Oakwood Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chico, California.
- Location
- 375 Cohasset Rd, Chico, California 95926
- CMS Provider Number
- 055656
- Inspections on file
- 64
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Oakwood Healthcare Center during CMS and state inspections, most recent first.
A resident admitted without pressure injuries later developed a stage 2 coccyx PI and heel PIs that were not promptly recognized or managed. Nursing staff missed early skin changes, delayed ordering a low air loss mattress, and did not complete a required significant change MDS. The care plan was not updated to include the coccyx PI for several days and did not include the heel PIs until days after their discovery. The RD was not notified of the PIs in a timely manner, and appropriate non-dairy nutritional supplementation to support wound healing was significantly delayed.
A nurse failed to document multiple administrations of controlled medications on the MAR for six residents with conditions including anxiety, muscle spasms, Parkinson’s disease with dyskinesia, and chronic pain syndromes. Facility policy required the person administering medications to record the date and time in the medical record and maintain complete and accurate documentation. Review of narcotic sign-out sheets and MARs by the DON showed that doses of Xanax, Percocet, and Norco were signed out on the narcotic log but not recorded on the MAR. Staff interviews confirmed that the narcotic log and MAR were required to match and that not signing the MAR created the potential for medication errors, including double dosing or administering medications too early.
Surveyors found that three of four shower rooms, including two in Station 1 and one in Station 2, were not maintained in a clean, safe, and homelike condition. Observations revealed dark black substances along floor-to-wall seams and in corners of shower stalls, with discoloration concentrated in grout and caulked joints. One shower room had six missing wall tiles near the faucet, exposing a surface with brown and black substances, while another had darkened, stained grout and cracked, worn tiles along the shower floor perimeter. During an interview, the Admin acknowledged the discoloration, missing tiles, and uncleanable exposed areas, despite the expectation that a resident be showered in an area that is in good condition and homelike.
Surveyors found that multiple nurse aides (NAs) were hired, scheduled, and used in CNA rotation slots to provide direct resident care, including 1:1 care, feeding, changing, and unit assignments, before they were certified by the state. Facility job descriptions required NAs to complete theory and competency skills and be enrolled in a state-approved NATP, yet Facility 3 did not have a CDPH-approved NATP or clinical training site status. Several NAs were documented as working independently or unpaired with a CNA after NATP graduation but before certification, and one NA remained uncertified for months while working independently. Interviews with the DSD, scheduler, NAs, and NATP staff confirmed that uncertified NAs were treated as able to perform nearly all CNA duties, that competency assessments and orientation were lacking, and that leadership knew Facilities 1 and 3 were not approved NATP sites while still employing NAs in these roles.
The governing body failed to ensure proper oversight of the administrator and hiring practices, resulting in multiple nurse aides in training being employed and scheduled to provide independent direct care before state CNA certification and documented competency. Facility policies stated that uncertified aides could not perform general direct resident care until theory and competency skills were completed, and that aides must be enrolled in a state-approved NATP; however, the facility did not have an approved NATP or serve as a clinical training site. Despite this, several aides were hired prior to certification, assigned to CNA rotation slots, worked independently on units, and provided 1:1 care and other direct services to residents, while leadership staff confirmed that these NAs were treated as employees and allowed to perform most CNA duties.
A resident who was fully dependent on staff for toileting and had multiple medical conditions reported feeling rushed and spoken to in a demeaning manner by a CNA, resulting in emotional distress. The CNA admitted to raising her voice and being task-focused, while facility leadership confirmed that the care provided did not meet standards for dignity and respect as outlined in facility policy.
A deficiency was identified when a resident with severe cognitive impairment and behavioral issues yelled profanities and swung her hands at another resident in a hallway, resulting in verbal abuse and possible physical contact. Staff and video evidence confirmed the aggressive behavior, and the incident was reported to administration. The facility's abuse prevention policy was not effectively implemented to prevent this occurrence.
The facility did not follow its laundry policies or provide required training and competency checks for a laundry tech, resulting in hot kitchen laundry being removed from the dryer before the cycle was complete and placed in a plastic bag, which led to smoldering and a fire department response. Staff interviews and record reviews confirmed a lack of training, unclear procedures, and missing documentation regarding laundry safety protocols.
Staff did not consistently follow a resident's care plan requiring use of a Hoyer lift for transfers, instead sometimes manually lifting the resident with two people. The resident, who had Parkinson's disease, dementia, and was non-ambulatory, was later found with a bruised and fractured toe. Documentation and staff interviews confirmed that the care plan was not always followed.
A resident with limited mobility and a history of spinal fusion was injured during a transfer when staff failed to properly secure a Hoyer lift sling, used a damaged and incorrectly sized sling, and did not provide adequate supervision or follow required procedures. The resident fell, sustaining multiple fractures, severe pain, and required hospitalization with increased pain management and supplemental oxygen.
Four residents who were unable to bear weight and required mechanical lifts for transfers did not have care plans documenting this need, despite facility policy requiring such plans. Review of records and interviews confirmed the absence of care plans specifying mechanical lift use for these dependent residents.
Staff continued to use a broken mechanical lift for multiple dependent residents, despite being aware of its malfunctioning legs and detachable handle. The issue was not properly reported or documented, and maintenance staff did not remove the lift from service or perform thorough inspections, resulting in repeated use of unsafe equipment for resident transfers.
Two residents were not treated with dignity and respect when one was left without appropriate clothing for an extended period, resulting in social isolation and embarrassment, and another was not provided adequate privacy during personal care due to an insufficient privacy curtain. Staff interviews and observations confirmed these deficiencies, which were contrary to facility policy and led to diminished autonomy and well-being for the affected residents.
The facility did not act promptly on repeated resident council grievances about delayed call light response times, especially during night shifts. Residents reported excessive wait times, with some experiencing waits of up to several hours, and noted that CNAs and registry staff often failed to respond or turned off call lights without providing care. Despite ongoing complaints documented in council meetings, there was minimal evidence of timely or effective staff in-services or interventions to address the issue.
Two direct care staff failed to follow infection control protocols and ensure resident privacy. One CNA did not wear an N-95 mask while caring for a resident with Covid, contrary to facility policy, and there was no evidence of staff education on proper mask use. Another CNA did not fully close privacy curtains during personal care, allowing roommates to observe, and had a record of performance issues without documented in-service education.
CNAs were observed entering the room of a symptomatic Covid-19 positive resident while wearing surgical masks instead of the required N-95 respirators, despite being aware of facility policy and recent instructions. The Infection Preventionist could not provide evidence of staff training on Covid-19 or proper mask use.
A resident with acute and chronic respiratory failure and diabetes was transferred to a GACH following a significant decline in condition. The facility did not provide the required Notice of Transfer or Discharge, bed hold notice, or notify the Ombudsman, as confirmed by interviews with the MRD, DON, and an LN. These documents were missing from the resident's record and had not been completed as required by policy.
A treatment nurse failed to stop enteral feeding and lowered a resident with a G-tube to a flat position during care, despite orders and policy requiring the head of bed to be elevated during feedings. The resident had significant medical conditions, and the nurse acknowledged the feeding pump should have been turned off during the procedure.
Discontinued medications were found unsecured in a medication room, and the facility's destruction log lacked required signatures, dates, and reasons for destruction. A nurse confirmed the medications were not secure and that the process for destroying discontinued medications was unclear, while the DON verified the documentation deficiencies.
The facility did not ensure that staff and visitors handling food brought in from outside were educated on safe food handling practices, as required by policy. Interviews revealed that staff were unaware of the policy and had not received training, and the admission packet did not include information for residents or visitors. This affected all residents receiving an oral diet.
A resident with dementia and a recent hip fracture experienced a fall that was not documented or reported by the LNs as required by facility policy. The post-fall evaluation, care plan update, and witness interviews were delayed by two days, and the DON and Administrator were not notified promptly. Staff interviews revealed confusion about responsibilities, resulting in a lack of timely assessment and documentation.
The facility did not report an outbreak of respiratory illness involving multiple residents and staff to public health authorities within the required timeframe, despite several individuals exhibiting symptoms such as cough, shortness of breath, and being diagnosed with pneumonia or bronchitis. The delay in reporting was confirmed by the Infection Preventionist, who was new to the role, and was not in accordance with facility policy or state regulations.
A resident verbally abused another resident in a hallway, repeatedly yelling profanities and derogatory comments while staff and other residents were present. The incident was documented by nursing staff and confirmed in interviews, with the victim reporting emotional distress and a lack of immediate intervention. Both residents had complex medical and mental health histories, and the facility's abuse prevention policies were not followed during the event.
A resident was subjected to verbal aggression and profanities by another resident, but the facility did not report the abuse allegation to CDPH, Ombudsman, or law enforcement within the required two-hour timeframe. The mandated SOC341 form was submitted three days after the incident, as confirmed by the DON, contrary to facility policy.
A resident with a documented history of methamphetamine abuse, who tested positive for the drug and was found with methamphetamine in their possession, did not have a care plan developed to address their substance use. Facility staff, including the MDS nurse and DON, confirmed the absence of interventions or monitoring for the resident's drug use, despite facility policy requiring comprehensive care planning.
A resident with a known history of substance use disorder and multiple complex medical conditions was allowed to leave and return to the facility without proper assessment for drug use or overdose, and staff did not consistently document the resident's departures or condition upon return. Facility staff, including CNAs, nurses, and the Social Service Director, had not received training on managing emergencies or behaviors related to substance use disorder. Additionally, no care plan was developed to address the resident's substance use disorder, despite facility policy requiring such planning.
A resident with a history of methamphetamine abuse exhibited frequent aggression and behavioral outbursts, including verbal and physical altercations with other residents and staff. Despite the facility's assessment identifying a need for staff with competencies in managing SUD, interviews and record reviews confirmed that no SUD-specific training had been provided to staff, leaving them unprepared to address the resident's behaviors.
A long-term care facility was found to have multiple infection control deficiencies, including staff not performing hand hygiene and using bare hands to handle resident food, unlabeled g-tube feeding bags, and improper cleaning of medical equipment. These actions were confirmed as infection control concerns by the facility's Infection Preventionist and Director of Nursing.
The facility failed to provide adequate ADL care for three residents, including missed showers and nail care. A resident missed important Saturday showers, impacting his spiritual activities. Another resident had long, unkempt nails, and a third resident was not showered twice a week for four months, leading to body odor. These deficiencies were confirmed through interviews and record reviews.
A facility failed to document the administration of Norco, a narcotic pain medication, for a resident in the MAR, despite its removal being recorded in the CDR. This discrepancy occurred on multiple occasions, violating the facility's policy requiring documentation in both records. The DON confirmed the missed documentation after reviewing the records.
A facility failed to ensure the safe use of psychotropic medications for a resident who had a PRN order for phenobarbital without a specified duration. Despite a recommendation to discontinue the medication, the order remained active without documentation of its use or assessment. The facility's policy required PRN psychoactive medications to have a duration not exceeding 14 days unless justified by a physician, which was not adhered to in this case.
The facility reported a medication error rate of 9.68%, exceeding the acceptable 5% threshold. A resident did not receive food with a potassium tablet as ordered, and another resident received two medications mixed together via G-tube, contrary to guidelines. These errors were confirmed by the involved nurse and the DON.
The facility failed to adhere to safe medication and supply storage practices. Medication Cart 3 stored an unopened eye drop requiring refrigeration and undated glucometer test strips. The medication room had expired blood test tubes and culture swabs, while the treatment cart contained improperly stored sterile wound care supplies. These practices were not in line with facility policy or expectations.
The facility failed to maintain food service safety standards when food preparation equipment was found unclean during an initial tour. Four baking sheets with a black charred substance were observed, which the Dietary Manager confirmed could cause cross-contamination. The DM acknowledged the need for replacement of the baking sheets.
A facility failed to maintain complete medical records for a resident due to the RNA's lack of documentation of range of motion exercises. The resident, diagnosed with dementia and trigger finger, was to receive passive range of motion exercises as per a physician's order. However, the EMR showed missing documentation for these exercises over several weeks, confirmed by the DSD.
The facility failed to follow its arbitration agreement policy for three residents, leading to misunderstandings and unauthorized signings. One resident felt rushed and uninformed, another's representative was unaware of signing, and a third resident's agreement was signed by the facility's team without proper authority documentation.
The facility failed to maintain an electrical outlet cover in a resident's room, which was loose and had a gap between it and the wall. The outlet cover was near a privacy curtain, and when the curtain was fully closed, it almost touched the cover. The Maintenance Supervisor confirmed the issue, which was against the facility's maintenance policy aimed at protecting health and safety.
A resident with severe cognitive impairments alleged physical abuse by an unknown male staff member. The facility conducted a skin check and notified the police, but failed to report the incident to CDPH within the required two-hour timeframe. The administrator mistakenly believed CDPH had been informed, but no confirmation of notification was found.
A resident with a history of depression and dementia expressed suicidal thoughts, but the facility failed to revise the care plan to address this. Despite the resident's fall and subsequent aggressive behavior, there was no follow-up or care plan update to ensure safety. Interviews revealed a lack of awareness and action from staff, resulting in a significant oversight in care planning.
A resident with a known petroleum allergy received Tacrolimus cream, which contains petroleum, due to a medication order entry error by a Licensed Nurse. The error was not flagged by the facility's system, leading to multiple doses being administered before the mistake was identified. The resident experienced burning on the skin and was later diagnosed with Candidal dermatitis, requiring hospitalization.
A resident with chronic conditions was transferred to a hospital due to altered mental status, but the facility failed to document the change of condition and transfer in the medical record as required by policy. Interviews confirmed the lack of documentation, highlighting a deficiency in maintaining accurate records.
The facility failed to protect residents from abuse, with one resident experiencing harassment from another resident and another feeling uncomfortable due to inappropriate behavior by a staff member. The facility did not promptly report or address these incidents, leading to ongoing distress for the affected residents.
The ADM failed to implement the abuse policy, delaying the reporting of an incident involving a resident and a male staff member. Additionally, the ADM did not report a facility lockdown to the state agency, initiated when a former resident returned and threw bottles at the building. Furthermore, a resident lived with an unreported ceiling leak for three days due to a malfunctioning air conditioning unit, highlighting the ADM's failure to ensure a safe environment.
A resident's room experienced a three-day leak from an air conditioning unit, causing distress and mobility issues. Additionally, the facility's fire alarm system was silenced for five hours without a fire watch, posing safety risks. The facility failed to maintain essential equipment, leading to unsafe conditions.
A resident reported feeling uncomfortable after a male staff member from the laundry department touched her shoulder. Despite the facility's policy requiring timely reporting of such incidents, the report to Adult Protective Services was delayed by 20 days. The resident, who was alert and had no mental impairment, required substantial assistance for mobility and had a history of anxiety and depression. The delay in reporting violated state regulations and the facility's own procedures.
A resident experienced distress and safety hazards due to a ceiling leak in her room caused by a malfunctioning HVAC unit. Despite being offered a room change, she chose to stay with her belongings. The leak persisted for three days, with maintenance delays and inadequate communication among staff, leading to continued discomfort and risk for the resident.
The facility failed to maintain a safe environment by not addressing a damaged fire door and an unsecured staff locker room door, both posing significant risks to residents. Additionally, a resident suffered a fall due to a known issue with a loose toilet that was not repaired, resulting in injury and distress.
A resident with diabetes and dementia developed a severe pressure ulcer due to the facility's failure to implement preventive measures and timely interventions. Despite being at high risk, the resident did not receive necessary pressure-relieving interventions or regular podiatry consultations. The ulcer worsened, leading to infection and a below-the-knee amputation, causing significant distress and pain for the resident.
The facility failed to meet food safety and sanitation standards, with expired food items found in storage, improper labeling, and unsanitary kitchen conditions. Observations revealed sticky residues, worn equipment, and improper use of an eyewash station for handwashing. These deficiencies posed a potential risk for food- and waterborne illnesses among residents.
The facility's ADM failed to maintain a safe environment, with a damaged fire door and unsecured hazardous areas. Staffing issues led to long call light response times, and dietary services were inadequate, with expired food and unsanitary conditions. Pharmacy services were deficient, and resident grievances were not addressed, indicating a lack of effective oversight.
Failure to Prevent and Timely Manage New Pressure Injuries and Related Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of pressure injuries (PIs) and to provide timely, coordinated care once PIs were identified for a resident who was admitted without any PIs. The resident was admitted with vertebral fractures and had a BIMS score of 7/15, indicating poor decision-making ability. Initial assessments documented that the resident had no pressure ulcers on admission. A licensed nurse later discovered a new stage 2 PI on the resident’s coccyx, confirming that the resident developed this PI after admission. The facility’s own policy required staff to observe for signs of potential or active pressure injury daily, but the coccyx PI was not recognized until it had progressed to stage 2, and a prior skin check did not mention any coccyx PI. After the coccyx PI was identified, the facility did not promptly implement appropriate pressure-redistributing interventions. Although the nurse who discovered the coccyx PI stated she requested a low air loss (LAL) mattress, there was no documentation of such an order in the record, and the physician’s order for an LAL mattress was not obtained until 11 days after the coccyx PI was discovered. During this period, the resident remained on a standard medical-grade mattress, which was acknowledged as not being the mattress the resident needed. In addition, nursing staff failed to recognize the development of PIs on the resident’s heels in a timely manner. A weekly evaluation completed by a nurse did not include an actual assessment of the resident’s heels, and the nurse later acknowledged that she had missed checking them. The facility used two separate skin assessment tools that were described as time-consuming and redundant, and leadership acknowledged that this contributed to difficulty in recognizing the heel PIs. The facility also failed to complete required assessments and care planning related to the resident’s PIs. No change in condition MDS assessment was completed for the resident after the PIs were identified, despite facility policy requiring a skin risk evaluation upon significant change in condition and the corporate resource nurse confirming that a significant change in condition MDS was not optional when PIs did not heal within 14 days. The resident’s care plan was not updated to include the stage 2 coccyx PI until eight days after its discovery and did not include the heel PIs until five days after they were discovered, even though the DON confirmed that care plans for PIs should have been developed right away after discovery. Additionally, the registered dietitian was not notified of the resident’s PIs until 10 days after the coccyx PI and seven days after the heel PIs were discovered, delaying nutritional evaluation and intervention for wound healing. The RD documented a recommendation for health shakes three times per day, but a non-dairy fortified shake appropriate for the resident’s needs was not obtained until 23 days after the coccyx PI was discovered.
Failure to Document Controlled Medication Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medication administration documentation for six sampled residents when a licensed nurse did not sign the medication administration record (MAR) after administering medications, including controlled substances. Facility policies titled “Medication Administration” and “Completion and Correction” required that the person administering medications document the date and time of administration in the resident’s medical record and that professional documentation be complete and accurate. Despite these policies, review of records and interviews showed that medications were documented as given on the narcotic sign-out sheets but were not signed on the MAR by Licensed Nurse (LN) B. Resident 1, admitted with anxiety and not their own responsible party, had a physician’s order for Xanax 0.5 mg every six hours as needed for anxiety. The Director of Nursing (DON) confirmed that narcotic sign-out sheets for two dates showed LN B administered Xanax at 3:00 p.m. and 9:00 p.m., but these doses were not signed on the MAR. Resident 2, admitted with muscle spasms and their own responsible party, had an order for Percocet 5-325 mg every six hours as needed for moderate pain. The DON confirmed that the narcotic sign-out sheet showed LN B administered one tablet at 9:00 p.m., but this was not documented on the MAR. Resident 3, admitted with Parkinson’s disease with dyskinesia and their own responsible party, had an order for Norco 5-325 mg, two tablets every six hours as needed for severe pain. The DON confirmed that narcotic sign-out sheets for two dates showed LN B administered two tablets at 3:00 p.m. and 9:00 p.m., but these administrations were not signed on the MAR. Resident 4, with chronic pain syndrome and their own responsible party, had an order for Norco 5-325 mg as needed for moderate or severe pain; narcotic sign-out sheets showed LN B administered one tablet on two early-morning occasions, but these were not signed on the MAR. Resident 5, admitted with chronic pain, had an order for Percocet 10-325 mg every six hours as needed for moderate pain, and Resident 6, admitted with chronic pain syndrome, had an order for Norco 10-325 mg every six hours as needed for moderate to severe pain. For both residents, the DON confirmed that narcotic sign-out sheets showed LN B administered one tablet on an early-morning date, but these doses were not documented on the MAR. LN A and the DON both stated that the narcotic log and MAR should match and that failure to sign the MAR could result in medication errors, including double dosing or giving medications too early. The Administrator confirmed that LN B did not document the administered medications on the MAR.
Unclean and Deteriorated Shower Rooms Compromise Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain three of four shower rooms in a safe, clean, comfortable, and homelike condition for residents receiving shower services. During an observation of two shower rooms in Station 1, surveyors noted a dark black substance along the floor-to-wall seams and in the corners of the shower stalls, with discoloration concentrated along grout lines and caulked joints. In one of these Station 1 shower rooms, six 4-inch by 4-inch wall tiles were missing from the wall surface beside and beneath the shower faucet handle, and the exposed area beneath the missing tiles contained a brown and black substance. In a separate observation of the shower room in Station 2, surveyors observed a black substance throughout the floor seams where the wall meets the floor and in the corners of the shower stall, extending along the perimeter of the shower floor. The grout lines were visibly darkened and uneven in coloration, with gray and black staining across multiple areas of the floor, and several tiles showed cracks and signs of wear. During a concurrent observation and interview in one of the Station 1 shower rooms, the Administrator acknowledged the discoloration, the missing tiles, and the brown and black substance on the exposed surface, and further acknowledged that the affected area was uncleanable, despite the expectation that residents be showered in an area that is in good condition and homelike.
Uncertified Nurse Aides Used as Independent Direct Care Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides (NAs) were properly certified, trained, and deemed competent before independently providing direct resident care. The facility’s own undated Nursing Assistant Job Description stated that uncertified NAs were expected to provide routine daily nursing care only in areas where they had received clinical instruction and demonstrated competence, and that general direct resident care duties could not be performed until theory and competency skills were accomplished. The job description also required that NAs be enrolled in a state-approved Nurse’s Aide Training Program (NATP) and maintain clinical competency while enrolled. However, record review showed that Facility 3 did not have a California Department of Public Health (CDPH)–approved NATP or serve as a clinical training site, despite employing NAs in training and assigning them to direct care roles. Surveyors’ review of hiring dates, NATP graduation dates, and state certification dates for seven NAs showed that multiple NAs were assigned to independent resident care duties before they were state certified. NA 1, NA 2, and NA 3 were hired, later graduated from NATP, and became certified on a later date, but were assigned to resident care—sometimes unpaired with a CNA—before certification. NA 4 was hired and remained uncertified for months while being scheduled to work independently on a unit without pairing to a specific CNA. NA 5 graduated from NATP but never became certified before resigning, yet was assigned to independent unit work and 1:1 resident care. NA 6 and NA 7 had graduated from NATP and remained uncertified; they reported working as NAs at Facility 3 until certification, and were observed at the facility on a scheduled shift, although they did not appear on the written schedule provided for review. Interviews with staff further demonstrated that uncertified NAs were being used as direct care providers. The Director of Staff Development (DSD 1) stated that graduated NAs could do everything a CNA could do except operate machinery like a Hoyer lift, and that they could perform 1:1 care, accompany residents to appointments, and “pretty much everything a CNA can do.” The scheduler confirmed that NAs were scheduled full time and placed into CNA rotation slots. The NATP instructor and DSD 2 from Facility 2 stated that uncertified NAs were not supposed to provide hands-on care without CNA or licensed nurse supervision and that they were unaware NA graduates were not permitted to work at Facility 1 or 3 prior to certification. NA 3 reported performing direct resident care, including touching and changing residents with CNA supervision, and described confusion about what NAs were allowed to do, noting that the facility had not assessed skill competencies or provided orientation during their work as an NA. The Governing Body’s representative acknowledged that Facilities 1 and 3 were not approved NATP sites and agreed that NAs should not be feeding and changing residents, while also confirming that the Administrators and Governing Board were responsible for ensuring NATP and NA hiring followed federal and state regulations.
Governing Body Failed to Prevent Uncertified Nurse Aides from Providing Independent Care
Penalty
Summary
The deficiency involves the governing body’s failure to provide adequate oversight of the administrator and ensure that nurse aides were properly certified and competent before providing independent resident care. The facility’s operations manual stated that the governing body was legally responsible for establishing and implementing policies and procedures for management and operation of the facility, including appointing an administrator and providing administrative services to develop those policies. The nursing assistant job description specified that uncertified nursing assistants were only to provide routine daily nursing care and services in which they had received clinical instruction and demonstrated competence, and that general direct resident care duties could not be performed until theory and competency skills were accomplished. The job description also required that nursing assistants be enrolled in a state-approved Nurse’s Aide Training Program (NATP) and maintain clinical competency while enrolled. Record review showed that Facility 3 did not have a CDPH-approved NATP and was not a clinical training site, yet multiple nurse aides in training were hired and scheduled to provide resident care. Several nurse aides (NAs 1, 2, and 3) were hired before they became state-certified CNAs and were assigned to resident care areas, initially to orient with CNAs and later, in some instances, to work independently or provide 1:1 observation or care for specific residents. One aide (NA 4) was hired and remained uncertified for months while being assigned to work independently on a unit without pairing with a CNA. Another aide (NA 5) graduated from NATP but remained uncertified until resignation and was assigned to independent unit work and 1:1 care. Additional aides (NAs 6 and 7) were hired, completed NATP, and remained uncertified as of the survey date. Interviews confirmed that these nurse aides in training were treated and scheduled as staff providing direct resident care. The Director of Staff Development stated that Facility 3 did not have an approved NATP and was not a clinical training site, and that their knowledge of the NATP was minimal. The DSD also stated that graduated nurse aides could do almost everything a CNA could do, including 1:1 care and accompanying residents to appointments. The scheduler reported that NAs were scheduled full time and placed into CNA rotation slots in advance so they could transition into CNA positions with an established schedule. The accounts payable/payroll clerk confirmed that NAs in training were employees of Facility 3. The governing body’s representative acknowledged responsibility for oversight of the facilities and stated that only Facility 2 had an approved NATP, while Facility 1 and 3 were not approved due to regulatory compliance history, and agreed that NAs should not be feeding and changing residents. These facts demonstrate that the governing body did not ensure compliance with certification and competency requirements before NAs provided independent resident care.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during care. The resident, who was totally dependent on staff for toileting and had multiple medical conditions including cellulitis, rectal abscess, hyponatremia, dysphagia, glaucoma, osteoarthritis, bilateral hearing loss, hypokalemia, high blood pressure, and a history of falls, reported feeling rushed and spoken to in a demeaning tone by the CNA. The resident, who had mild cognitive impairment but was able to make her own decisions, stated that the CNA expressed frustration about having to assist frequently and did not display kindness during care, leading the resident to feel angry, helpless, and emotionally hurt. The facility's policies require staff to treat residents with kindness, respect, and dignity at all times, and prohibit demeaning practices. Interviews confirmed that the CNA was task-focused, lacked self-awareness regarding her attitude, and did not provide the expected level of kindness during care. The Director of Nursing and the administrator both acknowledged that the CNA's behavior violated the resident's rights to dignity and respect.
Failure to Prevent Resident-to-Resident Abuse in Facility Hallway
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical and verbal abuse by another resident. The incident involved a resident with severe cognitive impairment and behavioral issues, who was observed yelling profanities and swinging her hands at another resident in the hallway. Multiple staff interviews confirmed that the resident with cognitive impairment had a history of aggressive behaviors, including yelling and refusing medication, and that she had recently exhibited increased confusion and agitation. The other resident involved was cognitively intact and reported being called a profanity and hit in the mouth, though she stated the hit was not hard and that the incident was captured on video, which showed hand-waving and swinging but did not clearly show a hit. Staff members, including CNAs, activity staff, and nurses, were aware of the behavioral issues of the resident with cognitive impairment and noted that both residents had a history of arguing. The incident was reported immediately by a nurse, and the administrator and DON reviewed the situation. The video footage did not provide a clear view of physical contact, but staff acknowledged the verbal abuse and the intimidating behavior displayed in the hallway. The resident who was the target of the abuse expressed embarrassment and frustration but denied being afraid. The facility's abuse prevention policy, revised shortly before the incident, outlines the responsibility to prevent all forms of abuse, including verbal and physical, and assigns the administrator as the abuse prevention coordinator. Despite these policies, the facility did not prevent the incident of verbal and possible physical abuse, as evidenced by the resident's report, staff observations, and the partial video evidence. The failure to prevent this interaction resulted in a deficiency related to resident-to-resident abuse and the facility's obligation to maintain a safe environment.
Failure to Follow Laundry Procedures and Provide Staff Training Leads to Smoldering Laundry Incident
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by not adhering to its own laundry policies and procedures and by not providing adequate training and competency assessment for laundry staff. Specifically, Laundry Tech (LT) A removed kitchen laundry from the dryer before the cycle, including the cooling period, was complete and immediately placed the hot laundry into a plastic bag. This action led to smoldering laundry, which was later discovered by the fire department after staff reported smelling smoke in the laundry room. The fire department found a laundry bag emitting heat, which ignited into flames when opened, and the fire was extinguished on site. Further investigation revealed that LT A had not received training or competency evaluation regarding the facility's laundry procedures, including the requirement to pre-soak kitchen and housekeeping laundry in degreaser or detergent before washing, as outlined in the facility's policy. LT A was unaware of these procedures and reported being moved from housekeeping to laundry without formal training or documentation of competency. The review of LT A's employee file showed no evidence of completed competencies at the time of transition, and the competency checklist was only completed after the incident. Other staff interviews confirmed a lack of clarity and adherence to proper laundry protocols, particularly regarding the use of chemicals and pre-soaking procedures.
Failure to Consistently Implement Resident Mobility Care Plan
Penalty
Summary
Staff failed to consistently implement the physical mobility care plan for a resident with significant mobility limitations and multiple diagnoses, including Parkinson's disease, schizophrenia, and dementia. The resident was non-ambulatory and care plans specified the use of a Hoyer lift for all transfers. However, documentation and staff interviews revealed that staff sometimes transferred the resident manually with two people lifting her under the arms, rather than using the Hoyer lift as required by the care plan. This deviation from the care plan was confirmed by multiple CNAs and a review of handwritten notes, which indicated that the Hoyer lift was not always used during transfers. The resident was found to have a bruise and an acute fracture of the left pinky toe, with the cause initially unknown. Medical records and staff interviews confirmed that the resident was dependent on staff for all transfers and that the care plan had been updated to reflect the need for mechanical lift assistance. Despite this, staff admitted to not always following the care plan, instead choosing manual transfers based on their judgment of the resident's condition at the time. The incident was reported to the Department of Public Health, and the facility's Director of Nursing confirmed the care plan requirements and the injury.
Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to ensure the safe use of a Hoyer lift during a transfer, resulting in a resident falling and sustaining multiple serious injuries. The staff did not properly secure the sling straps to the lift, leading to both lower straps detaching simultaneously and causing the resident to fall onto the metal leg of the lift and the floor. At the time of the incident, only one certified nurse assistant (CNA) and one nurse assistant (NA, still in training) were present, rather than the required two CNAs. The NA operated the lift while the CNA was not positioned to guide or support the resident during the transfer, contrary to facility policy and standard training, which require one staff member to operate the lift and the other to guide and stabilize the resident. The sling used during the transfer was found to have damaged, rigid, and stiff straps, which should not have been used according to the manufacturer's guidelines and facility procedures. Additionally, the sling lacked a label indicating its size, brand, or weight limit, and staff had not received training on how to select the correct size sling for residents. Instead, staff determined sling size by visual estimation. Both the CNA and NA confirmed that they had not been trained on proper sling selection prior to the incident, and the sling used was not verified to be the correct size for the resident. The resident involved had a history of spinal fusion and limited movement in both legs, requiring total assistance from two staff members for transfers. As a result of the fall, the resident sustained four fractures in the lower back and pelvis, experienced severe pain requiring increased narcotic pain medication, required supplemental oxygen, and was hospitalized. Prior to the fall, the resident was independent in certain activities and did not require oxygen. The incident led to significant physical and emotional distress for the resident, including the inability to attend medical and personal appointments.
Failure to Develop Care Plans for Mechanical Lift Use
Penalty
Summary
The facility failed to develop and implement care plans for four residents who required the use of a mechanical lift for transfers. Despite facility policy requiring a comprehensive, person-centered care plan for each resident to address safety and health care needs, there was no written plan outlining the use of a mechanical lift for these residents. Record reviews showed that each of the four residents was dependent on staff for transfers and could not bear weight, as documented in their respective admission records, Minimum Data Sets (MDS), and lift/transfer evaluations. During a review of the care plans with the facility administrator, it was confirmed that none of the four residents had an active or discontinued care plan indicating the need for a mechanical lift for transfers. The administrator acknowledged that such a care plan should have been present for residents requiring this level of assistance. The absence of these care plans was identified through both record review and staff interview.
Failure to Remove and Report Broken Mechanical Lift Used for Resident Transfers
Penalty
Summary
Facility staff failed to follow established Resident Safety and Maintenance Service policies and procedures regarding the use and maintenance of mechanical lifts. Staff were aware that a mechanical lift, used to transfer non-ambulatory residents, was broken but did not report the issue or remove the equipment from service. Instead, the broken lift continued to be used to transfer four residents who were entirely dependent on staff for mobility and could not bear weight. Observations confirmed that the lift's legs would open and close on their own, and the handle used to operate the legs would detach, yet staff continued to use the device for multiple transfers throughout the day. Interviews with CNAs and the Maintenance Supervisor revealed that the mechanical lift had a history of malfunctioning, with staff reporting the issue verbally but not documenting it in the maintenance log. The Maintenance Supervisor acknowledged knowledge of the recurring problem with the handle but did not ensure the lift was removed from service. Maintenance staff also failed to perform thorough inspections, as they did not check the security of the handle during routine checks, and there were lapses in monthly maintenance documentation for the mechanical lifts. The user manual for the lift specified that damaged or broken lifts should not be used, and that the handle must be locked in place for safe operation, but these instructions were not followed. Residents affected by the deficiency included individuals with quadriplegia, dementia, muscle weakness, and adult failure to thrive, all of whom were fully dependent on staff for transfers. One resident expressed concerns about the safety of the lift, describing experiences where the legs would close or the handle would detach during transfers, causing instability and fear. Despite these ongoing issues, the broken lift remained in use, and there was no evidence that the Administrator or other responsible parties were notified of the equipment's condition.
Failure to Provide Dignity, Privacy, and Appropriate Clothing to Residents
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect in two separate incidents involving two residents. In the first case, a resident with moderate cognitive impairment and significant physical limitations was not provided with appropriate clothing. Upon admission, the only clothing items documented were a pair of shoes and socks. The resident reported having only a hospital gown and brief for daily care and outside appointments, which prevented participation in activities and caused feelings of embarrassment. Staff interviews confirmed the lack of clothing for at least three weeks, with a donated outfit having gone missing after laundering. Social Services had not addressed the clothing issue until three months after admission, and there were no donated clothes available in the resident's size. In the second incident, another resident who was fully dependent on caregivers for personal care, including bathing and dressing, was not provided adequate privacy during care. Observations showed that the privacy curtain in the resident's shared room did not fully enclose the bed, allowing roommates to see personal care being provided. The CNA acknowledged the curtain's limitations and stated there was nothing more that could be done to protect the resident's privacy. The Director of Staff Development confirmed that the expectation was for staff to ensure complete privacy, including from roommates, during personal care. Both incidents were in direct violation of the facility's own policies, which require residents to be treated with dignity, provided with appropriate clothing, and afforded privacy during personal care. The failures resulted in residents experiencing social isolation, embarrassment, and a diminished sense of dignity and autonomy.
Failure to Address Resident Council Grievances on Call Light Response
Penalty
Summary
The facility failed to ensure that grievances raised by the resident council regarding delayed call light response times were acted upon and promptly addressed. Multiple resident council meeting minutes documented ongoing concerns about excessive wait times for call lights to be answered, particularly during the night shift. Residents reported that CNAs, including registry staff, were either not responding to call lights or were turning them off without addressing residents' needs. Despite repeated documentation of these concerns in resident council meetings, there was a lack of evidence that effective in-services or corrective actions were implemented in a timely manner. Only one in-service related to call light response was provided after several months of ongoing complaints, and there was no documentation of the content or attendance for most of the supposed interventions. Confidential interviews with residents confirmed that long wait times for call light responses persisted, with some residents reporting waits of up to several hours, especially at night. Residents expressed frustration and a sense that their care needs were not a priority. Facility administrative staff acknowledged ongoing issues with CNA performance and oversight, particularly on the night shift, and confirmed that management interventions had been limited. The deficiency centers on the facility's failure to address and resolve repeated resident council grievances about call light response times, as required by facility policy and resident rights regulations.
Failure to Ensure Staff Competency in Infection Control and Resident Privacy
Penalty
Summary
Two direct care nursing staff failed to demonstrate the necessary competencies and skills required to meet resident care and service needs. One CNA entered the room of a resident with Covid while wearing only a surgical mask, despite facility policy and infection preventionist instructions requiring the use of an N-95 mask for such situations. The CNA admitted to not wearing the N-95 mask because it was uncomfortable, and the infection preventionist could not provide evidence that staff had been educated on proper mask use or on caring for residents with Covid. Another CNA did not ensure privacy for a resident during personal care. The privacy curtain was only partially drawn, allowing roommates to see the care being provided. Additionally, this CNA had a history of performance issues, including leaving the dining room before all residents finished eating and failing to provide care to all assigned residents. The Director of Staff Development confirmed that there were ongoing issues with CNA performance and that there was a lack of documentation of in-service education related to these deficiencies.
Failure to Enforce Proper Mask Use for Covid-19 Positive Resident
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by both its own policy and current CDC guidelines. Certified Nursing Assistants (CNAs) were observed entering the room of a resident with symptomatic Covid-19 while wearing surgical masks instead of the required N-95 respirators. Both CNAs acknowledged awareness of the policy and the expectation to wear N-95 masks, with one CNA stating a personal preference against N-95 masks due to discomfort. The Infection Preventionist confirmed that staff had been instructed to use N-95 masks when caring for residents with Covid-19. Record review showed that the facility's infection control policy required adherence to CDC recommendations, which specify the use of NIOSH-approved N-95 respirators for healthcare professionals entering the rooms of patients with confirmed or suspected Covid-19. The resident involved had been admitted with multiple diagnoses, including rhabdomyolysis, encephalopathy, and dorsalgia, and was symptomatic for Covid-19. Additionally, the Infection Preventionist was unable to provide evidence of staff training on Covid-19 or proper mask use during the investigation.
Failure to Provide Required Transfer and Discharge Documentation
Penalty
Summary
The facility failed to provide the required transfer and discharge documentation for a resident who was transferred to a General Acute Care Hospital (GACH). Specifically, the resident was not given a Notice of Transfer or Discharge, was not provided with a notice of a bed hold, and the Ombudsman was not notified of the transfer or discharge. These omissions were confirmed through interviews and record reviews with the Medical Records Director, a Licensed Nurse, and the Director of Nursing, all of whom acknowledged that the necessary documents were missing from the resident's medical record and had not been completed as required by facility policy. The resident involved had a history of acute and chronic respiratory failure with hypoxia and diabetes, and was able to make his own health care decisions. On the date of transfer, the resident experienced a significant decline in oxygen levels and other symptoms, leading to a physician's order for transfer to the emergency room. Despite this change in condition and subsequent transfer, the facility did not complete or provide the required documentation or notifications related to the resident's rights, appeal process, or bed-hold policy.
Failure to Maintain Proper Head of Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when a treatment nurse placed a resident with a gastrostomy tube (G-tube) in a flat position while the enteral feeding pump was still running. The facility's policy and the resident's physician orders required the head of bed (HOB) to be elevated 30-45 degrees during tube feedings, and the resident's care plan specified the HOB should be elevated 45 degrees during and for thirty minutes after tube feeding. Despite these directives, the nurse lowered the resident's HOB to a flat position and turned the resident on her side to perform a brief change and wound dressing change, without stopping the enteral feeding pump. The resident involved had a medical history including stroke, myotonic muscular dystrophy, respiratory failure, dysphagia, and gastro-esophageal reflux disease, all of which increase the importance of proper tube feeding management. The nurse confirmed during an interview that the feeding pump had not been turned off while the resident was laid flat and acknowledged that it should have been. The DON also stated that tube feeding should be turned off when a resident is laid down for care.
Improper Storage and Documentation of Discontinued Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in one of two medication rooms were not properly stored, disposed of, or documented according to facility policy and accepted professional standards. Discontinued medications were found in an unsecured, three-tier plastic storage container on the floor of the medication room. A licensed nurse confirmed that these medications were not secure and acknowledged the ease with which someone could steal them. The nurse also indicated a lack of knowledge regarding the frequency of medication destruction and stated that the facility needed a better process for handling discontinued medications. A review of the facility's Non-Controlled Substance Destruction Log revealed that it did not include required information such as the signatures of two licensed nurses, the reasons for destruction, or the dates the medications were destroyed, as specified in the facility's policy. The Director of Nursing confirmed these omissions during an interview and record review. These actions and inactions resulted in discontinued medications being improperly stored and inadequately documented, contrary to facility policy and regulatory requirements.
Lack of Staff and Visitor Education on Safe Food Handling for Outside Food
Penalty
Summary
The facility failed to ensure that visitors and staff who handled food brought in from outside were educated on safe food handling practices, as required by facility policy. The policy specified that staff should be made aware of procedures for outside food, assist families and visitors in understanding safe food handling (including cooling, reheating, temperature control, cross-contamination prevention, and hand hygiene), and provide residents or their representatives with information about the use and storage of food brought in by visitors. However, during interviews, a licensed nurse stated she was unaware of the policy and had not received education on this topic during orientation, despite working at the facility for five months. The Director of Staff Services confirmed that safe food handling practices were not included in orientation competencies and could not provide evidence of staff education on this subject. Additionally, the Admissions Coordinator reported being unaware of any safe food handling information provided to residents or visitors and confirmed that the admission packet did not include such education. These findings were based on observation, interviews, and review of facility policy and procedures. The lack of staff and visitor education on safe food handling had the potential to affect the 53 residents receiving an oral diet at the facility.
Failure to Timely Initiate Post-Fall Procedures and Documentation
Penalty
Summary
The facility failed to follow its Fall Management Program policy and procedure for one resident who experienced a fall. According to the facility's policy, after a resident falls, the Licensed Nurse (LN) is required to perform a post-fall evaluation, notify the Physician, Director of Nursing (DON), and responsible party, and initiate a Post-Fall Huddle within 15-20 minutes. This huddle should include updating the care plan, interviewing witnesses, and documenting the incident in the medical record. However, for this incident, the required post-fall documentation was not initiated until two days after the resident's fall. The resident involved had a history of dementia and a recent right hip fracture that required surgery. The fall occurred at 10:00 pm, but there was no documentation or notification of the event until two days later. The care plan reflecting the actual fall was not initiated until three days after the incident. Interviews with staff revealed that the LN on duty did not document the fall or notify the appropriate parties as required by policy. The DON and Administrator confirmed that the fall was not reported or documented in a timely manner. Further review and interviews indicated confusion among staff regarding the timing and responsibility for post-fall assessment and documentation. The LN on duty at the time of the fall stated that he was not aware of the incident until days later and did not perform or document the required assessment. The oncoming nurse reportedly handled the situation, but the necessary documentation and notifications were not completed as outlined in the facility's policy.
Failure to Timely Report Respiratory Illness Outbreak to Public Health Authorities
Penalty
Summary
The facility failed to comply with state and local public health authority requirements for timely reporting of a respiratory illness outbreak. Between 3/30/25 and 4/8/25, a total of 11 residents and 3 staff members exhibited symptoms such as cough, runny nose, sore throat, and shortness of breath, with some being diagnosed with pneumonia or bronchitis and others requiring hospital transfer. Despite the facility's policy requiring prompt communication and determination of reportable infections, the outbreak was not reported to the California Department of Public Health (CDPH) until 4/8/25, exceeding the required 24-hour reporting timeframe outlined in state regulations. Record review and interviews confirmed that the Infection Preventionist (IP), who was new to the position, did not submit the outbreak report to CDPH until several days after the initial cases were identified. The facility's own infection control surveillance policy and the State Operations Manual both require immediate action and reporting when a communicable disease outbreak is suspected. The delay in reporting was acknowledged by the IP during the survey, and the facility's documentation showed a clear timeline of symptom onset and diagnoses among residents and staff prior to the eventual notification to public health authorities.
Failure to Protect Resident from Verbal Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident verbally abused another resident in the hallway, using derogatory language and profanities. The incident was witnessed by staff and documented in behavior notes, which described the aggressor yelling and cursing at the other resident to move her chair. Despite the victim's request for patience and to not be spoken to in such a manner, the verbal abuse escalated, with the aggressor continuing to use inappropriate language. Multiple staff interviews confirmed the occurrence of the verbal altercation, with one nurse noting that the aggressor was in a hurry for a smoke break and became increasingly angry, yelling profanities as he moved through the facility. The resident subjected to the verbal abuse reported feeling hurt and stated that the aggressor frequently yells at others, expressing that no action was taken to address the behavior at the time. Both residents involved were capable of making their own healthcare decisions and had significant medical histories, including chronic illnesses and mental health conditions. The facility's policies on abuse prevention and residents' rights explicitly prohibit verbal abuse and require protection from such incidents, but these were not effectively implemented in this case.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an abuse allegation involving one of four sampled residents within the required timeframe. Specifically, after a resident made derogatory comments and yelled profanities at another resident in the hallway, the incident was not reported to the California Department of Public Health (CDPH), Ombudsman, or local law enforcement within two hours as required by facility policy and state regulations. Instead, the abuse allegation was reported three days after the event occurred. Record review showed that the incident was documented, but the mandated SOC341 form was not completed and submitted until three days later. The Director of Nursing confirmed during an interview that the reporting was delayed and acknowledged that the report should have been made within two hours of the initial allegation. This delay in reporting had the potential to leave the affected resident and others vulnerable and unprotected from mistreatment.
Failure to Develop Care Plan for Resident's Methamphetamine Use
Penalty
Summary
The facility failed to develop and implement a care plan to address a resident's use of methamphetamine, despite documented evidence of substance abuse. The resident, who was capable of making healthcare decisions, had a history of methamphetamine abuse noted in the medical record and tested positive for methamphetamine during a drug screen. Additionally, facility staff discovered a bag containing a substance identified as methamphetamine under the resident's pillow, which was confirmed by local law enforcement. Interviews and record reviews with the MDS nurse and the DON confirmed that there was no care plan in place to manage the resident's illegal drug use. The facility's policy required comprehensive, person-centered care planning to address all health, safety, psychosocial, and behavioral needs, but this was not followed in the case of the resident's substance abuse. The lack of a care plan meant that there were no interventions or monitoring measures documented to address the resident's drug use.
Failure to Monitor and Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that a resident with a known Substance Use Disorder (SUD) received adequate monitoring and supervision to prevent avoidable accidents and hazards. The resident, who had a history of methamphetamine abuse and multiple complex medical conditions including osteomyelitis, end stage renal disease, diabetes, heart failure, and paraplegia, was allowed to leave the facility on pass frequently. Upon return, there was no documented assessment or evaluation for signs of drug use or overdose, and staff interviews confirmed that monitoring for drug use was not consistently performed. Documentation of the resident's departures and returns was incomplete, with no records in nursing progress notes or sign-in/sign-out logs regarding the resident's condition upon return to the facility. Nursing and other facility staff had not received training or education on how to manage emergencies related to SUD, including recognizing signs and symptoms of drug intoxication or overdose. Multiple staff members, including CNAs, nurses, and the Social Service Director, confirmed they had not been trained in behavioral management or emergency response for residents with SUD. The Director of Nursing acknowledged that such training had not occurred, despite the resident's known history of drug use and behavioral outbursts, including aggression and altercations with other residents and staff. Additionally, the facility did not develop a care plan specific to the resident's SUD, with no documented goals or interventions to address the risks associated with substance abuse, such as potential accidents, hazards, or overdose. The Minimum Data Set Nurse confirmed that a care plan addressing SUD should have been developed but was not present in the resident's records. These failures were contrary to the facility's own policy requiring assessment and care planning for resident-specific safety risks.
Lack of Staff Training and Competency in Managing Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that staff were trained and competent to care for a resident with a Substance Use Disorder (SUD). The facility's own assessment identified that it serves residents with active or current SUDs and stated that staffing decisions would be informed by the need for appropriate competencies and skill sets. Despite this, staff interviews and record reviews revealed that no training on SUD had been provided to staff, including the Director of Staff Development, Social Service Director, Licensed Nurses, and Restorative Nursing Assistant. Staff consistently reported not knowing how to manage behaviors associated with SUD, and the Director of Nursing confirmed that no such training had occurred. The resident in question had a documented history of methamphetamine abuse, had been found with illegal drugs in his possession, and had tested positive for drugs during his stay. The resident exhibited frequent episodes of aggression, including yelling, swearing, and physical and verbal altercations with other residents and staff. Staff members expressed feeling unprepared and unsafe when dealing with these behaviors, and there was no documentation of SUD on the resident's admission record until it was later confirmed by the Medical Director. The lack of staff training and competency in managing SUD-related behaviors directly contributed to the ongoing behavioral incidents involving the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not performing hand hygiene and using bare hands to handle resident food. Certified Nurse Assistant (CNA) M and a Nurse Assistant (NA) were observed touching food items on meal trays with bare hands for three residents, without performing hand hygiene between resident interactions. This was confirmed by the Director of Staff Development and the Infection Preventionist, who acknowledged that these actions were considered infection control concerns with the potential to spread illness. Additionally, the facility did not ensure proper labeling of bags containing clear liquid and g-tube feeding bottles for residents with gastrostomy tubes. Unlabeled bags of clear liquid were observed in the rooms of three residents, and a plastic bottle containing liquid nutrition was missing the time it was prepared. The Director of Nursing and the Infection Preventionist confirmed that these labeling omissions were infection control issues, as they prevented staff from knowing how long the liquids had been in use, which could lead to potential contamination. The facility also failed to maintain cleanliness of medical equipment, such as pill cutters and blood pressure devices. A pill cutter was found with white powder residue and was improperly cleaned with bleach wipes, which were not suitable for food contact surfaces. Furthermore, a Licensed Nurse (LN) did not disinfect blood pressure cuffs between resident uses and failed to perform hand hygiene during medication administration for two residents. These practices were against the facility's policies and were confirmed by the Infection Preventionist and the Director of Nursing as infection control violations.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate care for three residents in terms of their Activities of Daily Living (ADL), specifically in showering and nail care. Resident 5, who was cognitively intact and dependent on staff for ADL care, missed two Saturday showers, which were important for his spiritual meetings on Sundays. This oversight was confirmed through interviews and record reviews, indicating a pattern of missed showers over several weeks. Resident 41, who had severe cognitive impairments and was dependent on staff for all ADL care, was observed with long, jagged fingernails and a dark substance under them. This condition was confirmed by a CNA and acknowledged by the Director of Nursing (DON) and the Administrator, who admitted that the required nail care had not been provided. Resident 7, who had severely impaired decision-making skills and was dependent on staff for ADL care, was not showered twice a week for four months, as confirmed by ADL flowsheets and interviews. The resident was observed with a notable body odor, and the Director of Staff Development confirmed the lack of showers and the absence of documentation for any refusals by the resident.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure the safe use and accountability of narcotic controlled medications for Resident 61. Specifically, Norco, a narcotic pain medication, was removed from the Controlled Drug Record (CDR) without corresponding documentation in the Medication Administration Record (MAR). This discrepancy was noted on multiple occasions, including specific dates where the removal of Norco was recorded in the CDR but not documented in the MAR. The facility's policy requires that each administration of a controlled substance be documented in both the CDR and MAR, including the drug, time administered, and the nurse's initials. During an interview, Licensed Nurse C demonstrated the correct procedure by documenting the removal and administration of Norco for another resident in both the CDR and MAR. However, the Director of Nursing confirmed the findings of missed documentation for Resident 61 after reviewing the records. The facility's policies on medication administration and controlled substance prescriptions emphasize the importance of accurate documentation to ensure accountability and safe drug handling, which was not adhered to in this case.
Failure to Ensure Safe Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for one resident, identified as Resident 42, who was reviewed for unnecessary drug use. Resident 42 had a PRN order for phenobarbital, an anti-seizure medication also used for mood and behavior problems, without a specified duration for its use. The medication was prescribed to be administered every 8 hours as needed for delirium, but there was no documentation of its use or assessment by the facility and medical doctor. Despite a recommendation from a telehealth mental health doctor to discontinue the medication, the order remained active without a documented reason or indication for its continued use. The facility's policy required that any psychoactive medication ordered on a PRN basis must not exceed a 14-day duration unless the physician documents the reasons for continued use. However, the PRN order for phenobarbital did not comply with this policy, as it lacked a specified duration and there was no documentation of a physician's note addressing the duration of use. Interviews with facility staff, including the MDS nurse and Infection Prevention Nurse, confirmed the oversight and inability to locate any documentation justifying the continued PRN order for phenobarbital.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 9.68%, which is above the acceptable threshold of 5%. This deficiency was observed in two residents during medication administration. For Resident 19, the facility did not administer food with a potassium tablet, despite the physician's order specifying that the medication should be taken with food and a 4-8-ounce glass of water. This oversight was confirmed by Licensed Nurse B during an interview, acknowledging the failure to follow the prescribed order. Additionally, for Resident 71, the facility did not adhere to proper gastric-tube medication administration protocols. Licensed Nurse B combined two crushed medications, hydrocodone/acetaminophen and Buspar, and administered them via G-tube simultaneously, contrary to guidelines that recommend administering medications one at a time with a flush in between. This practice was acknowledged by the nurse, who admitted to forgetting the correct procedure and noted previous issues with G-tube clogging due to similar errors. The Director of Nursing confirmed these lapses in medication administration practices.
Deficiencies in Medication and Supply Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices in the medication room and on two medication or treatment carts. Specifically, Medication Cart 3 at Station 2 stored an unopened and unused eye drop called latanoprost, which required refrigeration according to the manufacturer's specifications, but was not refrigerated. Additionally, an undated glucometer test strips bottle was found, which should have been dated upon opening to ensure use within 90 days as per manufacturer instructions. Licensed Nurses F and A confirmed these findings during observations and interviews. In the medication room at Station 1, expired blood test tubes and throat culture swab kits were found in active storage areas, with expiration dates clearly marked. Furthermore, the treatment cart at Station 1 contained multiple opened and partially used wound care supplies that were marked as sterile and single-use, but had been cut and stored improperly. Licensed Nurses E and G acknowledged these findings, and the Director of Nursing confirmed that these practices were not in accordance with the facility's policy or her expectations for nursing staff.
Unclean Food Preparation Equipment Poses Contamination Risk
Penalty
Summary
The facility failed to maintain professional standards of practice for food service safety, as observed during an initial tour. Specifically, food preparation equipment was found to be unclean, which posed a risk of contaminating food with germs and potentially causing foodborne illness. During an observation and interview with the Dietary Manager (DM) in the kitchen, four baking sheets were noted to have a black charred substance on their edges and sides. The DM confirmed that this burnt substance could lead to cross-contamination, acknowledging the need for the baking sheets to be replaced.
Incomplete Medical Records Due to Lack of Documentation
Penalty
Summary
The facility failed to maintain complete medical records for one resident, identified as Resident 46, due to the lack of documentation by the Restorative Nursing Assistant (RNA) responsible for providing range of motion exercises. The RNA did not document the care provided to Resident 46, which resulted in incomplete medical records. This deficiency was identified during a review of the facility's policy and procedure, which mandates that treatments provided to residents be documented as they occur. The absence of documentation made it unclear whether the physician-ordered care was provided. Resident 46, who was admitted to the facility with diagnoses of dementia and trigger finger, was supposed to receive passive range of motion exercises to the left hand and fingers three times a week as per a physician's order. However, a review of the electronic medical record (EMR) revealed missing documentation for these exercises. The Director of Staff Development confirmed that there were missing entries for four weeks, with one out of three entries missing each week, and no documentation was present for a subsequent period. This lack of documentation was confirmed during interviews with the RNA and the Director of Staff Development.
Failure to Properly Execute Arbitration Agreements
Penalty
Summary
The facility failed to adhere to its Arbitration Agreement policy and procedure for three residents, leading to deficiencies in the understanding and execution of binding arbitration agreements. Resident 27, who had a BIMS score indicating intact memory, reported not fully understanding the arbitration agreement and felt rushed during the signing process. The resident was not informed of the choice to refuse the agreement, and the facility staff did not ensure the agreement was explained in a manner that was understood, as required by the facility's policy. Resident 42's responsible party, who signed the arbitration agreement on behalf of the resident, stated that the arbitration process was not discussed with them, and they were unaware of having signed such an agreement. This indicates a failure by the facility to properly inform and discuss the arbitration agreement with the responsible party, as per the facility's policy, which requires that residents and their representatives be notified and understand the agreement before signing. For Resident 48, the facility's Interdisciplinary Team acted as the resident's surrogate and signed the arbitration agreement without proper documentation of authority, such as a durable power of attorney or conservatorship orders. The resident's medical records lacked documentation indicating the resident was conserved or had a legal power of attorney, which is a requirement according to the facility's policy. The facility's administrator confirmed that the IDT was not authorized to sign arbitration agreements on behalf of residents, highlighting a significant procedural lapse.
Loose Electrical Outlet Cover Near Privacy Curtain
Penalty
Summary
The facility failed to ensure the proper maintenance of an electrical outlet cover in a resident's room, which was observed to be loose and had a gap between it and the wall. This deficiency was identified during an observation in the room, where the electrical outlet cover was located near a privacy curtain. The proximity of the curtain to the outlet cover was such that when the curtain was fully closed, it almost touched the outlet cover. During a subsequent observation and interview with the Maintenance Supervisor, it was confirmed that the outlet cover was indeed loose and required fixing. The facility's policy and procedure for maintenance services, revised on January 1, 2012, indicated that the maintenance department was responsible for maintaining all areas of the facility to protect the health and safety of residents, visitors, and staff.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report a physical abuse allegation involving a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved a resident who alleged that she was physically abused by an unknown male staff member. The resident, who had severe cognitive impairments and a history of bipolar disorder, anxiety, mood disorder, stroke, pain, and a fracture of the left leg, reported the abuse to staff on the evening of the incident. A skin check was conducted, and the police were called. However, the facility did not notify CDPH within the mandated time. During an interview and record review, it was revealed that the facility's administrator mistakenly believed that CDPH had been informed of the abuse allegation. Although the Ombudsman was notified via fax, there was no confirmation that CDPH had been contacted. The administrator confirmed that no phone call or fax was sent to CDPH within the required two-hour period following the incident, which was a violation of the facility's policy on abuse prevention and management.
Failure to Revise Care Plan for Suicidal Resident
Penalty
Summary
The facility failed to develop or revise a care plan for a resident who expressed suicidal thoughts, which is a deficiency in ensuring the resident's psychosocial and physical wellbeing. The facility's policy on handling threats of self-harm requires immediate reporting to the Director of Nurses and Social Services, followed by an interview to assess the resident's intent and the development of a care plan with specific interventions. However, this protocol was not followed for the resident in question. The resident, who had a history of major depressive disorder, dementia, and hemiplegia, expressed a desire to die and exhibited behaviors of sadness and depression. Despite these signs, the facility did not update the resident's care plan to include interventions for these expressions of self-harm. The resident's condition was further complicated by a fall, after which he was sent to the emergency department for evaluation. Upon return to the facility, there was still no follow-up or care plan revision addressing his suicidal statements. Interviews with the Unit Manager and Social Service Director revealed a lack of awareness and follow-up on the resident's suicidal expressions. The Social Service Director admitted that had she been informed, she would have implemented monitoring protocols to ensure the resident's safety. The absence of documented interventions in the care plan for the resident's suicidal ideation was confirmed, highlighting a significant oversight in the facility's care planning process.
Medication Error Due to Incorrect Order Entry and Allergy Oversight
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders, resulting in a resident receiving Tacrolimus External cream, which contained petroleum, an ingredient to which the resident was allergic. This error occurred when a Licensed Nurse incorrectly selected Tacrolimus instead of Triamcinolone from a drop-down menu while entering the medication order into the computer system. The resident, who had a known allergy to petroleum, experienced burning on his back after the application of the cream. The error was not immediately identified, and the resident received multiple doses of the incorrect medication over two days. The facility's system failed to flag the allergy because petroleum was listed as an inactive ingredient. The resident subsequently developed a rash and was diagnosed with Candidal dermatitis, requiring hospitalization and treatment with antifungal medication. Interviews with facility staff, including the Director of Nursing and the Pharmacist, confirmed the medication error and acknowledged the oversight in checking for allergies.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to ensure that Licensed Nurses (LNs) documented a change in condition for a resident who was transferred to an acute hospital. The facility's policy required LNs to document the date, time, and pertinent details of any incident, including the assessment in the Nursing Notes, and to complete an inter-facility transfer form if a resident was transferred to a hospital. However, for one resident, there was no documentation in the nursing progress notes regarding the change of condition or the subsequent transfer to the hospital. The resident in question had a history of chronic kidney disease, diabetes, and an amputation below the right knee. The resident was transferred to the hospital due to altered mental status, but the required documentation was missing from the medical record. Interviews with the Director of Staff Development, Medical Record Supervisor, and Director of Nursing confirmed the absence of documentation and reiterated the requirement for nurses to assess and document any change in condition.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents who experienced inappropriate behavior from another resident and a staff member. Resident 2 made sexually explicit comments to Resident 3 and continued to harass her despite being asked to stop by staff and law enforcement. This behavior caused Resident 3 mental suffering and distress. Resident 2 had a history of homelessness and substance abuse, and his behavior was disruptive and intimidating to other residents and staff. Additionally, Laundry Personnel 2 (LP2) made Resident 1 uncomfortable by touching her shoulder and whispering in her ear. Resident 1, who was alert and had no mental impairment, reported feeling uncomfortable and anxious due to this interaction. The facility's response to the incident was delayed, and LP2 continued to work at the facility for several days after the incident before being terminated for poor job performance. The facility's policies and procedures for reporting and investigating abuse were not adequately followed. The incidents were not reported to the appropriate state agency in a timely manner, and there was a lack of immediate corrective action to protect the residents involved. The facility's failure to promptly address these issues resulted in ongoing distress and anxiety for the affected residents.
Administrator's Oversight Leads to Multiple Deficiencies
Penalty
Summary
The facility's Administrator (ADM) failed to ensure the implementation of the abuse policy, which resulted in a delay in reporting an incident involving a resident and a male staff member from the laundry department. The resident reported feeling uncomfortable when the staff member touched her shoulder, but the grievance was not immediately recognized as abuse and was not reported to the state agency until 20 days later. The staff member continued to work for several days after the incident before being terminated. The ADM's oversight in this matter put residents at risk for ongoing abuse. Additionally, the ADM did not report an unusual occurrence of a facility lockdown to the state agency. The lockdown was initiated when a former resident, who had been discharged against medical advice, returned to the facility and threw bottles at the building. The ADM acknowledged the failure to report the lockdown, which was a breach of the facility's policy on unusual occurrence reporting. This oversight could have affected the welfare, safety, and health of residents, employees, and visitors. The ADM also failed to ensure the building equipment was operating safely, as evidenced by a resident living in a room with an unreported ceiling leak for three days. The leak was caused by a malfunctioning rooftop air conditioning unit, and the ADM was not informed of the severity of the situation until later. This lack of communication and oversight resulted in an unsafe environment for the resident, highlighting the ADM's failure to allocate resources effectively and ensure compliance with federal and state regulations.
Failure to Maintain Essential Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, leading to two significant deficiencies. Firstly, an air conditioning unit in a resident's room leaked for three days, causing distress to the resident. The resident, who was in a wheelchair, reported the leak to staff, who placed a bucket under the leak but did not resolve the issue promptly. The Maintenance Supervisor was informed and called a plumber, who determined the issue was HVAC-related. Despite this, the repair was delayed, and the resident expressed frustration and concern about potential damage to personal belongings and difficulty navigating around the bucket. Secondly, the facility's fire alarm system malfunctioned, and staff silenced the alarm for five hours without conducting a fire watch. The Maintenance Supervisor acknowledged the issue and stated that one of the fire system zones was set to silent to stop the alarm. The Administrator was aware of the situation but did not ensure a fire watch was performed. The fire system was identified as outdated, and the facility was awaiting quotes for replacement. These deficiencies highlight the facility's failure to maintain essential equipment, posing potential risks to residents, staff, and visitors. The lack of timely repairs and appropriate safety measures, such as a fire watch, contributed to the unsafe conditions observed during the survey.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required 24-hour timeframe for one resident, which had the potential to affect all 89 residents in the facility. The facility's policy and procedure for unusual occurrence reporting mandates that allegations of abuse or neglect be reported to the appropriate state or federal agencies within 24 hours by phone and confirmed in writing. However, in this case, the incident involving a resident being touched on the shoulder by a male staff member from the laundry department was not reported to Adult Protective Services (APS) until 20 days after the incident occurred. The resident involved was an alert female with no mental impairment, as indicated by a perfect score on the Brief Interview for Mental Status. She required substantial assistance for mobility and had a history of anxiety and depression. The incident occurred when the resident was in her room, and a male staff member from the laundry department entered, touched her shoulder, and made her feel uncomfortable. The resident reported the incident to the Social Services Director and filed a grievance form. Despite this, the facility did not report the incident to the appropriate authorities in a timely manner. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) who first heard the resident's account of the incident did not report it, assuming the Social Services Director would do so. The facility's administrator acknowledged that the alleged abuser was identified within 24 to 48 hours of starting the investigation, yet the report to APS was delayed. This delay in reporting violated the facility's policy and state regulations, highlighting a significant deficiency in the facility's handling of abuse allegations.
Resident's Room Leak Causes Safety Hazard and Distress
Penalty
Summary
The facility failed to maintain a safe environment for Resident 5, who experienced a ceiling leak in her bedroom due to a malfunctioning rooftop air conditioning unit. The leak persisted for three days, causing Resident 5 to feel frustrated and worried about potential damage to her belongings, particularly her television. Despite being offered a room change, Resident 5 declined, preferring to stay with her belongings. The leak was reported to the maintenance department, but the issue was not resolved promptly, leading to a negative psychosocial outcome for the resident. The maintenance log indicated that the issue was identified on 7/8/24, and a plumber inspected the leak on 7/9/24, determining it was an HVAC issue. An HVAC company was scheduled to address the problem on 7/11/24. However, the leak continued to worsen, with water dripping into a large garbage can placed in the room, creating a hazard for Resident 5, who was in a wheelchair and had difficulty navigating around the bucket. The maintenance supervisor acknowledged the issue but did not expedite the repair process, resulting in continued discomfort and risk for the resident. Interviews with facility staff, including the administrator and maintenance supervisor, revealed a lack of urgency in addressing the leak. The administrator was aware of the leak but did not take immediate action to ensure Resident 5's safety, relying on the scheduled repair date. The maintenance supervisor did not communicate the severity of the situation to the administrator, leading to a delay in resolving the issue. This inaction contributed to Resident 5's distress and the unsafe conditions in her living environment.
Facility Fails to Address Safety Hazards and Resident Falls
Penalty
Summary
The facility failed to maintain a safe environment for its residents by not addressing significant safety hazards. One of the primary issues was a damaged fire door (FD A) that could not be completely closed or locked for over a year and a half. This door led to the facility's backyard, which had a steep creek, posing a risk for residents to wander unsupervised. The Maintenance Director was aware of the issue but stated that the door could not be fixed and needed replacement. Despite this knowledge, the necessary funds for a new door were not approved by the governing body, leaving the door unsecured and accessible to residents. Another significant deficiency was the failure to secure a staff locker room door (LD B), which was accessible to residents and contained hazardous materials. The locker room had unlocked lockers with stainless steel cleaner, personal protective equipment, and an industrial-sized container of a chemical rust remover, which could cause severe skin burns and serious eye damage if ingested. The Maintenance Director confirmed that the locker room door was not locked and lacked a locking device, relying solely on a Wanderguard device that only triggered an alarm if a resident wearing a Wanderguard bracelet attempted to enter. Additionally, the facility did not address a known issue with a loose toilet in Resident 38's bathroom, which contributed to the resident's fall and injury. Despite being aware of the problem, as noted in the maintenance logs, the toilet was not repaired, leading to Resident 38 sustaining a large bruise on his hip. The resident, who had a history of falls and was at high risk due to right-sided paralysis and weakness, reported the unsteady toilet to staff, but no action was taken to secure it, resulting in unnecessary pain and anxiety for the resident.
Removal Plan
- Securing FD A so that it closed and locked.
- Securing LD B so that it closed and locked.
Failure to Prevent Pressure Ulcer Leads to Amputation
Penalty
Summary
The facility failed to identify, evaluate, and intervene in a timely manner to prevent an avoidable pressure ulcer for a resident, resulting in severe consequences. The resident, who had a history of type 2 diabetes mellitus, idiopathic peripheral autonomic neuropathy, and dementia, was at risk for pressure ulcers. Despite this, the facility did not implement necessary preventive measures such as pressure-relieving interventions or regular podiatry consultations. The resident's care plans indicated a potential for pressure ulcer development, but no documented nursing skin checks or preventive actions were found in the records. The resident developed an unstageable pressure ulcer on the right heel, which was not properly addressed by the facility. Weekly skin assessments failed to identify the ulcer until it had progressed significantly. The wound doctor recommended several interventions, including offloading the heel and consulting a dietician, but these were not implemented in a timely manner. The resident's condition worsened, with the ulcer becoming infected and resistant to antibiotics, leading to a hospital admission. The resident's pressure ulcer deteriorated further, resulting in a diagnosis of osteomyelitis and necessitating a below-the-knee amputation. This outcome caused the resident significant anxiety, depression, and uncontrolled pain. The facility's lack of timely intervention and failure to follow its own policies on skin integrity management and diabetic care contributed to the resident's severe decline in health and quality of life.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met, as evidenced by the presence of expired food items in refrigerators, freezers, and dry storage areas. During a kitchen tour, a Certified Dietary Manager (CDM) identified and discarded several expired items, including a bag of unlabeled, undated frozen vegetables, a premade ham sandwich, a bag of diced ham, and shredded coconut that had been open longer than the allowed six months. Additionally, an emergency food supply storage area contained expired pureed green beans. A reused plastic container in the resident food refrigerator contained a five-day-old cold ravioli salad, which was also discarded. The facility's kitchen and food service equipment were not maintained in a sanitary condition. Observations revealed a knife rack with sticky residue, an unclean under-counter storage space for pots and pans, and frying pans with hard black residue. The vegetable steamer emitted a musty odor and contained brown residue, indicating it had not been deep cleaned as scheduled. Maroon bowls appeared worn, and a can opener blade was dull and dirty. Muffin pans also had hard black residue, and several items in the kitchen were not labeled or dated as required. The kitchen environment itself was unsanitary, with sticky film and food debris on the floor, oven racks with residue, and a black slimy residue on the wall behind the dishwashing sink. The facility's cleaning schedule was not followed, as evidenced by the presence of hardened black residue on dishwasher racks and the need for kitchen upgrades. Additionally, an eyewash station was improperly used for handwashing, which is against the 2022 Food Code guidelines. These deficiencies created a potential risk for exposure to food- and waterborne illnesses among the 78 residents receiving food from the facility's kitchen.
Deficiencies in Safety, Staffing, and Services
Penalty
Summary
The facility's Administrator (ADM) failed to ensure effective oversight and necessary resources to maintain a safe and clean environment for residents. A significant issue was the damaged fire door that could not be closed or locked, posing a safety hazard. Despite being aware of the problem for over a year and a half, the ADM did not secure the necessary funds for its replacement due to a lack of approval from the Governing Body. Additionally, the facility had unsecured areas accessible to residents, containing hazardous materials and equipment, further compromising resident safety. The ADM also failed to ensure adequate staffing levels and competencies, leading to significant delays in call light responses, with residents waiting over an hour for assistance. Residents reported that some CNAs would cancel call lights without providing help, and complaints about this issue were not addressed. The Director of Staff Development acknowledged awareness of these complaints but had not taken appropriate disciplinary actions against staff. Furthermore, the facility did not conduct audits of call light response times, exacerbating the problem. Dietary services were inadequate, with expired food items, improper storage, and unsanitary kitchen conditions. Residents reported receiving cold and unpalatable food, which did not meet their nutritional needs. Pharmacy services were also deficient, with improper storage and handling of medications, including psychotropic drugs, without proper assessments or documentation. Additionally, the activities department failed to provide programs that met residents' needs and preferences, and resident grievances were not addressed in a timely manner, indicating a lack of effective oversight by the ADM.
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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