Oxnard Manor Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oxnard, California.
- Location
- 1400 West Gonzales Road, Oxnard, California 93036
- CMS Provider Number
- 056379
- Inspections on file
- 42
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Oxnard Manor Healthcare Center during CMS and state inspections, most recent first.
A resident with ESRD receiving HD via an AVF in the right upper arm did not receive care consistent with professional standards when facility nurses failed to consistently complete and accurately document pre- and post-dialysis evaluations and AVF site assessments. Dialysis unit records repeatedly noted that dressings applied after HD were left on for multiple days, resulting in damp, longstanding dressings and raw, sore skin at the access site. Facility records lacked documentation that post-dialysis dressings were removed or that the AVF site was monitored for infection, even after a wound culture from the access grew Pseudomonas aeruginosa and Staphylococcus aureus and antibiotics were started. Interviews with LNs and the DON confirmed that assessments were missed, access sites were charted as WNL despite available descriptors for abnormal findings, dressings were assumed to be from facility treatments, and required inspection of the AV shunt site for color, warmth, redness, edema, and drainage was not performed as outlined in facility P&P.
A resident with ESRD and dependence on hemodialysis developed a new infection at the AVF access site, confirmed by wound culture showing Pseudomonas aeruginosa and Staphylococcus aureus and resulting in orders for IV antibiotics. Facility staff did not complete a comprehensive assessment, did not develop an individualized care plan with interventions for the new infection, and did not document monitoring for signs and symptoms of infection or complications. Interviews with LNs confirmed that no change-of-condition process was initiated after dialysis staff reported positive cultures and antibiotic treatment, contrary to the facility’s change-in-condition policy requiring assessment, care planning, and physician notification with lab result reporting.
An electrical outlet in a resident's room was found without a protective cover plate, exposing wiring. The issue was not reported to maintenance or logged for repair, contrary to facility policy requiring hazards to be addressed.
A facility failed to document and notify a physician about a missed insulin dose for a resident with Type 2 Diabetes Mellitus. The MAR indicated the medication was held, but lacked documentation explaining the reason or any record of physician notification, contrary to facility policy. The DON confirmed these omissions during a review.
A facility failed to follow physician orders and medication administration policy for a resident with liver disease and hypertension. Staff did not seek physician clarification for Lactulose dosage adjustments, failed to notify the physician about the unavailability of Rifaximin, and did not check vital signs before administering Propranolol. These actions were identified during a review of the resident's records and staff interviews.
A facility failed to document a resident's cataract diagnosis, as revealed during a review of medical records and interviews with the DON. Despite evidence from an Eye Health Consult form and a Complete Exam/Visit-Office form from an eye clinic, the resident's diagnosis was not reflected in the facility's records, care plan, or physician orders. This oversight had the potential to negatively impact the resident's care.
The facility failed to label and discard perishable food items in accordance with its policy. During an inspection, an undated container of frozen stew and an undated plastic bag with rolls were found in the resident refrigerator. The facility's policy requires such items to be labeled with the resident's name and date received, and discarded after 48 hours if refrigerated. The DON and Administrator acknowledged the oversight, which could potentially lead to foodborne illness.
A resident at risk for falls due to decreased mobility and weakness sustained a fall. The care plan included hourly rounding to anticipate needs, but the facility failed to document or implement this intervention throughout the month. The Director of Nursing and Administrator confirmed the lack of documentation, highlighting a failure to follow the facility's care planning policy.
The RD at the facility failed to follow current standards of practice in nutrition assessments for obese residents and those with unstageable pressure injuries. The RD used an adjusted body weight method for an obese resident, potentially promoting unplanned weight loss, and did not reassess nutritional needs for a resident with an unstageable pressure injury. Additionally, the RD did not communicate a resident's diet preferences to the dialysis center, affecting coordinated care.
The facility failed to follow planned menus for therapeutic diets, affecting residents on mechanical soft and renal diets. Observations showed that residents on mechanical soft diets received intact salad instead of soft chopped vegetables, and a resident on a renal diet received milk at lunch against meal ticket instructions. These errors were identified by staff during meal service, highlighting the need for adherence to dietary guidelines.
The facility failed to maintain a homelike environment, as observed in one resident room with wall damage and a damaged bathroom door frame, and in two shower rooms with disrepair issues. The maintenance assistant and Environmental Services Director confirmed these deficiencies, which contradict the facility's policy to provide a safe, clean, and comfortable environment.
The facility failed to develop comprehensive care plans for two residents, leading to unmet needs. One resident's preference for warm water was not documented, requiring self-service. Another resident's nutrition care plan lacked clear weight goals and did not involve the responsible party in diet decisions. These oversights violated facility policies on resident rights and care planning.
A resident undergoing dialysis treatments did not have Lidocaine-Prilocaine cream documented as administered before treatment, and several medications were incorrectly signed as given while the resident was out of the facility. The DON confirmed these discrepancies, which contradict the facility's medication administration policy.
A resident with hearing impairment was not adequately assessed or assisted in obtaining a hearing device during their stay. Despite having a care plan recognizing the risk of miscommunication, there was no documentation of actions to address the resident's hearing condition. An audiology consult was scheduled, but the facility's policy to inquire about and secure the resident's hearing aid was not followed.
A facility failed to conduct proper post-dialysis assessments and maintain communication with a dialysis clinic for a resident. The resident's dialysis binder, containing instructions for post-dialysis care, was not reviewed, and there was no documentation of pain relief or vital signs. Additionally, the facility did not follow up on the resident's hospitalization after a change of condition during dialysis, as required by their contract with the dialysis clinic.
The facility failed to ensure the pureed spaghetti with meat sauce was prepared to the required smooth, pudding-like consistency, as observed during meal preparation. Despite guidelines, the initial and subsequent attempts by the Head Cook did not meet the necessary texture, potentially affecting residents with swallowing difficulties.
A dietary aide in an LTC facility failed to wash hands after handling dirty dishes before touching clean ones, as observed by another aide. The aide admitted to not being trained in proper hand hygiene. The dietary supervisor confirmed the lapse and found no competency assessment for the aide, contrary to facility policy.
A facility failed to update a resident's medical record to reflect a change in their POLST from Full Code to DNR. Despite a physician order indicating the change, the updated POLST was not uploaded into the EHR, contrary to facility policy. This oversight was confirmed during an interview and record review with an MDS nurse.
A facility failed to provide an arbitration agreement in a language that a resident's representative could understand, potentially violating the resident's rights. The resident's MDS indicated a preference for Spanish and a need for an interpreter, yet the agreement was only available in English. Interviews confirmed the representative's inability to communicate in English and the facility's practice of providing agreements solely in English.
A resident with moderate cognitive impairment left the facility unnoticed and was found at a local restaurant. The resident was not identified as an elopement risk, and staff interviews revealed a lack of adequate supervision. The facility's policy required a care plan for individual risk factors, which was not effectively implemented.
A facility failed to implement care planned interventions and physician orders for a resident, leading to missed occupational therapy sessions and inadequate follow-up on shower refusals. The resident did not receive all ordered OT treatments, and there was no documentation of attempts to address shower refusals as per the care plan.
Failure to Perform and Document Pre/Post-Dialysis Assessments and AV Fistula Site Care
Penalty
Summary
The deficiency involves the facility’s failure to provide hemodialysis care and services consistent with professional standards of practice for a resident with End Stage Renal Disease who was dependent on renal dialysis. The resident had an AV fistula in the right upper arm and standing orders for hemodialysis three times weekly, as well as an order directing staff to apply pressure and notify the MD if bleeding occurred at the AV shunt after dialysis. The resident’s care plan required staff to check and change the dressing daily at the access site, document this care, and monitor, document, and report signs and symptoms of infection and other complications. However, review of the medical record showed that pre- and post-dialysis evaluations were not consistently completed by licensed nurses on multiple dates when the resident had dialysis appointments. Dialysis documentation from the dialysis unit showed repeated comments over several weeks that the dressing on the hemodialysis access was being left on after treatment and not removed at the facility. Entries included notations that the dressing had been left on since prior treatments, that it must be removed to prevent clotting or damage to the access, and that dressings from prior dates remained in place. On one date, the dialysis staff documented that a dressing left on since a previous treatment was damp and had left raw skin and soreness at the access site. A subsequent wound culture from the access site grew heavy Pseudomonas aeruginosa and moderate Staphylococcus aureus, and the physician ordered antibiotics including Vancomycin and Ceftazidime. Despite this, there was no documentation in the facility record that the access site was monitored for infection after the positive culture and initiation of new antibiotic therapy. Interviews with multiple licensed nurses and the DON confirmed gaps and inaccuracies in assessment and documentation. One nurse acknowledged signing post-dialysis evaluations without documenting removal of the dialysis dressings. Another nurse acknowledged that pre-dialysis assessments documented the access site as within normal limits even though the electronic record offered more specific options such as redness, swelling, pain, bleeding, or skin discoloration, and that these more accurate descriptors were not selected. This nurse also stated she was unaware that the dressing on the AVF site was from the previous dialysis session and confirmed that no observations were done to monitor for signs of inflammation, infection, or to inspect the shunt site for color, warmth, redness, edema, and drainage. A third nurse confirmed that on several dates when she was assigned to the resident, pre- or post-dialysis assessments were not performed, and she had assumed the dressings on the AVF site were for facility-provided treatment. The DON confirmed that post-dialysis dressings should be removed within a specified time frame and that the dialysis center had communicated multiple times that the resident was returning with dressings still in place from prior treatments, contrary to facility policies requiring daily assessment and inspection of the AV shunt site once per shift.
Failure to Assess and Care Plan for New Dialysis Access Infection
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nurses were competent in providing quality care by not completing a comprehensive assessment and individualized care plan for a resident who developed a new infection at a dialysis access site. The resident was admitted with end stage renal disease and dependence on hemodialysis, with orders for dialysis three times weekly and specific instructions for managing bleeding at the arteriovenous fistula in the right upper arm. A microbiology report dated 1/24/26, from a wound culture collected at the access site, showed heavy growth of Pseudomonas aeruginosa and moderate growth of Staphylococcus aureus, and the physician ordered Vancomycin and Ceftazidime. Despite these findings and the initiation of antibiotic therapy, the medical record contained no documentation of a comprehensive assessment, no individualized care plan with interventions related to the new onset infection, and no monitoring for signs and symptoms of infection or complications. Interviews and record reviews further confirmed that required change-of-condition procedures were not followed. One licensed nurse acknowledged there was no change-of-condition documentation in the resident’s record related to the positive culture results and antibiotic therapy and stated that a change of condition should have been initiated but was not. Another licensed nurse, who was assigned to and familiar with the resident, confirmed that the receiving nurse did not initiate a change of condition when dialysis staff communicated that the resident had positive bacterial cultures and was receiving antibiotics. This was inconsistent with the facility’s “Change in Condition” policy, which requires the licensed nurse to assess the change, determine appropriate nursing interventions, and notify the physician/APP with a summary of the condition change, vital signs, and focused system review, including reporting laboratory and diagnostic results.
Uncovered Electrical Outlet Found in Resident Room
Penalty
Summary
The facility failed to maintain a safe and operable environment for residents by not ensuring that an electrical outlet in one of the resident rooms was in good repair. During an observation, it was found that the wall electrical outlet outside the bathroom in the specified room was missing a cover plate, leaving electrical wiring exposed. Review of the maintenance logbook revealed that no requisition for repair of the open outlet had been made, and the maintenance supervisor confirmed that the issue had not been reported to him or entered into the logbook by any staff. The facility's policy and procedure required the maintenance department to keep the building in good repair and free from hazards at all times.
Failure to Document and Notify Physician of Missed Medication Dose
Penalty
Summary
The facility failed to ensure accurate documentation and physician notification regarding a missed medication dose for a resident with Type 2 Diabetes Mellitus. The resident was prescribed Insulin Glargine Solution to be administered subcutaneously twice daily. On one occasion, the medication was not given, and the MAR indicated a hold with a note to see the progress note. However, there was no documentation on the back of the MAR explaining why the medication was held, nor was there any record of physician notification, as required by the facility's policy. During a review, the Director of Nursing confirmed the absence of necessary documentation and notification.
Failure to Follow Physician Orders and Medication Administration Policy
Penalty
Summary
The facility failed to adhere to physician orders and its medication administration policy for a resident with liver disease and hypertension. The resident had a physician order for Lactulose to be administered every four hours with the goal of achieving four bowel movements per day. However, the staff did not seek physician clarification when the resident had fewer than four bowel movements on consecutive days. Additionally, the staff did not notify the resident's physician about the continued unavailability of the prescribed medication Rifaximin, which was on hold due to pharmacy issues, nor did they follow up with the pharmacy to obtain the medication. Furthermore, the facility did not check the resident's blood pressure or heart rate before administering Propranolol, as required by the physician's order. The medication was administered on eight occasions without the necessary vital sign checks. The facility's policy on medication administration requires that vital signs be checked and recorded when medication administration is dependent on them, but this was not done. These failures were identified during a review of the resident's medical records and interviews with facility staff.
Failure to Document Resident's Cataract Diagnosis
Penalty
Summary
The facility failed to recognize and document a resident's diagnosis of cataracts, which was identified during a record review and interview with the Director of Nursing (DON). The DON confirmed that the facility's records did not indicate the resident had cataracts, despite evidence from an Eye Health Consult form and a Complete Exam/Visit-Office form from an offsite eye specialty clinic, both of which documented the diagnosis. The resident's medical records, including the care plan and physician orders, did not reflect this diagnosis, and the facility was unable to determine how long the resident had been at the facility with this condition. This oversight had the potential to negatively impact the resident's care.
Failure to Label and Discard Perishable Food Items
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the labeling and discarding of perishable food items brought in by visitors. During an inspection of the resident refrigerator, it was observed that there was one undated container of frozen stew and one undated plastic bag containing three rolls. According to the facility's policy, food brought in by visitors must be labeled with the resident's name and date received, and perishable food requiring refrigeration should be discarded after 48 hours if not consumed. The Director of Nursing and the Administrator acknowledged that the items should have been dated when placed in the refrigerator but were not, indicating a lapse in following the established procedures. This oversight had the potential to lead to negative outcomes for residents, including foodborne illness.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall care planned interventions for a resident, identified as Resident 1, who was at risk for further falls due to decreased physical mobility, decreased endurance, and weakness. On December 2, 2024, Resident 1 sustained a fall, as documented in the Change in Condition Evaluation form. The form noted that a loud noise was heard in Resident 1's room, and upon checking, the resident was found lying on the floor with their head by the bathroom door. The resident's care plan included an intervention for every one-hour (Q1H) rounding to anticipate needs, which was not documented as being carried out throughout December 2024. During an interview and record review on January 16, 2025, with the Director of Nursing and the Administrator, it was confirmed that the facility could not provide documentation to show that the Q1H rounding intervention was implemented for Resident 1 during the specified period. The facility's policy on Comprehensive Person-Centered Care Planning, dated November 2018, emphasizes providing person-centered, comprehensive, and interdisciplinary care to meet residents' health, safety, psychosocial, behavioral, and environmental needs. The lack of documentation and implementation of the care plan intervention for Resident 1 represents a failure to adhere to this policy.
Deficiencies in Nutrition Assessment and Communication
Penalty
Summary
The Registered Dietitian (RD) at the facility failed to implement current standards of practice in nutrition assessments, particularly for elderly residents classified as obese. The RD used an adjusted body weight method to assess the nutritional needs of Resident 53, who was obese, without considering the resident's actual body weight or discussing weight goals and preferences with the resident or responsible party. This approach contradicted the resident's nutrition plan of care aimed at weight maintenance and had the potential to promote unplanned weight loss. The RD acknowledged that this was her usual practice for residents who were 150% of their ideal body weight, despite professional standards recommending the use of actual body weight for such assessments. The RD also demonstrated a lack of awareness regarding the appropriate nutritional assessment for unstageable pressure injuries. Resident 28, who had an unstageable pressure injury, was assessed using the same criteria as for a Stage 1 pressure injury, rather than the more intensive nutritional needs required for Stage 3 or 4 injuries. This oversight could delay accurate nutrition assessments and timely interventions necessary for wound healing. The facility's policies and procedures lacked adequate directives to ensure nutrition assessments were performed according to professional standards, contributing to the RD's misunderstanding of the requirements for unstageable pressure injuries. Additionally, the RD failed to communicate effectively with the RD at the dialysis center regarding Resident 40's diet order. Resident 40, who had moderate dementia and attended a dialysis center, was not on a renal diet due to personal preference, but this information was not shared with the dialysis center's RD. This lack of communication hindered the coordination of care and could lead to inconsistencies in the resident's dietary management. The facility's policy on dialysis management emphasized the importance of communication between the facility and the dialysis provider, which was not adhered to in this case.
Failure to Follow Therapeutic Diet Menus
Penalty
Summary
The facility failed to adhere to the planned menu for therapeutic diets, specifically for residents on mechanical soft diets and a renal diet. Observations revealed that three residents, who were prescribed a mechanical soft diet, received intact salad instead of the appropriate soft chopped vegetables. The Dietary Supervisor confirmed that the menu should have included cooked chopped carrots or other soft, cooked vegetables, not raw lettuce salad. This discrepancy was noted during meal service, and the error was acknowledged by the Dietary Supervisor. Additionally, a resident on a therapeutic renal diet received a carton of regular milk during lunch, contrary to the meal ticket instructions that specified milk only for breakfast. The Licensed Nurse and Dietary Supervisor both identified the error, and the milk was replaced with a fruit drink as per the renal diet menu. This oversight in following the meal ticket instructions was observed during the lunch meal service. The facility's failure to follow the planned menus for therapeutic diets had the potential to increase the risk of choking for residents on mechanical soft diets and could impede the health status of the resident on a renal diet. The report highlights the importance of adhering to dietary guidelines to ensure the safety and nutritional needs of residents are met.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in one resident room and two shower rooms, as observed during a survey. In an interview with the maintenance assistant, it was confirmed that the facility was believed to be up to date with repairs. However, during a tour, an unoccupied room was found to have wall damage with peeling paint and a damaged bathroom door frame. The maintenance assistant confirmed these damages. Additionally, during a tour of the facility's two shower rooms with the Environmental Services Director, it was observed that the east side shower room had a door frame in disrepair, and the west side shower room had broken tiles along the wall's baseboards. The Environmental Services Director confirmed these issues and acknowledged the need for repairs. The facility's policy, dated 1/1/12, states that it provides residents with a safe, clean, comfortable, and homelike environment. However, the observed damages in the resident room and shower rooms indicate a failure to adhere to this policy, potentially impacting the residents' environment negatively.
Deficiencies in Person-Centered Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for two residents, leading to deficiencies in meeting their specific needs. For Resident 65, the care plan did not identify the resident's preference for warm drinking water, resulting in the resident having to obtain warm water independently from a dispenser. This oversight was confirmed during an interview with the Dietary Supervisor, who was unaware of the resident's preference. The facility's policy on resident rights emphasizes the importance of documenting personal preferences, which was not adhered to in this case. For Resident 40, the interdisciplinary team (IDT) nutrition care plan lacked clear, measurable objectives and did not involve the resident or responsible party in setting goals related to weight management. The care plan was unclear about the specific weight maintenance goal, which impeded effective monitoring and evaluation. Interviews with the Licensed Nurse and Director of Nursing revealed uncertainty about the resident's ideal weight, and the Registered Dietitian confirmed the absence of a detailed weight goal. The facility's policy requires the inclusion of resident preferences in care planning, which was not followed. Additionally, the facility failed to involve Resident 40's responsible party in decision-making regarding the refusal of a renal diet. The Registered Dietitian admitted to not informing the responsible party of the risks and benefits associated with the diet change. The facility's policy mandates the engagement of residents and their representatives in care planning, which was not observed in this instance. This lack of communication and documentation contributed to the deficiency in providing person-centered care.
Inaccurate Medication Documentation for Dialysis Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic medical record (eMAR) for a resident undergoing dialysis treatments. The resident, who required Lidocaine-Prilocaine cream to be applied to the dialysis access site before treatment, did not have this medication documented as administered on a specific date prior to being picked up for dialysis. Additionally, several medications, including Clonidine HCl, Miralax Oral Powder, Calcium Acetate, and Hydralizine HCl, were signed as administered in the eMAR while the resident was out of the facility for dialysis treatment, indicating a discrepancy in medication administration records. The Director of Nursing (DON) confirmed these findings during an interview and was unable to provide additional information regarding the administration of Lidocaine or the incorrect eMAR entries. The facility's policy and procedure for medication administration emphasize the importance of accurate documentation and administration as prescribed, which was not adhered to in this case. This lack of accurate documentation and administration has the potential to impact the resident's quality of life and well-being.
Failure to Assist Resident with Hearing Impairment
Penalty
Summary
The facility failed to ensure that a resident who was hard of hearing was assessed and assisted in obtaining a hearing device during their stay. The resident, identified as Resident 65, was observed in a wheelchair and expressed difficulty in hearing, stating that they left their hearing aids at home to prevent them from being lost. The medical record for Resident 65 indicated a care plan initiated in June, which recognized the risk of miscommunication due to impaired hearing. However, there was no documentation of actions or plans to address the resident's hearing condition, nor was there any record of the existence of a hearing aid at home. An audiology consult was scheduled for the resident, but the facility's policy and procedure for the care of hearing-impaired residents, which included asking the resident if they had a hearing aid and requesting family members to bring it, was not followed. During an interview, the social worker mentioned an ongoing audio consult but could not provide additional information regarding the resident's hearing aids at home. This lack of action and documentation potentially compromised the resident's ability to communicate effectively with the staff.
Failure in Post-Dialysis Assessment and Communication
Penalty
Summary
The facility failed to ensure proper post-dialysis assessment and communication for a resident who required dialysis services. Upon observation, it was noted that the dialysis binder book, which should contain forms and information exchanged between the facility and the dialysis clinic, was left in the resident's room without being reviewed since the resident's return from dialysis. The binder contained a form indicating that the resident was to receive Tylenol for right leg pain post-dialysis, but there was no documentation on whether the pain was relieved or any post-dialysis vital signs were recorded. Additionally, the facility did not follow up on a previous incident where the resident experienced a change of condition during dialysis and was sent to the hospital. There was no documentation or communication from the dialysis clinic regarding this hospitalization, and the facility did not request any information. This lack of communication and documentation was acknowledged by the facility's administrator during an interview. The facility's contract with the dialysis clinic requires the clinic to provide information on the management of the resident's care, including emergencies, which was not adhered to in this case.
Failure to Follow Pureed Diet Consistency Guidelines
Penalty
Summary
The facility failed to ensure that the pureed recipe for spaghetti with meat sauce was followed correctly, resulting in a texture that was not smooth, pudding-like, or of a soft mashed potato consistency as required. During an observation, the Head Cook (HC) was seen preparing pureed spaghetti with meat sauce for residents with a pureed diet order. After blending the food, the HC transferred it to a pan, believing it was ready to be served. However, upon inspection by the Dietary Supervisor (DS) 1, it was noted that the consistency was incorrect, with small noodle particles still present. DS 1 instructed the HC to further puree the mixture, and even after a second attempt, the consistency was still not appropriate. The facility's recipe and policy for pureed diets clearly indicated the need for a smooth, pudding-like consistency to prevent potential risks such as choking and aspiration in residents with swallowing difficulties. Despite these guidelines, the HC and DS 1 initially failed to achieve the correct texture, potentially affecting eight residents with a puree diet order. The facility's policy also required the Dietary Manager and Dietitian to observe meal preparation to ensure compliance with dietary orders, which was not adequately followed in this instance.
Sanitary Practices Lapse in Dietary Department
Penalty
Summary
The facility failed to ensure sanitary practices in the dietary department, as observed during a survey. A dietary aide was seen handling dirty dishes and then moving to handle clean dishes without changing gloves or washing hands. This action was observed by another dietary aide who informed the first aide of the oversight. The dietary aide admitted to not washing her hands and also indicated that she had not been trained to do so after handling dirty dishes. Further investigation revealed that the dietary supervisor acknowledged the lapse in hand hygiene and confirmed that the dietary aide should have washed her hands after handling dirty dishes. Upon reviewing the dietary aide's competency documentation, it was found that there was no competency assessment completed for the aide, which was against the facility's policy. The facility's policy on infection control clearly stated the need for proper hand washing after handling soiled equipment or utensils, and the staff competency assessment policy required department managers to ensure competency assessments were performed for their staff.
Failure to Update POLST in Resident's Medical Record
Penalty
Summary
The facility failed to update the medical record of a resident to reflect changes in the Physician Orders for Life-Sustaining Treatment (POLST). Specifically, the resident's electronic health record (EHR) indicated a POLST dated July 11, 2023, for a Full Code status, meaning the resident was to receive all resuscitative treatment. However, a subsequent physician order dated September 19, 2023, changed the resident's status to Do Not Resuscitate (DNR), indicating no life-sustaining resuscitation should be performed. This change was not updated in the resident's EHR, as confirmed during an interview and record review with the Minimum Data Set Nurse (MDS 1). The facility's policy and procedure for handling POLST forms require that any updates be scanned and placed in the appropriate section of the health care record. Despite this policy, the updated POLST form dated September 19, 2023, was not uploaded into the EHR, as acknowledged by MDS 1. This oversight had the potential to result in the resident's life-saving preferences not being carried out as ordered by the physician, as the facility did not adhere to its policy of ensuring the POLST form was accurately reflected in the resident's medical records.
Failure to Provide Arbitration Agreement in Understandable Language
Penalty
Summary
The facility failed to provide an arbitration agreement in a language that Resident 1 or their representative could understand, which had the potential to violate the resident's rights. Resident 1's Minimum Data Set indicated a preference for Spanish and a need for an interpreter to communicate with healthcare staff. Despite this, the arbitration agreement, dated 10/5/20, was signed by Resident 1's responsible party on 10/8/24, and was entirely in English. During interviews, the Director of Admissions confirmed that the representative could not communicate in English and that the facility only provided the arbitration agreement in English. The Administrator acknowledged that the arbitration agreement should be provided in a language the resident or their representative can understand.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident, leading to the resident leaving the facility without staff knowledge. The resident, who was admitted for post-surgery care and had moderate cognitive impairment, was not identified as an elopement risk in the admission baseline care plan. Despite this, the resident managed to leave the facility unnoticed and was later found alone at a local fast-food restaurant. Interviews with facility staff revealed that the resident was discovered missing by a certified nurse assistant and reported to the charge nurse. The facility's policy on wandering and elopement required the interdisciplinary team to develop a care plan considering individual risk factors, but this was not effectively implemented for the resident in question. Upon returning to the facility, the resident was evaluated and found to be without injuries.
Failure to Implement Care Plan and Physician Orders
Penalty
Summary
The facility failed to implement care planned interventions and physician orders for a resident, which had the potential to lead to negative outcomes. During a record review and interview, it was found that the resident had an order for skilled occupational therapy (OT) three times a week for four weeks. However, the resident only received two of the ordered three treatments during a specific week. The Director of Rehab acknowledged the missed visit, and neither the Director of Nursing nor the Director of Rehab could provide documentation explaining why the resident did not receive the ordered OT sessions. Additionally, the facility did not follow the care plan interventions for the resident who was at risk for injury or decline due to refusal of showers. The care plan included interventions such as attempting the procedure again later and explaining the risks and benefits of refusal to the resident. However, documentation showed that the resident refused a bath on a specific date, and there was no documentation indicating that the resident was informed of the risks or that another attempt was made to provide the bath later in the day. The Director of Nursing confirmed the lack of documentation for these actions.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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