in this case.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in condition and emergency hospital transfer for one of the sampled residents. The resident, who had a history of memory problems with agitation and aphasia, exhibited aggressive and combative behaviors, prompting a transfer to the emergency department. Despite the facility's policy requiring notification of the RR in such situations, the RR was not informed until contacted by the hospital the following day, leading to feelings of astonishment and upset. The clinical record indicated that the physician was notified and an order for hospital transfer was obtained, but the documentation showed discrepancies in the timing of the RR notification. The Licensed Nurse (LN) involved acknowledged these discrepancies and the lack of documentation regarding the RR's response. The Director of Nursing (DON) confirmed that the RR should have been notified after the physician, as per facility policy, and recognized the RR's reaction upon learning of the transfer from the hospital.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards of quality for three residents. Resident 39 and Resident 240 were administered oxygen at rates inconsistent with their physician's orders and care plans. Resident 39 was observed receiving four liters of oxygen per minute instead of the prescribed two liters, and Resident 240 was observed receiving five liters per minute instead of the prescribed two liters. Both discrepancies were confirmed by licensed nurses and the Director of Nursing, who acknowledged that the incorrect oxygen administration could lead to carbon dioxide retention due to their diagnoses of COPD and acute respiratory failure. The facility's policy on oxygen administration was not followed, as it requires verification of physician's orders for oxygen administration. Resident 5 was not provided with an incentive spirometer as ordered by the physician. Despite a physician's order for the use of an incentive spirometer three times a day to improve lung function, the device was not available in Resident 5's room, and the resident had never seen or used it. Licensed Nurse 3 confirmed the absence of the device and admitted to not instructing Resident 5 on its use. The Director of Nursing stated that nursing staff are expected to follow physician's orders accurately and ensure that residents receive the prescribed treatments. The facility's policies on carrying out physician orders and incentive spirometry were not adhered to in this case.
Failure to Ensure Accurate Accountability and Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three out of four residents. Specifically, the controlled medications for Residents 6, 189, and 190 did not reconcile between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For Resident 6, tramadol was signed out on the CDR but not documented on the MAR for specific dates in February and March 2024. Similarly, for Resident 189, hydrocodone/APAP was signed out on the CDR but not documented on the MAR for a specific date in March 2024. For Resident 190, oxycodone was signed out on the CDR but not documented on the MAR for multiple dates in March 2024. During an interview, the Director of Nursing (DON) confirmed that nursing staff were expected to document on both the MAR and CDR whenever a controlled medication was administered. The facility's policy and procedure for controlled medications, dated May 2022, also indicated that the licensed nurse administering the medication should immediately enter the date, time, amount administered, and their signature on both the accountability record and the MAR. The failure to follow these procedures resulted in inaccurate accountability of controlled medications and potential for abuse or misuse.
Medication Administration Errors
Penalty
Summary
The facility had a 10.42% medication error rate when five medication errors out of 48 opportunities were observed during a medication pass for two residents. Licensed Nurse 1 (LN 1) administered Trelegy Ellipta to Resident 5 without instructing the resident to rinse and spit after use, contrary to the manufacturer's specifications. LN 1 acknowledged that she normally instructs residents to rinse and spit to prevent fungal infections but failed to do so in this instance. Licensed Nurse 4 (LN 4) made several errors while administering medications to Resident 189. LN 4 did not prime the insulin glargine and insulin lispro pens before administration, did not swab the rubber cap of the heparin vial with an alcohol pad, and administered heparin with a large air bubble in the syringe. Additionally, LN 4 administered insulin lispro after Resident 189 had eaten breakfast, contrary to the physician's order to administer it before meals. LN 4 also prepared a multivitamin with minerals instead of the prescribed plain multivitamin. The Director of Nursing (DON) confirmed that the correct administration of injectable medications is expected and part of the nursing staff's competency. The facility's policies and procedures for administering medications and subcutaneous medication administration were reviewed, indicating that medications should be administered safely, timely, and as prescribed, including verifying the right dosage and expelling air from syringes.
Failure to Provide Adaptive Eating Utensil
Penalty
Summary
The facility failed to provide a special eating utensil, specifically a rocker knife, for a resident with left side hemiplegia, muscle weakness, and lack of coordination. Despite the resident's meal ticket indicating the need for a rocker knife, the resident was observed without it during meals. The resident was unable to cut her food using a regular knife, which led to her not eating her lunch. This was confirmed by multiple staff members, including a Restorative Nurse Assistant and Central Supply, who acknowledged the absence of the rocker knife and the resident's inability to cut her food with a regular knife. Further review of the resident's records, including the Minimum Data Set, Order Summary Report, and Nutrition Care Plan, indicated that the resident required a rocker knife as adaptive equipment to promote self-feeding independence. Interviews with the Kitchen Dietary Manager and the Director of Nursing revealed that the facility never had a rocker knife available, and staff failed to notify the appropriate personnel about the unavailability of the utensil. This oversight contributed to the resident's weight loss and increased dependence on staff for feeding assistance.
Failure to Maintain Sanitary Food Storage and Handling
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during a survey. Dietary staff were found not using hair nets and beard guards while in the kitchen, which is against the facility's dress code policy. Specifically, a Dietary Aid and the Kitchen Dietary Manager were observed without the required hair restraints. The Kitchen Dietary Manager confirmed that hair nets and beard guards are mandatory while in the kitchen. Additionally, several food items in the reach-in refrigerator and dry storage were not labeled with their open dates, and some were expired. This included two loaves of bread and heads of lettuce without date labels, expired left-over beef puree, and six opened bread bags without open date labeling. Furthermore, a Dietary Cook was about to reheat expired left-over roast beef, unaware of its expiration. The facility's policies on labeling, dating, and handling leftover foods were not followed, as confirmed by the Food Service Efficiency Consultant.
Infection Control Deficiencies in Hand Hygiene and Wound Care
Penalty
Summary
The facility failed to follow proper infection control practices in two observed instances. First, a dietary cook did not perform proper hand hygiene while in the kitchen. The cook was observed washing her hands without using soap and scrubbing for less than 20 seconds, and pat drying her hands using her clothes. This was confirmed by the Food Service Efficiency Consultant, who stated that staff must perform hand washing before providing food services. The facility's policy on hand washing, dated 2023, indicated that hands need to be washed with soap and water for at least 20 seconds before starting work in the kitchen. Second, a licensed nurse did not change gloves and perform hand hygiene during wound care for a resident with diabetes and a stage 4 pressure ulcer. The nurse was observed removing the old dressing, cleaning the wound, and applying a new dressing without changing gloves or performing hand hygiene between these steps. This was confirmed by the Director of Nursing, who stated that staff are required to change gloves from dirty to clean during the wound care process. These failures had the potential to spread infection within the facility.
Failure to Ensure Physician Approval for Self-Administered Medications
Penalty
Summary
The facility failed to ensure that self-administered medications kept at the bedside for one resident were reviewed and approved by a physician. During an observation, a Licensed Nurse (LN) was seen administering medications to a resident who had an albuterol inhaler on their bedside table without a pharmacy label. The resident mentioned that the inhaler was brought from the hospital and was not providing relief. Upon review, it was confirmed that there was no physician's order for the albuterol inhaler or for the resident to self-administer medications. The LN acknowledged that a physician's order was necessary for safe self-administration and that the medication should have been stored in a lockbox. The Director of Nursing (DON) stated that medications brought in by residents should be given to family members or securely stored with the DON. A resident assessment and a physician's order are required to allow self-administration of medication, and the medication should be stored in the medication cart. The facility's policies and procedures were reviewed, indicating that medications brought in by residents must be identified and approved by a physician or pharmacist, and residents may self-administer medications only if deemed safe by the attending physician and the Interdisciplinary Care Planning Team.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that Resident 62's respect and quality of care were maintained when the resident was unable to reach the call light. Resident 62, who was admitted in 2024 with diagnoses including asthma and a left lower limb infection, reported during an observation and interview that she could not reach the call light while in her wheelchair because it was located on the other side of her bed. The Director of Nursing confirmed that the call light should have been within reach of the resident. The facility's policy, dated December 2022, indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Provide a Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for Resident 37, who had a history of urinary tract infection, major depressive disorder, and paraplegia. Upon readmission from the hospital, Resident 37's room was cluttered with multiple personal belongings, including bags and boxes, which had not been unpacked since her return. Despite Resident 37's requests for assistance, the Social Services Assistant (SSA) and other staff members did not help her unpack, leading to a disorderly and cluttered room. This clutter prevented housekeepers from properly cleaning the area and created an unsafe environment for Resident 37, who was unable to adjust her bed or use the call light due to the clutter. The Director of Staff Development (DSD) and Licensed Nurse 1 (LN 1) acknowledged Resident 37's requests but failed to communicate them to the appropriate personnel, resulting in the continued disarray of her room. Resident 37's care plan indicated a need for a safe environment free from clutter due to her risk of falls related to paraplegia and gait/balance problems. However, the facility did not adhere to this care plan, as evidenced by the cluttered state of her room and the lack of assistance provided to unpack her belongings. The Director of Nursing (DON) confirmed that the SSA should have filed a grievance form or resident concern form and followed up until the problem was resolved. The facility's policy on providing a homelike environment was not followed, leading to Resident 37's increased anxiety and discomfort due to the disorderly state of her room and the inability to access her personal items.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for three residents. Resident 70's most recent quarterly MDS assessment did not reflect his impaired vision, despite observations and interviews indicating he had vision issues and had requested to see an eye doctor. The Activities Director and Social Services Assistant confirmed that Resident 70 used eyeglasses and had been requesting an optometrist visit, which had not been arranged yet. The Director of Nursing acknowledged that the MDS assessment should accurately reflect the resident's condition to develop an appropriate care plan. Resident 64's MDS inaccurately indicated that she had no feeding tube, despite her being observed with a feeding tube and her medical records confirming the need for enteral feeding due to gastrointestinal dysfunction. The MDS Coordinator and Director of Nursing confirmed the inaccuracy, noting that it could impact data collection, billing, and the delivery of specific care areas. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, which was not adhered to in this case. Resident 88's MDS inaccurately indicated that he was discharged to a hospital, while records and interviews confirmed he was discharged home with his daughter. The MDS Coordinator and Director of Nursing verified the discrepancy, acknowledging that the discharge status in the MDS was incorrect. These inaccuracies in the MDS assessments had the potential to affect the residents' care and interventions, as the assessments guide the development of care plans and other critical aspects of resident management.
Failure to Develop and Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and provide a baseline care plan (BCP) and written summary for one of 23 sampled residents (Resident 240) within 48 hours after admission. Resident 240 was admitted to the facility on [DATE], but the BCP was not completed until 3/19/24, and a printed summary was not provided to the resident or her representative. During an interview on 3/26/24, the Director of Nursing (DON) confirmed that the BCP was not completed within the required timeframe and acknowledged that the summary was not provided in writing. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a diagnosis of pulmonary dysfunction due to COPD exacerbation. The resident had physician's orders for the use of an incentive spirometer three times a day for 10 days and for the use of compression stockings for 10 hours daily. However, these orders were not included in the resident's care plan, which had the potential for the orders to be missed and not implemented. This was confirmed during interviews and record reviews with the licensed nurse, medical records director, and director of nursing, who all acknowledged the absence of the required care plans. The deficiency was identified during a review of the resident's medical records and order summary reports, which showed the specific orders for the incentive spirometer and compression stockings. Despite the facility's policy and procedure requiring comprehensive care plans to be developed and implemented for each resident within seven days, the care plans for these orders were not found. The director of nursing stated that she expects her staff to develop and revise care plans as necessary, but this was not done in this case.
Failure to Expel Air from Syringe Resulting in Incorrect Heparin Dose
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for Resident 189 when nursing staff did not expel air from a syringe, resulting in an incorrect dose of heparin being administered. During a medication pass observation, Licensed Nurse 4 (LN 4) was seen preparing ten medications for Resident 189, including heparin 5000 units/milliliter. LN 4 withdrew the medication and pulled the plunger back to the 1 milliliter measurement marker, but a large bubble was observed in the syringe, causing the heparin to be at the 0.88 milliliter measurement marker. LN 4 confirmed she had finished preparing the dose and administered the heparin into Resident 189's left lower abdomen without expelling the air from the syringe. A review of Resident 189's medical record indicated a physician's order for heparin 5,000 units/milliliter, to be injected 1 milliliter subcutaneously every 24 hours for deep venous thrombosis. During an interview, LN 4 acknowledged that she was unable to remove the bubble from the syringe and agreed that Resident 189 did not receive the correct dosage of heparin. The Director of Nursing confirmed that correctly administering injectable medications was an expectation and part of nursing staff's competency. The facility's policy and procedure for administering medications and subcutaneous medication administration both indicated that air should be expelled from the syringe before administering the medication.
Failure to Arrange Eye Doctor Consultation for Resident
Penalty
Summary
The facility failed to assist Resident 70 with the arrangement of an eye doctor consultation, which had the potential to delay the delivery of care to improve the resident's vision. Resident 70, who was admitted in June 2023 with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was observed squinting while watching television and reported that the reading glasses provided by the Activities Director caused headaches. Despite requesting to see an eye doctor, no consultation had been arranged by the time of the survey in March 2024. The Social Services Assistant (SSA) acknowledged that the last follow-up on Resident 70's request was documented in August 2023, with no further updates. The Director of Nursing (DON) confirmed that staff are expected to assess and identify residents' needs, including vision impairments, and assist in obtaining necessary services promptly. The facility's policies and procedures stipulate that staff should refer visually impaired residents for vision evaluations and provide medically-related social services to maintain or improve residents' abilities to meet everyday physical needs.
Failure to Follow Physician's Treatment Order for Pressure Ulcer
Penalty
Summary
The facility failed to follow a physician's treatment order for a stage 4 pressure ulcer for one resident. The resident, who was admitted in 2024 with diagnoses including diabetes and a stage 4 pressure ulcer, had a specific treatment order for the ulcer on the left posterior leg. The order required cleansing with normal saline, patting dry, applying collagen, hydroferra blue, triad cream to the margin, and a silicone border foam dressing with skin prep every Monday, Wednesday, and Friday during the day shift. However, during an observation, a licensed nurse did not use skin prep and collagen as prescribed while performing the dressing change. This was confirmed by the nurse during the observation and later by the Director of Nursing, who stated that staff are expected to follow physician orders for wound care. The resident's care plan, dated 3/25/24, indicated the presence of a pressure ulcer on the left leg and required the administration of treatment as ordered. The facility's policy on pressure ulcers, dated 4/2022, also indicated that the physician or nurse practitioner would order pertinent wound treatment, including wound cleaning and the application of topical agents. The failure to follow the prescribed treatment order had the potential to worsen the resident's current pressure ulcers.
Improper Checking of Roam Signal Device
Penalty
Summary
The facility failed to properly check the functionality of a roam signal device for a resident diagnosed with paranoid schizophrenia and Alzheimer's disease. The resident, who exhibited exit-seeking behavior, was observed wearing the device and propelling himself towards the dining room. The order summary indicated that the device should be checked for placement every shift and functionality every afternoon shift. However, the Licensed Nurse interviewed was unsure how to check the functionality and which staff was responsible for this task. The Director of Nursing confirmed that the device was checked by taking the resident near the main door, but acknowledged the need for a proper method to ensure the resident's safety. The facility's policy on assistive devices and equipment indicated that the facility provides, maintains, trains, and supervises the use of such devices for residents. Despite this policy, the improper checking method placed the resident at an increased risk for elopement. The Director of Nursing admitted awareness of the current checking method and recognized the necessity for a safer procedure. The failure to implement a proper checking method for the roam signal device led to the deficiency noted in the report.
Failure to Ensure Routine Midline Catheter Care
Penalty
Summary
The facility failed to ensure the routine care and dressing change of a midline catheter for one resident. During an observation and interview, it was noted that the dressing on the resident's midline catheter was dated 21 days prior, indicating it had not been changed as required. The Licensed Nurse confirmed that the dressing should have been changed. A review of the resident's physician's orders and medical records revealed no orders for flushing and locking the midline catheter or for changing the dressing. The Director of Nursing acknowledged that the nurses failed to add preset orders to the active orders, leading to the omission of necessary midline catheter care until the catheter was removed. This failure increased the risk of central line-associated bloodstream infections for the resident. The facility's policies and procedures for central venous catheter care and dressing changes were reviewed and indicated specific guidelines for flushing, locking, and changing dressings. These guidelines were not followed, as evidenced by the lack of documentation in the resident's medical records regarding the midline catheter care. The Director of Nursing confirmed that the nurses did not follow the facility's policies, resulting in the missed care and increased risk of infection for the resident.
Unattended Medications on Med Cart
Penalty
Summary
The facility failed to ensure medications were not stored on top of medication carts when left unattended. During an observation, a Licensed Nurse (LN 7) was seen preparing medications at a med cart in the hallway. LN 7 left the med cart unattended to locate a missing medication, leaving a bubble pack containing six hyoscyamine 0.125 mg tablets on top of the cart. LN 7 confirmed that the bubble pack was left unattended and not securely stored. The facility's policy and procedure for administering medication, dated April 2023, explicitly stated that no medications are to be kept on top of the cart.
Failure to Ensure Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the competency of Food and Nutrition Services staff, specifically Dietary Cook 1 (DC1), in two critical areas. First, DC1 did not correctly follow the cooling down process for turkey, as evidenced by the cooling log being documented as complete while the turkey was still cooking in the oven. This was confirmed by both the Kitchen Dietary Manager (KDM) and the Food Service Efficiency Consultant (FSEC). Additionally, there was no cooling down process training or in-service provided to DC1 in 2023, as confirmed by the KDM. Second, DC1 demonstrated a lack of knowledge and adherence to proper procedures for pureeing food. During observations, DC1 did not use recipes, measuring tools, or utensils while pureeing beef, vegetables, starch, and bread biscuits. DC1 confirmed not knowing the correct puree consistency and not using any measurable tools or recipes. This was further corroborated by the FSEC, who stated that dietary staff should use recipes and measuring utensils when pureeing food. The facility's policy requires Food and Nutrition Services employees to demonstrate competency in food safety principles and job skills, which was not adhered to in this case.
Failure to Use Recipes and Measuring Tools for Pureed Diets
Penalty
Summary
The facility failed to prepare food in a manner that conserves nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, pureed vegetable, and pureed starch. This deficiency was observed during the preparation of lunch, where the dietary cook used unmeasured amounts of ingredients and did not follow any recipes for pureeing beef, vegetables, sweet potatoes, and bread biscuits. The dietary cook confirmed that no measuring tools or recipes were used during the preparation process. The Food Service Efficiency Consultant confirmed that dietary staff should have used recipes and measuring utensils to maintain the nutritive value of the food. The facility's policy on food preparation, dated May 2023, indicated that food should be prepared by methods that conserve nutritive value, flavor, and appearance. This failure had the potential to decrease the nutrients in the food served and decrease food intake for five residents who received a pureed diet out of a facility census of 90.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was complete and posted on a daily basis at the beginning of each shift for a census of 90 residents. The Staffing Coordinator (SC) posted staffing information in the afternoon without including the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was observed on multiple occasions, including when the staffing information for the current date was not posted in the morning. The SC confirmed that the Direct Care Service Hours Per Patient Day (DHPPD) forms for several dates did not include the required information and that staffing information was not posted on one of the dates. The facility's policy required daily posting of nurse staffing data for each shift, but this was not adhered to, as confirmed by the SC.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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