Oroville Hospital Post-acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oroville, California.
- Location
- 1000 Executive Parkway, Oroville, California 95966
- CMS Provider Number
- 555281
- Inspections on file
- 35
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Oroville Hospital Post-acute Center during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with dementia, agitation, and a history of elopement was left unsupervised when a hospitality aide took a break without arranging coverage, resulting in the resident wandering into another room. The care plan required 1:1 supervision at all times, but staff did not follow this directive, and the facility lacked an appropriate care plan policy.
The facility failed to provide written bed hold notifications to residents or their representatives upon transfer to a hospital, affecting several residents with various medical conditions. Despite notifying the Long-Term Care Ombudsman, the facility did not comply with its policy to inform residents or their responsible parties about the bed hold policy, leading to a deficiency.
A long-term care facility failed to complete MDS assessments for several residents within the required timeframe, leading to potential delays in developing comprehensive care plans. The backlog was attributed to the facility being busy and understaffed, with the MDS RN expressing concern about care plans not reflecting current interventions. The Administrator was aware of the issue but not fully informed of its extent.
Several residents in an LTC facility did not receive necessary assistance with ADLs, including eating and personal hygiene. A resident with severe cognitive impairment was unable to eat due to an unreachable lunch tray, while others reported inconsistent oral care and hair brushing. Staff acknowledged oversights, and documentation showed gaps in care provision.
Two residents experienced deficiencies in care at the facility. A resident with multiple diagnoses, including Parkinson's and chronic kidney disease, did not receive documented coccyx treatments for her Moisture Associated Skin Damage as ordered. Another resident with anoxic brain damage and dementia had inconsistent monitoring of her venous ulcers, with several shifts lacking documentation of assessments. The facility's policies on skin integrity and medication administration were not followed, leading to these deficiencies.
The facility failed to implement downtime procedures during an internet outage, preventing staff from accessing residents' EMR and delaying care. Despite having a policy for such situations, staff were unable to use provided cell phones or jetpack devices to access records. Paper MARs were printed as a temporary solution until the internet was restored.
A survey found a 27.59% medication error rate in an LTC facility, involving two residents. Errors included improper medication administration via g-tube for a resident with dysphagia and dementia, and failure to provide vitamin D3 for another resident due to inventory issues. The DON confirmed protocol lapses and medication unavailability.
The facility failed to properly store and label medications, leading to several deficiencies. A medication label did not match the physician's order, and storage conditions were inadequate, with ice buildup in a medication refrigerator posing contamination risks. Unlabeled medication cups, expired Ativan, and improper storage of cleaning supplies with medications were also observed. Additionally, an unlabeled Kangaroo bag was found in a resident's room.
The facility failed to maintain a sanitary kitchen environment, with grime and dust observed on equipment and improper cleaning schedules. Staff did not consistently prevent cross-contamination, with improper use of hair restraints, gloves, and apron storage. Food cooling processes were inadequately documented, and pureed fish did not meet consistency standards. Despite ongoing training, these issues persisted, raising concerns about the effectiveness of the facility's oversight.
The facility did not follow a preplanned vegetarian menu cycle, potentially compromising the nutritional needs of vegetarian residents. Despite having a diet manual approved by the RD and Medical Director, there was no evidence of a comprehensive vegetarian menu cycle or nutrient analysis specific to vegetarian meals. Kitchen staff prepared meals based on available ingredients and personal judgment, and the RD was unaware if the nutrient analysis provided was for vegetarian alternatives or standard meals.
The facility failed to serve food at an appetizing temperature, as reported by several residents who consistently received cold meals. Observations showed delays in meal tray delivery and inadequate food temperatures, confirming the residents' complaints.
The facility failed to meet the dietary texture needs of several residents, as observed when whole parsley sprigs were placed on trays for residents on pureed and mechanical soft diets, contrary to the diet manual's instructions. Additionally, pureed fish was found to have a gummy texture, not meeting the required smooth consistency. A resident expressed dissatisfaction with the dryness of the food, and her preferences were not documented. The dietary services manager and RD acknowledged the texture issue, indicating a failure to adhere to dietary modifications and resident preferences.
The facility failed to maintain food safety and sanitation standards, with unsanitary kitchen conditions, improper storage and handling practices, and inadequate management of dented cans. Kitchen staff did not follow cross-contamination prevention protocols, and non-food-safe chemicals were used in nourishment rooms.
The facility failed to ensure sanitary food storage for residents' personal food in three nourishment rooms, where food was not labeled with patient identifiers. Observations revealed employee personal belongings and opened beverages in the rooms, along with soiled floors and counters. Interviews confirmed that staff personal items and food were a consistent problem, and the facility lacked a policy on employee property storage.
The facility failed to effectively use its QAPI program to address deficiencies in timely completion of resident assessments, affecting 13 residents. The MDS RN reported being behind due to insufficient nursing hours, leading to incomplete MDS assessments and potentially outdated care plans. The Administrator was aware of the backlog but not its full extent, and expected reporting for root cause analysis, which did not happen.
The facility's QAA committee failed to implement effective plans for infection control, as revealed by a lack of documentation and incomplete hand hygiene audits. The ongoing Infection Control PIP lacked essential elements like root cause analysis and action plans, as admitted by the ADON.
The facility exhibited multiple infection control deficiencies, including staff failing to perform hand hygiene during meal service, unsanitary nourishment rooms, and improper cleaning practices. Additionally, resident care equipment was found dirty, and staff did not follow proper procedures during resident care activities, posing infection control concerns.
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as cockroaches and unidentified bugs in resident areas and dining rooms. The Maintenance Supervisor acknowledged ongoing pest issues, but the pest control service primarily focused on exterior spraying, and deep cleaning was not routinely performed. The facility's nourishment rooms were unsanitary and cluttered, contributing to the infestation. Despite the known issue, there were no Quality Assurance/Performance Improvement processes in place to address the problem.
A resident expressed distress over staff going through her personal belongings without permission, but the facility failed to address her grievance. Despite the resident's clear complaint, the Social Service Director did not offer to file a grievance report, and the grievance binder showed no report for the incident. Interviews confirmed that staff were expected to file grievances, but the complaint went unaddressed, indicating a lapse in the facility's grievance handling process.
A facility failed to provide a written notice of transfer or discharge to a resident and the State LTC Ombudsman when the resident was sent to the hospital for emergency care. The resident, who was admitted with multiple diagnoses and was her own representative, was transferred to an acute hospital within 24 hours due to severe chest pain. The ADON confirmed that no written notice was provided, as required by the facility's policy.
The facility failed to complete Quarterly MDS assessments within the required timeframe for two residents, leading to overdue assessments. One resident's assessment was 35 days overdue, while another's was 18 days overdue. Staff cited a busy environment and insufficient nursing hours as reasons for the delays, raising concerns about the impact on residents' care plans.
A facility failed to ensure the accuracy of a Level 1 PASARR for a resident, missing a bipolar disorder diagnosis and incorrectly including dementia. The hospital conducted the initial PASARR, but the facility's medical records department was responsible for verifying its accuracy. Discrepancies were confirmed during interviews and record reviews, with the ADON acknowledging the issues.
A resident experienced significant weight loss due to the facility's failure to implement an individualized care plan. Despite being at risk for weight loss, no care plan was created, and the resident was not informed of any plan to address her condition. The facility's processes failed to manage the resident's nutritional needs effectively, as confirmed by the ADON and RD.
A resident with a peg-tube was subjected to improper care when LNs used a DeClogger without a physician's order, care plan, or monitoring system. The DeClogger, meant for use with a prescription, was used multiple times without proper water flushing, and the facility's DON confirmed the absence of necessary documentation and monitoring.
A resident with a history of UTIs and other medical conditions experienced repeated infections due to inadequate peri-care by CNAs. Despite being fully dependent on staff for hygiene, the resident reported insufficient cleaning after incontinent episodes, confirmed by staff observations. The Infection Preventionist had not provided necessary training, contributing to the issue.
A resident experienced significant weight loss over two weeks, which was not identified or addressed by the facility. Despite policies for monitoring and re-weighing, the RD failed to document the weight loss or initiate a care plan. The ADON confirmed no meetings were held to discuss the resident's weight loss, resulting in a failure to maintain the resident's nutritional status.
A resident with dementia and bipolar disorder was prescribed Asenapine and Haloperidol, but the facility failed to monitor specific behaviors and adverse reactions as required by their policies. This lack of monitoring was confirmed during an interview and record review with a Registered Nurse/Neuropsychiatric Assistant.
The facility failed to ensure adequate oversight of Food and Nutrition Services, as the RD did not provide evidence of regular consultations and audits. Sanitation and food safety concerns were observed, including soiled equipment and improper food handling. The facility also did not follow a pre-planned vegetarian menu cycle, with kitchen staff unaware of its existence, leading to concerns about meeting residents' dietary needs.
A resident, who primarily speaks Spanish, signed an arbitration agreement in English without understanding it, as the facility failed to provide the document in her language. The Admissions Transition Coordinator relied on the resident's English-speaking son for agreement, leading to the resident signing a document she did not comprehend.
A resident with a history of chronic pain and a broken leg experienced increased pain due to the facility's failure to administer Norco on time, as per the care plan and physician's orders. The medication was frequently given late, with staff citing busy shifts and shared medication carts as reasons. The Executive Nurse Director confirmed the late administration, which was not in line with the facility's policy.
A resident with severe cognitive impairment was abducted from a facility by a restricted visitor due to inadequate visitor screening and staff training. The visitor used a false name to enter the facility, and staff failed to verify the visitor's identity or check the restricted visitor list. The facility's lack of a comprehensive visitor management policy and insufficient staff training contributed to the incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required 1:1 Supervision for Resident with Elopement Risk
Penalty
Summary
The facility failed to follow the care plan for a resident with a history of elopement, impaired safety awareness, and multiple behavioral issues related to dementia and neurological conditions. The resident's care plan required 1:1 supervision at all times due to risks of wandering, elopement, and communication difficulties. Despite this, a hospitality aide assigned to the resident left the room for a break without ensuring another staff member was present to maintain supervision. As a result, the resident was left unattended and subsequently wandered from his room into another resident's room. Record reviews confirmed that the hospitality aide's job description required understanding and carrying out resident care plans, and the resident's care plan specifically mandated continuous 1:1 supervision. Interviews with the Director of Nursing confirmed that the facility did not have an appropriate care plan policy and that staff did not follow the established care plan or job expectations. The incident occurred when the hospitality aide failed to arrange for coverage during their absence, and the registered nurse did not provide the required supervision, leading to the resident's unsupervised wandering.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to five residents or their representatives when they were transferred to a hospital or for therapeutic leave. This deficiency was identified during a review of the facility's practices and documentation. The facility's policy requires that at the time of transfer, the resident or their responsible party should receive a copy of the bed hold policy, which specifies the duration for which the bed will be held and the conditions under which the resident must notify the facility of their intention to return. Resident 2, who has multiple diagnoses including dementia, Parkinson's disease, severe intellectual disability, and schizophrenia, was transferred to an acute care emergency department after becoming unconscious. The review of Resident 2's medical record showed no evidence that the resident or his representative was given notification of the bed hold requirement. Similarly, Resident 292, who was admitted with conditions such as anemia, depression, and chronic pain, was transferred to a hospital after reporting severe chest pain, but there was no documentation of a bed hold policy being provided. Additional residents, including Resident 14 with chronic kidney disease, Resident 73 with a cerebral infarction, and Resident 130 with a knee replacement, were also transferred to hospitals without receiving the required bed hold notification. Interviews with the Assistant Director of Nursing confirmed that the facility did not provide the necessary written notice to residents or their representatives, although the Long-Term Care Ombudsman was notified of the transfers.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments for 12 out of 29 sampled residents within the required timeframe. This deficiency was identified during interviews and record reviews, revealing that the MDS assessments were not completed within 14 days, as required by the Resident Assessment Instrument (RAI) Manual. The delay in completing these assessments had the potential to delay the development of comprehensive care plans necessary for providing appropriate individualized care and services for the residents. Resident 44's case highlighted the issue, as their annual MDS assessment, which was due on 11/24/24, was found to be 8 days overdue. Similarly, Resident 41's annual MDS assessment was 24 days overdue. The MDS Licensed Nurse (MDS LN) acknowledged the delay, attributing it to the facility being very busy and behind on completing residents' MDS assessments. This backlog was further confirmed by the MDS Registered Nurse (MDS RN), who stated that the facility was significantly behind on completing discharge assessments, going back to the end of August 2024. The report also detailed several other residents with overdue MDS assessments, including Residents 7, 14, 73, 87, 27, 55, 96, 100, 291, 293, and 294. These residents had various medical conditions, such as sepsis, diabetes, heart failure, and infections, which required timely and accurate assessments to ensure their care plans were up-to-date. The MDS RN expressed concern that the incomplete MDS assessments could result in care plans not reflecting the current interventions needed for the residents' care. The facility's Administrator was aware of the backlog but was not fully informed of the extent of the issue, indicating a lack of communication and oversight in addressing the deficiency.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in their care. Resident 5, who had severe cognitive impairment and required assistance with eating, was left with an untouched lunch tray out of reach, resulting in her being unable to eat. Staff acknowledged the oversight, indicating a lack of awareness of her needs. Similarly, Resident 334, who was dependent on staff for personal hygiene, was observed with long, dirty fingernails, and there was no documentation process in place to ensure nail care was addressed during showers. Residents 23 and 29, both with good cognition but requiring substantial assistance for personal hygiene, reported not receiving regular help with oral care and hair brushing. Resident 23 expressed discomfort in asking for help, while Resident 29's hair was tangled, and oral hygiene was neglected, despite her care plan indicating the need for assistance. Staff confirmed the lack of assistance, and there was a discrepancy between the resident's account and staff's claims of refusal. Residents 73, 291, and 46 also experienced inconsistent oral care. Resident 73, with severely impaired cognition, was found with dry mucus membranes and debris in the mouth, contradicting staff claims of regular oral care. Resident 291, mildly cognitively impaired, lacked access to oral hygiene items, and records showed infrequent care. Resident 46, with intact cognition, reported never being offered oral care, and staff could not locate his oral hygiene items. The facility's documentation indicated inconsistent care, and staff interviews revealed a lack of adherence to care plans and personal preferences for oral hygiene.
Deficiencies in Skin Care and Monitoring for Two Residents
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents. Resident 44, who was admitted with multiple diagnoses including sepsis, Parkinson's, and chronic kidney disease, experienced a deficiency in care related to her Moisture Associated Skin Damage (MASD). Despite having an order for coccyx treatments to be administered daily, there were 13 instances where the treatments were not documented as completed. Interviews with the Treatment Nurse and Assistant Director of Nursing confirmed the lack of documentation, indicating that the treatments may not have been administered as required. Resident 5, who was admitted with anoxic brain damage, dementia, and lymphedema, also experienced a deficiency in care. An order was in place to monitor her left lower extremity venous ulcers for signs of worsening or infection every shift. However, there were seven shifts where the monitoring was not documented, and the Assistant Director of Nursing confirmed that assessments were not performed on three specific shifts. This lack of consistent monitoring could have led to a change in condition going unnoticed. The facility's policies on skin integrity and medication administration were not adhered to, as evidenced by the missing documentation and unperformed treatments. The Assistant Director of Nursing acknowledged the deficiencies in both cases, highlighting a failure to ensure that residents received the necessary care and treatment as per their medical orders.
Failure to Implement Downtime Procedures During Internet Outage
Penalty
Summary
The facility failed to implement its downtime policies and procedures during an internet outage, which occurred on 12/13/24. This outage resulted in the staff's inability to access the residents' electronic medical records (EMR), potentially delaying resident care. The facility's policy, titled 'Downtime Access to Patient Records,' outlined that a 24-hour summary should be saved daily and accessible to staff during network outages. Additionally, the policy stated that a jetpack device should be used to connect to a wireless network to access the EMR remotely. However, during the outage, staff members, including Licensed Nurses (LNs) A and B, were unable to access the EMR using the provided cell phones or the jetpack devices, as these devices were not functioning as intended. Throughout the morning, staff members were observed struggling to access the EMR and were unable to document medication administration. The Assistant Director of Nursing (ADON) informed the LNs that paper Medication Administration Records (MARs) were being printed as a temporary solution. Despite efforts to resolve the issue, including contacting the facility's IT department, the internet remained down, and the jetpack devices were ineffective. The situation persisted until the internet was restored later in the morning, allowing staff to resume normal operations. The deficiency was confirmed by the ADON, who acknowledged the internet outage and the non-functional jetpack devices.
High Medication Error Rate and Inventory Issues
Penalty
Summary
The facility was found to have a medication error rate of 27.59% during a survey, which is significantly higher than the acceptable threshold of 5%. This was observed during medication passes for two residents. For Resident 73, who has a history of dysphagia, dementia, and gastrostomy status, several errors were noted. The Licensed Nurse (LN) A was observed preparing medications without measuring the water used for flushing the g-tube or mixing the Juven packet, contrary to the facility's policy and the manufacturer's instructions. Additionally, LN A attempted to administer Lansoprazole multiple times without success, as the medication beads did not dissolve properly due to the use of cold water instead of warm water as required. Furthermore, the Biotene Spray was not spread around the mouth as recommended. For Resident 184, the survey revealed that the facility failed to provide vitamin D3 as ordered. LN T was unable to locate the medication in the medication cart or storage rooms and subsequently planned to notify the physician and contact the pharmacy. This indicates a lack of proper medication inventory management, which led to the resident not receiving the prescribed medication. The Director of Nursing (DON) confirmed the absence of specific orders for water flushes between medications for Resident 73 and acknowledged the discrepancies in the water measurements used for the Juven packet. The DON also confirmed that the facility should not have run out of vitamin D3 for Resident 184. These findings highlight the facility's failure to adhere to medication administration protocols and ensure the availability of prescribed medications, which could potentially compromise resident health.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label drugs in accordance with professional standards, leading to several deficiencies. One incident involved a medication label that did not match the physician's order for a resident. The label indicated that modafinil was to be taken as needed, while the order specified it should be taken once daily. This discrepancy was confirmed by both the Licensed Nurse (LN) and the Director of Nursing (DON), who acknowledged that the label and order should have matched. In another instance, the medication storage conditions were found to be inadequate. The freezer section of the medication refrigerator in the [NAME] Wing had ice buildup and icicles, which posed a risk of contamination to medications stored nearby. An emergency medication kit was found in a tray with ice and clear liquid, further indicating potential contamination. The DON confirmed these observations and acknowledged the risk of medication contamination due to the storage conditions. Additional issues included unlabeled medication cups and a pill cutter covered in residual pill powder found in a medication cart, expired Ativan in an emergency kit, and a loose pill in another medication cart. Furthermore, a medication cart was found to have cleaning supplies stored alongside medications, which is against the facility's policy. An unlabeled Kangaroo bag used for administering water through a peg-tube was also found in a resident's room, lacking proper identification of its contents. These findings highlight the facility's failure to maintain safe and compliant medication storage and labeling practices.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during a survey conducted over several days. The kitchen had accumulated grime and dust, particularly in the walk-in refrigerator and on various kitchen equipment, such as food processors and storage containers. The Dietary Services Manager acknowledged that deep cleaning of pots and pans occurred weekly, but there was no evidence of a comprehensive cleaning schedule for other areas, such as the walk-in refrigerator. Staff did not consistently adhere to professional standards to prevent cross-contamination. Observations revealed that kitchen staff did not properly use hair restraints, with facial hair left uncovered, and gloves were not changed between tasks, leading to potential contamination. Aprons were improperly stored, increasing the risk of cross-contamination. Despite training on these topics, staff did not consistently follow the guidelines, as evidenced by multiple observations during the survey. The facility also failed to consistently document food cooling processes, which are critical for food safety. The cooling log for certain food items, such as flan, lacked start times, making it impossible to determine if cooling met safety requirements. Additionally, pureed fish prepared by staff did not match the consistency required by the facility's diet manual, resulting in a thick, gummy texture. Despite ongoing training and education, these issues persisted, raising concerns about the effectiveness of the facility's training and oversight processes.
Failure to Follow Preplanned Vegetarian Menu Cycle
Penalty
Summary
The facility failed to adhere to a preplanned standardized menu cycle or provide cooks with spreadsheets for vegetarian meals, potentially compromising the nutritional needs of vegetarian residents. The facility's assessment indicated a commitment to meeting individualized dietary requirements, including specialized diets and cultural or ethnic dietary needs. However, the facility did not have a vegetarian menu cycle or cook's spreadsheets, unlike other diets that had a four-week menu cycle. The Registered Dietitian (RD) and the Medical Director had approved a diet manual that included guidelines and a sample menu for a vegetarian diet, but there was no evidence of a comprehensive vegetarian menu cycle or nutrient analysis specific to vegetarian meals. Interviews with kitchen staff revealed that vegetarian meals were prepared based on available ingredients and personal judgment rather than a structured menu. The staff mentioned a vegetarian recipe binder, but it was not present in the kitchen as the RD had it. The facility provided a four-week vegetarian menu to surveyors, but it did not align with the meals reportedly prepared for a vegetarian resident, such as cheesy potatoes and tacos. The RD was unaware if the nutrient analysis provided was for vegetarian alternatives or standard meals, indicating a lack of clarity and organization in meeting the dietary needs of vegetarian residents.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food was served at an appetizing temperature, as observed during a survey. Four out of twenty-nine residents interviewed reported that their meals were consistently cold. Resident 29, who was on a fortified mechanical soft texture diet, expressed dissatisfaction with the taste and temperature of the meals, which were barely warm. Resident 284 and Resident 54 also reported that their food was cold, with Resident 54 noting that being in the last hall contributed to this issue. Resident 44 mentioned that the food was cold upon arrival and that staff were not allowed to reheat it. Observations during the survey revealed that the meal tray line was frequently stopped due to missing items, causing delays. The meal cart schedule indicated staggered delivery times, with the last trays being delivered significantly later. Temperature checks of test trays showed that food temperatures were below the recommended levels, with pureed and regular diet trays showing temperatures as low as 95 F to 116 F. Despite the flavor being deemed pleasant, the food was not warm enough, confirming the residents' complaints.
Failure to Meet Dietary Texture Needs
Penalty
Summary
The facility failed to meet the individual dietary texture needs of six residents, as observed during a survey. The deficiency was identified when the food consistencies provided did not align with the facility's diet manual standards or the residents' preferences. Specifically, during a lunch tray line observation, kitchen staff placed whole parsley sprigs on trays for residents on pureed and mechanical soft diets, contrary to the diet manual's instructions to use parsley flakes to reduce choking risks. Additionally, the pureed fish prepared by kitchen staff was found to have a gummy texture, which did not meet the required smooth consistency as per the facility's diet manual and recipe guidelines. The report also highlighted that a resident expressed dissatisfaction with the dryness of the food, stating that no one had inquired about her food preferences or need for moist foods. The resident's lunch tray ticket did not indicate any alerts regarding moist food preferences, although it did list specific food dislikes. The dietary services manager and registered dietitian acknowledged the gummy texture of the pureed fish during an evaluation, although they did not consider it a choking hazard. These observations and interviews indicate a failure in the facility's dietary services to adhere to prescribed dietary modifications and resident preferences, potentially impacting residents' ability to consume their meals safely and comfortably.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain professional standards of practice in food service safety, leading to several deficiencies. The kitchen was found to be unsanitary, with dust and grime accumulated in the walk-in refrigerator and freezer, and soiled equipment such as pots, pans, and storage bins. The cook's food preparation sink was used improperly for multiple tasks without proper cleaning, increasing the risk of cross-contamination. Additionally, a box fan in the kitchen was covered in thick dust, posing a contamination risk. Kitchen staff did not adhere to professional standards to prevent cross-contamination. Aprons were improperly stored with personal belongings, and gloves were not changed between tasks, leading to potential contamination. Hair restraints were not effectively used, as observed with a staff member's facial hair exposed during food preparation. The ambient food cool down process was inconsistently performed, with missing or incomplete temperature logs, raising concerns about food safety. The facility also lacked an effective process for managing dented cans, with dented cans found in the dry storage room without a designated area for separation. Three nursing unit nourishment rooms were unsanitary, with soiled condiment drawers, refrigerators, and counters, and personal items stored inappropriately. Non-food-safe chemicals were used to clean food contact surfaces in these rooms, contrary to manufacturer recommendations and facility policy.
Sanitary Food Storage Deficiency in Nourishment Rooms
Penalty
Summary
The facility failed to ensure sanitary food storage for residents' personal food in three nursing unit nourishment rooms. Observations revealed that resident food stored in the freezer was not labeled with patient identifiers such as name, room number, and date, which is necessary to ensure the correct patient receives their personal food items. This lack of labeling had the potential to cause foodborne illness and a decline in residents' quality of life if personal foods were discarded or given to someone else. During observations, the nourishment rooms were found to be commingled with large plastic closets full of employee personal belongings, including coats and opened beverages stored on counters. The rooms were also noted to have soiled and sticky floors, uncovered trash, and soiled condiment drawers. The refrigerators and freezers contained various unlabeled and undated food items, including ice cream, protein shakes, and fruit cocktail, which were not properly stored according to the facility's policy. Interviews with staff, including a housekeeper, the Dietary Services Manager, a Registered Dietician, and the Director of Nursing, confirmed that staff personal belongings and food were a consistent problem in the nourishment rooms. The Director of Nursing acknowledged that the rooms were not intended for staff use and that the facility had not removed the plastic closets used during COVID. The facility lacked a policy on the storage of employee personal property, food, or beverages, contributing to the ongoing issues in the nourishment rooms.
Deficiency in Timely Completion of Resident Assessments
Penalty
Summary
The facility failed to effectively utilize its Quality Assessment and Performance Improvement (QAPI) program to identify and resolve deficiencies related to the timely completion of residents' assessments. This deficiency affected 13 out of 29 sampled residents, potentially leading to inaccurate data regarding their health status and delaying the development of comprehensive, individualized care plans. The facility's QAPI policy outlines goals and objectives aimed at identifying and resolving negative outcomes, supporting root cause analysis, and coordinating performance improvement projects. However, the facility did not adhere to these guidelines, resulting in incomplete Minimum Data Set (MDS) assessments. During interviews, the Minimum Data Set Registered Nurse (MDS RN) acknowledged being significantly behind in completing MDS assessments, citing insufficient nursing hours as a contributing factor. The MDS RN expressed concern that incomplete assessments could lead to outdated care plans, impacting resident care. The Administrator admitted awareness of the backlog but was not fully informed of its extent. The Administrator expected the MDS RN to report such issues to facilitate a root cause analysis and corrective action, which had not occurred, contributing to the ongoing deficiency.
Inadequate Infection Control PIP Implementation
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to develop and implement appropriate plans of action to correct an identified deficiency related to infection control. This deficiency was noted during a review of the facility's Quality Assessment and Performance Improvement (QAPI) policy, which lacked a revised date. The policy outlined the design and scope of the QAPI program, governance and leadership, systems to monitor care and services, performance improvement projects, and systematic analysis and action. However, the facility did not adhere to these guidelines, particularly in the area of infection control. During interviews and record reviews, it was revealed that the facility had an ongoing Infection Control Performance Improvement Project (PIP) initiated by a previous Infection Control Preventionist (IP) in May 2023. The current IP had been conducting hand hygiene audits since July 2024, but only two audit reports were available, dated July 9 and July 16, 2024. The Administrator could not provide documentation of the resources, plan, action, and goals for the ongoing Infection Control PIP. Additionally, the Assistant Director of Nursing (ADON) admitted that the facility's document titled 'Hand Hygiene and Personal Protective Equipment QAPI Statement and Charter' did not contain essential elements of PIPs, such as root cause analysis, feedback systems, plans of action, implementation timelines, and benchmarks.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to ensure effective infection control practices in several areas, as observed during a survey. Staff members did not consistently perform hand hygiene during meal service, which is a critical procedure for preventing the spread of healthcare-associated infections. Multiple instances were noted where CNAs and other staff members handled food and interacted with residents without sanitizing their hands before and after these activities. This lack of adherence to hand hygiene protocols was confirmed through interviews with the staff, who either admitted to not following the procedures or were unsure of the requirements. The nourishment rooms in the nursing units were found to be unsanitary, with food debris, grime, and personal staff items stored inappropriately. The use of non-food-safe chemicals to clean food contact surfaces further compounded the issue, as the facility's disinfectant was not verified as safe for use in food service areas. Additionally, the RNA room was observed to be unsanitary, with live cockroaches present, and the room's condition was not conducive to maintaining a hygienic environment for resident care. Specific resident care practices also failed to meet infection control standards. For instance, a resident's CPAP and nebulizer equipment were found to be dirty, and oxygen tubing was observed on the floor where insects were present. In another case, a bedpan was improperly stored under a resident's bed without a barrier, and a CNA was observed handling personal care items with soiled gloves during peri care. Furthermore, a licensed nurse did not follow proper procedures when checking a resident's blood sugar, failing to use barriers and appropriate disinfectant wipes, which posed an infection control concern.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of pests in various areas. An unidentified bug resembling an earwig was observed in a resident's room, which was cluttered with cardboard boxes and had a buildup of grime. The Maintenance Supervisor acknowledged ongoing pest issues, including cockroaches, and noted that the facility had a monthly pest control service. However, the service primarily focused on spraying outside the facility, and there was a lack of deep cleaning in affected areas due to staffing shortages. In the Restorative Nursing Assistant (RNA) dining room, cockroaches were observed on multiple occasions, including during meal times when residents were present. The room was noted to be dirty, with grime on the floors and baseboards. Interviews with staff revealed that the pest control company did not regularly spray inside the facility, and deep cleaning was not routinely performed. The presence of cockroaches was a known issue, yet there were no additional actions taken to address the infestation effectively. The facility's nourishment rooms, where resident food is stored, were also found to be unsanitary and cluttered with employee personal belongings. Open beverages and uncovered trash were present, creating conditions conducive to pest infestations. Despite the ongoing presence of cockroaches, there were no Quality Assurance/Performance Improvement (QAPI) processes in place to address the issue. The facility's failure to implement an effective pest control program compromised the health and safety of residents, staff, and visitors.
Failure to Address Resident Grievance Regarding Privacy Violation
Penalty
Summary
The facility failed to address a grievance raised by a resident, identified as Resident 183, regarding staff going through her personal belongings without permission. Resident 183, who was admitted with severe sepsis, a urinary tract infection, and metabolic encephalopathy, expressed her concerns during an observation and interview. Despite the resident's clear expression of distress and her statement that the night staff had invaded her privacy, the Social Service Director (SSD) did not offer the resident the opportunity to file a grievance report. This oversight was noted during a review of the facility's grievance procedure, which mandates that grievances be taken seriously and reported appropriately. Further investigation revealed that the facility's grievance binder, managed by the Activities Director (AD), contained no grievance report for the month in question. Interviews with the SSD and the Assistant Director of Nursing (ADON) confirmed that staff were expected to file grievance reports on behalf of residents. However, the SSD acknowledged hearing the resident's complaint but did not take immediate action to file a report or initiate an investigation. This inaction led to the resident's grievance going unaddressed, highlighting a failure in the facility's grievance handling process.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and the State Long-Term Care Ombudsman when the resident was sent to the hospital for emergency care. The facility's policy requires that before a transfer or discharge, the resident and, if applicable, a family member or legal representative must be notified in writing, including the reasons for the move, the effective date, the location to which the resident is transferred, the right to appeal, and the contact information for the State LTC Ombudsman. However, this procedure was not followed for a resident who was admitted with multiple diagnoses, including anemia, depression, anxiety, chronic pain, heart disease, and lung disease, and who was her own representative. The resident was admitted to the facility and within less than 24 hours, she became agitated and reported severe chest pain, leading to her transfer to an acute hospital for further evaluation. During interviews, the Assistant Director of Nursing (ADON) confirmed that there was no written notice of discharge provided to the resident or the Ombudsman, as required by the facility's policy. This oversight had the potential to disrupt the coordination of support for the resident during discharge planning.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the required 92 days for two residents, Resident 57 and Resident 8. Resident 57, who was readmitted with multiple diagnoses including stroke, dementia, and chronic pain, had a quarterly MDS assessment dated 10/28/24 that was not completed by the due date of 11/12/24, making it 35 days overdue. During a review, the Minimum Data Set Licensed Nurse (MDS LN) acknowledged the delay and attributed it to the facility being very busy and behind on completing residents' MDS assessments. Similarly, Resident 8, admitted with conditions such as sepsis, heart failure, and bipolar disorder, had a quarterly MDS assessment dated 11/16/24 that was due by 11/30/24 but was 18 days overdue. The Minimum Data Set Registered Nurse (MDS RN) expressed concerns about the backlog of MDS assessments and the potential impact on residents' care plans, noting that the issue had been discussed with the facility's Administrator. The MDS RN highlighted the shortage of nursing hours as a contributing factor to the delay in completing the assessments.
Inaccurate PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Level 1 Preadmission Screening and Resident Review (PASARR) for a resident, which is crucial for determining the appropriateness of admission for individuals with mental disorders or intellectual disabilities. Specifically, the Level 1 PASARR for a resident was missing a diagnosis of bipolar disorder, which was present in the resident's admission records. Additionally, the PASARR incorrectly included a diagnosis of dementia, which was not documented in the resident's discharge summary or any records until a later date. This discrepancy was confirmed during interviews and record reviews with the Health Information Assistant (HIA) and the Minimum Data Set (MDS) nurse. The Assistant Director of Nursing (ADON) and HIA confirmed that the hospital was responsible for performing the initial PASARR, while the facility's medical records department was tasked with ensuring its accuracy. However, the facility did not provide a policy and procedure outlining the PASARR process when requested. The ADON acknowledged the discrepancies in the PASARR, which could potentially lead to residents being admitted without a proper understanding of their mental health needs or the facility's ability to meet those needs.
Failure to Implement Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to develop and implement an individualized care plan for a resident identified as malnourished at admission, resulting in significant weight loss. The resident, who was capable of making her own healthcare decisions, experienced an 11-pound weight loss, equating to 6.24% of her body weight, over a two-week period. Despite being at risk for weight loss due to inadequate intake and other factors, no care plan was created to address this issue. Observations and interviews revealed that the resident was aware of her weight loss but was not informed of any plan to address it. The Restorative Nursing Aid (RNA) confirmed that the resident's weight was monitored weekly and reported to the Registered Dietitian (RD) when significant weight loss was detected. However, the RD could not find documentation of any follow-up actions or discussions with the resident regarding her weight loss. Further review with the Assistant Director of Nursing (ADON) confirmed that the facility had regular meetings to discuss nutrition and weight loss issues, but no such meeting was held for this resident. The ADON acknowledged the absence of a weight loss care plan and the lack of an Interdisciplinary Team (IDT) meeting to address the resident's significant weight loss, indicating a failure in the facility's processes to manage the resident's nutritional needs effectively.
Improper Use of DeClogger on Resident's Peg-Tube Without Physician's Order
Penalty
Summary
The facility failed to provide professional standards of care for one resident when Licensed Nurses (LNs) used a DeClogger on the resident's peg-tube without a physician's order, a care plan, or a monitoring system in place. The DeClogger, a device used to de-clog peg-tubes, was used on a resident who was not their own responsible party and had been admitted with diagnoses including dysphagia, dementia, and gastrostomy status. The DeClogger package instructions indicated it was for use with a physician's prescription, yet no such order was present. During an observation, LN A was seen using the DeClogger multiple times on the resident's peg-tube without measuring the water mixed with medication and without flushing the tube after use. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed there was no physician's order for the DeClogger, and the resident's care plan did not include its use. Additionally, there was no treatment monitor to track the frequency of DeClogger use, which could lead to unnoticed peg-tube malfunctions and potential health declines.
Inadequate Peri-Care Leads to Repeated UTIs
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections (UTIs) for one resident, identified as Resident 44, due to improper peri-care by Certified Nursing Assistants (CNAs). Resident 44, who was fully dependent on staff for toileting and perineal hygiene, reported that CNAs did not clean her adequately after incontinent episodes, leading to discomfort and repeated hospitalizations for UTIs. The resident's medical history included conditions such as sepsis due to E. coli, urinary tract infection, Parkinson's disease, diabetes, and chronic kidney disease. Lab results confirmed the presence of E. coli in her urine, and she was treated with antibiotics. Interviews with staff revealed that the Infection Preventionist had not conducted peri-care training for CNAs, despite being aware of Resident 44's complaints about inadequate cleaning. A CNA reported finding dried bowel inside the resident's vagina, indicating incomplete cleaning after an incontinent episode. The Infection Preventionist acknowledged that improper peri-care could lead to UTIs and emphasized the importance of thorough cleaning from front to back. The Assistant Director of Nursing also stated that residents should be cleaned completely, aligning with the expectations for proper hygiene to prevent infections.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to maintain the nutritional status of Resident 288, who experienced significant weight loss over a two-week period. Resident 288, identified as malnourished upon admission, lost 11 pounds, equating to a 6.24% decrease in body weight, from November 19, 2024, to December 3, 2024. This weight loss was not identified in a timely manner, and no interventions were implemented to address the issue, despite the facility's policy requiring weekly weight monitoring and re-weighing in cases of significant weight changes. The Registered Dietitian (RD) and Restorative Nursing Aid (RNA) were involved in the weight monitoring process. The RNA reported Resident 288's weight loss to the RD on December 3, 2024, but the RD did not document this in the resident's clinical record. Additionally, the RD failed to initiate a weight loss care plan or bring the issue to the Interdisciplinary Team (IDT) for discussion, as required by the facility's procedures. The RD acknowledged the oversight but could not find any notes or documentation regarding the weight loss or any discussions with the resident about a plan to address it. The Assistant Director of Nursing (ADON) confirmed that the facility held regular meetings to discuss nutrition, hydration, and skin issues, where weight loss cases should be addressed. However, no such meeting was held for Resident 288, and no care plan was initiated to manage the resident's weight loss. The ADON expected the RD to identify and address the weight loss issues, but this did not occur, leading to a failure in maintaining the resident's nutritional status.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide necessary monitoring for a resident who was prescribed antipsychotic medications, specifically Asenapine and Haloperidol. The resident, who was not their own responsible party, had diagnoses including dementia, bipolar disorder, and unspecified psychosis. Despite the physician's orders for Asenapine Transdermal Patch to be applied daily for mood swings and outbursts, there was no monitoring in place to track specific behaviors related to the use of this medication. This lack of monitoring was confirmed during an interview and record review with a Registered Nurse/Neuropsychiatric Assistant (RN/NA). Additionally, the facility did not have monitoring in place to assess for adverse reactions to Haloperidol, which was prescribed to the resident for mood swings evidenced by emotional outbursts and aggression. The facility's policy required staff to monitor residents on antipsychotics for complications or side effects, but this was not done for the resident. The absence of monitoring for both medications was confirmed during the same interview and record review with the RN/NA, indicating a failure to adhere to the facility's policies and procedures.
Deficiencies in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure adequate oversight of the Food and Nutrition Services (FNS) by the Registered Dietitian (RD) and Dietary Services Manager (DSM). The RD did not provide evidence of regularly scheduled consultations and audits of the kitchen, and the documentation provided did not offer detailed insights into the issues identified. The RD's oversight was questioned as sanitation and food safety concerns were observed, including soiled equipment, potential cross-contamination, and improper food handling practices. The RD's audits showed declining scores in various areas, but there was no detailed information to understand the reasons behind these declines or if corrective actions were being taken. Effective systems and monitoring were not in place to ensure the sanitation of the kitchen, proper food cooling, consistency of pureed foods, and management of dented cans. The kitchen was found to be unsanitary, with dust and grime accumulation, improper use of the cook's prep sink, and inadequate cleaning practices. Food cooling logs were incomplete, and there was a lack of documentation to verify that food temperatures were being properly monitored. The preparation of pureed diets did not follow the prescribed recipes, resulting in improper food consistency. Additionally, dented cans were found in the kitchen's dry storage room, and there was no clear process for handling them. The facility also failed to follow a pre-planned vegetarian menu cycle for residents requiring vegetarian diets. Although a four-week vegetarian menu cycle was reportedly in place, kitchen staff were unaware of it and did not follow it. Instead, they prepared meals based on their discretion, which did not align with the documented menu. This lack of adherence to the planned menu cycle raised concerns about the facility's ability to meet the dietary needs of residents with specific dietary requirements.
Failure to Provide Arbitration Agreement in Resident's Language
Penalty
Summary
The facility failed to explain the terms of the arbitration agreement to a resident in a language that she understood. Resident 283, who was admitted with diagnoses including left knee osteoarthritis and an artificial left knee joint, primarily speaks Spanish and is capable of making her own healthcare decisions. However, the arbitration agreement was provided to her only in English, despite the Admissions Transition Coordinator (ATC) being aware that Resident 283 only spoke and understood Spanish. The ATC relied on the resident's son, who spoke English, to agree to the terms, leading to Resident 283 signing a document she did not comprehend. During an interview with the assistance of an interpreter, Resident 283 confirmed that she signed the agreement because her son instructed her to do so, without understanding its contents. The ATC admitted to providing the arbitration agreement in English and acknowledged that no effort was made to communicate the terms in Spanish or ensure that Resident 283 understood what she was signing. This oversight resulted in the resident being unable to make an informed decision regarding the arbitration agreement, potentially denying her rights.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain medication to a resident in accordance with the resident's comprehensive care plan and physician's orders, leading to increased pain and discomfort. The resident, who had a history of a broken leg, muscle weakness, lung disease, and chronic pain, was supposed to receive Norco every four hours. However, the medication was frequently administered late, beyond the 60-minute window allowed by the facility's policy. The resident reported that the delay in receiving pain medication caused her pain to increase, making it difficult to manage. The Medical Administration Record (MAR) showed that from June 11 to June 26, the resident received 12 doses of Norco more than 60 minutes late. Interviews with the nursing staff revealed various reasons for the delays, including busy shifts and shared medication carts, which contributed to the late administration of medication. The Executive Nurse Director confirmed that the Norco tablets were given late on 12 occasions, contrary to the facility's policy. Despite one nurse's claim that the medication was administered on time but recorded late, the narcotic count book did not support this assertion. The facility's failure to adhere to the scheduled times for administering pain medication resulted in the resident experiencing increased pain and discomfort.
Resident Abducted by Restricted Visitor Due to Inadequate Visitor Screening
Penalty
Summary
The facility failed to protect a resident from mistreatment and mental abuse when a restricted visitor abducted him from the facility. The resident, who had severe cognitive impairment and was unable to make his own healthcare decisions, was taken by a restricted visitor to a local check cashing business with the intent of financial exploitation. The facility's visitation policy lacked procedures to address visitor precautions or restrictions, allowing the restricted visitor to enter the facility using a fictitious name without being identified or questioned. The receptionist on duty at the time of the incident was not fully trained on handling visitors and did not check the Visitor and Phone Call Precautions list, which included the names of restricted visitors. The receptionist allowed the visitor to sign in with a false name and did not verify the visitor's identity or reason for the visit. Additionally, the facility staff, including nurses and certified nursing assistants, were not adequately informed or trained on the procedures for handling restricted visitors, leading to a lack of communication and awareness about the resident's vulnerability and the presence of restricted visitors. The facility's failure to implement a comprehensive visitor screening system and adequately train staff on visitor management contributed to the resident's abduction. The staff did not consistently check the restricted visitor list or the resident's care plan for special instructions regarding visitors. The lack of a coordinated approach to visitor management and the absence of a clear policy for handling restricted visitors resulted in the resident being taken from the facility without proper authorization or supervision.
Removal Plan
- All facility staff training on the new policy titled Visitation which included checking identification for all visitors coming to visit a resident on the Visitor and Phone Call Precaution list.
- The Visitor's log will now include reason for visit and pictures of restricted visitors.
- Nursing staff should be aware of all visitors and any concerns regarding visitors should be reported to immediate supervisor or security/maintenance.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
