Meadowbrook Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 461 E. Johnston Avenue, Hemet, California 92543
- CMS Provider Number
- 055401
- Inspections on file
- 41
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Meadowbrook Post Acute during CMS and state inspections, most recent first.
Surveyors found the kitchen’s double prep sink area in an unsanitary condition, with both basins covered yet containing dried food particles, a red bucket of yellowish gray fluid under one sink, and a wet blanket on the floor nearby. The DM and ADM reported the sinks had been non-operational for several days due to a collapsed drainage pipe, with unsuccessful in-house repair attempts and plumber evaluations confirming the issue. During this time, staff used plastic bus tubs to clean fruits and vegetables instead of the prep sinks. The Cook confirmed the dirty condition and acknowledged the kitchen was not sanitary, while the DON reported no resident complaints or hospital transfers for food-borne illness, despite a facility policy requiring all kitchen areas to be kept clean and free of garbage and debris.
A resident with dementia and a history of falls experienced multiple unwitnessed falls and injuries due to the facility's failure to implement and document required supervision and monitoring interventions. Despite care plans specifying frequent checks and visual monitoring, staff did not consistently follow or record these measures, and concerns raised by CNAs about the resident's safety were not addressed by nursing leadership.
The facility did not post complete daily nurse staffing information, as only projected hours were displayed and actual direct care service hours were left blank. The DSD confirmed that actual hours were not calculated or posted daily due to lack of timely access to payroll data, resulting in incomplete staffing information being available to residents and the public.
The facility did not provide or document wound care treatments as ordered by physicians for four residents with complex medical conditions, including diabetes, osteomyelitis, congestive heart failure, and gangrene. On multiple occasions, the Treatment Administration Record lacked evidence that wound care was performed, and staff interviews confirmed the treatments were missed. Facility policy requires documentation of all treatments, but this was not followed for the affected residents.
A resident with multiple chronic conditions was transferred to a hospital for gangrene of the right foot, but the facility did not notify the LTC Ombudsman as required. Review of records and staff interviews confirmed the omission, despite facility policy mandating ombudsman notification for transfers.
Surveyors found a gallon of chocolate syrup with an open date more than six months prior stored on the kitchen counter and available for use. The Dietary Manager and Registered Dietician confirmed that facility guidelines require opened chocolate syrup to be discarded after six months, but this was not done, resulting in expired food being accessible in the kitchen.
Surveyors found the outdoor dumpster overflowing with trash and the lid not fully closed. Both the DM and facility owner confirmed that the dumpster should not be overflowing and the lid should be closed, in accordance with facility policy.
Two residents with respiratory needs did not have their oxygen cannulas and nebulizer masks changed, labeled, or stored according to infection control protocols. Equipment was found undated, left exposed, or not replaced as required by physician orders and facility policy. Staff interviews confirmed that weekly changes and proper storage in plastic bags were not consistently performed.
The facility failed to track and document controlled medications, leading to unaccounted medications for several residents. The DON was informed of missing medication count sheets and cards, and an investigation revealed discrepancies in documentation. The facility lacked a process to monitor receipt and reconciliation of controlled medications, resulting in potential misuse or diversion.
The facility failed to accurately code the MDS for several residents, including those with PASRR Level II evaluations and an indwelling catheter. A resident with severe cognitive impairment and a PASRR Level II was not coded correctly, and another resident with an indwelling catheter was not identified in the MDS. These oversights were acknowledged by the MDS Coordinator and highlighted by the DON and Administrator.
A resident with a urinary catheter was observed without a privacy bag on two occasions, exposing the urine and compromising their dignity. Despite facility policy and staff acknowledgment that privacy bags should be used, the resident's catheter bag remained uncovered. The resident had a history of hemiplegia, hemiparesis, skin infection, and sepsis, and required the catheter for urinary retention and wound management.
The facility failed to create care plans for two residents with urinary catheters, despite their medical histories and hospital interventions. One resident had an indwelling catheter placed for urinary retention, and another had a suprapubic catheter due to a UTI and sepsis. The absence of orders led to the lack of care plans, as care plans were based on MDS triggers. The DON acknowledged the oversight and took responsibility.
The facility failed to obtain orders and create care plans for urinary catheters for two residents upon admission. One resident returned with a suprapubic catheter after a hospital stay, and another was readmitted with an indwelling catheter. Both cases lacked documentation and care plans until identified during a survey. The DON and staff acknowledged the oversight, attributing it to failures in the admission and reassessment processes.
A resident with a history of respiratory issues had an order for supplemental oxygen at 2 lpm, but observations showed the oxygen was set higher than prescribed. The DON confirmed the discrepancy, stating changes should only occur with a new physician's order. The LVN was unaware of the reason for the increased setting, and the Administrator stressed the need to follow all orders.
A facility failed to properly assess and monitor a resident's condition before and after dialysis treatments and did not maintain effective communication with the dialysis center. The resident, with a history of end-stage renal disease, had incomplete Dialysis Assessment Records, missing critical information such as vascular access site assessments and vital signs. Significant incidents, like vomiting and low blood pressure, were not documented, leaving the dialysis center uninformed of these health changes. Staff interviews revealed a lack of communication and protocol adherence, contributing to the deficiency in providing safe dialysis care.
The facility implemented a policy to charge residents $25 if they required staff assistance to outside appointments, potentially deterring necessary medical visits. A resident with multiple diagnoses expressed concern about the charge, and facility leadership confirmed the policy.
Unsanitary Kitchen Prep Sink and Improper Maintenance of Food Preparation Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary conditions and improper maintenance of the kitchen’s double preparation sink. During an initial kitchen tour with the Dietary Manager (DM), both basins of the double prep sink were found covered by a long cookie sheet, with signs posted above each basin stating “DO NOT USE UNDER REPAIR,” yet both sinks contained multiple dried food particles. Under the first prep sink, surveyors observed a red bucket filled with yellowish gray fluid, and a wet yellow blanket was seen on the floor in the corner at the end of the double prep sinks. The DM reported that the prep sinks had a drainage issue beginning on March 18, 2026, that the maintenance supervisor had attempted repairs without success, and that two separate plumbers had determined the drainage pipe under the double prep sink was collapsed beneath the courtyard cement. The DM also stated that kitchen staff were using plastic bus tubs to clean fruits and vegetables during this period. In a concurrent observation and interview with the Administrator (ADM), DM, Cook, and Director of Nursing (DON), the ADM acknowledged that the double prep sinks had been non-operational since March 18, 2026, and confirmed the presence of dirty sinks, the red bucket with yellow-grey water, and the wet yellow blanket on the floor. The Cook stated that the sinks had been non-operational and dirty with old, dried food, with the red bucket of yellow-grey liquid and the wet yellow blanket in place since March 18, 2026, and acknowledged that the kitchen should be sanitary at all times and was not. The DON reported there had been no resident complaints or transfers related to signs or symptoms of food-borne illness. The facility’s written policy on sanitization stated that all kitchens, kitchen areas, and dining areas are to be kept clean and free from garbage and debris, which contrasted with the observed conditions in the prep sink area.
Failure to Provide Adequate Supervision and Prevent Accident Hazards
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident with dementia, anxiety, a history of falls, and impulsive behavior. Despite being identified as high risk for falls and self-harm, the resident experienced eight unwitnessed falls over a period of several months. The care plans for the resident included specific interventions such as being checked and changed every two hours, frequent visual monitoring, and later, checks every 30 minutes. However, there was no documented evidence that these interventions were consistently implemented or monitored by staff. On multiple occasions, the resident was found on the floor or under her roommate's bed, sometimes with visible injuries such as hematomas, skin tears, and severe bruising to the face and hands. Staff interviews revealed that CNAs were aware of the resident's behaviors and risks, but failed to consistently report significant findings, such as swollen eyes, to the nursing staff in a timely manner. Additionally, CNAs reported that their concerns about the resident's safety and the need for increased supervision, such as a one-on-one sitter, were communicated to nursing leadership but not acted upon. Record reviews confirmed the lack of documentation for required monitoring and supervision as outlined in the resident's care plans. The DON acknowledged that the facility did not follow its own policies and procedures for ensuring resident safety and that the falls could have been avoided with proper monitoring. The facility's policy required targeted interventions and adequate supervision to reduce accident risks, but these were not effectively implemented for this resident.
Incomplete Daily Nurse Staffing Data Posting
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing data was complete and accurate, as required. During an unannounced visit, it was observed that the posted documents for nurse staffing, specifically the Census and Direct Care Services Hours Per Patient Day (DHPPD), only included projected (estimated) hours and did not have the actual direct care service hours, average patient census, actual DHPPD, or actual CNA hours filled in for the reviewed dates. The section of the form designated for actual hours was left blank, despite instructions that it must be completed at the end of each 24-hour patient day. Interviews with the Director of Staff Development (DSD) revealed that actual DHPPD hours were not calculated or posted daily because the DSD did not have access to payroll hours until the day after paydays, which occur twice a month. As a result, only projected staffing hours were posted, and actual staffing data was not made available to residents and the public on a daily basis as required. This omission was verified during both document review and staff interviews.
Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide wound care treatments in accordance with physician orders for four residents. For one resident with diagnoses including diabetes, hypertension, osteomyelitis, and chronic kidney disease, the Treatment Administration Record (TAR) showed that wound care for a right foot stump was not documented as provided on three specific dates, despite active orders for daily or every-other-day treatment. Another resident with low back pain, congestive heart failure, and hypertension had no documentation of ordered wound care for a left heel wound on three separate dates, as indicated by the TAR. A third resident, diagnosed with diabetes, chronic obstructive pulmonary disease, and dysphagia, had no documentation of wound care for a left great toe on two dates, despite an order for daily treatment. The fourth resident, with subdural hemorrhage, gangrene, and on palliative care, had no documentation of wound care for a gangrenous toe on one date, even though the order specified treatment every 48 hours. In each case, the TAR lacked evidence that the prescribed wound care was performed as ordered. Interviews with the Treatment Nurse and the Director of Nursing confirmed that the wound treatments were not documented or administered on the specified dates for all four residents. The facility's policy requires that all treatments and procedures be documented in the resident's medical record, including details such as date, time, procedure, assessment, and the signature of the individual providing care. The absence of documentation and confirmation from staff indicated that the required wound care treatments were not provided as ordered.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman when a resident was transferred to a general acute care hospital. The resident, who had a medical history including diabetes, hypertension, osteomyelitis of the right foot, and chronic kidney disease, was transferred to the hospital for gangrene of the right foot. Documentation reviewed included the resident's admission record, progress notes, and SBAR, all confirming the transfer and the medical reasons for it. However, there was no evidence in the records that the ombudsman was notified of this transfer. Interviews with the Social Worker, Director of Nursing (DON), and Administrator confirmed that the facility's process requires notification of the ombudsman for all transfers or discharges, and that this notification did not occur in this case. The facility's policy also specifies that notice should be given to the ombudsman as soon as practicable before a transfer. Both the Social Worker and DON acknowledged the omission, and the Administrator verified the lack of documentation regarding ombudsman notification for the resident's transfer.
Expired Chocolate Syrup Found in Kitchen Storage
Penalty
Summary
During a kitchen tour, surveyors observed a gallon of chocolate syrup with an open date of October 19, 2023, stored on top of the kitchen overhead counter and readily available for use. The Dietary Manager confirmed that the chocolate syrup should have been discarded six months after opening, according to the facility's dry goods storage guidelines, but it remained accessible to staff well past this period. The Registered Dietician also stated that no expired food or food stored beyond its shelf life should be present in the kitchen, whether opened or not. The facility's documented guidelines specify that opened chocolate syrup should be discarded after six months, but this was not followed, resulting in the presence of expired food in the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an inspection of the facility's garbage disposal area, surveyors observed that the outdoor trash dumpster located by the parking lot was overflowing with trash and its lid was not completely closed. The Dietary Manager confirmed during the inspection that the dumpster should not be overflowing and that the lid should be fully closed to prevent attracting pests. The facility owner also acknowledged in an interview that the dumpster should not be overflowing and the lid should be closed. A review of the facility's policy on food-related garbage and refuse disposal indicated that outside dumpsters are to be kept closed and free of surrounding litter.
Failure to Follow Infection Control Practices for Respiratory Equipment
Penalty
Summary
The facility failed to follow infection control practices for two residents who required respiratory equipment. For one resident with a history of pneumonia, the oxygen cannula in use was not dated, and a nebulizer mask was found undated and left exposed on the nightstand, rather than being stored in a plastic bag as required. The resident's physician order specified that the nasal cannula and mask should be changed weekly, and facility policy required respiratory equipment to be labeled, dated, and stored in a plastic bag when not in use. Staff interviews confirmed that these procedures were not followed, and the equipment was not properly stored or dated. For another resident, also with a diagnosis of pneumonia, the nebulizer mask had not been changed since admission, despite physician orders and facility policy requiring weekly changes. The mask was observed in a belongings bag with an outdated label, and the resident confirmed that the mask had not been replaced since admission. Staff interviews revealed that the responsibility for changing the equipment was assigned to the night shift, but the change had not occurred as scheduled. The equipment was also not stored according to infection control protocols. Both residents' records and staff interviews indicated a lack of adherence to established infection control policies regarding the maintenance, labeling, and storage of respiratory equipment. The facility's own procedures required weekly changes and proper storage of such equipment to prevent contamination, but these steps were not consistently implemented for the residents reviewed.
Failure to Track and Document Controlled Medications
Penalty
Summary
The facility failed to implement a system to accurately track the movement of controlled medications, leading to the inability to account for missing controlled medications for ten residents. The Director of Nursing (DON) was informed by a Licensed Vocational Nurse (LVN) about missing controlled medication count sheets and medication cards for two residents. An investigation revealed that a total of ten residents were affected by the missing controlled medications. The facility suspected a new hire per diem nurse of diverting the medications, and a police report was filed. However, the facility lacked a process to monitor the receipt of controlled medications, and the DON admitted there was no reconciliation process in place to identify loss or potential diversion. Additionally, during a random controlled medication audit, discrepancies were found in the documentation of medication administration for four residents. The controlled medications were signed out on the count sheet but not documented on the Medication Administration Records (MAR), resulting in inaccurate accountability. For instance, Resident 11 had two doses of Norco unaccounted for, and Resident 12 had eight doses missing. Similar discrepancies were found for Residents 9 and 13 with their Ativan prescriptions. The nursing staff failed to document the administration of these medications on the MAR, as required by the facility's policy and procedure. The facility's policies on controlled substances and medication administration were not followed, contributing to the deficiencies. The policies required that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, and that medication administration be documented immediately on the MAR. The failure to adhere to these policies resulted in unaccounted controlled medications, raising concerns about potential misuse or diversion.
Inaccurate MDS Coding for Residents with PASRR Level II and Indwelling Catheters
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for several residents, leading to deficiencies in the assessment and care planning process. Resident #11, who was admitted with a history of major depressive disorder, schizophrenia, bipolar disorder, and anxiety disorder, had a Preadmission Screening and Resident Review (PASRR) Level II evaluation completed, which was not accurately reflected in the MDS. The MDS Coordinator acknowledged forgetting to code the PASRR Level II, despite the information being available in the resident's electronic health record. Similarly, Resident #18, with a history of major depressive disorder and schizophrenia, also had a PASRR Level II evaluation that was not coded in the MDS. The resident's care plan indicated the use of psychotropic medications for schizophrenia, yet the MDS did not reflect the PASRR Level II status. The Director of Nursing and the Administrator both expressed expectations for accurate MDS coding, but the oversight persisted. Additionally, Resident #39, who had severe cognitive impairment and a PASRR Level II evaluation, was not accurately coded in the MDS. The MDS Coordinator admitted that the PASRR Level II should have been triggered. Furthermore, Resident #26, who had an indwelling urinary catheter, was not coded for the catheter in the MDS, as the MDS Coordinator did not notice the catheter and there were no orders prompting its inclusion. These inaccuracies in MDS coding highlight a pattern of oversight in the facility's assessment process.
Failure to Use Privacy Bag for Urinary Catheter
Penalty
Summary
The facility failed to ensure the use of a privacy bag for a resident with a urinary catheter, compromising the resident's right to a dignified existence. The resident, who was admitted with a medical history of hemiplegia, hemiparesis following a stroke, skin infection, and sepsis, had an indwelling urinary catheter due to urinary retention and wound management. Observations on two separate occasions revealed that the resident's urinary catheter bag was not covered with a privacy bag, exposing the urine. Interviews with facility staff, including CNAs, an LVN, the Director of Nursing, and the Administrator, confirmed that urinary catheter bags should be covered with privacy bags. Despite this policy, the resident's catheter bag was observed without a privacy cover, indicating a lapse in adherence to the facility's policy and the resident's rights. The Director of Nursing acknowledged the requirement for privacy bags and expressed uncertainty about why it was not being used for the resident.
Failure to Develop Care Plans for Residents with Urinary Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with urinary catheters, as required by their policy. Resident #26 was admitted with a history of hemiplegia, hemiparesis, and sepsis, and had an indwelling urinary catheter placed during a hospital stay for urinary retention. Upon readmission to the facility, there were no orders or care plans related to the urinary catheter, and the MDS Coordinator did not notice the catheter during the assessment, leading to the absence of a care plan. The Director of Nursing (DON) acknowledged that a care plan should have been created for the urinary catheter. Resident #34, with a history of obstructive and reflux uropathy and hydronephrosis, was admitted to the hospital where a urinary catheter was placed due to a UTI and sepsis. Upon returning to the facility, there were no orders or care plans for the suprapubic catheter. The MDS Coordinator stated that care plans were created based on MDS triggers, and since there was no order for the catheter, it was not included in the care plan. The DON admitted that the staff missed the catheter during readmission and took responsibility for the oversight. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that care plans were typically created based on MDS triggers and that nurses had the ability to update them. However, the absence of orders for the urinary catheters led to the lack of care plans for both residents. The Administrator and DON both expressed that care plans should be completed timely and accurately, covering all necessary aspects of resident care.
Failure to Document and Manage Urinary Catheters for Two Residents
Penalty
Summary
The facility failed to ensure that upon admission, orders were obtained for the placement and ongoing care and maintenance of urinary catheters for two residents. Resident #34 was admitted with a suprapubic catheter following a hospital stay for sepsis secondary to pyelonephritis and a right-sided staghorn ureteral calculus. Despite returning to the facility with the catheter, there were no orders or care plans in place for its management until a recertification survey identified the oversight. The Director of Nursing (DON) acknowledged the lapse, stating that the staff missed the catheter during the resident's readmission assessment. Similarly, Resident #26 was readmitted to the facility with an indwelling urinary catheter placed during a hospital stay for urinary retention. The facility's records did not reflect any orders or care plans for the catheter until the deficiency was noted during a recertification survey. The MDS Coordinator and Licensed Vocational Nurse (LVN) #2 both confirmed that the catheter was not documented in the resident's chart, and the DON admitted that the catheter should have been noted during the admission assessment. Interviews with facility staff, including the Administrator, revealed that the admitting nurse should have conducted a full body assessment and contacted the doctor for orders regarding the urinary catheters. The lack of documentation and care planning for the catheters was attributed to failures in the admission and reassessment processes, as well as a lack of communication among the nursing staff.
Failure to Follow Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident requiring supplemental oxygen. Resident #17, who was admitted with a medical history of shortness of breath, acute upper respiratory infection, and dependence on supplemental oxygen, had an active order for oxygen therapy at 2 liters per minute (lpm) due to continuously low oxygen saturation. However, observations on two separate occasions revealed that the resident's oxygen was set at higher levels than prescribed, specifically at 4 lpm and 5 lpm. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the oxygen settings were not in accordance with the physician's order. The DON acknowledged that the oxygen should have been maintained at 2 lpm and that any changes to the oxygen settings should have been preceded by obtaining a new order from the doctor. The LVN was unaware of why the oxygen setting was increased, and the facility's Administrator emphasized the importance of following all orders and obtaining a new order if the resident's oxygen saturation levels were low.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's condition before and after dialysis treatments, as well as maintain effective communication with the dialysis center. The facility's policy required licensed nurses to complete baseline information and pre- and post-dialysis sections of the Nurses Dialysis Communication Record, but these were often incomplete. For Resident #53, who had a history of end-stage renal disease and was dependent on dialysis, several Dialysis Assessment Records lacked critical information such as vascular access site assessments, pre-dialysis weight, and vital signs. The facility also failed to document significant incidents related to the resident's condition. For instance, after returning from dialysis, the resident experienced vomiting, and there was no documentation of this episode in the Dialysis Assessment Record. Additionally, the resident had multiple instances of low blood pressure following dialysis, which were not recorded in the assessment records. These omissions meant that the dialysis center was not informed of the resident's low blood pressure or the new medication order for Midodrine to manage this condition. Interviews with facility staff revealed a lack of communication and protocol adherence. A dialysis technician noted that the facility did not communicate important information, such as low blood pressure readings and medication changes, which could have influenced the dialysis treatment approach. The Director of Nursing and other staff acknowledged that the dialysis center should have been informed of the resident's nausea, vomiting, and low blood pressure to ensure appropriate care. The facility's failure to document and communicate these critical health changes contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Facility Imposed Charges for Staff Assistance to Outside Appointments
Penalty
Summary
The facility failed to ensure residents were free of imposed charges for services required to achieve their goals and needs safely. Specifically, the facility developed and implemented a policy to charge residents $25 if they required facility staff to accompany them to appointments outside of the facility. This policy was communicated to residents starting February 1, 2024, and had the potential to deter residents from attending necessary appointments due to the additional cost. Resident 1, who has multiple diagnoses including osteoarthritis of the hip, spondylosis, mood disorder, and anxiety, expressed concern about the charge and indicated she might avoid outside appointments because of it. During the investigation, it was confirmed that Resident 1 needed substantial assistance with transfers and used a wheelchair for mobility. The facility's Director of Nursing and Administrator both confirmed the implementation of the $25 charge for staff assistance during outside appointments. The facility's policy and notice letter regarding the escort service fee were reviewed, both indicating the new charge. This policy potentially imposed charges on residents for services that should be covered, thereby violating residents' rights and potentially impacting their access to necessary medical care.
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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