Main West Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Turlock, California.
- Location
- 812 West Main Street, Turlock, California 95380
- CMS Provider Number
- 055475
- Inspections on file
- 28
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Main West Postacute Care during CMS and state inspections, most recent first.
During a transition from contracted to in-house rehab services, five residents with physician orders and established care plans for PT and/or OT did not receive their prescribed treatments for multiple weeks. Orders for therapy to address muscle weakness, gait and mobility abnormalities, and pelvic issues were in place, but no PT or OT staff were available to evaluate residents or continue existing treatment plans after the contract ended. The ADM and DON confirmed that therapy services were unavailable during this period, that plans of care and orders were not followed, and that physicians were not notified to clarify or adjust treatment orders, contrary to facility policies requiring timely, coordinated, and documented therapy services.
The facility failed to properly dispose of garbage and refuse, resulting in a cluttered area at the rear of the facility with items like stained mattresses and clothing bags. These items had been accumulating for months, and staff interviews confirmed the need for regular disposal. The area, although not accessible to residents, posed a potential pest risk.
A resident reported missing candy bars, but the grievance was not escalated to the Grievance Officer for investigation. The CNA informed a nurse, but no further action was taken. The LVN involved did not notify anyone else, assuming the issue was resolved when the resident's family brought more candy. The facility's policy required grievances to be documented and reported immediately, which was not followed.
Two residents reported abuse incidents to the police, but the facility failed to notify the Administrator and the state agency as required. One resident alleged being restrained by staff, while another claimed a CNA pushed them. The facility's policy mandates immediate reporting of such allegations, but staff did not adhere to this, resulting in a deficiency.
A resident with a history of anxiety and depression reported being pushed by a CNA, but the facility failed to properly investigate the allegation. The incident was brought to the facility's attention by a police officer, yet there was no evidence of a thorough investigation or reporting to the Administrator or state agency, contrary to facility policy.
The facility failed to complete timely comprehensive assessments for four residents, including those with dementia, COPD, and metabolic encephalopathy. The MDS Nurse identified a backlog of incomplete assessments, while the DON was unaware of the issue. The Administrator expected adherence to the RAI Manual for timely assessments.
The facility failed to complete quarterly MDS assessments every 92 days for three residents, as required by federal guidelines. A resident with dementia, another with pneumonia, and a third with type 2 diabetes mellitus did not have timely assessments. The MDS Nurse, new to the facility, acknowledged the backlog of assessments, while the DON was unaware of the issue. The Administrator expected adherence to the RAI Manual for timely MDS completion.
A facility failed to ensure the accuracy of the MDS for a resident with schizophrenia and major depressive disorder. The MDS inaccurately indicated the resident was not considered to have a serious mental illness, despite active diagnoses. Interviews with staff revealed a lack of awareness of the inaccuracies, and the Administrator confirmed the expectation for accurate MDS assessments.
A facility failed to ensure the accuracy of a PASARR for a resident with a history of mental disorders, including schizophrenia and bipolar disorder. The PASARR incorrectly indicated the absence of serious mental disorders, despite the resident's documented medical history. Interviews revealed that the admissions person was responsible for reviewing the PASARR, but no staff member was currently designated to verify its accuracy.
A resident with chronic respiratory conditions was observed administering their own nebulizer treatments without nurse supervision, contrary to the facility's policy. Nursing staff admitted to leaving the resident alone during treatments, and the DON was unaware of this practice.
A facility failed to implement a pharmacist's recommendation for a resident's medication order. The resident, with a history of constipation, was prescribed multiple bowel care medications. The pharmacist suggested adding a directive to hold the medication for loose stools, but this was not done. Interviews revealed that charge nurses did not act on pharmacy reviews, and the responsibility was left to RN supervisors or the DON. The administrator acknowledged the oversight, indicating a lapse in the process.
A resident with oral health issues did not receive timely dental care due to the facility's failure to arrange necessary appointments. Despite recommendations for dental procedures, such as bridge replacement and extractions, the resident's needs were unmet due to barriers in accessing care. Facility staff acknowledged the oversight, indicating a lapse in ensuring adequate dental services.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection prevention and control. A resident with a surgical wound did not receive proper EBP during wound care, as the nurse did not wear a gown. Another resident with a gastrostomy tube did not receive proper EBP during medication administration, as the LVN wore gloves but not a gown. Both instances were contrary to the facility's policy, which requires gown and glove use for residents with open wounds or gastrostomy tubes.
The facility failed to submit MDS assessments to CMS within the required 14 days for several residents, with delays ranging from 20 to 39 days. Staffing changes and gaps in the MDS Coordinator role contributed to the issue, as the new MDS Nurse was still in training and the DON was unaware of the need to sign and lock assessments completed before the new nurse's tenure. The facility's policy and federal guidelines were not adhered to, leading to these deficiencies.
The facility failed to provide the required minimum square footage per resident in 17 rooms, with measurements ranging from 75.6 to 78.7 square feet per resident. Staff interviews confirmed awareness of the deficiency, and a waiver was mentioned for the non-compliant rooms.
A resident in the facility did not receive the necessary splint and finger sleeve as indicated in their care plan, which was essential to prevent contractures in their right hand. Despite having a clear care plan, the nursing staff failed to provide these items, and there was no follow-up to ensure the interventions were implemented. The resident, who was cognitively intact, had a history of Type 1 Diabetes Mellitus and other conditions affecting their right hand.
A resident with multiple chronic conditions and mental health disorders was planned to be discharged to a homeless shelter, causing significant distress and anxiety. The facility failed to provide adequate preparation and support, leading to increased medication and mood swings. Interviews revealed inconsistencies in the resident's functional assessment, highlighting the potential for an unsafe discharge.
A resident's MDS assessment inaccurately indicated independence in mobility, affecting her care and placement. Despite the MDS showing she could walk 50 and 150 feet independently, interviews with staff and the resident revealed she only walked short distances within her room. The DON and MDS Consultant acknowledged the discrepancies, suggesting the MDS entries were erroneous.
A resident diagnosed with HIV did not receive requested HIV treatment due to a lack of coordination between the facility and the hospice provider. The facility's staff assumed the hospice was responsible for the medication, while the hospice indicated no communication from the facility regarding the resident's request. This resulted in the resident not receiving necessary HIV treatment.
A resident experienced significant weight loss and low meal intake, but the RD was not notified in a timely manner, preventing necessary nutritional interventions. The facility's failure to communicate the weight loss compromised the resident's nutritional status.
Failure to Provide Ordered PT/OT Services During Therapy Provider Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered Physical Therapy (PT) and Occupational Therapy (OT) services for five residents during a transition from contracted to in-house therapy services. Physician orders and therapy plans of care were in place for all five residents, but PT and OT services were not delivered as prescribed for multiple weeks. For Resident 1, who had a BIMS score of 15 indicating no cognitive impairment, PT and OT were ordered on 12/26/25 for muscle weakness, with a plan for services five times per week from 12/26/25 to 1/22/26. Resident 1 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in eight missed PT and eight missed OT treatments. Resident 2, also with a BIMS score of 15 and no cognitive impairment, had PT and OT ordered on 1/20/26, and a PT plan dated 1/21/26 for muscle weakness with services five times per week from 1/21/25 to 2/4/26. Resident 2 did not receive PT during the weeks of 1/26/26 and 2/2/26, totaling seven missed PT treatments, and there was no OT evaluation or OT treatments documented. Resident 3, with a BIMS score of 7 indicating severe cognitive impairment, had PT and OT ordered on 12/26/25 and a PT/OT plan dated 12/28/25 for muscle weakness, with services five times per week from 12/28/25 to 1/24/26. Resident 3 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in thirteen missed PT treatments and fifteen missed OT treatments. Resident 4, with a BIMS score of 4 indicating severe cognitive impairment, had PT and OT ordered on 12/21/25 and a PT/OT plan dated 12/23/25 for abnormalities of gait and mobility, with services five times per week from 12/23/25 to 1/19/26. Resident 4 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in thirteen missed PT and fifteen missed OT treatments. Resident 5, with a BIMS score of 13 indicating no cognitive impairment, had PT and OT ordered on 12/13/25 and a PT/OT plan dated 12/15/25 for pelvic issues and abnormalities of gait and mobility, with services five times per week from 12/15/25 to 1/11/26. Resident 5 did not receive PT or OT during the week of 1/5/26, resulting in five missed PT and five missed OT treatments. Interviews with facility leadership and therapy staff confirmed that PT and OT services were not available from 1/5/26 to 1/22/26 due to the termination of contracted therapy services before in-house therapists were hired. The Consultant Administrator stated that PT and OT services should have continued without disruption after the contracted services ended on 1/5/26, but actual services did not restart until after 1/22/26. The DON confirmed that therapy services are expected to be evaluated and initiated within 72 hours of orders and that there was no PT or OT available during the identified period to conduct evaluations or continue treatment plans for the five residents. The PT, who was hired on 1/22/26 and had previously worked with the contracted provider, stated that residents did not receive therapy services from 1/5/26 to 1/22/26 because no one was hired to provide them and expressed concern about how the contract termination was handled. The Administrator acknowledged that the plans of care and physician orders for the five residents were not followed according to the medical record and that therapy services policies were not followed. The Administrator also stated that the primary physicians should have been notified of the delays and orders clarified to readjust treatments, but this did not occur. The OT, hired on 1/20/26 and providing services via telehealth, stated she could not speak to what occurred before her hire date but described the current process of instructing staff during telehealth sessions. Facility policies reviewed by surveyors, including "Scheduling Therapy Services" and "Care Plans, Comprehensive Person-Centered," require that therapy be scheduled and provided in accordance with the resident’s treatment plan, coordinated with nursing, documented in the medical record, and incorporated into a comprehensive care plan with measurable objectives and timetables. These documented expectations contrasted with the period in which no PT or OT services were provided despite active orders and treatment plans for the five residents. The DON and Administrator both described that from the time contracted services ended until in-house therapists were hired, there was no PT or OT available to evaluate residents or continue existing treatment plans. Nursing staff were responsible for notifying therapy of new orders, but there were no therapists available to receive or act on those notifications. As a result, the ordered rehabilitative services for muscle weakness, gait and mobility abnormalities, and pelvic issues were not delivered as planned for the five residents during the specified weeks, constituting the failure to provide specialized rehabilitative services as required by physician orders and facility policy.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. At the rear of the facility, there was a cluttered area containing 13 bags of clothing items, seven stained mattresses, a dusty plate warmer, and pallets. These items had been accumulating for three to six months, according to the Housekeeping Supervisor, and were the responsibility of the maintenance staff to clean. The Maintenance Assistant confirmed that the facility rented a dumpster every six to eight months to dispose of such items, as the facility's single dumpster could not accommodate all the refuse. Interviews with various staff members, including the Laundry Staff, Maintenance Director, Director of Nursing, and the Administrator, revealed that the cluttered area contained items either needing repair or disposal. The Maintenance Director acknowledged that the area could attract pests, and the Director of Nursing and Administrator both agreed that the area needed to be cleaned. Despite the area not being accessible to residents or their families, the presence of clutter and potential pest attraction posed a risk to the facility's environment.
Failure to Report and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure that a resident's grievance was reported to the designated Grievance Officer, preventing an investigation from being initiated. The facility's policy required that all grievances be investigated and corrective actions taken. However, in the case of a resident who reported missing chocolate candy bars, the grievance was not properly escalated. The resident, who had intact cognition and was dependent on staff for all activities of daily living, reported to a CNA that their candy bars were missing. The CNA informed a nurse, but no further action was taken to report the grievance to the Grievance Officer. The LVN involved acknowledged that the resident had mentioned the missing candy bars, but he did not notify anyone else, assuming the issue was resolved when the resident's family brought more candy. The Interim Social Services Director and the Director of Nursing both stated that grievances should be documented and reported immediately, but this process was not followed. The Administrator also expected staff to adhere to the grievance process, which was not done in this instance, leading to a failure in addressing the resident's grievance according to the facility's policy.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to management and the state survey agency for two residents. Resident #57, who had a history of traumatic events and intact cognition, called the police alleging that a staff member restrained them. Despite the police informing the facility staff of the call, the Administrator, who was the Abuse Coordinator, was not notified within the required two-hour timeframe. The Director of Nursing (DON) and Registered Nurse (RN) #9 were aware of the police visit but did not report the incident to the Administrator immediately, as required by the facility's policy. Resident #69, who also had intact cognition, reported to the police that a CNA pushed them, but did not inform the facility staff. The facility's investigation packet lacked evidence that the allegation was reported to the Administrator or the state agency. The Administrator later stated that the state agency was not notified because the staff's account did not align with the resident's allegation, suggesting the incident was not considered abuse. The facility's policy mandates immediate reporting of abuse allegations to the Administrator and the state agency, especially if it involves serious bodily injury. However, in both cases, the facility staff failed to adhere to this policy, resulting in a deficiency. The lack of timely reporting and investigation of these allegations highlights a significant lapse in the facility's abuse prevention and reporting protocols.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to properly identify and investigate an allegation of abuse involving a resident who reported being pushed by a CNA. The incident came to light when a police officer visited the facility after the resident called to report the alleged abuse. Despite the facility's policy requiring immediate investigation and reporting of abuse allegations, there was no evidence that the allegation was reported to the Administrator or the state agency. The Director of Nursing (DON) acknowledged that investigations should begin immediately, and involved staff should be suspended pending the investigation. The resident involved had a history of obstructive sleep apnea, major depressive disorder, and anxiety disorder, and was noted to have intact cognition. The resident's care plan indicated a tendency to become upset when staff entered their room at night, and there were interventions in place to manage these behaviors. However, the facility's investigation packet lacked documentation of a thorough investigation, including interviews with staff and witnesses, as required by their policy. The Administrator confirmed that the expectation was for all abuse allegations to be reported, but this did not occur in this instance.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for four residents within the required timeframes, as mandated by federal regulations. Resident #89 was admitted with a diagnosis of dementia, and the last comprehensive MDS was completed shortly after admission, with no subsequent assessments conducted. Resident #9, diagnosed with chronic obstructive pulmonary disease, had their last comprehensive MDS completed over a year ago, with no further assessments documented. Resident #23, with a history of metabolic encephalopathy, also lacked a comprehensive assessment since their last significant change in status MDS. Additionally, Resident #66, admitted with pneumonia, did not have an admission MDS completed at all. Interviews with facility staff revealed a lack of awareness and oversight regarding the overdue assessments. The MDS Nurse, who began employment in early 2025, acknowledged the backlog of incomplete assessments and identified the residents who were overdue for their annual MDS. The Director of Nursing was unaware of the incomplete assessments, and the Administrator stated that the expectation was for staff to adhere to the RAI Manual and complete assessments timely. This deficiency highlights a significant lapse in the facility's adherence to regulatory requirements for resident assessments.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments at least every 92 days for three residents, as required by federal guidelines. The facility's policy, dated January 2018, mandates adherence to federal and state submission timeframes for resident assessments. However, the facility did not complete a quarterly MDS for Resident #24 in January 2025, despite the resident having a medical history of dementia. Similarly, Resident #66, who was admitted in May 2023 with a diagnosis of pneumonia, did not have a quarterly MDS completed in January 2025. Resident #93, admitted in October 2024 with type 2 diabetes mellitus, had a quarterly MDS with an Assessment Reference Date of January 26, 2025, but it was not completed until March 4, 2025. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of MDS assessments. The MDS Nurse, who began employment on January 27, 2025, acknowledged that many MDS assessments were overdue or incomplete and expressed a plan to catch up on these assessments. The Director of Nursing (DON) was unaware of the incomplete MDS assessments, and the facility Administrator stated that the expectation was for staff to follow the Resident Assessment Instrument (RAI) Manual and complete MDS assessments in a timely manner. This deficiency indicates a failure in the facility's processes to ensure timely and accurate resident assessments.
Inaccurate MDS Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident reviewed for preadmission screening and resident review (PASARR). The resident, admitted on 05/03/2019, had a medical history of schizophrenia and major depressive disorder. An annual MDS assessment dated 06/10/2024 indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. However, the MDS inaccurately stated that the resident was not considered by the state level II PASARR process to have a serious mental illness or intellectual disability, despite active diagnoses of depression and schizophrenia. Interviews with the MDS Nurse and Director of Nursing revealed a lack of awareness regarding any inaccuracies in the MDS assessments, and the Administrator confirmed the expectation for MDS assessments to be accurate.
Inaccurate PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASARR) for a resident with a medical history that included unspecified psychosis, schizophrenia, major depressive disorder, bipolar disorder, and anxiety disorder. The resident's PASARR Level I Screening, dated August 7, 2023, incorrectly indicated that the resident did not have a serious diagnosed mental disorder, despite their documented medical history. Interviews with the Director of Nursing (DON) and the Administrator revealed that the admissions person was responsible for reviewing the PASARR for accuracy, but there was no current staff member designated to verify the accuracy of the PASARR at the facility.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses stayed with a resident to ensure all medication was administered as ordered by the physician. Resident #8, who was admitted to the facility with a medical history including chronic obstructive pulmonary disease and acute respiratory failure, was observed administering their own nebulizer treatments without a nurse present. The resident had intact cognition, as indicated by a BIMS score of 15, and was observed on multiple occasions taking their breathing treatment alone, with aerosol vapor coming from the nebulizer machine. Interviews with the nursing staff revealed that the nurses placed the medication in the nebulizer machine for the resident and left them to administer the treatment independently. RN #3 admitted to placing the medication in the machine and leaving the room, while LVN #4 also acknowledged not staying with the resident for the entire duration of the treatment. The Director of Nursing was unaware of this practice and stated that it was expected for nurses to stay with residents during nebulizer treatments, as per the facility's medication administration policy.
Failure to Implement Pharmacist's Recommendation for Medication Order
Penalty
Summary
The facility failed to implement the pharmacist's recommendation for a resident who was reviewed for unnecessary medications. The resident, who was admitted with a diagnosis of constipation, was prescribed multiple medications for bowel care management, including polyethylene glycol 3350, senna, and docusate sodium. The consultant pharmacist recommended adding a directive to hold the medication for loose stools, but this recommendation was not incorporated into the resident's medication order. Interviews with facility staff revealed a lack of follow-through on pharmacy recommendations. The Licensed Vocational Nurse indicated that charge nurses did not act on pharmacy reviews, leaving it to the RN supervisor or the Director of Nursing. The Director of Nursing confirmed that charge nurses and supervisors were responsible for following up on pharmacy recommendations. An RN stated that pharmacy recommendations should be completed within one to two days if the physician agreed, but this was not done for the resident in question. The facility administrator acknowledged that pharmacy recommendations should be followed, indicating a lapse in the process.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to address the dental needs of a resident, who was admitted on February 15, 2024, and had a care plan indicating oral/dental health problems due to poor oral hygiene and missing and broken teeth. Despite having an order for a dental consult and treatment dated September 27, 2024, there was no evidence that the recommended dental procedures, such as bridge replacement and multiple extractions, were completed. The resident, who had intact cognition, expressed concerns about their dental issues and reported asking the social worker for assistance, which had not been provided. The facility's policy required social services to make necessary dental appointments, but the resident's records showed multiple barriers to accessing dental care. The resident was a gurney patient, and local dental offices were unable to accommodate them, with the only option being an alternate county that was fully booked for the year. Despite recommendations for full mouth extractions, there was no evidence that these procedures were scheduled, and the resident continued to experience dental problems. Interviews with facility staff, including the Interim Social Service Director, DON, and Administrator, revealed that the social services department failed to arrange timely dental appointments for the resident. The DON and Administrator acknowledged that the resident's dental needs should have been addressed promptly, and alternative arrangements should have been made when the in-house vendor could not meet the resident's needs. The deficiency highlights a failure in the facility's process to ensure timely and adequate dental care for residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection prevention and control. Resident #93, who was admitted with a medical history including type 2 diabetes mellitus and a surgical wound from a transmetatarsal amputation, did not receive proper EBP during wound care. The Treatment Nurse did not wear a gown while providing care, despite the facility's policy requiring gown and glove use for residents with open wounds. The nurse acknowledged the oversight, stating she believed EBP was only necessary for draining wounds, despite the Director of Nursing's expectation that EBP should be implemented for any wound care. Similarly, Resident #252, admitted with a diagnosis of dysphagia and a gastrostomy tube, did not receive proper EBP during medication administration. The Licensed Vocational Nurse (LVN) administering medications via the gastrostomy tube wore gloves but failed to wear a gown, contrary to the facility's policy. The LVN admitted the mistake, and the Director of Staff Development confirmed that staff had been instructed to wear gowns and gloves for residents with gastrostomy tubes. The Director of Nursing reiterated the expectation for staff to adhere to EBP when administering medications through a gastrostomy tube.
Delayed MDS Submissions Due to Staffing and Process Gaps
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days after completion for several residents. The report highlights that multiple residents had their MDS assessments completed but not submitted in a timely manner, with delays ranging from 20 to 39 days past the completion date. This issue affected at least nine residents, including Residents #31, #79, and #88, among others. The delays in submission were attributed to staffing changes and gaps in the MDS Coordinator role. The MDS Nurse, who started at the facility in late January 2025, was still undergoing training and was responsible for managing both current and overdue assessments. The Director of Nursing (DON) was not initially aware of the need to sign and lock assessments completed before the new MDS Nurse's tenure, which contributed to the delays. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument Manual require timely submission of MDS assessments, which was not adhered to in these cases. Interviews with the MDS Nurse and the DON revealed a lack of clear communication and understanding of the submission process. The MDS Nurse was relying on electronic medical record software for scheduling, while the DON was new to the process and learning alongside the MDS Nurse. The Administrator expected timely transmission of MDS assessments within 14 days, as per the facility's policy and federal guidelines, but this expectation was not met due to the aforementioned issues.
Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum square footage per resident, as observed in 17 out of 43 rooms. Specifically, rooms 6 through 11 and rooms 17 through 27 did not provide the mandated 80 square feet per resident, with measurements ranging from 75.6 to 78.7 square feet per resident. This deficiency was identified during an observation on March 3, 2025, and confirmed through a Client Accommodations Analysis conducted on March 6, 2025. Interviews with facility staff, including the Director of Nursing, Maintenance Director, and Administrator, revealed an acknowledgment of the deficiency. The Director of Nursing expressed an expectation for residents to have adequate space and mentioned the facility's intention to request a waiver for non-compliant rooms. The Maintenance Director confirmed the existence of a waiver for the 17 rooms in question, where three residents were housed in each room. The Administrator also acknowledged the issue of rooms not meeting the required square footage.
Failure to Implement Care Plan Interventions for Resident
Penalty
Summary
The facility failed to ensure that the interventions indicated in the care plan for a resident were being provided by the nursing staff in accordance with professional standards of practice. Specifically, the resident's splint and finger sleeve were not available, which was necessary to prevent contractures in the resident's right hand. The resident had a diagnosis of Type 1 Diabetes Mellitus, essential primary hypertension, stiffness of the right hand, and other muscle spasms, and was cognitively intact with a BIMS score of 15. During an observation and interview, it was noted that the resident did not have the required finger sleeve or splint on their right hand. The Licensed Vocational Nurse (LVN) acknowledged that these items should have been applied as per the care plan. The LVN admitted that the staff failed to provide the necessary items listed in the care plan interventions, placing the resident at risk for potential contractures. Further interviews revealed that the interventions were ordered but never received, and there was no follow-up to ensure the care plan was implemented. The Director of Nurses (DON) confirmed that the nursing staff did not follow the physician's orders and care plan interventions. There was confusion regarding the splinting, and the staff failed to follow up on ordering the necessary apparatus. The facility's policy and procedure emphasized the importance of following comprehensive, person-centered care plans and ensuring that residents' activities of daily living do not diminish unless unavoidable. However, the staff did not adhere to these policies, resulting in the deficiency.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge for a resident with complex medical and physical needs. The resident, a female with multiple chronic conditions including Multiple Sclerosis, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was planned to be discharged to a homeless shelter. This decision was made after the resident's insurance provider indicated that she no longer required the level of care provided by the facility. However, the resident expressed significant distress and anxiety about the discharge plan, which was not adequately addressed by the facility. The resident's medical records indicated a history of mental health disorders, including Generalized Anxiety Disorder and Bipolar Disorder, which were exacerbated by the discharge plan. The facility's staff, including the Social Services Director and Director of Nursing, were involved in the discharge planning but failed to provide a suitable alternative to the homeless shelter. The resident's condition required continuous oxygen, blood glucose monitoring, and multiple medications, which raised concerns about her ability to manage her health independently in a homeless shelter environment. Interviews with the resident, her family member, and facility staff revealed inconsistencies in the assessment of her functional abilities. The resident and several staff members reported that she was unable to walk outside her room and required assistance with daily activities, contradicting the facility's documentation that she was independent in certain activities. The resident's emotional state deteriorated, as evidenced by increased anxiety, mood swings, and angry outbursts, leading to an increase in her antipsychotic medication. The facility's failure to adequately prepare and support the resident for discharge resulted in a potential for an unsafe discharge and significant emotional distress.
Inaccurate MDS Assessment Leads to Potential Misplacement
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, which had the potential to affect her care and facility placement. The resident, a female who had been admitted to the facility six years ago, was issued a 30-day discharge notice after her health insurance provider determined she no longer required the level of care provided by the facility. This decision was based on her MDS assessment, which inaccurately indicated that she was independent in her mobility, specifically in walking 50 feet with two turns and 150 feet, despite evidence to the contrary. Interviews with various staff members, including the Social Services Director, Director of Nursing (DON), Medical Records Director, Registered Nurse (RN), and Certified Nursing Assistants (CNAs), revealed that the resident had not been observed walking in the hallway or performing the activities as indicated in the MDS. The resident herself confirmed that she had not walked up and down the hallway in years and required oxygen to walk short distances from her wheelchair to the bathroom. Staff members consistently reported that the resident only walked within her room, covering distances much shorter than those recorded in the MDS. The MDS Consultant acknowledged that the sudden improvement in the resident's mobility, as recorded in the MDS, should have been verified by facility staff. The DON admitted to not knowing why the MDS was coded to reflect such independence in mobility and suggested that it could be an error. The inaccuracies in the MDS assessments, spanning from December 2023 to June 2024, were not consistent with the resident's actual capabilities as observed by the staff and reported by the resident herself.
Failure to Provide HIV Treatment for Hospice Resident
Penalty
Summary
The facility failed to follow its policy and procedure regarding the provision of hospice services for a resident diagnosed with HIV. The resident requested HIV treatment, but the facility did not collaborate with the hospice provider or the resident's primary physician to ensure the treatment was provided. The facility's Director of Nurses (DON) and a Registered Nurse (RN) both assumed that the hospice was responsible for providing the HIV medication, while the hospice indicated that the facility had not reached out to them regarding the resident's request. This lack of communication and coordination resulted in the resident not receiving the necessary HIV treatment, despite being eligible for it according to the hospice provider. The resident's family member and the resident himself expressed concerns about the lack of HIV treatment. The resident, who was cognitively intact according to his Minimum Data Set (MDS) assessment, stated that he wanted the treatment but was not receiving it. The facility's policy indicated that it was responsible for coordinating with the hospice to meet the resident's needs, including administering prescribed therapies. However, the facility did not follow this policy, leading to the resident's increased risk of weakened immunity due to untreated HIV.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status when the Registered Dietitian (RD) was not notified of the resident's significant weight loss of 6.8 pounds (9.6%) over three weeks and a by mouth (PO) intake of 60%. This lack of communication prevented the RD from providing timely recommendations to prevent further unplanned weight loss. The resident's compromised nutritional status was not addressed, which had the potential to lead to further medical complications. The resident was admitted to the facility with diagnoses including hypertension, long-term use of insulin, and muscle weakness. The RD's nutrition assessment indicated the resident was at high risk for unintended weight loss and required 1800 to 2150 calories and 75 to 85 grams of protein per day. Despite the resident's significant weight loss and low meal intake, the RD was not informed of the weight loss during the Interdisciplinary Team (IDT) meeting on 1/30/24. The RD only became aware of the weight loss during her monthly assessment on 2/7/24, at which point she recommended health shakes to provide extra calories. The facility's policy required the RD to be notified of significant weight changes, but this did not occur. The Dietary Supervisor and Director of Nurses confirmed that the RD was not notified of the weight loss despite attending weekly IDT meetings. The facility's failure to communicate the resident's weight loss to the RD resulted in a delay in implementing necessary nutritional interventions, thereby compromising the resident's nutritional status and overall health.
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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