Ojai Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ojai, California.
- Location
- 601 North Montgomery Street, Ojai, California 93023
- CMS Provider Number
- 055861
- Inspections on file
- 40
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ojai Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to meet the mandated 3.5 direct care hours per patient day (DHPPD) staffing minimum on multiple days, as shown by staffing logs indicating direct care hours below 3.5 on two reviewed dates. The DON acknowledged awareness of the 3.5 DHPPD requirement but was unaware that the facility had not met this minimum during the reviewed month. A workforce shortage staffing waiver in effect applied only to the 2.4 CNA staffing standard and explicitly required the facility to continue to provide at least 3.5 DHPPD, confirming that the minimum direct care staffing requirement remained in force.
Nurse aides who had worked more than four months were not confirmed as trained and competent, and those with less than four months of employment were not verified as enrolled in the required training program.
A resident with moderate cognitive impairment and multiple medical conditions was found unsupervised outside the facility after falling from a wheelchair while smoking. The resident kept cigarettes and a lighter in his room and did not use the designated smoking area or safety equipment. Facility records indicated the resident required supervision during smoking, but this was not provided, contrary to facility policy.
Staff did not consistently or accurately document existing wounds and pressure ulcers on skin monitoring forms for two residents, despite these conditions being noted in other clinical assessments. The DON confirmed the omissions and could not provide a specific policy for CNA documentation of skin observations.
Staff failed to report a suspicion of abuse involving a resident to CDPH as required. Multiple staff members, including a nurse, HR, and the Director of Staff Development, reported the allegation only to the Operations Manager, who did not ensure external reporting. The facility's policy required immediate reporting to state officials, but this was not followed, resulting in a delay in notifying authorities.
A CNA reported an alleged sexual abuse incident involving a resident's roommate to a night shift LN, who failed to report it to the administration or include it in the shift report, delaying the investigation. The facility's policy requires immediate reporting of such allegations, but this was not followed, as confirmed by the DON and other staff.
The facility failed to obtain informed consent for the use of bed rails for a resident. During an observation, the resident was found sleeping with two full-length bed rails raised. A review of the resident's records showed no evidence of informed consent, which was confirmed by an LN. The facility's policy requires staff to inform residents or their representatives about the benefits and risks of bed rails and obtain consent, which was not adhered to in this case.
The facility failed to inform four residents about their right to formulate an advanced directive. Admission packets lacked documentation of discussions on advanced directives, confirmed by interviews with an LN and the SSD, who also noted the absence of a relevant policy.
The facility failed to provide a safe environment by not ensuring a toilet grab bar was present in a resident's restroom, despite the resident reporting the issue weeks prior. Additionally, another resident's room temperature was not maintained within the ideal range, leading to discomfort despite multiple complaints. The maintenance supervisor was unaware of the missing grab bar, and the room temperature was recorded below the facility's policy range.
A resident with mental health diagnoses was admitted with a positive PASRR Level I screening, indicating the need for a Level II evaluation. However, the evaluation was not completed as the resident was unable to participate, and the case was closed without further action. The DON confirmed the oversight, which was contrary to the facility's policy requiring follow-up evaluations for positive screenings.
A resident with Wernicke's encephalopathy and major depressive disorder experienced a significant decline in cognitive function, as indicated by BIMS scores. Despite this, the care plan was not updated to address the resident's needs. The DON acknowledged the oversight, which was contrary to the facility's policy requiring care plan revisions as conditions change.
A resident's package containing ginger ale was opened and had missing items after being delivered to the facility. The package was initially misplaced and later found at the nursing station, with a nurse admitting to forgetting to report the issue. Facility policies require unopened and timely delivery of mail to residents, which was not followed in this instance.
A facility failed to administer a prescribed pain medication, Oxycodone HCl 20 mg, to a resident within 24 hours of the order date. The medication, ordered to be given every 6 hours as needed, was not administered until several days later. The DON confirmed the delay and could not provide an explanation, despite the facility's policy requiring timely administration according to prescriber orders.
The facility failed to maintain a temperature range of 71-81°F, with temperatures recorded between 64.9 and 65.2°F. Residents and staff were observed using extra blankets and jackets due to the cold. A space heater was found in a resident's room, posing a fire risk. Staff confirmed the facility was cold at night, and the DON acknowledged the issue, referencing regulations for minimum temperatures.
A facility failed to comply with state laws requiring staff to wear name badges, as observed during a survey where six out of seven employees lacked them. This included CNAs and LVNs from an outside registry and facility employees. Interviews confirmed the absence of name badges, with the DON acknowledging the issue.
A facility failed to report an unusual occurrence when a resident was hospitalized for an alleged medication overdose. The resident, with a history of multiple health issues, was suspected of opioid abuse after being found lethargic and unable to follow commands. Naloxone was administered, and the resident was sent to a hospital. The Emergency Department noted methadone use, not prescribed to the resident. The Director of Nurses was unaware of the reporting requirement, violating the facility's policy to report such incidents within 24 hours.
A facility failed to maintain a safe environment by not addressing a cracked window in a resident's room. The window, located next to the resident's bed, had a starburst pattern crack with multiple lines extending to the frame. The resident reported the window had been cracked since their arrival five weeks ago. The DOM confirmed the window had been cracked for months and was not documented in maintenance logs, contrary to the facility's policy.
A facility failed to follow physician orders for a resident, missing COVID-19 tests on days 3 and 5 after admission and omitting several temperature checks over a week. The DON confirmed these lapses, which could have led to missed health changes and treatment delays.
The facility failed to post accurate and accessible contact information for the California Department of Public Health (CDPH). A resident reported difficulty obtaining the complaint phone number, and observations showed incomplete and hard-to-read information in a display case. The DON and DOO acknowledged the deficiencies, which could hinder residents' rights to be informed about filing complaints.
The facility's maintenance department was found cluttered with overflowing trash bins, posing a potential safety risk. Observations included piled-up cardboard boxes, a broken closet door, and an air conditioner vent covered with a black substance. Hazardous items like paint and insecticide were left out in the open. The maintenance staff acknowledged the state of the department, which contradicted the facility's policy for maintaining a safe environment.
The facility failed to maintain a sanitary environment for residents, as the drinking water dispenser had a brown slimy substance in the drip tray, and the ice machine had grime and a broken drain pipe. Staff confirmed the lack of cleaning records, and the facility's infection control policy was outdated, posing a risk of waterborne illness.
The facility failed to supervise a resident during transportation to and from an appointment, resulting in the resident leaving the appointment, falling out of their wheelchair near a busy road, and expressing confusion about their location. The resident had a history of severe cognitive impairment and was totally dependent on staff for movement.
Failure to Meet 3.5 DHPPD Minimum Staffing Requirement
Penalty
Summary
The facility failed to meet the required 3.5 direct care hours per patient day (DHPPD) staffing minimum on 2 of 28 days reviewed in February 2026, resulting in a deficiency related to insufficient nursing staff. Review of the facility’s DHPPD staffing logs for 2/1/26–2/28/26 showed that on 2/2/26 the facility provided 3.40 direct care hours and on 2/8/26 it provided 3.46 direct care hours, both below the mandated 3.5 DHPPD. During an interview on 4/2/26 at 11:40 a.m., the DON stated they were aware of the 3.5 DHPPD staffing requirement but were not aware that the facility had failed to meet this minimum for the month of February 2026. A review of the facility’s workforce shortage staffing waiver, dated June 2, 2025, showed that the waiver applied only to the 2.4 CNA staffing standard and explicitly required the facility to continue to provide no less than 3.5 direct care service hours per patient day, confirming that the 3.5 DHPPD requirement remained in effect. This failure had the potential to result in unmet care needs, inadequate supervision, delayed response to changes in condition, and avoidable adverse outcomes for residents.
Failure to Ensure Nurse Aide Training and Competency
Penalty
Summary
Nurse aides who have worked more than four months were not confirmed to be trained and competent, and nurse aides who have worked less than four months were not verified as being enrolled in the appropriate training program. This failure to ensure proper training and competency or enrollment in training for nurse aides was identified during the survey.
Failure to Supervise Resident During Smoking Results in Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent accidents during smoking for one resident. The resident, who had a history of alcohol abuse, unspecified dementia, alcoholic cirrhosis, bipolar disorder, COPD, prostate cancer with urinary catheter, partial foot amputation, and difficulty ambulating, was observed lying in the street after falling from his wheelchair while unsupervised outside the facility to smoke. The resident was found with cigarettes and a lighter in his possession and stated that he keeps his own cigarettes in his room and smokes outside whenever he wants, without supervision or use of the facility's designated smoking area or safety equipment. Review of the resident's medical record and facility documentation revealed that the resident had moderate cognitive impairment (BIMS score of 8) and was assessed as requiring supervision while smoking, with adaptive equipment such as a smoking apron recommended. Despite this, the resident was not supervised during smoking sessions, and staff confirmed that supervision had not been provided as required by the facility's policy. The facility's smoking policy also prohibits residents from keeping smoking items except under direct supervision, which was not followed in this case.
Failure to Accurately Document Resident Skin Conditions on Monitoring Forms
Penalty
Summary
The facility failed to ensure that staff consistently and accurately documented observations of residents' skin issues and conditions on the designated skin monitoring forms. Certified Nursing Assistants (CNAs) were responsible for using the Skin Monitoring (SM): CNA Shower Review form to record skin observations during resident bed baths or showers, including noting specific skin issues and their locations. However, for two residents with documented wounds and pressure ulcers, the SM forms on multiple dates did not reflect the presence of these existing conditions, despite their persistence being noted in other clinical assessments and wound evaluation reports. Specifically, one resident had a wound on the right medial malleolus with serous drainage, and another had multiple pressure ulcers, including a Stage IV ulcer on the sacrum, as documented in comprehensive skin assessments and wound evaluation reports. On review, the SM forms for these residents failed to document these ongoing skin issues on several occasions. During interviews and record reviews, the Director of Nursing (DON) confirmed the omissions and was unable to provide a specific policy regarding CNA documentation of resident skin observations.
Failure to Report Suspected Abuse to State Authorities
Penalty
Summary
The facility failed to report a suspicion of abuse involving one resident to the California Department of Public Health (CDPH) as required. A licensed nurse became aware of rumors regarding alleged abuse and reported the information to the former Operations Manager (FOM), who requested a written statement but did not ensure further reporting. Human Resources confirmed that an internal investigation was conducted, resulting in the termination of the implicated employee, but believed that the FOM was responsible for notifying CDPH. Other staff members, including the Director of Staff Development and the facility receptionist, also reported the information only to the FOM and did not escalate the report to external authorities. A review of the facility's policy and procedure on reporting and investigating abuse confirmed that any suspicion of abuse must be reported immediately to the administrator and appropriate state officials. During interviews, both the Operations Manager and Director of Nursing acknowledged that staff did not follow the established policy, and the required external reporting to CDPH was not completed. The failure to report the suspected abuse as mandated had the potential to delay investigation and affect the well-being of the resident involved.
Failure to Report Alleged Abuse Delays Investigation
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the reporting of alleged abuse, resulting in a delay in the investigation of an alleged sexual abuse incident. A Certified Nurse Assistant (CNA 1) reported an allegation of sexual abuse involving a resident's roommate to a Licensed Nurse (LN 1) during the night shift. However, LN 1 did not report the allegation to the administration or include it in the change-of-shift report, as required by the facility's policy. This omission led to a delay in addressing the alleged incident. The facility's policy, titled 'Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,' mandates that any suspicion of abuse must be reported immediately to the administrator and other officials according to state law. Despite this, LN 1 failed to follow the policy, as confirmed by interviews with the Director of Nursing (DON) and other staff members. The DON acknowledged that any allegations made by a resident must be investigated promptly, and LN 1's failure to report the incident delayed the investigation process.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of bed rails for one of the sampled residents. During an observation, it was noted that Resident 4 was sleeping in bed with two full-length bed rails raised. A subsequent interview and record review with a Licensed Nurse revealed that there was no evidence of informed consent in Resident 4's electronic or paper records regarding the use of bed rails. The facility's policy and procedure on Bed Safety and Bed Rails, dated May 2024, mandates that staff must inform the resident or their representative about the benefits and potential hazards of bed rails and obtain informed consent before use. This policy was not followed, as confirmed by the Licensed Nurse, indicating a lapse in ensuring that Resident 4 or their representative was provided with the necessary information to make an informed decision.
Failure to Provide Information on Advanced Directives
Penalty
Summary
The facility failed to provide information about the right to formulate an advanced directive for four sampled residents. During a review of the residents' Admission Packet Forms, it was found that the packets did not contain any written form indicating that a review of the process in the formulation of an advanced directive was discussed with and acknowledged by the residents or their representatives. Interviews with a Licensed Nurse and the Social Services Director confirmed the absence of written evidence regarding discussions about advanced directives in the residents' records and the lack of a policy pertaining to documentation about advanced directive discussions during admission.
Facility Fails to Maintain Safe Environment and Ideal Room Temperature
Penalty
Summary
The facility failed to ensure the presence of a toilet grab bar in a resident's restroom, compromising the resident's ability to safely move from sitting to standing. During an observation, it was noted that the grab bar was missing, with visible holes where it should have been. The resident reported the issue to the maintenance supervisor three weeks prior, but the maintenance supervisor was unaware of the problem as it was not documented in the maintenance log. The facility's policy requires maintenance personnel to maintain the building in good repair and free from hazards. Additionally, the facility did not maintain the room temperature within the ideal range as per its policy, affecting another resident's comfort. The resident was observed wearing warm clothing and using a blanket due to the cold room temperature, which had been an issue since October 2024. Despite multiple communications to staff, the room temperature was recorded at 65 degrees Fahrenheit, below the facility's ideal range of 72 to 74 degrees. The Director of Nursing acknowledged that ensuring a comfortable environment is a shared responsibility among staff.
Failure to Complete PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) Level II Evaluation was completed for a resident identified as needing further evaluation. The resident, a male with diagnoses including disorganized schizophrenia, unspecified psychosis, and suicidal ideations, was admitted to the facility with a positive Level I PASRR screening, indicating the need for a Level II Mental Health Evaluation. However, the evaluation was not completed because the resident was unable to participate, and the case was closed without further action. The Director of Nursing (DON) confirmed that the resident had a positive Level I screening but had not undergone a Level II evaluation. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders, and if a Level I screen is positive, a Level II evaluation should be conducted. Despite this policy, the necessary follow-up screening was not performed, resulting in a deficiency in the facility's compliance with PASRR requirements.
Failure to Revise Care Plan for Cognitive Decline
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident 46, following a significant decline in their cognitive function as indicated by the Brief Interview for Mental Status (BIMS) scores. The resident, a male with a history of Wernicke's encephalopathy and major depressive disorder, showed a decline from a BIMS score of 11, indicating moderate impairment, to a score of 3, indicating severe impairment, over several assessments. Despite this decline, the care plan, which was last updated on 5/2/23, did not reflect any changes or interventions to address the resident's deteriorating cognitive status. During an interview and record review, the Director of Nursing (DON) confirmed that the care plan should have been updated to include appropriate interventions for the resident's cognitive decline. The facility's policy on comprehensive person-centered care plans requires that care plans be revised as the resident's condition changes, which was not adhered to in this case. This oversight had the potential to result in the resident not receiving appropriate care and services tailored to their current cognitive needs.
Misappropriation of Resident's Package
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a package delivered to the resident was opened and had missing items. The resident, who was admitted with diagnoses including below the knee amputation, acute respiratory failure, and depression, had ordered a six-pack of ginger ale from Amazon. The package was confirmed delivered and signed for by a staff member, but when the resident inquired about it, the package was initially not found. Later, a night staff employee returned the package to the resident, noting that it had been kept at the nursing station and was missing two bottles of ginger ale. Licensed Nurse 2 confirmed finding the opened package at the nursing station and admitted to forgetting to inform administration to replace the missing items due to a busy day. The Director of Nursing stated that mail and packages should be delivered to residents unopened and promptly. The facility's policy and procedure on mail and electronic communication, as well as resident rights, emphasize the importance of delivering mail unopened and within 24 hours, ensuring residents' privacy and confidentiality.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to follow physician orders for a resident when a prescribed pain medication, Oxycodone HCl 20 mg, was not available within 24 hours from the order date. The order, dated 10/14/24, specified that the medication should be administered every 6 hours as needed for pain management. However, the Medication and Administration Record (MAR) indicated that the first dose was not given until 10/19/24, despite the order start date being 10/15/24. The Controlled Drug Record confirmed that the medication was filled on 10/18/24 and first administered on 10/19/24 at 9:50 a.m. During an interview and record review with the Director of Nursing (DON) on 11/15/24, it was confirmed that the medication was not received and administered as per the order, which is expected within one day. The DON was unable to provide an explanation for the delay. The facility's policy and procedure for administering medications, dated 2001, states that medications should be administered in accordance with prescriber orders, including any required time frame.
Facility Temperature Deficiency and Space Heater Risk
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature range of 71-81 degrees Fahrenheit, with recorded temperatures between 64.9 and 65.2 degrees Fahrenheit throughout the facility. This deficiency was observed during a tour, where residents were seen using multiple blankets to keep warm, and staff were also using blankets and wearing jackets. A space heater was found plugged in but turned off in a resident's shared room, posing a potential fire risk. Interviews with staff, including CNAs and LVNs, confirmed that the facility was cold at night, and residents frequently complained about the low temperatures. The Director of Nursing acknowledged the temperature issue and referenced regulations requiring a minimum temperature of 71 degrees Fahrenheit. The charge nurse, upon being informed of the space heater, promptly removed it from the resident's room. The deficiency affected all 72 residents' rights to a comfortable and safe environment, as the facility's temperature was consistently below the required range, leading to discomfort among residents and staff.
Facility Non-Compliance with Name Badge Requirements
Penalty
Summary
The facility failed to comply with state laws regarding the use of name badges for employees actively caring for residents. During a tour of the facility, it was observed that six out of seven employees did not have name badges. This included certified nursing assistants (CNAs) and licensed vocational nurses (LVNs) from an outside registry, as well as employees directly hired by the facility. Interviews with these staff members revealed that they were either never given a name badge or had been working without one for an extended period. The absence of name badges was confirmed by a registered nurse (RN) who acknowledged the issue and mentioned that it took her many months to receive her own name tag. The lack of name badges for staff members, including those from an outside registry, was acknowledged by the Director of Nursing (DON), who agreed that staff need to wear name badges. The report highlights that the facility's failure to provide name badges could potentially allow unauthorized individuals to pose as employees and prevent residents from knowing who is caring for them. The facility's non-compliance with the California Business & Professional Code, which mandates health care practitioners to disclose their name and license status on a name tag, was evident during the survey.
Failure to Report Unusual Occurrence of Medication Overdose
Penalty
Summary
The facility failed to adhere to its policies and procedures for reporting unusual occurrences when a resident was brought to the hospital for an alleged medication overdose. The resident, a female with a history of diabetes mellitus type II, thrombocytopenia, lymphedema, repeated falls, knee contusion, acute respiratory infection, and psychoactive substance abuse, was admitted to the facility. On a specific date, the resident was found lethargic and unable to follow commands, leading to a physician's assessment that suspected opioid abuse. Naloxone was administered, providing relief, and the resident was sent to an acute care hospital for further evaluation. The Emergency Department Physician Report indicated that the resident had taken methadone, which was not prescribed to her, resulting in two episodes of loss of consciousness. During interviews, the resident claimed not to take any unprescribed medication and believed she had an overdose of Naloxone. The Director of Nurses was unaware that this incident was reportable to the Department of Public Health. The facility's policy on Unusual Occurrence Reporting required such incidents to be reported to appropriate agencies within 24 hours, which was not done in this case.
Cracked Window in Resident's Room Not Addressed
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not addressing a cracked window in the resident's room. During an observation and interview, it was noted that a window next to the resident's bed had a starburst pattern crack with approximately 20 lines extending to the window frame. The resident mentioned that the window had been cracked since their arrival five weeks prior. The Director of Maintenance (DOM) acknowledged that the window had been cracked for a couple of months and required attention. However, the cracked window was not documented in the facility's maintenance logs, and the facility's policy and procedure for maintenance, which requires maintaining the building in good repair and free from hazards, was not followed.
Failure to Follow Physician Orders for COVID-19 Testing and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in a deficiency. Specifically, the orders required COVID-19 testing on days 1, 3, and 5 after admission, but only the day 1 test was documented. Additionally, the orders mandated temperature checks every shift, yet there were multiple missing entries for both day and night shifts over a specified period. The Director of Nursing confirmed these lapses during an interview, acknowledging that the required COVID-19 tests and temperature checks were not performed as ordered. This failure had the potential to result in missed changes in the resident's health condition and a delay in treatment.
Inadequate Posting of State Agency Contact Information
Penalty
Summary
The facility failed to accurately post contact information for the California Department of Public Health (CDPH) in an accessible and understandable manner. During an interview, a resident expressed difficulty in obtaining the phone number to file a complaint, indicating that the information was not readily available. Observations revealed that the posted information in a glass display case near the First Hall nurses station was incomplete and did not include the names, addresses, and phone numbers of all pertinent state agencies. Additionally, the signage did not reflect the current name of the State Survey Agency, and the font size was too small for easy reading, especially for individuals in wheelchairs. The Director of Nursing (DON) and the Director of Operations (DOO) acknowledged the deficiencies in the posted information. The DON agreed that the information was incomplete and the font size was inadequate. The DOO was unable to provide the location of the contact information for the CDPH when asked. These failures had the potential to hinder residents' rights to be informed about these agencies and services, as there was no statement indicating that residents could file a complaint with the State Survey Agency concerning any suspected violations of state or federal nursing facility regulations.
Maintenance Department Clutter and Overflowing Trash
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for residents, staff, and the public, as evidenced by the conditions observed in the maintenance department. During an interview and observation, the maintenance staff acknowledged that the department was cluttered and trash bins were overflowing. Specific observations included multiple large cardboard boxes piled up and overflowing with trash, a broken closet door leaning against a wall covering an open doorway, and an air conditioner vent covered with a black organic substance. Additionally, trash bins were overflowing with yard waste, and trash cans were overflowing with trash. Hazardous items were also left out in the open, including a one-gallon can of paint and a one-gallon container of Spectracide Bug Stop Home Barrier. The maintenance staff admitted that the department always appeared in this state. A review of the facility's policy and procedure titled 'Maintenance Service' indicated that the Maintenance Director is responsible for ensuring that the buildings, grounds, and equipment are maintained in a safe and operable manner, and that maintenance personnel should follow established infection control precautions and safety regulations. However, these procedures were not followed, leading to the observed deficiencies.
Sanitation Deficiencies in Water Dispenser and Ice Machine
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for all 61 residents, as evidenced by the condition of the residents' drinking water dispenser and the ice machine. During an observation, the drinking water dispenser was found to have a brown slimy substance in several areas of the drip tray. This was confirmed by a Certified Nursing Assistant (CNA), the Director of Operations (DOO), and housekeeping staff (HS), all of whom acknowledged the dispenser's unclean state. The HS admitted there was no record of when the dispenser was last cleaned or sanitized, and the daily cleaning log was incomplete, with the last entry dated several months prior. Additionally, the facility's ice machine was observed to have a brown grime substance, hair, and a broken drain pipe at the air gap vent. The DOO confirmed these observations and acknowledged that the air gap vent should be clean and sanitary. The maintenance supervisor (MSV) was unable to provide current daily cleaning logs for both the water dispenser and the ice machine, indicating a lack of proper documentation and oversight in maintaining these essential pieces of equipment. The facility's policy and procedure on infection control, last revised in October 2018, was reviewed and indicated the importance of maintaining a safe, sanitary, and comfortable environment to prevent and manage infections. However, the DOO was unable to provide a specific policy and procedure for the cleaning and maintenance of the residents' drinking water dispenser, highlighting a gap in the facility's infection control practices. These deficiencies had the potential to cause waterborne illness among the vulnerable resident population.
Failure to Supervise Resident During Transportation
Penalty
Summary
The facility failed to provide adequate supervision and assistance for Resident 1 during transportation to and from an appointment outside of the facility. This failure resulted in Resident 1 not waiting for transportation and leaving the appointment. Subsequently, Resident 1 fell out of their wheelchair near a road with heavy traffic and expressed confusion about their location and how to return to the facility. Resident 1 had a history of major traumatic brain injury, subdural hematoma, and fractures, leading to reduced mental acuity, dependency, and major depressive disorder. The resident was non-ambulatory, totally dependent on staff for movement, and had poor trunk control and safety awareness. Despite these conditions, the facility did not have a policy regarding accompanying residents to appointments, which contributed to the incident.
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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