Mayers Memorial Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River Mills, California.
- Location
- 43563 Hwy 299 E, Fall River Mills, California 96028
- CMS Provider Number
- 056416
- Inspections on file
- 30
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Mayers Memorial Hospital during CMS and state inspections, most recent first.
Two residents were denied access to portable oxygen tanks due to repeated equipment failures, forcing them to use large, non-portable concentrators that restricted their movement and participation in activities. Both residents reported feeling embarrassed and confined, and staff confirmed ongoing issues with the oxygen supply system and the impact on residents' daily lives.
Surveyors found that multiple resident bathrooms had unsanitary conditions, including missing or damaged caulking around toilets, grime buildup, and floors in disrepair. Staff and a family member confirmed the bathrooms were not clean or homelike, and facility policies requiring daily cleaning and maintenance were not followed.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
A controlled medication bin was found sealed with a zip tie whose number did not match the number recorded on the controlled count sheet. This discrepancy was confirmed by a nurse and acknowledged by the DON, indicating a failure to accurately document and secure controlled substances as required by facility policy.
Pharmacy recommendations for medication regimen reviews were not addressed by the physician, DON, or nursing staff for three residents, including those with dementia and complex medical histories. Recommendations regarding antipsychotic use, high-risk medication combinations, and the need for behavior documentation and dose reductions were left unanswered for several months, contrary to facility policy.
Two residents experienced medication errors when a nurse was unable to administer a prescribed antibiotic due to unavailability and another resident received omeprazole after breakfast instead of on an empty stomach as ordered. These incidents resulted in a medication error rate above 5%, with issues including lack of medication availability and discrepancies between the MAR and physician orders.
Surveyors found expired insulin lispro and tuberculin purified protein derivative vials in medication storage areas. Nursing staff and administration confirmed these medications were expired and should have been removed according to facility policy and manufacturer guidelines.
A licensed nurse used the same blood pressure monitor on multiple residents during medication pass without cleaning or disinfecting the device between uses. Both the nurse and DON acknowledged that the equipment should be sanitized between each resident, and facility policy as well as manufacturer instructions required cleaning after each use. This failure breached infection prevention and control protocols.
The facility did not ensure the pharmacist established and maintained records for controlled medications, leading to undetected diversion of narcotics. A nurse was observed removing narcotic cassettes, and an audit found thousands of missing narcotic tablets and vials, with missing documentation and lack of pharmacy tracking. The pharmacist was unaware of regulatory responsibilities and did not perform required audits or collaborate with staff to ensure safe handling of controlled substances.
Two residents with significant fall risk factors, including dementia and mobility issues, experienced avoidable falls resulting in hip fractures and hospitalizations after staff failed to follow care planned interventions. One resident was not assisted to bed or the bathroom as required, and another was not provided with non-skid footwear, leading to falls and injuries. The facility's policy and care plans were not followed, contributing to these incidents.
Two residents with severe cognitive impairment experienced physical and verbal abuse when one CNA was rough and pushed a resident, while another CNA cursed, pushed a resident, and threw personal care items onto the resident's chest. These actions were witnessed by staff and other residents, and resulted in emotional distress and fear for the affected residents.
A facility failed to thoroughly investigate an allegation of staff-to-resident abuse when a resident with severe cognitive impairment was allegedly mistreated by a CNA. Although a roommate witnessed the incident and confirmed she was not interviewed, the facility's investigation did not include her account, and the DON acknowledged this omission.
A resident with dementia was not promptly monitored or documented for changes in condition after experiencing abuse by a CNA. Required change in condition charting was not completed immediately, and alert charting to monitor the resident for 72 hours was initiated late, contrary to facility policy.
The facility did not follow its abuse reporting policy for several residents, including failing to send investigation results to CDPH after altercations between residents and not reporting a family member's verbal abuse of a resident within the required timeframe. These lapses involved residents with dementia, mood disorders, and other chronic conditions, and resulted in delayed or missing notifications to regulatory authorities.
A resident experienced verbal abuse from an RN who yelled and cursed at her, instructing her not to use her call light. The resident, with a BIMS score indicating good memory and decision-making skills, reported the incident, which was corroborated by CNAs. The facility's investigation substantiated the abuse, and the resident's medical history included COPD, cognitive decline, insomnia, diabetes, depression, and hypertension.
A CNA in an LTC facility verbally abused five residents, including those with dementia, stroke, and Parkinson's disease. The CNA refused to provide food to a resident in pain, made derogatory comments about another's size, and was described as unprofessional and disrespectful by others. These incidents were corroborated by staff and documented in facility records.
Two residents at an LTC facility eloped due to inadequate assessment and monitoring for wandering and elopement risks. One resident with severe cognitive impairment was found in the parking lot, while another with moderate impairment was located at a gas station by law enforcement. Risk assessments for both were completed only after the incidents.
The facility did not meet the required daily RN hours for PBJ staffing information submitted to CMS. The Quality Manager confirmed that RN coverage was not met for 20 days in the first Federal Quarter of 2024, with no RNs present on the schedule for these dates. The XML Submission Form showed specific dates with gaps in RN coverage, confirming the deficiency.
The facility failed to report abuse allegations in a timely manner for several residents. One resident was verbally and physically abused by the DON, and staff did not report the incident due to fear and lack of knowledge. Another incident involved two residents, where one hit the other, but the report was delayed. The facility lacked a culture that supported abuse reporting.
The facility failed to review and revise the Care Plans for two residents when information about their risk for elopement and exit alarm devices was not included. Both residents had severe cognitive impairment and physician's orders for Wander guard devices, but their Care Plans lacked entries about elopement risk or the devices. The ADON confirmed the omission and mentioned that a new elopement policy was being drafted.
The facility failed to ensure the environment was free of accident hazards for two residents with orders for Wanderguard devices but lacked follow-up or monitoring. Both residents had severe cognitive impairments and were not wearing the Wanderguard devices as ordered, with no documentation in the MAR to monitor elopement behaviors. The ADON confirmed the lack of documentation and mentioned an unapproved new elopement policy.
The facility failed to protect a resident from physical and verbal abuse when the DON was observed yelling at and shaking the resident's wheelchair. The resident, who has a history of high blood pressure, intellectual disability, and traumatic brain injury, was wheeling herself backwards down the hallway when the incident occurred. This behavior violated the facility's policy on abuse and has caused the resident to feel afraid to leave her room.
The facility failed to ensure professional food safety and sanitation practices, as evidenced by an unclean microwave, expired food items, improperly labeled bagels, and a dented can of soup. These deficiencies were confirmed by the Certified Dietary Manager and had the potential to result in foodborne illness for the facility's 79 residents.
Failure to Provide Portable Oxygen Tanks Limits Resident Dignity and Mobility
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect by not providing access to portable oxygen tanks. Instead, residents were required to use large, noisy, non-portable oxygen concentrators that needed to be plugged into electrical outlets. This limitation prevented the residents from moving freely within the facility, going outdoors, attending appointments, or leaving with family, as the concentrators were cumbersome and required constant access to electricity. The issue was ongoing due to repeated malfunctions of the equipment used to fill portable tanks, and the facility's oxygen service provider was frequently called for repairs, but the problem persisted. Resident records indicated that one resident had severe cognitive impairment and was not their own representative, while the other had intact cognition and made their own medical decisions. Both residents expressed feelings of embarrassment, confinement, anger, and anxiety due to their restricted mobility and reliance on the concentrators. Staff interviews confirmed the recurring equipment failures, the need for staff assistance to move the concentrators, and the resulting impact on residents' ability to participate in activities and outings. The facility's own resident rights documentation emphasized the right to dignity and individuality, which was not upheld in this situation.
Unsanitary Resident Bathrooms and Lack of Homelike Environment
Penalty
Summary
Surveyors observed that 6 out of 8 resident bathrooms had unsanitary conditions, including gaps around toilet bases where caulking was torn or missing, resulting in grime and discolored buildup that resembled urine or fecal matter. The linoleum flooring in these bathrooms was described as old, scratched, and in disrepair, with additional observations of loose dirt debris, black scuff marks, and yellow staining. These conditions were confirmed by both family members and staff, who stated that the bathrooms were not in acceptable or sanitary condition. Facility documentation indicated that housekeeping procedures required daily and thorough cleaning of environmental surfaces, but these standards were not met in the observed bathrooms. Interviews with staff, including the Assistant Director of Nursing and Environmental Services Manager, acknowledged awareness of the maintenance and cleanliness issues in the resident restrooms. Both staff and family members expressed that the bathrooms were not maintained to a homelike or sanitary standard, with one family member stating they would not allow their home restroom to be in such a condition. The facility's own policies required a clean, sanitary environment, but observations and interviews confirmed that these expectations were not being fulfilled in the resident bathrooms at the time of the survey.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Inaccurate Controlled Drug Record-Keeping
Penalty
Summary
The facility failed to maintain accurate pharmacy services for its census of 69 residents when the controlled drug record form was not properly filled out and signed. During an inspection of the controlled medication bin, it was observed that the bin was locked and sealed with a numbered zip tie that did not match the number recorded on the controlled count sheet. The discrepancy was confirmed by a charged nurse, who acknowledged the error, and the DON recognized the potential risk associated with mismatched tag numbers. Review of facility policy indicated that discontinued medications and controlled substances are to be handled securely, but the observed practice did not align with this requirement.
Failure to Respond to Pharmacy Recommendations for Medication Regimen Reviews
Penalty
Summary
A deficiency occurred when pharmacy recommendations were not followed or responded to by the physician, DON, or nursing staff for three of six sampled residents over periods extending up to ten months. For one resident with dementia, chronic kidney disease, and emphysema, the physician failed to respond to the pharmacist's recommendations regarding the use of Rexulti for agitation for five months. Another resident with a history of stroke, dementia, and nerve pain had a high-risk medication combination of gabapentin and an opioid, with the pharmacist requesting a risk-benefit analysis and effectiveness documentation, but the physician did not respond for ten months. A third resident with dementia and aggressive behaviors was prescribed Zyprexa, and the pharmacist's repeated recommendations for a gradual dose reduction and improved behavior documentation went unaddressed for four consecutive months. The facility's policy required that the consultant pharmacist review medication regimens and that the physician respond to recommendations, documenting the rationale for continuing medications if indicated. However, clinical record reviews showed a lack of physician or nursing staff response to the pharmacist's recommendations in the medical records for the residents involved. The pharmacist confirmed that reminders were given to the DON and nursing staff regarding the need for specific behavior documentation and consideration of dose reductions, but these recommendations remained unaddressed.
Medication Error Rate Exceeds 5% Due to Missed and Improperly Timed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors identified out of 31 opportunities during medication administration observations. For one resident, a licensed nurse was unable to administer doxycycline as ordered for bronchitis because the medication was not available at the time of administration. The nurse reported that the prescription had been extended by the provider, but the medication had not yet been received from the pharmacy, resulting in a missed dose. Facility policy requires that medications be administered as prescribed and available for administration. In another instance, a licensed nurse administered omeprazole to a resident after the resident had already consumed half of their breakfast, despite physician orders specifying that the medication should be given on an empty stomach before breakfast for gastrointestinal protection. The nurse acknowledged that the order summary on the MAR did not match the prescription label, and the MAR had not been updated to reflect the correct administration time. Facility policy requires that medications be administered at the correct time and as prescribed, with accurate reconciliation between the MAR and physician orders.
Expired Medications Found in Storage Areas
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and removal of expired medications. During an inspection of a medication cart, an expired insulin lispro pen was found with an expiration date that had already passed. The licensed nurse present acknowledged the medication was expired and confirmed it should have been removed. Review of the medication's provider information indicated that insulin lispro should not be used past its expiration date and that opened vials should be discarded after 28 days. The Director of Nursing stated that nurses are expected to check for expired medications each time they take over the cart, and that expired insulin pens should be dated and replaced. Additionally, an expired multi-dose vial of tuberculin purified protein derivative testing agent was found in a medication room refrigerator. The vial was labeled with an open date and a discard date that had already passed. The Assistant Director of Nursing confirmed the medication was expired and should have been removed from active storage. Facility policy and procedure documents reviewed by surveyors stated that outdated medications are to be removed from storage areas and are not to be available for patient use.
Failure to Disinfect Blood Pressure Monitor Between Resident Uses
Penalty
Summary
The facility failed to follow infection prevention and control practices when a blood pressure monitor was not disinfected according to the manufacturer's instructions after use during medication pass observations. On multiple occasions, a licensed nurse used the same blood pressure monitor to measure the blood pressure of different residents in their rooms and then placed the device back on the medication cart without cleaning or disinfecting it between uses. This practice was observed with several residents during the medication pass. During interviews, the licensed nurse acknowledged that the blood pressure monitor and cuffs were not cleaned or sanitized between residents, and the Director of Nursing confirmed that the equipment should be disinfected between each use to reduce infection risk. Review of the facility's policy and the manufacturer's cleaning recommendations indicated that both the monitor and cuff should be cleaned with a soft, moistened cloth and mild detergent after each use to maintain hygiene. The failure to adhere to these procedures constituted a breach of infection control protocols.
Failure to Maintain Controlled Substance Records and Oversight by Pharmacist
Penalty
Summary
The facility failed to ensure that the pharmacist was responsible for establishing and maintaining a system of records for the receipt and disposition of all controlled medications, as required by federal regulations. The facility's policy required consistent receiving and tracking of controlled substances to prevent and detect diversion, but this was not followed. A narcotic reconciliation issue was identified when an LVN requested additional narcotics for a resident before it was due, and video surveillance later showed the LVN removing narcotic cassettes from the locked medication room. An audit revealed that 2550 narcotic tablets and 2 vials of morphine were missing, with missing paperwork on 85 narcotic cassettes and 2 vials of liquid morphine. The facility identified contributing factors such as lack of overflow accountability and the pharmacy not tracking required control sheets, with leadership changes cited as a root cause for process failures. The pharmacist stated he was unaware of his federal responsibilities and had not established or maintained records of receipt and disposition of controlled medications, nor performed routine audits to reconcile narcotic drug usage or collaborated with facility staff to ensure safe and secure handling of these drugs. The pharmacist believed his responsibility ended once the narcotics were dispensed to nursing, and he relied on DEA software alerts to identify issues. This lack of oversight and failure to follow established procedures allowed narcotic medications to be diverted without detection.
Failure to Implement Care Planned Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care planned fall prevention interventions for two residents who were identified as high risk for falls. For one resident with diagnoses including dementia, rheumatoid arthritis, prostate cancer, vision problems, and high blood pressure, the care plan required staff to follow the resident to his room and assist with toileting or lying down. Despite this intervention, the resident experienced multiple falls in his room, including an incident where he attempted to transfer himself from his wheelchair to his bed, resulting in a fractured right hip that required surgical repair. The Director of Nursing confirmed that staff did not follow the care plan intervention at the time of the fall. Another resident, also at high risk for falls due to conditions such as dementia, depression, anxiety, insomnia, repeated falls, chronic pain, heart failure, lung disease, incontinence, arthritis, osteoporosis, and prior fractures, had a care plan intervention to ensure the use of non-skid footwear when ambulating or mobilizing in a wheelchair. This intervention was not followed, and the resident was found wearing slippers that were not non-skid at the time of a fall. The resident attempted to self-transfer from a wheelchair to a recliner, slipped, and sustained a fractured left hip requiring surgical repair. A post-fall committee meeting identified inappropriate footwear as the root cause of the fall, and a nurse confirmed the care plan was not followed. Both residents had documented histories of falls and were assessed as high risk using the Morse Fall Scale. The facility's own policy required the implementation of evidence-based interventions for residents at risk for falls, including addressing fall risks in care plans and providing non-skid footwear. The failure to follow these care planned interventions directly resulted in avoidable falls and serious injuries for both residents.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to prevent physical and verbal abuse for two residents with severe cognitive impairment. One resident, diagnosed with dementia, chronic pain, and weakness, was reported by her roommate to have been pushed and handled roughly by a CNA. A nursing note documented that this resident was emotional and distraught following the incident. Another resident, also with dementia and a severely impaired BIMS score, experienced an incident where a CNA cursed, pushed the resident, and threw personal care items onto the resident's chest. A witness CNA reported that the resident expressed fear of the CNA due to her aggressive behavior. The facility's policy prohibits all forms of abuse and mistreatment, but interviews and record reviews confirmed that staff members engaged in rough and aggressive conduct toward these residents. The incidents were directly observed or reported by other staff and residents, and the affected residents were noted to be emotionally distressed and fearful as a result of the staff's actions.
Failure to Interview Witness During Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse involving a resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. According to facility policy, all suspected incidents of abuse require obtaining written statements from all persons involved and conducting staff and resident interviews. However, despite a roommate witnessing the alleged abuse and confirming she was not interviewed, the facility's investigation records did not include an interview with this witness. The Director of Nursing confirmed that no interview was conducted with the roommate, despite her being a witness to the incident.
Failure to Timely Monitor and Document After Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident who experienced abuse was properly monitored for any resulting problems. Specifically, after a Certified Nursing Assistant (CNA) was rough with the resident and threw personal care items at him, staff did not complete required change in condition charting immediately following the incident. Additionally, alert charting, which is meant to provide ongoing documentation and monitoring for 72 hours after such incidents, was not initiated until two days after the event. These actions were not in accordance with the facility's own policies, which require documentation of significant changes in condition and monitoring after abuse or unusual occurrences. The resident involved had a diagnosis of dementia, which affects memory and decision-making abilities. Review of the resident's progress notes confirmed the absence of timely change in condition documentation and a delay in starting alert charting. The Assistant Director of Nursing verified that these documentation requirements were not met as per policy following the incident of abuse.
Failure to Timely Report and Document Abuse Investigations
Penalty
Summary
The facility failed to follow its abuse reporting policy for six out of fourteen residents sampled for abuse. In multiple instances, altercations and allegations of abuse between residents, as well as an incident involving a family member verbally abusing a resident, were either not reported to the California Department of Public Health (CDPH) as required or were reported late. The facility's policy mandates that results of abuse investigations be reported to the appropriate authorities, including CDPH, with documentation of dates and times. For one incident, a resident with vascular dementia threw a plate at another resident with dementia and chronic pain. Although an initial report was made, the follow-up investigation results were not sent to CDPH as required by policy. In another case, a resident with dementia, stroke, and dysphagia was involved in altercations with two other residents, one involving physical contact and another involving verbal aggression. Investigations were conducted for both incidents, but there was no documentation that the results were reported to CDPH. Additionally, a resident with dementia, mood disturbance, and anxiety was verbally abused by a family member during a visit. Staff overheard the family member using profanity and belittling the resident. The incident was not reported to CDPH within the required 24-hour timeframe, instead being reported 46 hours after the event. These failures to report and document abuse investigations as per facility policy had the potential to subject residents to mistreatment, neglect, or abuse.
Verbal Abuse by RN Towards Resident
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident by a registered nurse (RN A). The incident involved RN A yelling and cursing at the resident, instructing her not to use her call light, which caused the resident distress and feelings of unmet needs. The resident, who had a BIMS score indicating good memory and decision-making skills, reported the verbal abuse, which was corroborated by witness statements from certified nursing assistants (CNAs). These statements detailed RN A's frustration with the resident's frequent use of the call light and included instances of RN A turning off the call light and instructing CNAs to ignore the resident's calls unless it was an emergency. The resident's medical history included chronic obstructive pulmonary disease, age-related cognitive decline, insomnia, diabetes, depression, and hypertension. Despite these conditions, the resident expressed satisfaction with the facility overall. However, the verbal abuse incident was substantiated by the facility's investigation, which included a review of witness statements and an email from RN A acknowledging the difficulty in working with the resident. The Director of Nursing confirmed the findings of verbal abuse during an interview.
Verbal Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect five residents from verbal abuse by a Certified Nurse Assistant (CNA 1). Resident 1, who suffers from dementia, anxiety, spinal stenosis, and high blood pressure, reported that CNA 1 refused to provide food unless the resident sat up, despite the resident's pain. This incident was corroborated by another CNA and an Activities Aide, who both witnessed CNA 1's rude behavior. Additionally, CNA 1 was reported to have taken away Resident 1's dinner tray, causing distress to the resident. Resident 2, who has a history of stroke, obesity, hearing loss, and arthritis, was also subjected to verbal abuse. CNA 1 was overheard yelling that Resident 2 was too big to handle alone and made derogatory comments about the resident's size. This behavior was documented in the facility's progress notes and reported by other staff members. Resident 3, who is cognitively intact and has obesity, fibromyalgia, and diabetes, described CNA 1 as a bad CNA, although the resident did not provide further details. Resident 4, diagnosed with Parkinson's disease, cancer, and a history of falls, expressed that CNA 1 was unprofessional and disrespectful, making the resident feel belittled. The resident reported that CNA 1 did not listen and made dismissive comments. Similarly, Resident 5, who has Alzheimer's, a hip replacement, anxiety, and arthritis, stated that CNA 1 was bossy and rushed the resident, refusing assistance to the toilet. These incidents were documented in the facility's records and reported by the residents to the nursing staff.
Failure to Assess and Monitor Residents for Wandering and Elopement Risks
Penalty
Summary
The facility failed to ensure proper assessment and monitoring for two residents who were at risk for unsafe wandering and elopement. Resident 1, who had a severe cognitive impairment due to an anoxic brain injury, eloped from the facility and was found in the parking lot by a staff member. Despite wearing a Wander Guard, the resident's wandering and elopement risk assessments were only completed after the incident occurred, two months post-admission. Resident 2, with moderate cognitive impairment and medical diagnoses including cancer, depression, and anxiety, was found by law enforcement at a gas station after eloping from the facility. The resident's wandering and elopement risk assessments were not completed until nearly five months after the incident. Interviews with facility staff confirmed that the assessments for both residents were not conducted until after their respective elopements.
Failure to Meet Required RN Coverage
Penalty
Summary
The facility failed to meet the required daily Registered Nursing (RN) hours for Payroll Based Journaling (PBJ) staffing information submitted to the Centers for Medicare and Medicaid Services (CMS). During a concurrent record review and interview, the Quality Manager (QM) confirmed that the required RN coverage was not met for 20 days of the first Federal Quarter of 2024. The QM acknowledged that there were no RNs present on the schedule for these dates, although RNs were encouraged to clock in when providing resident care. The QM reviewed the XML Submission Form with the surveyor, pointing out specific dates where gaps in RN coverage were evident, confirming that no RNs were listed for resident care as required by CMS.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report abuse allegations in a timely manner for several residents. One resident, who was cognitively intact and had a history of high blood pressure, intellectual disability, and traumatic brain injury, was verbally and physically abused by the Director of Nursing (DON). The DON yelled at the resident and physically shook her wheelchair, causing the resident to feel embarrassed and in tears. Staff members were aware of the incident but did not report it due to fear of retaliation and a lack of understanding of reporting procedures. The incident was not reported to the California Department of Public Health as required by regulations. Another incident involved two residents, one with severe cognitive impairment and the other with behavioral disturbances. A Certified Nurse Assistant (CNA) witnessed one resident hitting the other in the hallway. The incident was documented in the clinical records but was reported late to the appropriate authorities. The facility's policy requires that such incidents be reported within two hours, but this was not adhered to. Interviews with staff revealed a lack of knowledge about the abuse coordinator and the proper procedures for reporting abuse. The Quality Manager acknowledged that the facility did not have a culture that supported reporting abuse, which contributed to the failure to report the incidents in a timely manner. The facility's training program on abuse reporting was reviewed, and it was confirmed that staff were educated to report suspected abuse within two hours, but this protocol was not followed in these cases.
Failure to Include Elopement Risk and Wander Guard Devices in Care Plans
Penalty
Summary
The facility failed to review and revise the Care Plans for two residents when information about their risk for elopement and exit alarm devices was not included. Resident 27, who had severe cognitive impairment and a history of anoxic brain damage and a prior heart attack, had a physician's order for a Wander guard device to be applied for safety. However, the Care Plan for Resident 27 did not include any entries about elopement risk or the Wander guard device. Similarly, Resident 128, who had severe cognitive impairment, dementia, anxiety, and legal blindness, also had a physician's order for a Wander guard device. Yet, Resident 128's Care Plan also lacked entries about elopement risk or the Wander guard device. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that the elopement risk and Wander guard devices were not included in the Care Plans for Residents 27 and 128, and acknowledged that they should have been. The ADON mentioned that they usually discussed elopement risk during the resident's Care Conference and were in the process of drafting a new elopement policy, which had not yet been approved.
Failure to Monitor Wanderguard Devices for Residents
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for two residents who had orders for Wanderguard placement but lacked follow-up or monitoring. Resident 27, who had severe cognitive impairment and a history of anoxic brain damage and a prior heart attack, was admitted with a physician's order for a Wanderguard device to be applied to their left ankle and checked every shift. However, there was no documentation in the Medication Administration Record (MAR) to monitor elopement behaviors, and during an observation, it was confirmed that Resident 27 was not wearing the Wanderguard device as ordered. Additionally, the Multidisciplinary Care Conference note did not mention the risk of elopement or the Wanderguard device, indicating a lack of proper documentation and follow-up on the resident's care plan. Similarly, Resident 128, who had severe cognitive impairment, dementia, anxiety, and legal blindness, had a physician's order for a Wanderguard device to be applied and checked twice a day. However, the MAR also showed no monitoring for elopement behaviors. During an interview, the Assistant Director of Nursing (ADON) confirmed that Resident 128 was not wearing the Wanderguard device as ordered and acknowledged the lack of documentation. The ADON mentioned that an initial elopement risk assessment is usually done on admission, but there was no documentation to support this for Resident 128. The facility was in the process of drafting a new elopement policy, which had not yet been approved, further highlighting the gap in ensuring resident safety from elopement risks.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to ensure that Resident 10 was free from physical and verbal abuse. The incident occurred when the Director of Nursing (DON) was observed by a confidential informant (CI1) yelling at and shaking Resident 10's wheelchair. Resident 10, who has a history of high blood pressure, intellectual disability, and traumatic brain injury, was wheeling herself backwards down the hallway due to weakness in her right side extremities. After accidentally bumping into another resident, the DON came out of her office, yelled at Resident 10, and physically shook her wheelchair, causing Resident 10 to feel embarrassed and cry. This incident was corroborated by interviews with Resident 10 and two confidential informants (CI1 and CI2), who confirmed the DON's inappropriate behavior and frequent yelling at residents. The facility's policy and procedure on abuse, dated 7/15/2022, clearly states that residents have the right to be free from all forms of abuse, including verbal and physical abuse. Despite this policy, the DON's actions violated these guidelines, resulting in physical and verbal abuse of Resident 10. The incident has led to Resident 10 feeling afraid to leave her room due to fear of being yelled at again. The failure to protect Resident 10 from abuse has the potential to negatively impact her psychosocial wellbeing and lead to isolation.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure professional food safety and sanitation practices were in place, as evidenced by several deficiencies observed during a kitchen inspection. The interior of the microwave oven used to prepare resident food was found to be unclean, with red-colored material splattered on its ceiling and sides. Additionally, two plastic bags containing grated cheese were found to be expired, and a sealed bottle of a nutritional shake had a printed expiration date that had passed. Furthermore, three bagels were stored in a plastic bag without a use-by date, and a large can of soup was dented along its seam, which should have been discarded. These deficiencies were confirmed by the Certified Dietary Manager (CDM) during the inspection. The presence of food debris or dirt on nonfood contact surfaces, such as the microwave, can provide a suitable environment for the growth of microorganisms, which employees may inadvertently transfer to food. The expired food items and the lack of proper labeling on the bagels also pose a risk of foodborne illness. The dented can of soup further increases the risk of physical contamination. These failures had the potential to result in foodborne illness for the facility's 79 residents who consumed food prepared in the facility.
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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