Lincoln Square Post Acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 1032 N. Lincoln Street, Stockton, California 95203
- CMS Provider Number
- 555186
- Inspections on file
- 28
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lincoln Square Post Acute Care during CMS and state inspections, most recent first.
A resident reported that a nurse spoke to him in a rude manner in the snack room, allegedly accusing him of being a thief and stating he would be the main suspect if items went missing. The resident told a nurse supervisor about the interaction and later described it as verbal abuse to another nurse, a transition-of-care nurse with his insurance, and the Ombudsman. One nurse on duty confirmed the resident said he felt abused and reported this to the supervisor. The involved nurse denied calling the resident a thief and did not actually report the incident to administration despite initially claiming she had, and no documentation of the event was found in the EMR. The concern was handled as a grievance rather than an abuse allegation, and the facility did not follow its abuse policy requiring immediate reporting of known or suspected abuse to the administrator and external authorities.
A resident with severe cognitive impairment exited the facility through an unsecured rear Dining Room door and was missing for over an hour before staff noticed. The resident, who had not previously been identified as an elopement risk, sustained injuries after falling outside and was found at a nearby hospital. The door lacked an alarm or Wander Guard system at the time, and staff were unaware of the resident's absence until a routine check during dinner service.
The facility failed to protect residents' privacy by discarding meal tickets containing sensitive information in the kitchen garbage. Observations showed a Dietary Aide disposing of these tickets improperly, and interviews with staff confirmed the lack of a proper disposal process. The Registered Dietician and DON acknowledged this practice violated HIPAA and facility policies.
The facility failed to maintain food safety standards, with expired and improperly labeled food, non-food items in storage, and unclean equipment. Expired strawberries and tomatoes were found, and food items lacked proper labeling. Non-food items were stored in the dry food area, and the coffee machine's water filter was not maintained. A dirty fan, wet pans, and a dirty ice machine further compromised safety. These issues were confirmed by the Dietary Service Supervisor and Registered Dietician, posing a risk of illness to residents.
The facility failed to maintain proper garbage disposal, as observed with overflowing trash bins and open lids, contrary to the facility's normal process. Staff interviews confirmed the importance of closed lids to prevent pest issues, aligning with FDA guidelines on waste management.
The facility failed to implement an antibiotic stewardship program, leading to inappropriate antibiotic prescriptions for two residents. Antibiotics were prescribed without meeting infection criteria, and there was a lack of documentation and communication with medical staff. The facility's policies on antibiotic use were not followed, contributing to the deficiency.
A facility failed to maintain the dignity of a resident by not covering the resident's genital area with a sheet while sleeping. A CNA confirmed the exposure and acknowledged the expectation for covering residents to prevent loss of dignity. The ADON emphasized the importance of covering residents for dignity and making rounds to ensure decency. The resident preferred not wearing undergarments for easier bathroom use. The facility's policy requires staff to protect resident privacy.
A resident with type 2 diabetes experienced a hypoglycemic event after staff administered rapid-acting insulin without proper parameters and failed to notify the physician when the resident refused a meal. The insulin order lacked specific instructions on when to hold the medication, leading to a dangerously low blood glucose level and the need for emergency treatment.
A facility failed to accurately document narcotic medications for a resident under hospice care, leading to discrepancies in the Medication Administration Record (MAR). The resident, with chronic kidney disease and a non-pressure chronic ulcer, was prescribed Morphine Sulfate for pain management. Both facility LNs and hospice nurses administered the medication, but coordination and documentation were lacking. The Director of Nursing confirmed inaccuracies in the MAR, and the facility's policy for medication administration was not followed.
A resident was given an antibiotic without meeting the facility's criteria for its use, as required by the antibiotic stewardship program. The necessary Infection Screening Evaluation was not completed before the medication was administered, and there was no communication with the medical doctor about the lack of criteria met. The Pharmacist Consultant indicated that the antibiotic was not needed, and the facility's policies on infection prevention and control were not followed.
A resident with chronic kidney disease and a non-pressure chronic ulcer received incorrect dosages of Morphine Sulfate due to discrepancies between physician orders, MAR, and CDR. The facility's failure to follow medication administration policies led to the administration of incorrect dosages, as confirmed by the DON.
The facility failed to properly label, store, and dispose of medications, as observed with an unlabeled psyllium fiber supplement, an unlabeled cough medicine, and medications for a discharged resident found in the medication cart. The DON confirmed that these practices did not align with facility policy, posing a risk of medication errors.
A facility failed to implement proper infection prevention practices, leading to a deficiency. A resident was placed in a room with another who tested positive for RSV without Droplet Isolation Precautions. Additionally, a resident who tested positive for RSV was not placed under isolation precautions until several days later, increasing the risk of infection transmission. The facility's policy for Transmission-Based Precautions was not followed, resulting in a deficiency.
A facility failed to document the offer and consent for an influenza vaccine for a resident with COPD and dementia. The resident's conservator was not reached for consent, and no documentation of attempts was made. The facility's policy required annual vaccine offers and documentation of refusals.
A facility failed to submit a new Level I PASRR for a resident with schizophrenia, leading to an incomplete Level II Mental Health Evaluation. The resident was isolated for health precautions, and the necessary new Level I screening was not conducted, potentially risking the resident's care. The ADON and DON confirmed the oversight, acknowledging the risk of inadequate treatment and monitoring.
A resident was discharged with a discontinued medication due to a failure in medication reconciliation. The resident, who had been prescribed Mirtazapine for depression, was sent home with the medication despite it being discontinued. The error was identified during a review of discharge records, and the responsible nurse was counseled and no longer worked at the facility.
Failure to Report Resident’s Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse in accordance with its abuse policy and mandated reporting requirements. A resident, admitted in 2025, stated that in the early morning hours of 1/10/26 he went to the snack room to get hot water for coffee and a licensed nurse told him he could not go into the snack room. The resident reported that this nurse accused him of being a thief and told him that if anything went missing he would be the number one suspect. The resident stated that the way the nurse spoke to him felt like verbal abuse and slander. He reported the incident to the licensed nurse supervisor, who told him he could enter the snack room to get hot water and that she would take care of it. In subsequent interviews, the involved nurse (LN 1) acknowledged asking the resident not to go into the snack room at night and to use the call light so staff could get snacks or hot water for him, explaining that night shift staff kept their belongings in the snack room. LN 1 denied calling the resident a thief or saying he would be the number one suspect if anything was missing. LN 1 stated she wrote a progress note in the electronic medical record and reported the incident to administration, but could not identify to whom she reported it and ultimately confirmed she did not actually report it, stating she did not see the relevance. Review of the resident’s electronic medical record showed no progress note documenting the incident. The facility’s grievance binder showed that the nurse supervisor completed a grievance form on 1/12/26 after the resident reported that a nurse was rude and told him it was not okay to take food from the snack room at night; the grievance did not characterize the concern as abuse. Additional interviews showed that the resident described the incident as verbal abuse to individuals outside the immediate facility chain. A transition-of-care nurse from the resident’s insurance reported that on 1/27/26 the resident called and stated he was verbally abused by a nurse, leading to a three-way call attempt to the Ombudsman’s office during which the resident left a voicemail stating he was verbally abused. Another nurse on duty the night of the incident (LN 2) stated the resident told him that a nurse had called him a thief and that he felt abused; LN 2 reported the incident to the nurse supervisor. The Ombudsman reported receiving a message that the resident had called on 1/26/26 and, upon returning the call, the resident stated that a nurse verbally assaulted him but did not provide the nurse’s name. The facility’s Elder/Dependent Adult Abuse policy required that any mandated reporter who has knowledge of an incident that reasonably appears to be abuse, or is told by an elder that they have experienced behavior constituting abuse, must immediately report the known or suspected abuse to the administrator and appropriate external authorities within specified time frames. Despite the resident’s statements to staff and others that he felt verbally abused, the allegation was not reported as required by policy and state law.
Resident Elopement and Injury Due to Unsecured Exit Door
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes mellitus, chronic kidney disease, and spinal stenosis exited the facility through an unlocked rear Dining Room door and was missing for approximately one and one-half hours before staff became aware. The resident, who had a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, was found to have left the facility in her wheelchair and was later discovered at a nearby hospital emergency department after sustaining a fall and injuries, including facial lacerations and contusions. The incident was captured on facility camera footage, which showed the resident leaving through the rear Dining Room door, crossing the street, and moving out of camera view. Prior to the incident, the resident had not been assessed as being at risk for elopement, as indicated by multiple Elopement/Wandering Risk Assessments completed before the event, all scoring below the threshold for elopement risk. The resident had intermittent confusion and was ambulatory with assistance, including the ability to self-propel in a wheelchair. The facility had equipped the resident with a wheelchair alarm that sounded when she stood up, but there was no Wander Guard device in place before the incident. The rear Dining Room door, through which the resident exited, did not have an alarm or Wander Guard system at the time of the event. Staff became aware of the resident's absence during the dinner tray pass, after which a search was initiated, and the resident was eventually located at the hospital. Interviews with staff and administration confirmed that the rear Dining Room door was not considered a hazard prior to the incident, as the resident had not previously attempted to leave the facility. The door was not locked or alarmed, and its status as an exit was misunderstood among staff, with some believing it was not a designated fire exit. The lack of adequate supervision and environmental safeguards contributed to the resident's unsupervised exit and subsequent injury.
Improper Disposal of Meal Tickets Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by improperly disposing of meal tickets in the kitchen garbage bin. During observations, it was noted that a Dietary Aide discarded uneaten food, used napkins, and residents' meal tickets into the trash. These meal tickets contained sensitive information such as residents' names, unit, room, and bed numbers, diet orders, allergies, food notes, and preferences. The Dietary Service Supervisor confirmed the practice and acknowledged the lack of a proper disposal process for these meal tickets. Interviews with the Registered Dietician and the Director of Nursing revealed that the practice of throwing meal tickets in the trash did not meet their expectations and violated HIPAA regulations. The Registered Dietician stated that the meal tickets should have been shredded to prevent unauthorized access to residents' information. The Director of Nursing emphasized that the meal tickets are part of the residents' medical records and should be shredded to protect against unauthorized access. The facility's policies on health information and confidentiality also indicated the need to secure residents' information against unauthorized access.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by several deficiencies observed during a kitchen tour. Expired food items, including strawberries and tomatoes, were found in the reach-in refrigerator and dry storage, posing a risk of foodborne illnesses to residents. Additionally, food items were improperly labeled and dated, which could lead to the consumption of spoiled food. The Registered Dietician acknowledged that the quality of produce was overlooked, and the findings did not meet the facility's expectations. Non-food items, such as folding chairs, were improperly stored in the dry food storage room, which is designated solely for food storage. The Dietary Service Supervisor was unable to provide a reason for the placement of these chairs. Furthermore, the water filter for the coffee machine was not changed according to the manufacturer's guidelines, and there was no tracking system in place to monitor the filter's usage. This oversight could result in contaminants entering the water supply. Additional issues included a dirty fan in the food preparation area, wet tray line pans and a food processor bowl, and a dirty ice machine. The fan, covered in a grey fuzzy substance, posed a risk of contaminating food with particles. Wet pans and a food processor bowl could foster the growth of microorganisms, while the ice machine's unclean condition could lead to resident illness. These conditions were confirmed by the Dietary Service Supervisor and the Registered Dietician, who stated that they did not meet the facility's expectations and could potentially make residents sick.
Improper Garbage Disposal Leading to Potential Pest Infestation
Penalty
Summary
The facility failed to maintain proper disposal of garbage and refuse, as observed during a survey. On the specified date, the trash bin for the facility was found overflowing with trash bags, and the lid was placed completely behind the bin. This situation was confirmed during an interview with a staff member, who indicated that the trash service had left the bins in that condition. The open and overflowing trash bins were not in line with the facility's normal process, as stated by the Dietary Services Supervisor, who emphasized the importance of keeping dumpster lids closed to prevent pest infestations. Further interviews with the Registered Dietician reinforced the expectation that dumpster lids should be closed and that garbage should not overflow to avoid sanitation issues and potential pest problems. The report references the 2022 Food Code by the FDA, which outlines the necessity of proper storage and disposal of garbage to minimize odors, prevent attraction and breeding of pests, and maintain sanitary conditions. The failure to adhere to these guidelines posed a risk of insect and rodent infestation due to the improper handling of waste.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to consistently implement an antibiotic stewardship program, which is crucial for ensuring that antibiotics are used only when necessary and appropriate. This deficiency was observed in the cases of two residents, where the Loeb and McGeer criteria were not consistently applied to assess the initiation and appropriateness of continued antibiotic use. For Resident 122, an antibiotic was prescribed for a suspected upper respiratory infection without meeting the necessary infection criteria, and there was no documentation of an infection screening evaluation on the day the antibiotic was first prescribed. In the case of Resident 56, an antibiotic was prescribed following a family member's request, despite the resident not meeting the infection screening criteria. The Infection Screening Evaluation was completed two days after the antibiotic was started, and it did not support the reason for the antibiotic prescription. There was no record of communication with the medical doctor to address the discrepancy between the prescribed antibiotic and the infection criteria. The facility's policies on antibiotic stewardship and infection prevention were not adhered to, as evidenced by the lack of appropriate documentation and communication regarding antibiotic prescriptions. The Pharmacist Consultant noted that inappropriate antibiotic orders were not addressed in stewardship meetings, as he was not invited to participate. This lack of adherence to established protocols and communication failures contributed to the deficiency in the facility's antibiotic stewardship program.
Failure to Maintain Resident Dignity by Ensuring Privacy
Penalty
Summary
The facility failed to ensure the dignity of Resident 119 by not covering the resident's genital area with a sheet while he was sleeping in bed. This incident was observed during a concurrent observation and interview with a Certified Nursing Assistant (CNA), who confirmed that the resident's genitals were exposed. The CNA acknowledged the expectation for residents' private parts to be covered to prevent a loss of dignity and feelings of shame. The Assistant Director of Nursing (ADON) also stated that residents should be covered with a sheet for dignity and that staff should make rounds to ensure residents are decently covered. Resident 119 mentioned a personal preference for not wearing undergarments to facilitate easier bathroom use. The facility's policy on Quality of Life - Dignity, revised in February 2020, indicates that staff should promote, maintain, and protect resident privacy, including bodily privacy.
Failure to Administer Insulin with Proper Parameters Leads to Hypoglycemic Event
Penalty
Summary
The facility failed to provide quality care to a resident with type 2 diabetes mellitus and diabetic chronic kidney disease when staff administered rapid-acting insulin without appropriate parameters. The insulin order did not include specific instructions on when to hold or not administer the insulin, leading to the administration of 10 units of Insulin Lispro to the resident when their blood glucose (BG) level was 129. This administration occurred despite the resident's responsible party indicating that the resident did not take insulin at home. Following the insulin administration, the resident refused their scheduled meal, which was not communicated to the physician by the staff. As a result, the resident experienced a hypoglycemic event with a dangerously low BG level of 36, requiring emergent medical treatment. The facility's documentation indicated that the resident was observed to be sleepy and sweaty, and emergency interventions, including the administration of a Glucagon Emergency Kit and orange juice with sugar, were necessary to stabilize the resident's condition. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that there was a lack of communication and clarification regarding the insulin order. The staff did not contact the physician to clarify the order or obtain hold parameters, which could have prevented the hypoglycemic event. The facility's protocols emphasized the importance of considering the risk of hypoglycemia and incorporating physician-ordered parameters into the care plan, which was not adhered to in this case.
Inaccurate Documentation of Narcotic Medication for Resident in Hospice Care
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for a resident, identified as Resident 55, by not accurately documenting narcotic medications in the Medication Administration Record (MAR) when removed from the Controlled Drug Record (CDR). This discrepancy was observed during a review of Resident 55's records, which indicated that the dosages of Morphine Sulfate, a narcotic medication prescribed for pain, were not accurately recorded. The Director of Nursing (DON) confirmed that the staff documented Resident 55's doses of Morphine Sulfate inaccurately on the MAR for November and December 2024, and that the facility policy was not followed. Resident 55 was admitted with diagnoses including chronic kidney disease and a non-pressure chronic ulcer of the right midfoot and heel. The resident was under hospice care, which involved both facility licensed nurses (LNs) and hospice nurses administering Morphine Sulfate for pain management. However, there was a lack of coordination and documentation between the facility staff and hospice nurses regarding the administration of the medication. The hospice nurse, LN 2, stated that medications given by hospice nurses were obtained from the facility's medication cart and documented by facility LNs, but the hospice binder for Resident 55 was not found. The facility's policy and procedure for medication administration emphasized the importance of the 'Five Rights'—right resident, right drug, right dose, right route, and right time—and required a triple check of these rights during medication preparation. Despite these guidelines, the facility failed to maintain accurate records of the narcotic medication administration, which could potentially impact the well-being of Resident 55. The facility's policy also outlined responsibilities for administering prescribed therapies, including those determined appropriate by hospice, but these were not adequately followed in this case.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Resident 56 was administered an antibiotic, Levofloxacin, despite not meeting the criteria established by the facility's antibiotic stewardship program. The antibiotic was prescribed for chest congestion and left ear pain, but the necessary Infection Screening Evaluation was not completed prior to the initiation of the medication. The Nurse Consultant confirmed that the evaluation, which should have been done before starting the antibiotic, was only completed two days later and did not support the use of the antibiotic for the reasons it was prescribed. During a review of the resident's medical records, it was found that there was no communication with the medical doctor regarding the lack of criteria met for the antibiotic prescription. The Pharmacist Consultant noted that had the antibiotic been active during his drug regimen review, he would have recommended against its use, as the resident did not meet the infection criteria. The Pharmacist Consultant also highlighted that Levofloxacin is not typically prescribed for bronchitis unless there is a history of it progressing to pneumonia, which was not documented in this case. The facility's policies on infection prevention and antibiotic stewardship were not adhered to, as the protocols for monitoring antibiotic use and ensuring appropriate prescriptions were not followed. The facility's policy required that prescribers provide complete antibiotic orders with indications for use, which was not done in this instance. The failure to follow these protocols resulted in the unnecessary administration of an antibiotic to Resident 56, which could lead to adverse effects and the development of antibiotic-resistant organisms.
Resident Received Incorrect Dosage of Narcotic Pain Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident received more than the prescribed dose of a narcotic pain medication for over a month. The resident, who was admitted with chronic kidney disease and a non-pressure chronic ulcer, was prescribed Morphine Sulfate in varying concentrations and dosages over time. However, discrepancies were found between the physician's orders, the medication administration records (MAR), and the controlled drug record (CDR), leading to the administration of incorrect dosages. The physician's orders for Morphine Sulfate changed multiple times, specifying different concentrations and dosages for pain management. Despite these changes, the facility's records indicated that the resident received doses that were inconsistent with the prescribed orders. The Director of Nursing (DON) confirmed that the doses documented as given were less than those removed from the medication cart, indicating a failure to administer the correct dose. This discrepancy was attributed to errors in documentation by the staff, who did not follow the facility's policy on medication administration. The facility's policy required a triple check of the five rights of medication administration, which include the right resident, drug, dose, route, and time. However, this procedure was not followed, leading to the administration of incorrect dosages. The DON acknowledged that the staff failed to clarify the physician's orders, resulting in the resident not receiving the correct dose of pain medication. This oversight had the potential to impact the resident's quality of life and well-being.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were labeled, stored, and disposed of according to standards of practice for a census of 57 residents. During an observation and interview, it was found that an opened, unlabeled container of psyllium fiber supplement and an opened, unlabeled bottle of cough medicine were stored in the medication cart. Additionally, medications for a discharged resident were also found in the medication cart. The Licensed Nurse (LN) acknowledged that these items should not have been in the medication cart and removed them. The Director of Nursing (DON) confirmed that medications for discharged residents should be removed from the medication cart, locked in a cabinet in the medication storage room, and destroyed routinely. The DON stated that the presence of discharged residents' medications in the cart posed a risk of being administered to another resident in error. The facility policy required open dates to be placed on medications, but this was not followed, as acknowledged by the DON. The facility's policy and procedure for the storage of medications indicated that medications should be stored safely and securely, with expiration dating and open dates clearly labeled, which was not adhered to in this instance.
Failure to Implement Droplet Isolation Precautions for RSV
Penalty
Summary
The facility failed to implement proper infection prevention practices for a census of 57 residents, leading to a deficiency. Resident 171 was placed in a room with another resident who tested positive for RSV without Droplet Isolation Precautions in place. This oversight occurred on December 15, 2024, and was confirmed through observation and interviews with facility staff. The lack of isolation precautions increased the risk of infection transmission to Resident 171, who was not tested for RSV as he showed no symptoms at the time. Resident 9, who tested positive for RSV on December 11, 2024, was not placed under Droplet Isolation Precautions until December 16, 2024. This delay in implementing isolation measures was confirmed by the facility's Infection Preventionist, who acknowledged that the facility's policy was not followed. The absence of isolation precautions for Resident 9 exposed other residents, staff, and visitors to the risk of RSV infection. The facility's policy, as outlined in their procedure for initiating Transmission-Based Precautions, was not adhered to in these cases. The policy requires that precautions be implemented when a resident has a confirmed infection and is at risk of transmitting it to others. The failure to follow this policy resulted in a deficiency, as the necessary precautions were not in place to prevent the spread of infection within the facility.
Failure to Document Influenza Vaccine Offer and Consent
Penalty
Summary
The facility failed to provide the influenza vaccine to one of the five sampled residents, identified as Resident 11, as there was no documented evidence in the resident's medical record that the vaccine had been offered, given, or refused. Resident 11 was admitted to the facility in 2022 with diagnoses including chronic obstructive pulmonary disease and dementia. The resident's admission record listed a conservator as the responsible party, with contact information provided. During a review of Resident 11's electronic medical record with the Infection Preventionist (IP), it was confirmed that there was no record of the influenza vaccination being offered or administered for the current flu season. The IP stated that attempts were made to contact the conservator for consent, but no response was received, and there was no documentation of these attempts in the medical record. In an interview with the Director of Nursing (DON) and the Nurse Consultant (NC), it was stated that the influenza vaccine was available and offered to residents starting in September, with documentation required on the consent form if the vaccine was given or declined. The DON indicated that the expectation was for the IP to document any attempts to obtain consent from a resident's responsible party. If contact could not be made, staff were expected to continue trying weekly and document these attempts in the resident's medical record. The facility's policy on the influenza vaccine, dated October 2019, required that all residents without medical contraindications be offered the vaccine annually, with refusals documented in the medical record.
Failure to Complete Required PASRR Evaluation
Penalty
Summary
The facility failed to submit a new Level I Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with schizophrenia, who was admitted in 2022. The initial Level I PASRR indicated a positive result for suspected mental illness, necessitating a Level II Mental Health Evaluation. However, this evaluation was not completed because the resident was isolated as a health or safety precaution. The facility was required to submit a new Level I screening to reopen the case, but this was not done, potentially placing the resident at risk of not receiving necessary care or services. During interviews and record reviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the Level II evaluation was not completed and a new Level I screening was not conducted. The ADON acknowledged that the resident's behavior could worsen without proper treatment, and the DON noted the potential for missing behavior monitoring and proper treatment, which could put both the resident and the facility at risk. The facility's policy on PASRR was reviewed, and it was confirmed that the policy was not followed, as a new Level I screening should have been completed to reflect the resident's mental health diagnosis.
Medication Reconciliation Failure at Discharge
Penalty
Summary
The facility failed to accurately complete a medication reconciliation for a resident at the time of discharge, resulting in the resident being sent home with a discontinued medication. The resident, who was admitted with diagnoses including depression and muscle weakness, was initially prescribed Mirtazapine, which was later discontinued. However, during the discharge process, Mirtazapine was included among the medications sent home, despite not being listed in the discharge instructions. The error was confirmed during a review of the resident's discharge records by the Director of Nursing and a Licensed Nurse. The nurse responsible for the discharge was counseled and no longer worked at the facility. The facility's policy required that medications be reconciled and verified against current physician orders, but this process was not followed, leading to the inclusion of the discontinued medication in the resident's discharge medications.
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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