Napa Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Napa, California.
- Location
- 3275 Villa Lane, Napa, California 94558
- CMS Provider Number
- 555161
- Inspections on file
- 35
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Napa Valley Care Center during CMS and state inspections, most recent first.
Surveyors observed that food items in the kitchen's walk-in fridge and freezer were not properly labeled or were expired, including parsley, red onions, fully cooked bacon, and gluten free white bread. Staff interviews revealed that kitchen staff did not consistently label or date food items, expecting the Dietary Manager to handle this task, which was not in line with facility policy requiring all refrigerated and frozen foods to be labeled, dated, and discarded by their use-by date.
The facility did not consistently follow infection prevention and control protocols, including delayed initiation of contact precautions for a resident with MRSA, improper storage of dirty items in a clean shower area, and failure to label and properly store personal care items. Additionally, Enhanced Barrier Precautions were not promptly implemented for a resident with a wound vac, and staff did not consistently use required PPE during high-contact care activities.
A resident with chronic respiratory failure was transferred to a hospital due to jaundice and confusion, but the facility did not provide written notification of the transfer or inform the resident or representative of bed-hold rights as required. The relevant documentation section was left blank, and the DON confirmed the absence of written notification.
A resident with a wound that tested positive for MRSA was placed on contact precautions, but the facility did not create a care plan addressing these precautions until a month later. This delay meant that the required individualized plan for infection control and care was not in place as required by facility policy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
The facility did not maintain adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
A resident with diabetes was given rapid-acting insulin by an LVN without being provided a meal or snack, contrary to physician orders and facility policy. The resident had not eaten after the injection, and staff interviews confirmed the insulin was administered too early, increasing the risk for hypoglycemia.
A medication cart containing drugs and biologicals was observed unlocked and unattended, contrary to facility policy requiring carts to be locked when not in use. Both the IP and DON confirmed that medication carts should always be secured to prevent unauthorized access.
Garbage and refuse were not properly disposed of, with open compactor and garbage can lids and trash bags left on the ground, leading to pest attraction and foul odors. Staff interviews confirmed that receptacles should be kept closed and the area clean to prevent unsanitary conditions.
A speech therapy evaluation ordered for a resident with Myasthenia Gravis and Parkinson's Disease was not completed, despite facility policy and staff responsibilities requiring timely completion of such consults. The omission was confirmed by the speech therapist and Director of Rehabilitation, with nursing staff acknowledging their role in verifying consult completion.
Three Stop sign banners used to prevent wandering were found with hair and lint on their velcro areas in a hallway, as confirmed by both the DSD and housekeeping staff. Housekeeping reported that while the banners were sanitized and replaced, the facility lacked tools to remove the debris, resulting in the banners not appearing clean.
A resident with advanced dementia and nonverbal status was found with extensive bruising and a fractured femur of unknown origin. Facility staff could not explain the cause of the injury, and the DON delayed reporting the incident to authorities, citing lack of investigation and unawareness of reporting requirements. The facility's policy requiring immediate reporting of such injuries was not followed.
Disposable razors were found left on top of or partially inserted into full sharps containers in three communal shower and tub rooms, with the sharp portions exposed and no protective covers. Staff and the IP acknowledged this was unsafe and not in line with facility policy, which requires immediate disposal of contaminated sharps and timely replacement of full containers.
A resident with multiple sclerosis and dementia fell and sustained a head hematoma during a transfer from bed to recliner using a mechanical lift. The incident occurred because a staff member operated the lift alone, contrary to facility policy and manufacturer guidelines requiring two staff members. The recliner tipped over due to improper positioning, leading to the fall.
A facility failed to provide a written notification of a hospital transfer for a resident with schizophrenia and a left femur fracture to her Responsible Party (RP). The resident was transferred for chest pain and fainting, but the RP was not successfully informed due to reliance on phone calls, which were unanswered. The facility's policy required written notice within 24 hours of an emergency transfer, but this was not followed, contributing to the deficiency.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and late provision of care for residents. A resident requiring maximal assistance reported waiting up to an hour for help, causing frustration and anxiety. Another resident, needing supervision for daily activities, experienced similar delays, leading to upset feelings. A third resident, with conditions like obstructive sleep apnea and anxiety, faced even longer wait times, particularly at night, fearing for her safety. Staff interviews confirmed short staffing issues, with some responsible for up to 12 residents, making timely responses challenging.
The facility failed to ensure staff awareness of the Antibiotic Stewardship Program, leading to inappropriate antibiotic use for a resident without proper indication. Despite negative test results, antibiotics were administered based on physician orders without reassessment, highlighting a significant gap in staff education and communication.
A licensed staff member at an LTC facility allowed a family member to administer medication to a resident, violating the facility's policy that only nurses should administer medications. The resident, who required maximal assistance due to chronic kidney disease, cachexia, and hyperlipidemia, was at risk due to this practice. Multiple staff members confirmed the policy breach, emphasizing the importance of nurse-administered medications for safety.
Failure to Properly Label and Discard Expired Food Items in Food Service Department
Penalty
Summary
The facility failed to store food in safe and sanitary conditions within the food service department. During an observation in the kitchen's walk-in fridge, surveyors found an opened bag of parsley with a date of 7/20/2025, a container with eight red onions with an expiration date of 7/12/2025, and two boxes of fully cooked bacon with no date. The Dietary Manager confirmed that the parsley and red onions were expired and should have been discarded, and that the bacon was not labeled. In a separate observation in freezer number 3, a bag of gluten free white bread was found with a use-by date of 7/6/2025, which was also expired. The Kitchen Aide acknowledged that this item was expired and should have been discarded. Interviews with the Registered Dietitian revealed that kitchen staff had not been labeling the received date and expiration date of food items, as they expected the Dietary Manager to perform this task. The Registered Dietitian stated this was not acceptable and that kitchen staff were also responsible for labeling and dating food products. Review of the facility's policy and procedure on Food Receiving and Storage confirmed that all foods stored in the refrigerator or freezer are required to be covered, labeled, and dated, and that refrigerated foods must be monitored and used by their use-by date or discarded.
Failure to Implement and Maintain Infection Control Practices
Penalty
Summary
The facility failed to implement and follow infection prevention and control practices in several instances. For one resident with a wound positive for MRSA, contact precautions were not initiated immediately upon identification of the multidrug-resistant organism (MDRO), despite facility policy requiring prompt initiation of transmission-based precautions. Although a contact precautions sign was eventually posted, there was a delay in placing the order and implementing the necessary precautions as soon as the culture results were received. In another instance, dirty linen barrels and a rolling commode were found stored in a clean shower area, rather than in the designated dirty utility area. The facility was unable to provide a policy regarding the proper storage of dirty items when requested. Additionally, in a resident's shared bathroom, an unlabeled urinal was found in the sink next to uncovered oral hygiene items, and another set of unlabeled hygiene items was found stored on top of a toilet lid. Staff confirmed that these items should have been labeled and stored at the resident's bedside or in the bedside cabinet, not in the bathroom or on the toilet. The facility also failed to implement Enhanced Barrier Precautions (EBP) in a timely manner for a resident with a wound vac. Although an order for EBP was eventually placed, there was a significant delay after the wound vac was ordered, and signage indicating EBP was not consistently present on the resident's door. The resident reported that staff had not consistently worn gowns when providing hygiene or wound care, and staff interviews confirmed that EBP requires the use of gowns and gloves for high-contact care activities. Facility policy states that EBP should be in place for residents with wounds or indwelling devices, with appropriate signage and personal protective equipment readily accessible.
Failure to Provide Written Transfer Notification and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide a written transfer notification to a resident or the resident's representative when the resident was transferred to an acute care hospital. The resident, who had a diagnosis of chronic respiratory failure, was observed to be jaundiced and confused, prompting the physician to order a hospital transfer. Documentation in the progress notes confirmed the transfer process, including the time the resident left the facility with emergency medical technicians. Upon review, the section of the Bed Hold Policy and Notification form that should have been completed at the time of transfer was found to be blank. This section is intended to document the resident's name, transfer details, and confirmation that the resident or representative was informed of their rights regarding bed-hold policies. The DON confirmed during an interview that there was no documented evidence that a written transfer notification was provided at the time of the resident's transfer.
Failure to Timely Initiate Care Plan for Resident on Contact Precautions
Penalty
Summary
The facility failed to initiate and create a care plan for a resident who was placed on contact precautions after testing positive for MRSA in a wound. The resident, who had a history of facial weakness following a cerebral infarction, was admitted with a wound that later tested positive for MRSA. Contact isolation precautions were started, and the Infection Preventionist was notified of the new orders and culture results. However, a review of the records revealed that the care plan addressing the resident's isolation precautions was not created until a month after the positive MRSA result and the initiation of contact precautions. During interviews and record reviews, it was confirmed that the care plan for isolation precautions was created significantly later than when the precautions were started. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, and that care plans are revised as residents' conditions change. The delay in creating the care plan meant that the necessary direction for care and treatment related to the resident's infection control needs was not documented or implemented in a timely manner.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as the resident's medical history or condition at the time, are not provided in the report excerpt.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices, which revealed that staffing levels and licensed nurse coverage were insufficient to meet regulatory requirements.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Insulin Administered at Incorrect Time Without Meal
Penalty
Summary
A significant medication error occurred when a resident with Type 2 Diabetes Mellitus was administered rapid-acting insulin (Insulin Aspart) at an inappropriate time. The medication label and physician orders specified that the insulin should be given before meals, but the nurse administered the insulin without ensuring the resident was about to eat or providing food. Observations confirmed that no food was present in the resident's room at the time of administration, and the resident had not eaten following the injection. The resident later reported feeling tired and stated that insulin is usually given approximately 30 minutes before meals, but on this occasion, it was given earlier than usual without a meal following. Interviews with facility staff, including the DON, the nurse involved, and the pharmacist, confirmed that the insulin was administered too early and not in accordance with the facility's policy or the physician's orders. The facility's policies on medication and insulin administration emphasize the importance of timing, particularly for rapid-acting insulin, which has an onset within 15 minutes and peaks within 0.5-1.5 hours. The failure to coordinate insulin administration with meal timing placed the resident at risk for complications associated with hypoglycemia.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart containing drugs and biologicals was found unlocked and unattended on Unit 1A during an observation with the Infection Preventionist. The Infection Preventionist confirmed that the cart should be locked when not in use. The Director of Nursing also stated in an interview that medication carts are required to be locked at all times when not in use. Review of the facility's policy and procedure on storage of medications indicated that compartments containing drugs and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible to others.
Improper Garbage Disposal and Open Receptacles Attract Pests
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by multiple observations of the garbage disposal area where the garbage compactor was left open and piles of trash bags were found on the ground, resulting in the presence of flies and a foul odor. During separate observations, a garbage can lid was also found open, allowing birds to access the contents. Interviews with the Housekeeping Supervisor, Housekeeping staff, and the Infection Preventionist confirmed that the compactor and garbage can lids should be kept closed to prevent odors and pest attraction, and that the area should be kept clean. Review of the FDA Food Code further supported the requirement for tight-fitting lids and proper cleaning to prevent unsanitary conditions.
Missed Speech Therapy Evaluation Order
Penalty
Summary
A speech therapy evaluation ordered by a physician for one resident with Myasthenia Gravis and Parkinson's Disease was not completed as required. The physician's order for the evaluation was placed, but 43 days later, there was no documentation in the resident's record indicating that the evaluation had been performed. The speech therapist confirmed that the evaluation was missed, and the Director of Rehabilitation acknowledged that such evaluations should be completed within approximately 48 hours of the order. Nursing staff interviewed stated that they were responsible for verifying that speech therapy consults were completed to ensure residents received the correct diet. The facility's policy indicated that specialized rehabilitative services, including speech pathology, are to be provided upon written physician order. Despite these policies and staff responsibilities, the required speech therapy evaluation was not conducted for the resident.
Unsanitary Stop Sign Banners Observed in Hallway
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment when three Stop sign banners hanging on Hallway 3A rails next to resident rooms were observed to have hair and lint on the velcro areas. During a concurrent observation and interview, both the Director of Staff Development and a member of the housekeeping staff confirmed the presence of hair and lint on the banners. The housekeeping staff stated that while the banners were sanitized and replaced, the facility did not have the appropriate tools to remove hair and lint from the velcro, resulting in the banners not appearing clean. Review of the facility's infection control policy indicated an objective to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was nonverbal and unable to advocate for himself. The resident, who had Lewy Body dementia and multiple medical diagnoses, was found by CNAs to have deep purple discoloration, swelling, and pain in his left leg. Upon assessment by a nurse, the leg was noted to be in an abnormal position, very firm to the touch, and the resident exhibited facial grimacing when range of motion was attempted. Emergency medical services were called, and the resident was transported to the emergency department, where a comminuted and markedly displaced fracture of the left femur was diagnosed. There was no reported fall, and staff were unable to explain how the injury occurred. The Director of Nursing (DON) did not report the injury immediately to the appropriate authorities, stating that the facility had not completed its investigation and was unsure if the injury was of known or unknown origin. The investigation was not started until two days after the injury was discovered, and the DON was unaware of the requirement to report injuries of unknown origin within two hours if serious bodily injury is involved, or within 24 hours if not. Facility policy required immediate reporting of suspected abuse or injury of unknown source, but this was not followed in this case.
Plan Of Correction
POC accepted with Spencer Hadley, admin 6/3/25 at 3:40pm. BIC date 5/15/25. CM, HFES 35362 Preparation and/or execution of this response and Plan of Correction (POC) do not constitute an admission or agreement by the provider of truth or accuracy of alleged facts or conclusions set forth in this Statement of Deficiencies. This POC is prepared and/or executed solely for provisions of Federal and State required regulations. This POC is not an admission of noncompliance with cited regulation(s). F 609 How corrective action(s) will be accomplished: All Residents may potentially be affected by this deficiency. A facility wide audit was conducted by the Assistant Director of Nursing (ADON) on 5/15/25 to review with facility Primary Care Physician (PCP) all residents. Nine (9) residents were identified as high risk related to diseases and co-morbidities. Care plans and diagnosis were updated on 5/15/25. PCP reviewed and ordered supplements if not contraindicated. In addition, a facility wide staff interview was conducted on 5/5/25 to determine if there are any residents who have visible injuries of unknown origin that need to be reported as an unusual occurrence. The results of the interviews did not determine any injury of unknown origin, which will require investigation. How will facility identify other residents having the potential to be affected: Director of Staff Development (DSD) proactively gave an in-service to staff on skin discolorations reporting, root cause analysis collaboration with team including nurse and peers on 5/6/25. DSD and DON collaborated in providing in-service to staff on Unusual Occurrence Policy and Procedures including time frame and reporting to appropriate agencies on 5/14/25. Administrator/Designee is the ultimate person responsible for reporting injuries of unknown origin to the Department of Health and other agencies. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not reoccur: Director of Staff Development (DSD) proactively gave an in-service to staff on skin discolorations reporting, root cause analysis collaboration with team including nurse and peers on 5/6/25. DSD and DON collaborated in providing in-service to staff on Unusual Occurrence Policy and Procedures including time frame and reporting to appropriate agencies on 5/14/25.
Improper Disposal of Disposable Razors in Communal Shower and Tub Rooms
Penalty
Summary
The facility failed to follow its infection control policy regarding the disposal of contaminated sharps, specifically disposable razors, in three communal shower and tub rooms. Observations revealed that disposable razors were found either on top of or partially inserted into the lids of sharps containers, with the sharp portions exposed and no protective covers in place. In each instance, the sharps containers were full of used disposable razors, and the razors left on or in the lids were not properly discarded. Staff interviews confirmed that this practice was unsafe and not in accordance with facility policy, which requires immediate disposal of contaminated sharps and replacement of containers when they are 75% to 80% full. The Infection Preventionist and the DON acknowledged that the containers were not being changed as required and that staff were not following proper procedures for sharps disposal. The DON also noted that while she did not believe CNAs would reuse razors on different residents, the improper storage of razors on top of sharps containers could lead to such an occurrence. Facility policy review confirmed that contaminated sharps should be discarded immediately and that full containers should be replaced to prevent injury and improper handling.
Resident Falls During Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer from bed to recliner using a mechanical lift, resulting in the resident falling and sustaining a hematoma on the head. The incident occurred when a staff member operated the mechanical lift alone, contrary to the facility's policy and manufacturer guidelines, which require at least two staff members to be present during such transfers. The resident, who had multiple sclerosis and dementia, was not properly positioned on the recliner, causing it to tip over and the resident to fall. Interviews with staff revealed that the mechanical lift was frequently used in the facility, and it was standard practice to have two staff members present to ensure resident safety during transfers. The Director of Nursing confirmed that the fall was preventable and attributed it to the absence of a second staff member to assist with the transfer and ensure proper positioning of the resident. The facility's policy and the lift manufacturer's guidelines both emphasize the necessity of having two staff members present to safely conduct transfers using a mechanical lift.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide a written notification of a hospital transfer for a resident to her Responsible Party (RP). The resident, who had diagnoses including schizophrenia and a left femur fracture, was transferred to acute care for chest pain and fainting. Despite the facility's protocol to notify responsible parties via phone calls, the RP was not successfully informed. Licensed staff attempted to call the RP, leaving a voicemail, but did not receive a response. The Social Services Director indicated that written Transfer Notice Forms were only sent for planned transfers, not emergency ones, and the Notice of Proposed Transfer/Discharge form for the resident was incomplete, lacking a mailed certified section. The facility's policy required that notice of transfer or discharge, including bed-hold and return policies, be provided to the resident and representative within 24 hours of an emergency transfer. However, the policy was not followed, as the RP did not receive a written notice. The failure to notify the RP in writing had the potential to hinder the RP's ability to advocate for the resident's needs and coordinate care with the receiving hospital. The facility's reliance on phone calls, which were often unanswered, and the lack of a written notice contributed to the deficiency.
Inadequate Staffing Leads to Delayed Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by the experiences of three residents who reported delayed responses to call lights and late provision of care. Resident 2, who required maximal assistance for personal care due to conditions such as osteoarthritis and insomnia, expressed frustration and anxiety over the long wait times for assistance, which sometimes extended up to an hour. Resident 3, who needed supervision for activities of daily living due to muscle weakness and chronic pain, also reported waiting between 30 minutes to an hour for staff to respond to his call light, leading to feelings of frustration and upset. Resident 4, who required supervision to maximal assistance for activities of daily living and suffered from obstructive sleep apnea and anxiety disorder, reported even longer wait times, ranging from one to two hours, particularly during the night. This resident expressed fear for her safety, worrying that staff would not be available in case of a medical emergency. Interviews with both licensed and unlicensed staff confirmed the issue of short staffing, with some staff members responsible for up to 12 residents at a time, making it difficult to respond to call lights promptly and complete tasks in a timely manner. The facility's policy and procedure documents, which mandate answering call lights as soon as possible and providing sufficient staff to ensure resident safety, were not adhered to. Staff interviews consistently highlighted that call lights should be answered within 5 minutes to prevent safety risks, yet the actual response times were significantly longer, contributing to the residents' distress and potential safety hazards. The Director of Staff Development acknowledged that short staffing could lead to accidents, falls, and late provision of care, further emphasizing the facility's failure to meet its staffing requirements.
Lack of Awareness and Inappropriate Antibiotic Use
Penalty
Summary
The facility failed to ensure that six out of nine licensed staff were aware of the Antibiotic Stewardship Program (ASP), which is designed to promote the appropriate use of antimicrobials, including antibiotics. Interviews with Licensed Staff A, B, C, E, F, and G revealed a lack of familiarity with the ASP, indicating a significant gap in staff education and awareness. This lack of knowledge among the staff contributed to the inappropriate use of antibiotics, as they continued to follow physician orders without questioning the necessity or appropriateness of the prescriptions. The facility also failed to promote the appropriate use of antibiotics for a resident who was prescribed Augmentin ES-600 and Vancomycin without proper indication. The resident received these antibiotics for aspiration pneumonia and C.Diff prophylaxis, despite not meeting the criteria for active infection. The Chest X-Ray and infection screening form indicated no acute pneumonia, and there was no reassessment or documentation to justify the continued use of antibiotics. The Infection Preventionist confirmed that the resident did not meet the criteria for antibiotic use, yet the antibiotics were administered based on the physician's order. Interviews with various staff members, including the Director of Staff Development and the Infection Preventionist, highlighted a lack of reassessment and communication regarding the necessity of continued antibiotic therapy. The pharmacy consultant emphasized that antibiotics should only be used when indicated by positive laboratory or imaging results, and there should be ongoing assessments to determine the need for continued therapy. However, the facility did not document any reassessment or justification for the continued use of antibiotics, putting residents at risk for adverse outcomes associated with inappropriate antibiotic use.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice when a licensed staff member allowed a family member to administer medication to a resident. This incident involved Resident 1, who was admitted with diagnoses including chronic kidney disease stage 3A, cachexia, and hyperlipidemia. The resident required maximal assistance for personal care, indicating a high level of dependency on staff for daily needs. Interviews with various staff members, including Licensed Staff A, B, C, the Director of Staff Development, and the Infection Preventionist, revealed that the facility's policy mandated that only nurses were permitted to administer medications to residents. Despite this policy, Licensed Staff C admitted to leaving medications with Resident 1's daughter for administration, particularly when the resident refused to take medications from her. This practice was not in line with the facility's policy, which was confirmed by multiple staff members who emphasized the importance of nurses administering medications to ensure safety and compliance. The facility's policy and procedure on administering medications, revised in December 2012, clearly stated that only licensed or permitted individuals were authorized to prepare, administer, and document medication administration. The Director of Staff Development and other staff members reiterated that leaving medications at the bedside or allowing family members to administer them posed a safety risk. The failure to adhere to these policies and procedures resulted in a deficiency, as it compromised the safety and proper care of the resident involved.
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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