Oakdale Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakdale, California.
- Location
- 275 South Oak Avenue, Oakdale, California 95361
- CMS Provider Number
- 056155
- Inspections on file
- 18
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oakdale Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Nursing staff left medication carts unlocked and unattended during medication passes, and expired or discontinued medications were found stored in both medication carts and the medication storage room. Additionally, the facility failed to monitor the temperature of the medication storage room as required by policy. These actions were acknowledged by staff and the DON as being contrary to facility procedures.
The facility failed to employ a qualified Dietary Manager with the required CDM credential and did not provide adequate onsite oversight by a Registered Dietitian. The acting DM lacked formal training and supervision for most of the week, while the full-time RD worked remotely and relied on CNAs and LVNs to perform nutrition-focused physical assessments, which is outside their scope. This resulted in insufficient supervision, training, and knowledge among dietetic staff, placing all residents at risk for food safety and nutritional issues.
Expired food and unlabeled personal food items were found in facility refrigerators, including an expired tuna sandwich and a bottle of wine without a received date. Staff interviews revealed that there was no log or checklist to ensure removal of expired items, and facility policy requiring labeling and timely discarding of food was not followed. These failures affected all residents receiving regular diets and at least one resident with a personal food item.
Several residents experienced violations of their rights to dignity and privacy when a Foley catheter bag with visible urine was left uncovered and visible from the hallway, and when dependent feeders were lined up in the hallway and not allowed to enter the dining hall until independent feeders had finished eating. Staff and leadership acknowledged that these practices did not align with facility policy or residents’ rights.
A resident's care plan was not reviewed or revised by the IDT after re-admission, leading to the resident receiving small meal portions instead of the regular portion ordered by the physician. Despite the resident's repeated complaints and clear cognitive status, communication failures between nursing, dietary, and the remote RD resulted in the resident continuing to receive the incorrect diet, contrary to facility policy and physician orders.
A resident received restorative nursing services, such as range of motion exercises and ambulation, from a CNA who was not certified as a Restorative Nurse Assistant (RNA). The CNA performed these duties without the required certification or competency training, and facility leadership was unaware of the certification requirement. Facility records confirmed the CNA was regularly assigned RNA duties, despite the job description requiring RNA certification.
Multiple infection control lapses were observed, including a urinal with urine placed next to food and medication on a resident's bedside table, improper disinfection of a glucometer between uses for two residents, and staff failing to use required PPE while providing direct care to a resident on Enhanced Barrier Precautions for MRSA. These actions did not follow facility policy or standard precautions, as confirmed by nursing and infection prevention staff.
Staff failed to report an allegation of sexual abuse, a nurse did not follow a physician's order for blood pressure management, a resident did not receive required assistive eating devices, and medication was left unattended at a bedside without proper assessment or authorization. These actions and inactions resulted in unaddressed allegations, missed medication administration, lack of support for resident independence, and unsafe medication practices.
A resident did not receive a comprehensive nutritional assessment upon readmission and quarterly, as required, resulting in the resident receiving small meal portions instead of the physician-ordered regular portion. The RD, working remotely, relied on staff reports rather than direct observation or communication with the resident, and the resident's dietary needs and preferences were not addressed due to lack of proper assessment and communication.
Two residents did not receive individualized, person-centered care plans to address their specific needs. One resident with legal blindness lacked a care plan for feeding assistance and safety during meals, resulting in inconsistent staff support. Another resident with a deep tissue injury did not have a care plan for wound treatment, despite having a treatment order, leading to uncoordinated care. Staff interviews confirmed that required care planning procedures were not followed, and the facility's policy for comprehensive care plans was not implemented.
A resident with a recent surgical wound and multiple health conditions was found with dry, flaky, and reddened skin on the scalp and clothing due to inadequate grooming and skin care. CNAs and nursing staff did not provide appropriate scalp care during bed baths, failed to document shower refusals, and did not notify the charge nurse about the resident's condition, leading to the resident feeling uncomfortable and embarrassed.
A resident with severe cognitive impairment and known wandering behavior entered another resident's room and bit their hand while the assigned CNA was on break. The incident occurred due to a lack of monitoring and communication among staff, despite the care plan indicating the need for constant awareness of the resident's location.
The facility failed to document discussions about advance directives during the admission process for three cognitively intact residents. Interviews revealed that the residents were either not offered information or their refusals were not documented, contrary to the facility's policy.
The facility failed to ensure the activity program was directed by a qualified professional, affecting all 99 residents. The Administrator, who was appointed as the Activity Director after the previous AD was terminated, did not meet the required qualifications and had not completed the necessary state-approved training course.
Medication Storage and Security Deficiencies
Penalty
Summary
Nursing staff, including RNs and LVNs, repeatedly left medication carts unlocked and unattended during medication passes. On several occasions, nurses walked away from the carts to attend to other tasks, such as checking assignments or entering resident rooms, leaving the carts accessible in hallways. Both staff and the Director of Nursing acknowledged that this practice was against facility policy and posed a safety risk, as outlined in the facility's medication administration guidelines. Expired over-the-counter medications, such as ibuprofen, and eye drops past their use date were found stored in both medication carts and the medication storage room. Staff confirmed that these medications were expired and should have been removed and destroyed according to facility policy. Additionally, discontinued oral medications, eye drops, inhalation, and injectable medications were found stored in drawers labeled for discontinued medications, rather than being promptly removed and disposed of as required by policy. The facility also failed to monitor and document the temperature of the medication storage room, as required by both facility policy and medication manufacturer instructions. Nurses reported that only the medication refrigerator temperature was being checked, and the thermometer in the medication storage room was not functioning. The DON confirmed that monitoring the room temperature was necessary to ensure proper medication storage.
Unqualified Dietary Manager and Inadequate Dietitian Oversight
Penalty
Summary
The facility failed to ensure that dietetic staff had the appropriate qualifications and competencies to carry out the functions of the food and nutrition service. The full-time Dietary Manager (DM) did not possess the required Certified Dietary Manager (CDM) credential, as mandated by state law, and had not yet taken the credentialing exam. The DM had been acting as the kitchen supervisor since the previous DM left, but was only working under the oversight of a Registered Dietitian (RD) who was present onsite one day per week. The DM reported not having received formal training for her role and lacked direct supervision for most of the week. The facility's staffing arrangement further contributed to the deficiency. RD 2, who previously worked full-time onsite, transitioned to per diem status and was only present once a week, leaving the DM without qualified oversight on the remaining days. RD 1, the full-time consultant dietitian, worked remotely from another state and only visited the facility once a year. RD 1 did not provide physical oversight or direct supervision of the DM and was not involved in daily kitchen operations. Interviews with facility leadership confirmed that the DM was unqualified to independently supervise the kitchen without direct oversight and had not received official training for the position. Additionally, RD 1 did not follow current standards of practice for nutrition-focused physical exams, as she relied on Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) to perform physical assessments, which is outside their professional scope. RD 1 completed nutrition assessments and reports based on chart reviews and information provided by CNAs and LVNs, rather than conducting in-person assessments. The Director of Nursing confirmed that CNAs and LVNs were not trained to perform focused nutrition assessments, and this practice placed all residents at risk for inaccurate assessments and nutritional deficiencies.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to ensure that food was stored and served safely in accordance with professional standards, as evidenced by two main findings. First, an individually wrapped tuna sandwich was found expired in the nourishment refrigerator. The Dietary Manager (DM) confirmed that the sandwich was past its expiration date and should have been removed by a dietary aide. The DM also stated that kitchen staff were expected to stock, clean, and remove expired food items from the nourishment refrigerator every morning and evening, but there was no log, record, or checklist to verify these tasks were completed, nor were specific staff assigned to them. Both the Registered Dietician (RD) and the Director of Nursing (DON) confirmed that all residents on regular textured diets were at risk of being served expired food, and that expired items could cause foodborne illness. Second, a bottle of wine belonging to a resident was found in the resident refrigerator without a received date or manufacturer expiration date, only labeled with the resident's name and room number. The DM stated that all personal food items were required to have a received date to determine expiration, and facility policy dictated that such items be discarded after three days. The RD, DON, and a Certified Nursing Assistant (CNA) all confirmed that labeling with a received date was necessary to ensure timely discarding of expired items, and that the absence of such labeling meant there was no way to determine if the item was expired. The resident in question could not recall when the wine was brought into the facility. Review of facility policies and job descriptions confirmed the expectation that food products be stored safely, with potentially hazardous foods discarded after three days, and that all personal food items from outside sources be labeled with the resident's name and received date. However, the lack of documentation, assignment, and verification of these tasks led to expired and unlabeled food items remaining in the refrigerators, putting residents at risk of consuming expired products.
Failure to Maintain Resident Dignity and Privacy in Catheter Care and Dining Practices
Penalty
Summary
Four residents experienced violations of their rights to dignity and respect due to facility staff actions and inactions. One resident, who was bedbound, had a Foley catheter bag with visible urine hanging on the side of the bed that was clearly visible from the hallway. The resident’s room was located near a busy area, and the bag was not covered with a decency bag as required by the resident’s care plan and facility policy. Multiple observations confirmed that the catheter bag was visible to anyone passing by, including staff, residents, and visitors. Both nursing and CNA staff acknowledged that the bag should have been covered or positioned to maintain privacy, and the DON confirmed that the care plan was not followed, resulting in a violation of the resident’s dignity and privacy. Three other residents, all with severe cognitive impairment and significant physical disabilities, were lined up in the hallway outside the dining hall and not allowed to enter or eat until other residents, who were independent feeders, had finished their meals. Observations showed that these dependent feeders had to wait in the hallway, watching others eat, before being allowed into the dining hall. Staff interviews revealed that this practice had been ongoing for at least 2.5 years, with dependent feeders consistently made to wait until the dining room was cleaned after the independent feeders finished. Staff, including CNAs and RDs, stated that this practice was not appropriate and that it violated the residents’ rights and dignity. Facility policies and job descriptions reviewed during the investigation emphasized the importance of respecting residents’ rights to privacy, dignity, and respectful care. Despite these policies, the observed practices did not align with the stated expectations, resulting in residents being denied privacy and equal access to dining, and being subjected to undignified treatment. The DON and other staff confirmed that these actions were inconsistent with facility policy and the residents’ rights.
Failure to Update Care Plan After Re-Admission Results in Incorrect Diet Served
Penalty
Summary
The facility failed to review and revise the care plan for one resident following her re-admission, as required by facility policy and federal regulations. After being re-admitted, the resident's care plan was not updated by the Interdisciplinary Team (IDT) to reflect her current dietary needs and physician's orders. The resident, who was cognitively intact and able to communicate her preferences, repeatedly expressed concerns about receiving small food portions instead of the regular portion specified in her physician's order. Despite her complaints to both the kitchen manager and staff, her meal portions remained unchanged. Record reviews and staff interviews revealed that the resident's care plan still listed a small portion diet, even though the physician's order upon re-admission specified a regular portion with no added salt and regular texture. The Dietary Manager was not informed of the diet change, and the Registered Dietitian, who worked remotely, was unaware of the updated dietary order. Communication breakdowns between nursing, dietary, and the dietitian led to the resident continuing to receive the incorrect diet for an extended period. Further review of the facility's policies confirmed that care plans are to be reviewed and updated upon re-admission, as well as during regular intervals and significant changes in condition. However, the last documented IDT weight meeting and care conference for the resident occurred months prior to her re-admission, and the care plan was not revised to reflect her current dietary needs. This failure resulted in the resident being served the incorrect diet and had the potential to place her at risk for unintended weight loss.
Uncertified CNA Provided Restorative Nursing Services
Penalty
Summary
Nursing staff at the facility failed to ensure that only individuals with the appropriate competencies and certifications provided restorative nursing services. A Certified Nursing Assistant (CNA) who was not certified as a Restorative Nurse Assistant (RNA) was assigned and performed restorative nursing services, including range of motion exercises and ambulation, for a resident. The CNA confirmed during interviews that she was not RNA certified, despite being assigned to deliver RNA programs to multiple residents without supervision. The facility's Director of Staff Development was unaware that RNA certification was required, and no RNA competency training or checklist was provided by the facility. The resident involved was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, and was observed receiving restorative services from the uncertified CNA. Facility records and interviews with other staff confirmed that the CNA was regularly assigned RNA duties and documented RNA services for several residents. The facility's job description for the RNA position explicitly required an RNA certificate, but this requirement was not enforced, and the Director of Nursing acknowledged that the CNA should have been RNA certified before performing RNA duties.
Infection Control Failures in Resident Care and Equipment Disinfection
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for four residents, resulting in multiple infection control deficiencies. In one instance, a cognitively intact resident with a history of sepsis, cellulitis, chronic kidney disease, and anxiety was found with a urinal filled with urine placed on his bedside table next to drinking cups, protein shakes, and medication. The resident stated the urine had been there for a while. Multiple staff, including the ADON, IP, CNA, RN, and DON, confirmed that this was a violation of standard precautions and acknowledged the risk of cross-contamination, as the urinal should not have been placed near food or drink items. In another instance, an LVN failed to properly clean and disinfect a glucometer after use with two residents. The LVN used a disinfecting wipe for only a few seconds and did not follow the manufacturer's recommended contact time for disinfection. The glucometer was also placed on the medication cart without a barrier. Both the IP and DON admitted confusion regarding the correct procedure and acknowledged that the facility's training and policy did not align with the manufacturer's guidelines for disinfection, increasing the risk of infection transmission between residents. Additionally, staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with MRSA in the urine. Both the DSD and a CNA provided direct care, including meal setup and feeding, without wearing gowns or gloves, despite clear facility policy and signage indicating the need for EBP. The DON, IP, and RN confirmed that all staff were expected to use appropriate PPE when providing high-contact care to residents on EBP, and that failure to do so placed other residents at risk for cross-contamination and infection.
Failure to Meet Professional Standards in Abuse Reporting, Medication Administration, and Resident Support
Penalty
Summary
The facility failed to meet professional standards of practice in several instances involving four residents. In one case, a resident reported to a CNA that another CNA had committed sexual abuse during personal care. The CNA who received the allegation did not file a report or notify management or authorities, as instructed by a charge nurse who dismissed the claim based on the resident's history. The incident was not investigated, and the required abuse reporting protocols were not followed, despite the resident being cognitively intact and staff being trained as mandated reporters. In another instance, a registered nurse did not follow a physician's order to administer antihypertensive medication when a resident's systolic blood pressure exceeded the prescribed threshold. The nurse also failed to document the elevated blood pressure in the clinical chart. This omission resulted in the resident not receiving the prescribed medication and the physician not being notified of the resident's condition, contrary to facility policy and professional standards. Additional deficiencies included a resident not receiving assistive eating devices as ordered on her diet tray card, with kitchen staff failing to provide foam grips on silverware to support the resident's independence during meals. Furthermore, another resident was found with medication left unattended at the bedside without a completed self-administration assessment or a physician's order, and without nursing staff present. The nurse responsible left the medication due to time constraints, which was against facility policy and created a safety issue, as confirmed by interviews with nursing leadership.
Failure to Complete Comprehensive Nutritional Assessment and Ensure Appropriate Diet
Penalty
Summary
A deficiency occurred when a resident did not receive a comprehensive nutritional assessment upon readmission and at the required quarterly interval, as mandated by federal regulations. The resident, who was cognitively intact and able to communicate her needs, expressed dissatisfaction with receiving small meal portions and stated she had not been assessed by a dietitian nor had her preferences addressed, despite informing the kitchen manager. The resident's medical record indicated a physician's order for a regular portion, no added salt diet, but the resident continued to receive small portions due to a lack of updated assessment and communication. The Registered Dietitian (RD) responsible for nutritional assessments worked entirely remotely and relied on Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and the Dietary Manager (DM) to provide information for assessments, rather than conducting direct observation or communication with the resident. The RD completed assessments primarily through chart reviews and staff reports, without direct resident interaction. The facility's policies required comprehensive assessments, including direct observation and resident interviews, but these were not followed in this case. Record reviews showed that the resident's nutritional risk assessments were not completed at readmission or quarterly as required, and the assessments that were completed did not involve direct observation or communication with the resident. The DON confirmed that the RD should have completed these assessments and that the resident's diet order was not properly communicated to the kitchen. As a result, the resident did not receive an appropriate diet consistent with her needs and preferences.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies in meeting their individualized care needs. For one resident with legal blindness, epilepsy, major depressive disorder, and morbid obesity, the care plan addressed insufficient vision but did not include specific interventions for feeding assistance or monitoring during meals. Observations revealed that staff provided some verbal prompts at the start of meals but left the resident alone at times, leading the resident to use his fingers to identify food items and express difficulty eating without continuous guidance. Interviews with staff confirmed that there was no care plan addressing the resident's need for ongoing assistance and safety during meals, despite recognition of the risks involved. For another resident with a deep tissue injury (DTI) to the outer left foot, the facility did not create a care plan for wound treatment, even though a treatment order was in place. Staff interviews indicated that a care plan should have been developed concurrently with the treatment order to ensure the wound was properly acknowledged and managed. The absence of a care plan meant that goals and interventions specific to the DTI were not established or tracked, and communication among staff regarding the resident's wound care was lacking. The resident had multiple diagnoses, including hemiplegia, hemiparesis following a stroke, dysphagia, Parkinsonism, and constipation, and was assessed as having severe cognitive impairment. Facility policy required comprehensive care plans with measurable objectives and time frames for each resident, incorporating identified or potential problem areas and risk factors. However, in both cases, the required person-centered care plans were not developed or implemented, and staff acknowledged that the facility's policy and procedure for comprehensive care planning was not followed. The lack of individualized care planning for these residents resulted in unmet care needs and potential safety concerns, as documented by staff and observed during the survey.
Failure to Maintain Resident Grooming and Skin Care
Penalty
Summary
The facility failed to maintain proper grooming for one resident who was unable to perform activities of daily living independently. During observation, the resident was found with patches of dry, white flakes and redness on his scalp, as well as flakes on the front of his shirt and pants. The resident, who had a recent surgical wound and was refusing showers to avoid getting his dressing wet, expressed feeling bad, uncomfortable, and embarrassed about his appearance. Certified Nursing Assistants (CNAs) and nursing staff acknowledged that the resident's grooming needs, specifically scalp care, were not met, and that the condition of his skin was not normal for him. The CNAs admitted that they should have washed, brushed, and applied lotion to the resident's scalp during bed baths or showers, and should have reported the condition to the charge nurse. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that CNAs were responsible for daily grooming and skin checks, and that documentation and notification protocols were not followed when the resident refused showers or when skin issues were observed. The resident's medical record indicated diagnoses including cancer, diabetes, muscle weakness, and a need for assistance with personal care, with cognitive function assessed as intact. Facility policies required daily grooming and skin care to prevent injury and infection, but these were not adhered to in this case, resulting in the resident experiencing discomfort and embarrassment due to inadequate grooming.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a resident-centered comprehensive care plan for a resident with known wandering behavior, resulting in an altercation. On 4/10/24, Resident 1, who has severe cognitive impairment and a history of wandering into other residents' rooms, entered Resident 2's room and bit Resident 2's hand. This incident occurred while the assigned CNA was on break, and the LVN on shift was not aware of Resident 1's wandering behavior, highlighting a lapse in monitoring and communication among staff. Resident 1's care plan, dated 8/18/23, indicated that all staff should be aware of Resident 1's location and distract her from wandering by offering pleasant diversions. However, on the day of the incident, Resident 1 was left unattended, leading to the altercation with Resident 2. Interviews with staff revealed that Resident 1's behavior was known, but proper monitoring was not in place during the CNA's break, and the LVN was not informed about Resident 1's tendencies. The Director of Nursing emphasized the importance of the care plan in ensuring staff awareness of residents' specific care needs. The failure to monitor Resident 1 and prevent her from entering other residents' rooms directly led to the altercation with Resident 2. This deficiency highlights the need for consistent implementation and communication of care plans to ensure resident safety.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure there was documented evidence to indicate advance directives were discussed during the admission process for three residents. Resident #11, admitted on 06/15/2016, was cognitively intact with a BIMS score of 13. The social services (SS) staff person stated that Resident #11 refused to complete the advance directive form, but there was no documentation to indicate the resident's refusal. Resident #11 also stated that the facility had not offered information about advance directives. Similarly, Resident #31, admitted on 03/20/2021, was also cognitively intact with a BIMS score of 13. The SS staff person mentioned that Resident #31 declined to complete the advance directive form, but again, there was no documentation to indicate the resident's refusal. Resident #31 also confirmed that they had not been offered information about advance directives by the facility. Resident #89, admitted on 10/31/2023, was cognitively intact with a BIMS score of 15. Resident #89 stated that no one from the facility had talked with them about advance directives. Interviews with the Director of Nursing and the Administrator revealed that they were not fully aware of the details of the advance directive process, although the Administrator expected SS to offer advance directives information to residents and their responsible parties. The facility's policy required that advance directives be discussed during the admission process, but this was not documented for the three residents mentioned.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional, affecting all 99 residents. The job description for the Director of Activities required completion of rehabilitation/recreational therapy coursework or equivalent qualifications. However, the Administrator, who was appointed as the Activity Director after the previous AD was terminated, did not meet these qualifications. The Administrator acknowledged his lack of eligibility for certification as a therapeutic recreation specialist or activity professional and admitted he had not completed the required state-approved training course. The appointment was made by the chief financial officer and chief executive officer following staff layoffs, and the Administrator had not had time to complete the necessary training since the termination of the previous AD.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
