Orchard Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 4840 E.tulare Avenue, Fresno, California 93727
- CMS Provider Number
- 056225
- Inspections on file
- 25
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Orchard Post Acute during CMS and state inspections, most recent first.
A resident with type 2 diabetes experienced hypoglycemia, but the LTC facility failed to document a change of condition assessment as required by policy. Despite the resident's low blood sugar and symptoms, the necessary documentation was not completed, potentially delaying care. Interviews with staff confirmed the expectation for such assessments, highlighting a lapse in following professional standards.
A resident with Type 2 Diabetes Mellitus received insulin in a manner inconsistent with physician orders at an LTC facility. The resident had separate orders for Humalog insulin: a scheduled dose after meals and a sliding scale dose before meals. However, LVNs combined the doses and administered them after meals, contrary to the orders. This practice was confirmed through interviews and MAR reviews, with both LVNs acknowledging the deviation. The facility's policy emphasized adherence to physician orders, and the improper administration had the potential to affect the resident's health.
A resident's personal belongings were not inventoried upon admission and readmission, leading to the temporary loss of items like a wallet and checkbook. The facility's process required a CNA to list belongings and an LVN to enter them into the EMR, but this was not done. The items were later found in the dining room, highlighting a failure to follow the facility's policy on personal property.
The facility failed to administer oxygen according to physician orders for multiple residents, with discrepancies in the prescribed and actual oxygen flow rates. Additionally, an antibiotic was started for a resident without obtaining a necessary wound culture, contrary to standard practice. The facility also did not manage responsible party designations correctly for residents with cognitive impairments, leading to potential issues in informed consent.
The facility failed to properly store and label medications, with an unlocked medication cart, an emergency kit missing a zip tie, and hearing aid batteries stored with medications. Unlabeled medications and an insulin pen without a resident's name were found, posing risks of administration errors. A treatment cart was left unattended with keys in the lock, risking unauthorized access.
The facility failed to adhere to professional standards for food safety, affecting 91 residents. Observations included uncovered food in storage, lack of an air gap in the kitchen sink, uncalibrated and unsanitized thermometers, improper glove use, and incorrect portion control. A dietary aide was also seen without a hair net, risking contamination. These actions placed residents at risk for foodborne illness.
The facility failed to follow its policy for garbage disposal, as one trash bin was left uncovered with debris scattered around it. Interviews with the CDM, RD, and ED confirmed that trash bins should be closed and free of surrounding litter to prevent pest infestations. The facility's policy requires food waste to be stored in a manner inaccessible to pests.
Two residents experienced a lack of dignity in their care. A resident was addressed by an LVN using terms like 'mama' and 'honey' instead of her name, despite her preference. Another resident's foley catheter bag was left uncovered, compromising his privacy and dignity. Both incidents were contrary to the facility's policies on resident dignity and rights.
A resident with hereditary and idiopathic neuropathy was inaccurately assessed in their MDS, showing no impairment despite being dependent on staff for daily activities due to upper extremity limitations. The MDS Nurse did not perform a bedside assessment and relied on other staff inputs, leading to the error. Both the DON and MDS Nurse were new to their roles, contributing to the oversight.
The facility failed to implement baseline care plans for five residents on Aspirin, lacking monitoring for bleeding or bruising. This deficiency involved residents with various medical conditions, including venous insufficiency, joint replacement surgery, and cerebral infarction. Interviews confirmed that care plans should have been individualized to include anticoagulation monitoring.
The facility failed to create comprehensive care plans for three residents, leading to potential risks and unmet needs. A resident with psychosis lacked a care plan for their condition, another resident with hearing impairment did not have a care plan for hearing aid use, and a resident who spoke a foreign language had no communication plan. Staff interviews confirmed the absence of these care plans, which were necessary to address the residents' specific needs.
The facility failed to maintain an effective infection prevention and control program, with unsanitary conditions in the medication room, improper cleaning of pill crushers, and lapses in hand hygiene practices. Observations included dust, hair, and cockroaches in the medication room, pill crushers coated with debris, and staff not performing hand hygiene after handling bodily fluids or administering medication. These actions were contrary to facility policies and CDC guidelines.
A resident was prescribed Citalopram and Quetiapine without signing the informed consent form, despite being cognitively intact. The facility's policies on informed consent and medication use were not followed, as the consent form was not properly signed and dated by the resident and physician.
A resident was not treated with dignity during a meal when a CNA stood over her while spoon-feeding her breakfast in bed. The resident, dependent on staff for daily living activities, was not provided a respectful dining experience. Facility policy requires staff to sit at eye level with residents during meals to ensure dignity.
The facility failed to provide a homelike dining environment for three residents by serving meals on plastic trays without removing the items, contrary to the facility's policy. Staff interviews confirmed that the standard practice was to place items directly in front of residents to promote a homelike atmosphere, which was not followed in this instance.
A facility failed to complete and transmit MDS assessments for a resident who was discharged and readmitted, as required by guidelines. The MDSN did not follow the RAI guidelines, leading to potential unmet needs. The DON was not trained on MDS, and the ADM expected complete and accurate assessments.
A resident with severe cognitive impairment and multiple medical conditions experienced a decrease in meal intake, yet the LTC facility failed to update the care plan to address this change. Despite staff observations and reports of the resident's refusal to eat, the care plan had not been revised, potentially leaving the resident's nutritional needs unmet.
A resident was served a sandwich on white bread instead of their preferred wheat bread, leading to refusal to eat. The facility's staff, including the Dietary Manager and CNAs, failed to communicate and adhere to the resident's meal preferences, as indicated on the meal ticket. This oversight was acknowledged by the staff, highlighting a breakdown in procedure adherence.
A resident's hearing aids were not documented on her inventory sheet, leading to her not wearing them and staff being unaware of their location. The resident, with moderate cognitive impairment, was observed without her hearing aids, and staff had to raise their voices to communicate. The facility's policies required documentation of personal belongings, but the hearing aids were not included, resulting in a lack of awareness among staff.
Failure to Document Change of Condition for Hypoglycemic Episode
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who experienced an episode of hypoglycemia. The resident, who was admitted with a diagnosis of type 2 diabetes mellitus, had a documented fasting blood sugar level of 51, indicating hypoglycemia. Despite this significant change in condition, the licensed nurses did not complete a change of condition assessment as required by the facility's policy and procedure. The resident's medical records showed that staff reported the resident was sweating and had to change clothes twice within a short period. When a nurse entered the room, the resident was awake but not verbally responsive. However, there was no documentation of a change of condition assessment in the electronic medical record, which was confirmed during an interview with a registered nurse. The facility's policy mandates that such assessments be completed to communicate changes in a resident's health status effectively. Interviews with the director of nursing and a licensed vocational nurse confirmed that the facility's expectation was to complete a change of condition assessment when there was a change in a resident's health status. The failure to document and assess the resident's change in condition resulted in incomplete documentation and had the potential to delay care. The facility's policies on change in condition and charting and documentation emphasize the importance of accurate and complete documentation to ensure appropriate communication and response to changes in a resident's condition.
Improper Insulin Administration
Penalty
Summary
The facility failed to ensure that insulin administration for a resident with Type 2 Diabetes Mellitus was conducted according to the physician's orders. The resident had two separate orders for Humalog insulin: a scheduled dose of 10 units to be administered subcutaneously after meals and a sliding scale dose to be administered before meals based on blood sugar levels. However, Licensed Vocational Nurses (LVNs) 1 and 2 combined the sliding scale insulin with the scheduled dose and administered the total amount after meals, contrary to the physician's instructions. The resident, who was cognitively intact, reported receiving more than 10 units of insulin after meals, which was confirmed by the Medication Administration Records (MAR) and interviews with the LVNs. LVN 1 admitted to administering the combined insulin doses after meals on multiple occasions, while LVN 2 also confirmed doing the same on different dates. Both LVNs acknowledged that they did not follow the physician's orders, which required the sliding scale insulin to be administered before meals. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were aware of the separate insulin orders but were not informed that the LVNs were administering the insulin in a manner inconsistent with the physician's orders. The facility's policy and procedure for insulin administration emphasized the importance of following physician orders and administering medications safely and timely. The deviation from the prescribed insulin administration protocol had the potential to cause unstable blood sugar levels in the resident, affecting their health and wellness.
Failure to Inventory Resident's Belongings
Penalty
Summary
The facility failed to adhere to professional standards of quality by not completing an inventory of personal belongings for a resident upon admission and readmission. The resident, who was cognitively intact with a BIMS score of 15, was admitted with personal items including a wallet, checkbook, and bank card. However, no inventory list was completed during the initial admission or subsequent readmissions, as confirmed by the medical records and interviews with staff. The process at the facility required a Certified Nursing Assistant (CNA) to take inventory of a resident's belongings and hand it over to a Licensed Vocational Nurse (LVN) for entry into the Electronic Medical Record (EMR). However, this process was not followed for the resident in question. Interviews with the CNA, LVN, and Director of Nursing (DON) revealed that the inventory list was not completed, and the facility's policy and procedure for personal property were not adhered to. The failure to inventory the resident's belongings led to the temporary loss of the resident's wallet, checkbook, and bank card, which were later found in the dining room. The Social Services Director confirmed that a grievance had been filed regarding the missing items, and the facility's policy required an inventory to be completed upon admission to prevent such occurrences. The lack of documentation and adherence to policy posed a risk to the resident's personal belongings.
Oxygen Administration and Antibiotic Protocol Failures
Penalty
Summary
The facility failed to ensure that oxygen was administered according to physician orders for several residents. Resident 40 was supposed to receive 3L/min of oxygen via nasal cannula but was only receiving 2.5L/min, as confirmed by both the resident and the Licensed Vocational Nurse (LVN) 8. This discrepancy was observed over multiple days, and the Director of Nursing (DON) confirmed that the expectation was for licensed nurses to check and ensure the correct oxygen settings. Similarly, Resident 337 was receiving 5L/min of oxygen instead of the ordered 2L/min, which was verified by LVN 1. The DON emphasized the importance of following physician orders to prevent potential harm. The facility also failed to follow professional standards regarding antibiotic administration. Resident 38 was started on an antibiotic without obtaining a wound culture, which is not standard practice. The Infection Preventionist (IP) and the DON both acknowledged that a wound culture should have been done before starting the antibiotic. The facility's policy on antibiotic stewardship was not followed, as it requires cultures to be obtained before initiating antimicrobial therapy to ensure appropriate use and prevent resistance. Additionally, the facility did not properly manage the responsible party (RP) designations for residents with cognitive impairments. Resident 24's RP was not informed about changes to the resident's low air loss mattress, despite the resident having a moderate cognitive impairment. Similarly, Resident 19, who also had moderate cognitive impairment, was incorrectly listed as her own RP. The facility's policy requires residents with a BIMS score under 13 to have an RP, but this was not adhered to, leading to potential issues in informed consent and decision-making for these residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, resulting in several deficiencies. One medication cart was left unlocked and unattended by an LVN, allowing potential unauthorized access to medications. Additionally, an emergency kit in the medication storage room was found with a missing zip tie, which could lead to unauthorized access and tampering. Hearing aid batteries were improperly stored with medications in a medication cart, increasing the risk of confusion and potential administration errors. Further observations revealed that medications were stored in unlabeled containers, including a multivitamin pill in a cup and sodium pills in a clear plastic bag, which were not properly discarded. An insulin pen was also found without a resident's name or open date, posing a risk of administration to the wrong resident. These lapses in labeling and storage practices could lead to medication errors and compromised resident safety. Additionally, a treatment wound cart was left unattended with keys in the lock, creating a risk for residents to access treatment supplies unsupervised. Interviews with staff, including LVNs and the DON, confirmed that these practices were against the facility's policies, which require medications and treatment supplies to be securely stored and attended by authorized personnel.
Food Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety, affecting 91 of 96 residents. Observations revealed several deficiencies, including an uncovered plastic container of dry bran cereal and an uncovered Styrofoam cup with brown liquid left on top of an ice chest in the dry food storage area. These actions were contrary to the facility's policy and procedure, which mandates that all foods be covered to prevent contamination. Further deficiencies were noted in the kitchen, where the food preparation sink lacked an air gap, a critical component to prevent backflow and contamination. The cook did not calibrate the food thermometer before use, nor was it sanitized before being placed in freshly cooked broccoli. Additionally, the temperature of the soup was not measured before serving, and the cook failed to change gloves after touching multiple surfaces, leading to potential cross-contamination. The cook also did not adhere to portion control guidelines, using the same scoop size for small, regular, and large portions, which could affect residents' nutrition. A dietary aide was observed walking through the kitchen without a hair net, risking contamination of the food. These failures collectively placed residents at risk for foodborne illness, as the facility did not adhere to its own policies and professional standards for food safety.
Improper Garbage Disposal Practices
Penalty
Summary
The facility failed to adhere to its policy and procedure for Food-Related Garbage and Refuse Disposal, as observed during a survey. One of the three outside trash bins was found uncovered, with a significant amount of plastic and debris scattered on the ground behind it. This observation was made in the trash bin storage area behind the facility. Interviews with the Certified Dietary Manager (CDM), Registered Dietitian (RD), and Environmental Director (ED) confirmed that the trash bins should remain closed at all times, and there should be no trash on the ground to prevent attracting pests. The facility's policy, dated October 2017, clearly states that all food waste should be stored in containers that are inaccessible to pests, and outside dumpsters should be kept closed and free of surrounding litter. The Administrator also acknowledged that the trash bins should always be covered to discourage insects and animals from accessing the trash, which could lead to the spread of infection. The failure to comply with these procedures had the potential to attract animals, insects, and pests, leading to infestations and unsanitary conditions.
Failure to Uphold Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by two specific incidents involving Resident 14 and Resident 67. In the first incident, a Licensed Vocational Nurse (LVN) addressed Resident 14 by calling her 'mama' and 'honey' instead of using her name, despite Resident 14 expressing a preference to be addressed by her name. Resident 14, who was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 8 out of 15, stated that being called 'mama' or 'honey' did not sound right to her. The facility's policy on dignity, which was reviewed with the Director of Nursing (DON), indicated that residents should be addressed by their name unless specified otherwise in their care plan. In the second incident, Resident 67's foley catheter drainage bag was observed uncovered, violating his right to dignity and privacy. Resident 67 expressed discomfort with the visibility of his urine, especially when it was red with blood, during a hospital transfer. A Certified Nursing Assistant (CNA) and an LVN both acknowledged that the catheter bag should have been covered to preserve Resident 67's dignity. The facility's policy on resident rights emphasized treating all residents with kindness, respect, and dignity, which includes maintaining their privacy. The DON confirmed that the expectation was for all staff to ensure catheter bags are covered to uphold residents' dignity.
Inaccurate MDS Assessment for Resident with Neuropathy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding the resident's functional limitation in the range of motion. The deficiency was identified for a resident who was observed to be dependent on staff for all activities of daily living due to upper extremity impairments. Despite these observations, the resident's quarterly MDS assessments inaccurately indicated no impairment of the upper extremities. The MDS Nurse admitted to not performing a bedside assessment and relied on information from CNA charting, therapy, and the Director of Nursing (DON), leading to the inaccurate coding. The resident in question was admitted with diagnoses including hereditary and idiopathic neuropathy, which contributed to the functional limitations observed. The MDS Nurse acknowledged the inaccuracy in the assessments and expressed the need to review the Resident Assessment Instrument (RAI) manual to prevent future errors. The DON, who was new to the position, was not oriented on MDS processes, and the Administrator noted that the MDS Nurse was also new to her role. The facility's policy emphasized the importance of accurate assessments, but the lack of proper assessment and communication led to the deficiency.
Failure to Implement Baseline Care Plans for Anticoagulation Monitoring
Penalty
Summary
The facility failed to develop and implement baseline care plans for five residents who were on anti-platelet medication, specifically Aspirin, to monitor for signs and symptoms of bleeding or bruising. This deficiency was identified for Residents 25, 31, 58, 67, and 74, who did not have individualized care plans addressing the need for anticoagulation monitoring. The absence of these care plans placed the residents at risk for complications related to bleeding, as their care needs were not adequately planned or monitored by licensed nurses. Resident 25, who had been in the facility for four months, was on Aspirin for prophylaxis but did not have a care plan for monitoring bleeding or bruising. Similarly, Resident 31, admitted with a history of joint replacement surgery and other conditions, was also on Aspirin without a care plan for monitoring bleeding. Resident 58, with a non-healing abdominal wound, was taking Aspirin but lacked a care plan for anticoagulation monitoring, despite having orders to observe for bleeding every shift. Resident 67, who had recently returned from the hospital due to bleeding after a urinary catheter change, was on Aspirin for stroke prophylaxis but did not have a care plan for monitoring bleeding. Lastly, Resident 74, with a history of cerebral infarction and Alzheimer's disease, was on Aspirin without a care plan for monitoring side effects. Interviews with the LVN and the DON confirmed that care plans should have been individualized and included monitoring for bleeding and bruising for residents on anti-platelet medications.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential risks and unmet needs. Resident 55, who was admitted with a diagnosis of psychosis, did not have a care plan addressing this condition. Despite being cognitively intact, Resident 55 exhibited behaviors such as yelling and non-compliance with activities of daily living. Interviews with staff, including CNAs and LVNs, revealed that there was no care plan in place for psychosis, which was acknowledged as necessary by the Director of Nursing. Resident 47, who had moderate cognitive impairment and was hard of hearing, did not have a care plan for the use of hearing aids. Observations showed that Resident 47 was not wearing hearing aids, and staff had to raise their voices to communicate. Interviews with CNAs and LVNs confirmed that the use of hearing aids should have been included in the care plan upon admission to ensure staff awareness and proper communication of care needs. Resident 387, who spoke a foreign language, lacked a care plan for communication. The absence of a communication plan meant that staff were unaware of the resident's language needs, and family members had to assist with translation. The Director of Nursing and other staff acknowledged the importance of a communication care plan, which was not developed upon admission, leaving the resident's communication needs unmet.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the medication room, unsanitary conditions were noted, including the presence of dust, hair, and cockroaches on the floor, as well as the absence of a trash bin for proper disposal of waste. This was confirmed by a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the medication room should be kept clean according to facility policy and CDC guidelines. Additionally, the facility did not adhere to proper cleaning protocols for pill crushers. Observations revealed that pill crushers on multiple medication carts were coated with powder-like debris, and LVNs were using bleach disinfectant wipes contrary to the manufacturer's instructions, which specified cleaning with soap and water. The DON confirmed that bleach should not be used and that the pill crushers should be kept clean to prevent medication mixture. Furthermore, there were lapses in hand hygiene practices among staff. A Certified Nursing Assistant (CNA) failed to perform hand hygiene after handling a bag with feces, and an LVN did not remove gloves or perform hand hygiene after administering insulin to a resident. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene to prevent cross-contamination and the spread of infections. The DON and Infection Preventionist reiterated the necessity of adhering to hand hygiene protocols to maintain a safe environment for residents.
Failure to Obtain Informed Consent for Psychotropic and Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that informed consent was obtained for the use of psychotropic and antipsychotic medications for one resident. The resident, who was cognitively intact with a BIMS score of 14, was prescribed Citalopram and Quetiapine without signing the informed consent form. The resident was admitted with diagnoses of major depressive disorder and bipolar disorder, and began taking these medications shortly after admission. However, the informed consent form was not signed by the resident, and the physician's signature was undated, rendering the consent invalid. Interviews and record reviews revealed that the Licensed Vocational Nurse and the Pharmacy Consultant were aware of the missing signatures and had recommended obtaining them. Despite these recommendations, the consent form remained unsigned by the resident. The Director of Nursing acknowledged that the informed consent was not valid without the proper signatures and dates, and that medications should not have been administered without a valid consent. The facility's policies on informed consent and medication use were not followed, leading to the deficiency.
Resident Dignity Compromised During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during a meal. Specifically, a Certified Nursing Assistant (CNA) was observed standing over a resident while spoon-feeding her breakfast in bed. The resident, who was dependent on staff for all activities of daily living due to conditions such as intervertebral disc degeneration and muscle weakness, was lying in bed with the head elevated and the bed in the highest position. The CNA acknowledged that standing over the resident while feeding her was inappropriate and recognized it as a dignity issue. Interviews with another CNA and the Director of Nursing (DON) confirmed that the proper practice when assisting residents with meals in bed is to lower the bed, elevate the head of the bed, and sit next to the resident at eye level. The facility's policy and procedure on dignity and resident rights emphasize the importance of treating residents with respect, kindness, and dignity, which was not adhered to in this instance.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for three residents when meals were served on plastic trays without removing the food plates, beverage glasses, utensils, and napkins. This practice was observed during a dining session, where staff placed the entire tray in front of each resident, contrary to the facility's policy and procedure for creating a homelike environment. The residents involved in this observation included individuals with significant medical conditions such as hemiplegia, hemiparesis, and a displaced fracture of the femur. Interviews with various staff members, including a Center Scheduler, Rehabilitative Nursing Assistant, Certified Dietary Manager, Licensed Vocational Nurse, and the Director of Nursing, confirmed that the standard practice was to remove items from the plastic trays and place them directly in front of residents to promote a homelike atmosphere. The staff acknowledged that leaving items on the trays did not align with the facility's policy and the residents' rights to a comfortable and homelike environment. The facility's policy emphasized person-centered care and minimizing institutional characteristics, which was not adhered to in this instance.
Failure to Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to meet the required timelines for encoding, completion, and transmission of Minimum Data Set (MDS) assessments for a resident, identified as Resident 55. The MDS Nurse (MDSN) did not complete or transmit the necessary discharge and readmit MDS tracking assessments for this resident. Resident 55 was sent to an acute hospital and readmitted to the facility, but the MDSN did not find completed and transmitted MDS assessments for these events. The MDSN acknowledged the oversight, stating it was a mistake and that she did not follow the Resident Assessment Instrument (RAI) guidelines, which recommend opening assessments for discharges and readmissions. The Director of Nursing (DON) was unaware of the MDS process and had not been trained on it, while the Administrator expected MDS assessments to be complete and accurate, noting that the MDSN was new and could have asked questions if unsure. The facility's policy requires individuals completing MDS assessments to certify their accuracy, and the professional guidelines specify that discharge assessments are necessary when a resident is admitted to a hospital or other care setting. This deficiency resulted in the potential harm of residents' needs upon discharge going unmet.
Failure to Update Care Plan for Decreased Meal Intake
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for a resident, identified as Resident 34, who experienced a decrease in meal intake. Despite being admitted with multiple medical conditions including cerebrovascular disease, type two diabetes mellitus, hypertension, heart failure, and gastroesophageal reflux disease, the resident's care plan was not updated to address the significant change in their nutritional intake. Observations and interviews revealed that Resident 34 had severe cognitive impairment and was refusing meals, consuming less than 25% of his lunch on one occasion. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) noted the resident's decreased appetite and meal intake over a two-week period, yet the care plan had not been revised since the previous month. Interviews with facility staff, including CNAs and the Director of Nursing (DON), confirmed that the resident's decreased food intake was recognized but not documented in the care plan. The facility's policy and procedure for comprehensive person-centered care plans require updates when there is a significant change in a resident's condition, which was not adhered to in this case. The failure to update the care plan had the potential to leave Resident 34's nutritional needs unmet, as the care plan lacked interventions to address the decrease in meal intake.
Failure to Accommodate Resident Meal Preference
Penalty
Summary
The facility failed to accommodate a resident's meal preference by serving a sandwich on white bread instead of the requested wheat bread. This incident was observed during a meal service, where the resident expressed dissatisfaction and refused to eat the lunch provided. The resident's meal ticket clearly indicated a preference for wheat bread, which was not honored due to the kitchen running out of wheat bread the previous night. The Dietary Manager acknowledged the oversight and confirmed that the resident's preferences should have been followed. Interviews with various staff members, including the Dietary Manager, Dietary Aid, CNA, LVN, and the Director of Nursing, revealed a breakdown in communication and procedure adherence. Staff members were aware of the importance of following meal preferences to ensure residents eat their meals. However, the failure to notify the Dietary Manager about the shortage of wheat bread and to discuss alternatives with the resident led to the deficiency. The facility's policy and procedure documents also emphasized the importance of accommodating individual food preferences, which were not adhered to in this case.
Failure to Document Resident's Hearing Aids
Penalty
Summary
The facility failed to maintain complete and accurately documented records for a resident, identified as Resident 47, when her hearing aids were not documented on her inventory sheet. This oversight resulted in the resident not wearing her hearing aids, leading to her belief that they were missing. The resident, who had moderate cognitive impairment and was hard of hearing, was observed without her hearing aids, and staff were unaware of their location. During interviews and observations, it was revealed that Certified Nursing Assistants (CNAs) were responsible for documenting residents' belongings upon admission, including high-value items like hearing aids. However, Resident 47's hearing aids were not inventoried, and staff had to raise their voices to communicate with her. The hearing aids were eventually found in a drawer next to her bed, but they had not been documented in her records, including the Minimum Data Set (MDS), which should have reflected the care provided. The facility's policies and procedures required staff to inventory and document residents' personal belongings upon admission and update them as necessary. Despite these guidelines, the hearing aids were not included in the inventory sheet, leading to a lack of awareness among staff about the resident's belongings. Interviews with various staff members, including the Director of Nursing and the Social Services Director, confirmed the importance of documenting such items to prevent them from going missing.
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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