Meadowood A Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 3110 Wagner Heights Road, Stockton, California 95209
- CMS Provider Number
- 555713
- Inspections on file
- 29
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Meadowood A Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with impaired mobility was unable to summon assistance due to a malfunctioning call light that did not illuminate outside the room, resulting in an episode of incontinence when staff did not respond. Staff were unaware of alternative communication methods, and the resident was not provided with a hand bell, despite facility policy requiring such measures during call light outages.
The facility failed to record the temperature of soup served to eight residents during lunch, risking foodborne illness. Dietary staff heated soup without documenting its temperature, contrary to facility policies requiring temperature checks to ensure food safety.
The facility failed to implement proper infection control measures for residents on Enhanced Barrier Precautions (EBP). Signage indicating the need for PPE was missing from a resident's room, and PPE supplies were not readily available outside the rooms of several residents on EBP, increasing the risk of infection spread. Staff confirmed the absence of necessary precautions, and the facility's policy for isolation precautions was not followed.
A resident with Alzheimer's disease was left with a meal in front of her for over 20 minutes without being fed, compromising her dignity. The resident required assistance with feeding, but staff fed another resident instead. When finally fed, the meal was at an inappropriate temperature. Staff interviews and facility policies confirmed the failure to promptly assist and serve food at the correct temperature.
A facility failed to maintain a resident's Advance Directive in their medical record, despite the POLST form indicating its existence. The resident, admitted with hip surgery aftercare and a femur fracture, did not have their Advance Directive in either their physical chart or EHR. Interviews with the SSD and DON confirmed this oversight, which contradicted facility policy requiring the document's inclusion and review during admission and quarterly.
A resident's privacy was compromised when their incontinence care instructions were publicly displayed in their room. The instructions, related to the use of a condom catheter, were posted on the bathroom door facing into the room, visible to anyone entering. Staff acknowledged the breach and noted that the information could have been placed inside the bathroom door to maintain privacy.
A resident with Parkinsonism and dementia was unable to independently unbuckle a self-release belt in their wheelchair, classifying it as a restraint. Despite initial approval and demonstration of the belt's use, the resident was observed struggling to release it, requiring assistance from a nurse. The facility failed to reassess the resident's ability to use the belt independently during the quarterly MDS assessment, leading to a deficiency.
A resident in the facility was found to be receiving an incorrect oxygen rate due to the absence of a care plan for their oxygen needs. The resident was supposed to receive oxygen at 4 LPM continuously, but was instead receiving 2.5 LPM. Both the LN and DON confirmed the lack of a care plan, which is crucial for guiding nursing staff in administering the correct oxygen rate.
A resident with multiple diagnoses, including sepsis and bilateral hydronephrosis, experienced inadequate urinary catheter care when their catheter bag was found on the floor without a dignity cover. This was confirmed by two LNs and the DON, who acknowledged the risk of contamination and the importance of maintaining resident dignity. Facility policy and CDC guidelines were not followed, potentially affecting the resident's self-worth and increasing the risk of infection.
A resident receiving oxygen therapy was administered 2.5 LPM instead of the prescribed 4 LPM, as confirmed by a licensed nurse and the DON. This failure to follow the physician's order placed the resident at risk for hypoxia, contrary to the facility's policy on oxygen administration.
A facility failed to maintain safe medication administration practices, resulting in a medication error rate of 5.55%. Errors included not administering prescribed eye drops to a resident, yet documenting them as given. The DON confirmed that medications should not be charted if not administered, and the facility's policy requires timely administration with documentation of any deviations.
The facility failed to ensure safe medication storage, with staff personal items found in medication rooms and expired medication on a cart. Personal belongings were improperly stored in the Sequoia and Redwood/Harmony unit medication rooms, confirmed by LNs and the Administrator. An expired Ipratropium bromide/albuterol was found on a medication cart, posing risks of reduced effectiveness and adverse reactions, as confirmed by LN 7 and the DON.
A resident admitted with bronchiectasis and migraines did not receive necessary medications due to facility failures. Cefiderocol, required for infection, was delayed due to pharmacy order issues, and Sumatriptan for migraines was unavailable, leading to unrelieved pain. The facility did not adhere to its policies on admissions and medication shortages.
A facility failed to inform a resident's responsible party of the discharge appeal process. The resident, unable to make health care decisions due to severe dementia, signed her own discharge notice. The case manager did not verify the resident's decision-making capacity before obtaining her signature, contrary to facility policy. The responsible party was not informed of the appeal rights, potentially affecting the resident's access to necessary services.
A resident with severe dementia and a high fall risk suffered a hip dislocation after falling in a facility. The care plan lacked specific interventions like fall mats and a low bed position, contributing to the incident. Staff interviews revealed inconsistent adherence to fall prevention measures, despite awareness of the resident's risk.
A resident with Parkinson's disease fell from his wheelchair, resulting in the loss of his front teeth. Despite visible injuries and the resident's report of pain, the nursing staff failed to conduct an oral assessment or inform the physician about the potential dental damage. This oversight led to the resident experiencing pain, difficulty eating, and weight loss.
A resident missed 6 doses of dronabinol and 3 doses of vitamin B6 due to the facility's failure to acquire the medications from the pharmacy in a timely manner. The resident had severe protein calorie malnutrition and moderate cognitive impairment. The facility did not follow its policy for promptly ordering and delivering new medications.
A resident with diabetes experienced a low blood sugar episode, and the facility failed to follow the physician's orders for treatment. The nurse administered orange juice instead of glucagon gel, did not notify the physician, and did not recheck the blood sugar every 15 minutes as required.
Failure to Provide Functioning Call Light and Alternative Communication
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning properly, resulting in the resident being unable to summon assistance when needed. The call light in the resident's room did not illuminate outside the doorway when pressed, although it did activate the panel at the nurse's station. This malfunction persisted from a Saturday through the following Tuesday, during which time the resident experienced an episode of urinary incontinence because staff did not respond to his call for assistance to the bathroom. The resident, who had a history of pneumonia and lack of coordination, was unable to get up independently to use the bathroom. Interviews with staff revealed that when a call light was broken, the issue was logged for maintenance, but repairs were delayed over weekends. Staff were unaware of alternative methods for residents to call for help when the call light was not working, and the resident was not provided with a hand bell or other means of communication during the outage. Facility policy required that an alternative method, such as individual bells, be provided if the call light system malfunctioned, but this was not implemented. Maintenance records confirmed the call light was reported broken, and an incorrect bulb replacement further delayed the repair.
Failure to Record Soup Temperatures
Penalty
Summary
The facility failed to adhere to professional standards of food service safety by not recording the temperature of soup served to eight residents during lunch. On the specified date, during a tray line observation, it was noted that tomato soup was not initially available, prompting dietary staff to heat a pan of soup on the stove. Subsequently, servings of chicken noodle soup were placed on meal trays for the residents. However, there was no recorded temperature check for the soups before they were served, which is a critical step to ensure food safety. The Certified Dietary Manager confirmed that the temperature log for the lunch did not include a temperature check for the soups, acknowledging that this should have been done to ensure the food was in the safe temperature zone. A staff member stated that she typically checks and documents food temperatures before serving, as incorrect temperatures could lead to illness. The facility's policies on time and temperature control, as well as meal temperature, emphasize the importance of recording accurate temperatures to prevent foodborne illness. The failure to record the soup temperatures put the residents at risk for foodborne illness, as it was unknown if the soup was served at a safe temperature.
Inadequate Infection Control Measures for Residents on EBP
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents on Enhanced Barrier Precautions (EBP). Specifically, signage indicating the need for personal protective equipment (PPE) was not posted on or near the doorway of Resident 335's room, who was on EBP due to staph aureus bacteremia. The Unit Manager/Case Manager and the Infection Preventionist confirmed the absence of the EBP sign, which is crucial for informing staff about the necessary precautions to prevent the spread of infection. Additionally, PPE supplies were not readily available outside the rooms of several residents on EBP, including Residents 14, 35, 42, and 64. These residents had various conditions such as dialysis ports, pressure ulcers, and gastrostomy tubes, which increased their risk of infection. Staff members, including Licensed Nurses and Certified Nurse Assistants, confirmed that PPE supplies were either located inside the residents' rooms or in utility rooms, rather than being immediately accessible outside the rooms as required. The Director of Nursing and the Infection Preventionist acknowledged that the facility's policy and procedure for isolation precautions were not followed, which posed a potential risk for the spread of infection. The lack of proper signage and readily available PPE supplies compromised the facility's ability to effectively implement EBP and protect both residents and staff from infection and cross-contamination.
Resident's Dignity Compromised Due to Delayed Feeding
Penalty
Summary
The facility failed to honor a resident's right to be treated with dignity and respect when a resident with Alzheimer's disease was left with a meal in front of her for over 20 minutes without being fed. The resident, who required assistance with feeding due to her condition, was observed seated at a table with her meal while licensed staff fed another resident at the same table. The resident was alert and looking around the room, and later began crying out, yet her meal remained untouched until a licensed nurse began feeding her. At that point, the temperature of the food was recorded at 110 degrees Fahrenheit, which was below the appropriate serving temperature. Interviews with staff revealed that the licensed nurse had placed the meal in front of the resident expecting a CNA student to assist with feeding, but when no one came, the nurse proceeded to feed another resident. The Director of Nurses acknowledged that it was a dignity issue for residents not to eat their meals together and that a fresh meal should have been requested when the delay occurred. The Certified Dietary Manager confirmed that food should be served at temperatures between 145-150 degrees Fahrenheit and that the food served to the resident was inappropriate. Facility policies reviewed indicated that residents needing assistance should be promptly fed and that food should be served at safe and appetizing temperatures.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's rights related to treatment choices were known and protected, as a copy of the resident's Advance Directive was not maintained in their medical record. The resident, who was admitted with diagnoses including aftercare following right hip joint surgery and a fracture of the neck of the right femur, had a Physician Orders for Life-Sustaining Treatment (POLST) form indicating the existence of an Advance Directive. However, upon review, the Advance Directive was neither found in the resident's physical chart nor uploaded into their Electronic Health Record (EHR). Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed the absence of the Advance Directive in the resident's records. The SSD and DON both acknowledged that the Advance Directive should have been included in the resident's chart to ensure their treatment preferences were known and could be followed, especially during transfers to other facilities. The facility's policy required that the Advance Directive be obtained and reviewed during the admission process and at least quarterly thereafter, but this was not adhered to in this case.
Resident Privacy Breach Due to Public Posting of Care Instructions
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of Resident 12's personal and medical information. Resident 12, who was admitted with a diagnosis of urinary incontinence, had his incontinence care needs publicly displayed in his room. A handwritten sign and two photos detailing the care instructions for his condom catheter were posted on the bathroom door facing into the room, making the information visible to anyone entering the room. During interviews, a licensed nurse acknowledged that the information was posted to inform staff about the supplies needed for Resident 12's care but admitted that it could have been placed inside the bathroom door for privacy. The Director of Nurses also recognized that the posting of personal information without covering it with a blank page created a dignity issue for the resident. The facility's document on residents' rights emphasized the right to be treated with respect and dignity, which was not upheld in this instance.
Resident Unable to Independently Release Self-Release Belt
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 12, was free from physical restraints. Resident 12, who had been diagnosed with Parkinsonism and unspecified dementia, was observed to be unable to independently unbuckle a self-release belt while seated in his wheelchair. Despite the resident's request for the belt and initial demonstration of its use, during an observation, the resident was unable to release the belt independently, indicating it functioned as a restraint. Licensed Nurse 6 confirmed the resident's inability to release the belt without assistance. The MDS Coordinator acknowledged that Resident 12's condition, affected by Parkinson's disease, impacted his cognition and mobility, and confirmed that the resident's quarterly MDS assessment did not include a reassessment of the self-release belt, which should have been conducted. The facility's policy emphasizes a restraint-free environment unless medically necessary, and the resident's inability to remove the belt independently classified it as a restraint. The facility's failure to reassess the need for the belt and ensure the resident's ability to release it independently led to the deficiency.
Failure to Develop Oxygen Use Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident's oxygen needs, which led to the resident receiving an incorrect rate of oxygen. During an observation and record review, it was confirmed that the resident was receiving oxygen at 2.5 liters per minute (LPM) instead of the prescribed 4 LPM continuously. The Licensed Nurse (LN) confirmed the discrepancy and acknowledged that a care plan should have been in place to guide the nursing staff in administering the correct oxygen rate. Further interviews and record reviews with the Director of Nursing (DON) confirmed that no care plan was created for the resident's oxygen use. The DON emphasized the importance of a care plan in providing nurses with interventions and guidance to prevent such errors. The absence of a care plan potentially contributed to the resident receiving insufficient oxygen, which could lead to complications such as shortness of breath.
Inadequate Urinary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident 71, who was admitted with multiple diagnoses including sepsis and bilateral hydronephrosis. During an observation, it was noted that Resident 71's urinary catheter bag was placed on the floor and lacked a dignity cover. This was confirmed by Licensed Nurse 1, who acknowledged that the catheter bag should not be on the floor due to the risk of contamination and should be covered to maintain the resident's dignity. Licensed Nurse 2 also confirmed that the catheter bag should be placed below the bladder and attached to the bedrail when the resident is in bed, and should have a dignity cover. The Director of Nursing (DON) stated that the staff is expected to ensure urinary catheter bags are off the floor and covered at all times to prevent infection and protect resident dignity. The facility's policy on indwelling catheters also indicated that catheter bags should be covered to maintain resident dignity. The Centers for Disease Control and Prevention guidelines for preventing catheter-associated urinary tract infections also specify that catheter bags should not rest on the floor. These failures had the potential to affect Resident 71's sense of self-worth and self-esteem and placed the resident, and others in the facility, at risk for adverse medical outcomes.
Failure to Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who was receiving oxygen therapy. During an observation, it was noted that the resident was receiving oxygen at a rate of 2.5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 4 LPM. This discrepancy was confirmed by a licensed nurse who acknowledged that the oxygen order was not being followed as prescribed. The Director of Nursing also confirmed that the ordered amount of oxygen for the resident was 4 LPM continuously. The failure to administer the correct oxygen dosage placed the resident at risk for hypoxia, which is a condition where there is insufficient oxygen supply to the body's tissues. The facility's policy on oxygen administration, which requires licensed nurses to carry out oxygen therapy orders, was not adhered to in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 5.55%, which is above the acceptable threshold of 5%. This was observed during medication administration to a resident, where two errors occurred out of 36 opportunities. Specifically, the errors involved the failure to administer dorzolamide-timolol and Restasis eye drops to a resident as prescribed. Despite not administering these medications, the licensed nurse documented them as given at the scheduled time. During an interview, the Director of Nursing acknowledged that medications should not be charted as given if they were not administered. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, and any deviations should be documented with an explanatory note. The failure to adhere to these practices had the potential to result in unsafe medication use and affect the resident's health and well-being.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed during inspections of the medication storage rooms and medication carts. In the Sequoia unit medication room, personal items belonging to staff, such as an opened partial bottle of water, coffee cups, tote bags, and a staffing schedule, were found stored under the sink. Similarly, in the Redwood/Harmony unit medication room, personal items including a water bottle, backpack, lunch box, and another personal bag were found on the countertop and under the sink. Both Licensed Nurses (LN 4 and LN 5) confirmed the presence of these items and acknowledged that staff personal belongings should not be stored in medication rooms or under sinks. The Administrator also confirmed that staff personal belongings were not allowed in these areas. Additionally, an inspection of medication cart #2 on the Sequoia unit revealed an expired medication, Ipratropium bromide/albuterol, which was found with an opened date exceeding the recommended two-week usage period after opening. LN 7 confirmed the medication was expired and should have been removed from the cart, acknowledging the risk of reduced effectiveness and potential adverse reactions if administered to residents. The Director of Nursing (DON) stated that the expectation was to remove the medication 14 days after opening, as per the facility's medication storage policy, which emphasizes proper storage and organization of medications.
Failure to Provide Necessary Medications for Resident
Penalty
Summary
The facility failed to provide necessary medications for a resident, leading to potential prolonged illness and unrelieved pain. The resident was admitted with conditions including bronchiectasis with pseudomonas/klebsiella infections and migraines. The resident required intravenous Cefiderocol every 8 hours, but the medication was unavailable at the scheduled times due to a delay in the pharmacy receiving the infusion order request. The Director of Nursing (DON) had to approve medications above certain price points, and the approval for Cefiderocol was not given until the day after the resident's admission. Additionally, the resident required Sumatriptan for migraine headaches, which was also unavailable. The pharmacy informed the facility that the medication was temporarily out of stock and suggested an oral alternative if a doctor's order was obtained. However, there was no documentation that the medical doctor was informed of this request on the day it was made. Consequently, the resident experienced unrelieved pain, as the alternative narcotic pain reliever administered was ineffective. The facility's policies on admissions and medication shortages were not adhered to, as the facility admitted a resident whose needs could not be met and failed to ensure the availability of ordered medications. The DON confirmed that the nurse should have informed the medical doctor of the medication request, and the lack of available Sumatriptan led to the resident experiencing unrelieved pain.
Failure to Inform Resident's Representative of Discharge Appeal Rights
Penalty
Summary
The facility failed to ensure a resident's right to be fully informed of her discharge and the possibility for appeal was protected. Resident 1, who was deemed unable to make health care decisions due to severe unspecified dementia, signed her own discharge notice. The resident's responsible party was not informed of the discharge appeal process, which is a requirement when a resident is unable to make their own health care decisions. The resident's advance health care directive designated her husband as her agent for health care decisions, with her daughter and son as alternates, effective when her primary physician determined she was unable to make her own decisions. A physician order dated shortly before the discharge confirmed that Resident 1 was not capable of making her own health care decisions. The case manager admitted to not verifying Resident 1's decision-making capacity before having her sign the discharge paperwork, despite usually reviewing physician orders for such information. The facility's policy requires that residents and/or their representatives be provided with written notice of an impending transfer or discharge, including a statement of the resident's appeal rights. However, the documentation did not indicate that the responsible party was informed of the right to appeal the discharge decision. This oversight resulted in the responsible party being uninformed of the appeal rights, potentially affecting the resident's access to necessary services if an appeal was sought and upheld.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement adequate measures to prevent injury from falls for a resident who was at high risk for falling. The resident, who had severe dementia and was recovering from a hip hemiarthroplasty, was assessed with a high fall risk score. Despite this, the care plan did not include specific interventions such as the use of fall mats or ensuring the bed was kept in a low position. This oversight contributed to the resident sustaining a complete dislocation of the right hip after a fall. On the day of the incident, the resident was found on the floor with a dislocated hip, which required hospital readmission and surgical intervention. Interviews with staff revealed that the resident's bed was often left in a high position, contrary to the care plan's directives. The staff, including CNAs and licensed nurses, were aware of the resident's fall risk but failed to consistently implement the necessary precautions, such as keeping the bed low and using fall mats. The facility's policies on fall prevention and care planning were not adequately followed, as evidenced by the lack of specific interventions in the resident's care plan. The interdisciplinary team did not incorporate all identified risk factors into the care plan, which should have included measures to prevent falls and potential injuries. This failure to adhere to established protocols resulted in the resident's fall and subsequent injury.
Failure to Provide Dental Care After Resident's Fall
Penalty
Summary
The facility failed to provide necessary dental care for a resident who experienced an unwitnessed fall, resulting in the loss of his front teeth. The resident, who was admitted with Parkinson's disease and required assistance with personal care, fell from his wheelchair and was found bleeding from the mouth. Despite the visible injuries and the resident's report of pain and missing teeth, no oral assessment or follow-up dental care was provided. The nursing staff, including a Certified Nurse Assistant and a Licensed Nurse, observed the resident's injuries but did not take appropriate action to assess the dental damage or inform the physician about the potential loss of teeth. The Licensed Nurse admitted to not being sure about the resident's dental status prior to the fall and failed to communicate the possibility of lost teeth to the doctor. This lack of communication and assessment led to the resident experiencing pain and difficulty eating, which potentially contributed to weight loss. Interviews with family members and a speech therapist confirmed that the resident had a full set of teeth before the fall. The Director of Nursing acknowledged the expectation for nurses to notify the physician and representative party about such incidents and the importance of conducting a thorough oral assessment. The failure to assess and address the resident's dental needs after the fall had a negative impact on his well-being and quality of life.
Failure to Administer Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure that medications ordered by the physician were administered to a resident when dronabinol and vitamin B6 were not acquired from the pharmacy in a timely manner. This resulted in the resident missing 6 doses of dronabinol and 3 doses of vitamin B6. The resident, who was admitted with severe protein calorie malnutrition and had undergone gastric bypass surgery, had a BIMS score indicating moderate cognitive impairment. The missed doses were documented in the Medication Administration Record (MAR) as being unavailable and pending delivery from the pharmacy. During an interview and record review, a Licensed Nurse confirmed that there was no follow-up phone call to the pharmacy or the physician documented in the resident's record. The nurse stated that nursing staff should have contacted the physician to get an order to hold the medications until they were delivered. The facility's policy indicated that new medications should be promptly ordered and delivered to avoid delays in administration, but this procedure was not followed in this case.
Failure to Follow Physician's Orders for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. On 5/16/23, a Licensed Nurse (LN) administered orange juice to a resident with a low blood sugar reading of 59 mg/dL instead of the physician-ordered glucagon gel. Additionally, the LN did not notify the resident's physician of the low blood sugar reading as required by the physician's order and did not recheck the resident's blood sugar level every 15 minutes until it reached at least 110 mg/dL. These actions were not in compliance with the physician's orders and the facility's policy on administering drugs and treatments only upon the order of a licensed and authorized prescriber. The resident, who was admitted to the facility with a diagnosis of diabetes and had a moderate cognitive impairment, experienced a low blood sugar episode. The nurse's progress notes indicated that the resident's blood sugar levels were rechecked only twice from 8:51 a.m. to 2 p.m., instead of every 15 minutes as required. The blood sugar levels did not reach the target of 110 mg/dL. During an interview, another LN confirmed that the physician's orders were not followed, and the facility's policy was not adhered to in this instance.
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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