Manzanita Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 5318 Manzanita Avenue, Carmichael, California 95608
- CMS Provider Number
- 555083
- Inspections on file
- 32
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Manzanita Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence on staff developed multiple pressure injuries after staff failed to implement and document required interventions such as frequent repositioning, use of pressure-relieving devices, and regular skin assessments. Despite repeated indications of skin issues on inspection sheets, nursing staff did not follow up with assessments or communicate findings, and weekly summaries were not completed. The resident's wounds were only discovered upon hospital transfer, and family members were not informed of the injuries.
Multiple rooms were found to have flying insects present on beds, personal belongings, and around residents, causing ongoing disturbance and discomfort. Two residents reported the issue to staff and housekeeping without improvement, and both a nurse and the DON confirmed the infestation in four rooms. A maintenance work order had been submitted but the problem persisted, contrary to the facility's pest control policy.
A resident with moderate cognitive impairment and a history of aggression was punched by another resident with severe cognitive impairment and a pattern of physical aggression, leading to a fall and head injury. The incident was witnessed by staff, and both residents had documented behavioral issues. The event demonstrated a lack of adequate supervision to prevent accidents between residents with known behavioral risks.
The facility failed to maintain proper pharmacy services, as a nurse did not sign the medication control count sheet after administering hydromorphone to a resident, leading to an inaccurate drug count. Additionally, unused or expired controlled drugs were not properly destroyed, as pills were found identifiable in a storage container, contrary to the facility's policy.
A facility experienced a 14.29% medication error rate due to improper administration practices. An LPN crushed ER and DR tablets for a resident, contrary to orders, and omitted a prescribed medication. Another LPN failed to administer a medication due to its unavailability. The DON confirmed these errors, which violated the facility's medication administration policy.
The facility failed to store medications according to manufacturer's specifications and its own policies. A discontinued medication was improperly refrigerated, a probiotic supplement was not refrigerated as required, and a discontinued medication was found on the floor. The DON acknowledged these storage issues, which could lead to medication misuse and errors.
The facility failed to maintain the nutritive value of broccoli by cooking it for over two hours before lunch service, resulting in a mushy texture and potential nutrient loss. Observations showed broccoli was placed in the oven at 9:48 a.m., with lunch service starting at 12:22 p.m. The RD confirmed that overcooking leads to nutrient loss, and the DM's statement contradicted the observed practice. This deficiency could lead to nutrient deficiency for 96 residents.
The facility failed to maintain proper food storage and kitchen cleanliness, risking foodborne illness for 96 residents. Observations included dirty kitchen equipment, wet-stored pans, rusted pipes, a grooved cutting board, improperly sealed bulk containers, and a dusty fan. The Dietary Manager acknowledged these issues.
The facility failed to provide a refrigerator and microwave for resident use, necessary for safe food storage and reheating. Staff interviews revealed that the facility does not store or reheat food for residents, with inconsistent practices regarding how long food can be kept in rooms. The DON confirmed the absence of these facilities, contradicting the facility's policy requiring proper storage of perishable foods.
The facility failed to maintain essential kitchen equipment, including a walk-in freezer with ice build-up, a dish machine not reaching required sanitization temperatures, and a convection oven unable to achieve proper food temperatures. These deficiencies could potentially lead to foodborne illness for the 96 residents consuming facility-prepared meals.
A resident's dignity was compromised when their bilateral buttocks' sides were exposed during a hallway transfer on a shower chair. The resident, diagnosed with panic disorder, was wheeled by a CNA without proper coverage, leading to exposure in front of other residents, staff, and the resident's daughter. The DON acknowledged that the staff should have used a blanket to cover the resident during the transfer.
A resident with speech and language deficits was admitted to the facility, requiring a communication board to express basic needs. During an observation, an LN was unable to find the communication board in the resident's room, which was confirmed by the DON as a necessary tool for communication. The facility's policy emphasizes accommodating residents' limitations to promote communication.
A resident was prescribed divalproex sodium for dementia with behavioral disturbances, despite assessments showing no indicators of psychosis. The resident, who was often confused and sleepy, continued receiving the medication for nearly a year without reassessment for its necessity. Staff interviews confirmed the resident was not a danger to herself or others, and the facility's policy requires psychotropic medications to be prescribed only for specific diagnosed conditions. The facility's MD and consultant pharmacist failed to reassess the medication's use, and the DON could not explain this oversight.
A facility failed to follow infection control practices for three residents. An LPN did not change gloves during wound care for a resident with sepsis, risking cross-contamination. Another resident with a pressure ulcer received treatment without proper hand hygiene, increasing infection risk. A third resident's midline dressing was not changed for nine days, contrary to orders, risking infection. These actions compromised infection prevention efforts.
A resident with moderate cognitive impairment was physically abused by another resident, resulting in a swollen bruise on her face. The incident occurred during an argument about a secret smoking area. The cognitively intact resident admitted to the act, and the injured resident reported feeling unsafe.
Two residents experienced non-functional call lights in their shared bathroom, leading to a deficiency in resident safety and care. Despite being instructed not to use the emergency call light, the system failed to activate the hallway light or alarm. Maintenance and the DON confirmed the malfunction, which contradicted the facility's policy requiring a functional call system at all times.
A resident with schizophrenia and bipolar disorder was administered Invega, an antipsychotic medication, without documented behavior monitoring by the facility staff. The Minimum Data Set Coordinator confirmed the lack of documentation, and the DON acknowledged the oversight. The facility's policy requires monitoring of psychotropic medications, which was not followed.
A resident with dementia and significant memory problems was not assessed for elopement risk, despite being observed wandering alone and unable to return to her room. Facility staff confirmed the resident's high risk for elopement, but no assessment was completed, contrary to the facility's policy on wandering and elopements.
Failure to Prevent and Assess Pressure Injuries
Penalty
Summary
A resident with significant medical conditions, including Type 2 Diabetes, severe cognitive impairment, and complete dependence on staff for activities of daily living, was admitted to the facility and identified as being at risk for developing pressure injuries. The resident's care plan and facility policies required frequent turning and repositioning, use of pressure-relieving devices for both bed and chair, regular skin monitoring, and weekly skin assessments. Despite these documented interventions, the resident's physician orders did not include repositioning protocols or pressure-relieving devices, and these interventions were not consistently implemented or documented by staff. Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) failed to properly assess, document, and communicate changes in the resident's skin condition, despite repeated markings and notations of redness and open areas on the resident's posterior buttocks on shower day skin inspection sheets. The CNAs did not label their observations clearly, and the LNs did not follow up with assessments or notify the Treatment Nurse as required. Weekly Nursing Summaries, which were intended to capture changes in the resident's health status, were not completed for the month during which the pressure injuries developed. The Director of Nursing confirmed that the process for skin assessment and documentation was not followed, and that findings were not entered into the resident's chart or treatment records. As a result of these failures, the resident developed multiple pressure injuries, including an unstageable pressure injury on the sacrum, a stage III pressure injury on the left ischium, and a stage II pressure injury on the right ischium, which were discovered upon transfer to the hospital. The responsible party and family members were not informed of the presence or severity of these wounds, despite the resident's ongoing complaints of pain. The facility's lack of adherence to its own care plans and policies directly led to the development and worsening of these pressure injuries.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous flying insects in four residents' rooms in Unit C. Observations revealed that insects were seen flying around and landing on residents' beds, personal belongings, pillows, windows, side tables, walls, and curtains. Two residents, both with the mental capacity to make their own decisions, reported ongoing disturbances from the insects, including insects crawling into their noses during sleep and persistent disruption of rest. Both residents stated that the issue had been reported to staff and housekeeping, but no improvement was noted. Staff interviews and record reviews confirmed the ongoing problem. A licensed nurse and the DON both observed and acknowledged the presence of insects in multiple rooms, and the DON confirmed that the issue affected four rooms in Unit C. A maintenance work order had been submitted as a high priority several days prior, specifically noting the presence of moths, but the problem remained unresolved at the time of the survey. The facility's pest control policy required maintaining a pest-free environment, but this was not achieved, as confirmed by staff and documentation.
Failure to Provide Adequate Supervision Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of aggression was punched in the stomach by another resident with severe cognitive impairment and a documented pattern of physical aggression. This incident caused the first resident to fall and hit her head on a metal door frame, resulting in a head laceration and visible discoloration on her shoulder. The event was witnessed by a staff member, and documentation confirmed the injury and the circumstances leading to it. Both residents involved had histories of behavioral disturbances, with one resident's care plans noting multiple episodes of physical aggression, agitation, and aggression. Staff interviews confirmed that both residents had previously exhibited aggressive behaviors. The facility's policy emphasized the importance of resident safety and supervision, but the incident demonstrated a failure to provide adequate supervision and prevent accidents between residents with known behavioral risks.
Plan Of Correction
F 689 CORRECTIVE ACTIONS FOR RESIDENTS AFFECTED BY THIS DEFICIENT PRACTICE. Resident #1 and Resident #2 were immediately separated. Two staff members re-directed Resident #2's behavior and stayed with the resident until 911 paramedics arrived. Resident #1 was assessed from head to toe, provided first aid treatment, and staff members stayed with the resident. Both residents were assessed for emotional distress and given reassurance. Both residents were transferred to the hospital for further evaluation and treatment. CORRECTIVE ACTIONS TAKEN TO THOSE RESIDENTS IDENTIFIED THAT HAVE THE POTENTIAL TO BE AFFECTED BY DEFICIENT PRACTICE. All residents with interactions with Resident #2 can be affected by this deficient practice. Upon notification of the incident, the supervisor and all licensed nurses on duty conducted rounds on all residents to determine if they had any interactions with Resident #2, and none were found. No other residents were affected by this deficient practice. SYSTEMIC CHANGES IMPLEMENTED BY FACILITY TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR. The Director of Staff Development (DSD) conducted an in-service with staff on 4/17/25 on Residents' Rights on 04/17/2025. The IDT team will assess and identify residents at least quarterly or as necessary. Residents with challenging behaviors will have their POC updated to include de-escalation techniques and strategies, and the POC will be implemented to provide adequate supervision to prevent accidents. FACILITY'S PLAN TO MONITOR THAT SOLUTIONS ARE SUSTAINED. The Social Services Director (SSD) and/or designee will be the process owner who will monitor the plan of care that is in place and is implemented to ensure all residents are safe and have adequate supervision from staff. Any trends and discrepancies will be brought to the facility's QAPI committee for review and additional guidance or recommendations. DATE CORRECTIVE ACTIONS WILL BE COMPLETED. 04/21/2025
Deficiencies in Controlled Drug Management and Destruction
Penalty
Summary
The facility failed to maintain proper pharmacy services for its residents, specifically in the management of controlled drugs. During an inspection of medication cart A, it was found that the controlled drug count for a resident's hydromorphone was inaccurate. There were 10 tablets in the medication bubble pack, while the controlled drug log indicated there should be 11. A Licensed Nurse admitted to administering the medication earlier and forgetting to sign the medication control count sheet immediately after administration, which is required by the facility's policy. Additionally, the facility did not properly destroy unused or expired controlled drugs according to its policy. During an inspection of the storage area for unused and expired controlled medications, it was discovered that pills were identifiable and not destroyed, despite being placed in a container of liquid. The Director of Nursing acknowledged that the pills were not destroyed as per the facility's policy, which requires medications to be rendered unusable in the presence of a nurse and a witness.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 14.29% error rate during a survey. Licensed Nurse 2 (LN 2) administered medications to Resident 140 incorrectly by crushing extended release (ER) and delayed release (DR) tablets, which were not supposed to be crushed according to the physician's orders and pharmacy labels. This included isosorbide mononitrate ER and pantoprazole DR tablets. Additionally, LN 2 omitted the administration of Resident 140's prescribed amlodipine tablet, which was documented as given in the Medication Administration Record (MAR) but was not observed during the medication pass. Licensed Nurse 3 (LN 3) failed to administer the correct dose of simethicone to Resident 36 due to the unavailability of the medication in the facility. The Director of Nursing (DON) confirmed that the medications were not administered as prescribed and acknowledged the errors. The facility's policy on administering medications emphasizes that medications should be administered safely, timely, and as prescribed, which was not adhered to in these instances.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed during inspections. A discontinued medication, cyanocobalamin, was found stored in the refrigerator, contrary to the manufacturer's specifications which required it to be stored at room temperature. The Director of Nursing (DON) acknowledged this discrepancy, confirming that all medications should be stored according to the required temperature range. Additionally, a medication cart inspection revealed that an acidophilus probiotic dietary supplement was stored at room temperature, despite the manufacturer's instructions to refrigerate it after opening. The DON confirmed that medications requiring refrigeration should be stored in a designated refrigerator. Furthermore, a discontinued medication, clonidine, was found stored under the sink on the floor in the medication storage room. The DON acknowledged that this medication was for a discharged resident and should have been given to her for destruction. The facility's policy and procedure indicated that discontinued, outdated, or deteriorated medications should be returned or destroyed as per the dispensing pharmacy's instructions. These findings highlight the facility's failure to adhere to its own medication labeling and storage policy, potentially leading to medication misuse and administration errors.
Deficiency in Maintaining Nutritive Value of Broccoli
Penalty
Summary
The facility failed to maintain the nutritive value of food, specifically broccoli, by cooking it for over two hours prior to the lunch meal service. This was observed on February 4, 2025, when a staff member placed frozen broccoli into a convection oven at 9:48 a.m., and the lunch meal service began at 12:22 p.m. The broccoli served was noted to have a light green color and a soft, limp texture, which was confirmed by five surveyors who tasted the test trays at 1:30 p.m. The Registered Dietitian (RD) confirmed that vegetables should be cooked last to preserve their vitamins and minerals, which are lost when overcooked. The Dietary Manager (DM) stated that broccoli is usually cooked 30 minutes before meal service, contradicting the observed practice. A review of the facility's recipe for seasoned broccoli indicated a cooking time of 10-20 minutes, warning against overcooking to prevent the broccoli from becoming brown and mushy. The report references external sources that support the claim that overcooked broccoli loses nutrients, which are essential for the residents' health. This deficiency had the potential to lead to nutrient deficiency for the 96 residents receiving facility-prepared meals.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as well as kitchen equipment cleanliness, which could potentially lead to foodborne illness for the 96 residents consuming meals prepared by the facility. During an initial kitchen tour, several deficiencies were observed, including dirty baking sheets, a frying pan, a container for scoops, stove knobs, a convention oven, and a mixer. The Dietary Manager (DM) acknowledged these issues, noting that the baking sheets and frying pan were old and needed discarding, and confirmed the presence of food residue on the mixer and other equipment. Additionally, the facility stored ten pans, two frying pans, and a blender while still wet, which could promote bacterial growth. The DM confirmed the wet condition of these items and acknowledged the need for them to be fully dried before storage. Furthermore, the pipes under the three-compartment sink were found rusted and dirty, with the floor and counter in the area showing discoloration and buildup. The DM was unsure of the cause of this buildup and discoloration. Other issues included a yellow cutting board with deep grooves, which could harbor microorganisms, and four bulk storage containers with lids not tightly closed, risking contamination. A fan in the dishwashing area was also found with significant dust buildup. The DM confirmed these observations and acknowledged the potential for contamination due to these deficiencies.
Lack of Resident Food Storage and Reheating Facilities
Penalty
Summary
The facility failed to provide a refrigerator and microwave for resident use, which is necessary for the safe storage and reheating of food brought by family and visitors. Interviews with staff, including Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs), revealed that the facility does not have the means to store or reheat food for residents. CNA 1 mentioned that outside food is checked against the diet order before being given to residents, and any leftover food is discarded if not consumed within two hours. However, CNA 2 stated that residents could keep food in their rooms for up to 24 hours before it is discarded, indicating inconsistency in practice. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that there has never been a refrigerator or microwave available for residents. The facility's policy on foods brought by family or visitors, dated March 2022, specifies that perishable foods should be stored in resealable containers with tightly fitting lids in a refrigerator, and potentially hazardous foods left out for more than two hours should be discarded. The lack of proper storage and reheating facilities potentially limits residents' food options and enjoyment of favorite foods, as well as possibly contributing to weight loss.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which could potentially lead to foodborne illness for the 96 residents consuming meals prepared by the facility. The walk-in freezer was observed with significant ice build-up on the ceiling, walls, and fan unit, indicating potential temperature fluctuations. Despite maintenance efforts to remove the ice, the issue persisted, with high condensation and poor visibility noted during subsequent observations. The Environmental Services Director acknowledged the ice build-up, and the Registered Dietitian confirmed that such conditions could affect food quality and cause freezer burn. The dish machine used for sanitizing dishes was not reaching the required minimum temperatures for both the wash and rinse cycles. During multiple observations, the wash temperature gauge did not exceed 140 F, and the rinse temperature gauge failed to reach 180 F, as required by the facility's sanitization policy. The Dietary Manager confirmed the temperature discrepancies and indicated that the dish machine repair company would be contacted to address the issue. Additionally, the convection oven was not achieving the desired food temperature for pork entrees, which were found to be below the required 165 F before meal service. Despite attempts to reheat the pork in the convection oven, the temperatures remained insufficient until the pork was transferred to the stove. The Dietary Manager and staff confirmed the temperature issues, and it was noted that a repair company was called to fix the convection oven after the dinner meal service.
Resident Dignity Compromised During Hallway Transfer
Penalty
Summary
The facility failed to maintain respect and dignity for a resident when the resident's bilateral buttocks' sides were exposed in the hallway during a transfer. This incident involved a resident who was admitted to the facility with a diagnosis of panic disorder. During an observation and interview, it was noted that a Certified Nursing Assistant (CNA) was wheeling the resident on a shower chair in the hallway, and the resident's gown did not cover their bilateral buttocks' sides, exposing them to other residents, staff members, and the resident's daughter. The resident's daughter expressed concern about the respect and dignity issue due to the exposure. The Director of Nursing (DON) acknowledged that staff should have covered the resident with a blanket during the transfer to prevent exposure.
Failure to Provide Communication Board for Resident with Speech Deficits
Penalty
Summary
The facility failed to provide an appropriate communication method for a resident with speech and language deficits, identified as Resident 70. Upon admission in 2024, Resident 70 was noted to have these deficits, necessitating the use of a communication board to express basic needs. During an observation and interview, it was found that Licensed Nurse 7 (LN 7) was unable to locate a communication board in Resident 70's room, which hindered effective communication. LN 7 confirmed the absence of the communication board, which should have been available to assist Resident 70. The Director of Nursing (DON) also acknowledged that the communication board should have been present in the resident's room to facilitate communication. The facility's policy on accommodating individual needs emphasizes the importance of promoting communication by accommodating residents' physical or sensory limitations.
Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to keep a resident free from unnecessary psychotropic medication, specifically divalproex sodium, which was prescribed for an inadequate indication. The resident, a 78-year-old individual with diagnoses including worsening disease of the nervous system, anxiety, depression, and dementia with behavioral disturbance, was receiving divalproex sodium for dementia with behavioral disturbances manifested by hallucination. However, the resident's assessments indicated severely impaired cognition without indicators of psychosis, such as hallucinations or delusions. The resident's care plan noted a risk for falls and injury, and observations revealed the resident was often confused and sleepy, taking extended time to consume meals due to drowsiness. Interviews with staff, including a home health aide and a CNA, confirmed the resident was not a danger to herself or others and did not exhibit combative or hallucinatory behavior. Despite this, the resident continued to receive divalproex sodium over a period of almost a year, with no reassessment for its necessity or appropriateness for treating dementia. The facility's policy on psychotropic medication use requires that such medications are only prescribed when necessary to treat a specific diagnosed condition. However, the facility's MD and consultant pharmacist did not reassess the resident for the unnecessary use of divalproex sodium, which is not FDA-approved for treating dementia. The Director of Nursing was unable to explain why this reassessment had not occurred, highlighting a failure in adhering to the facility's policy and procedure regarding psychotropic medication use.
Infection Control Failures in Wound Care and Dressing Changes
Penalty
Summary
The facility failed to adhere to infection control practices during wound care treatment for three residents. Licensed Nurse 6 (LN 6) did not change gloves during the wound care treatment for Resident 441, who was admitted with a diagnosis of sepsis and had a left buttock wound. LN 6 placed trash bags next to the wound and touched the soiled dressing in the trash bag before touching the wound dressing without changing gloves or performing hand hygiene. This was confirmed by LN 6, who acknowledged the risk of cross-contamination and potential wound infection. For Resident 69, who was admitted with severe sepsis and had a stage three pressure ulcer on her tailbone, LN 6 failed to follow proper handwashing and glove-changing procedures. LN 6 used gloved hands to wash the unclean pressure ulcer and then applied medicated cream and dressing covers without changing the contaminated gloves. LN 6 admitted awareness of the need to change gloves and wash hands when moving from a contaminated to a clean body site, acknowledging the increased risk of infection due to improper hand hygiene. Resident 290, admitted with multiple diagnoses including sepsis and acute kidney failure, had a midline dressing on the left upper arm that was soiled and not changed for nine days. The dressing, dated 1/25/25, showed dark-colored drainage around the insertion site. Despite an order to change the dressing weekly or as needed if soiled, the dressing was not changed on the seventh day as required. Licensed Nurse 8 confirmed the oversight, and the Director of Nursing acknowledged the failure to follow the physician's order and facility policy, which could lead to a central line-associated bloodstream infection.
Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck her in the face. Resident 1, who was admitted with an irregular heartbeat and had a moderately impaired cognitive function, reported feeling unsafe after being hit by Resident 2. Resident 2, who was cognitively intact and admitted with spinal stenosis, admitted to slapping Resident 1 during an argument about a secret smoking area. The incident resulted in Resident 1 sustaining a swollen bruise on her face. The incident was documented in an SBAR Summary, which noted the physical injuries sustained by Resident 1. Interviews with the Assistant Director of Nursing and the Social Services Director confirmed that Resident 2 admitted to the act and did not deny the incident. The Social Services Director also observed the physical injuries on Resident 1 two days after the incident. The failure to prevent this incident resulted in Resident 1 feeling unsafe in the facility.
Non-Functional Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to provide a functioning call light system for two residents, leading to a deficiency in ensuring resident safety and care needs. Resident 3, who was admitted with a fracture of the right femur and had a BIMS score indicating cognitive intactness, reported that the call lights in their room were not working on the first night. Similarly, Resident 4, admitted with a rib fracture and a BIMS score indicating moderate cognitive impairment, also experienced non-functional call lights. Both residents were instructed by staff not to use the emergency call light in the bathroom, as it would render the room call lights inoperative. During an inspection, it was confirmed that the emergency bathroom call light did not activate the hallway light or alarm, as observed by the maintenance staff and the Director of Nursing. The facility's policy mandates that each resident should have a functional call system at all times, especially in toileting and bathing areas. The maintenance staff acknowledged the malfunction and recognized the urgency of the issue, while the Director of Nursing confirmed the expectation for the call light system to be operational to ensure residents' needs are promptly addressed.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide care according to accepted standards of quality for a resident who was prescribed an antipsychotic medication, Invega, for schizophrenia. The resident was admitted with diagnoses including schizophrenia and bipolar disorder. Despite the administration of the medication by a nurse from a psychiatric clinic, there was no documented behavior monitoring by the facility staff to assess the effectiveness and side effects of the medication. During a review of the resident's records, it was confirmed by the Minimum Data Set Coordinator that the antipsychotic medication was administered, but there was no documentation of behavior monitoring. The Director of Nursing acknowledged that the medication order should have included proper monitoring for targeted behavior and side effects. The facility's policy on psychotropic medication use requires that such medications be clinically indicated and monitored, which was not adhered to in this case.
Failure to Assess High-Risk Resident for Elopement
Penalty
Summary
The facility failed to assess a resident at high risk for elopement, which increased the risk of the resident wandering unsafely. The resident, admitted in May 2024 with unspecified dementia and behavioral disturbances, had a BIMS score of 4 out of 15, indicating significant memory problems. Despite being able to transfer and ambulate independently with a walker, the resident was observed wandering alone in the hallways without a walker and unable to return to her room without assistance. The resident also exhibited behaviors of wandering and expressed confusion, wanting to go outside to park her car. Interviews with facility staff, including the MDS Coordinator, Social Services Director, and Director of Nursing, confirmed that the resident was at high risk for elopement and should have been assessed properly. However, there was no record of an elopement assessment being completed for the resident. The facility's policy on wandering and elopements, revised in March 2019, requires identifying residents at risk for unsafe wandering and including strategies and interventions in their care plan to maintain safety, which was not adhered to in this case.
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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