Pacific Gardens Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 577 S. Peach Ave., Fresno, California 93727
- CMS Provider Number
- 056207
- Inspections on file
- 26
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pacific Gardens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure that all residents were treated equally in matters of transfer, discharge, and service provision, regardless of their payment source.
A resident did not receive restorative nursing assistant (RNA) services after being discharged from physical therapy, leading to a contracture in the right hand. The resident, with a history of hemiplegia and hemiparesis, was not transitioned to RNA services due to a lack of coordination between PT and RNA staff. The Director of Nursing acknowledged the failure to follow the process, which was crucial for maintaining the resident's activities of daily living.
The facility did not post accurate daily staffing information, omitting the total number and actual hours worked by RNs, LVNs, and CNAs. The Assistant Staff Development Coordinator admitted the posted form was incomplete, and the Administrator was unaware of CMS requirements. This deficiency prevented residents and families from accessing accurate staffing details.
Two residents in the facility were observed without dignity bags covering their foley catheter drainage bags, leaving the urine visible and violating their right to dignity. Staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The facility's policies emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
The facility failed to inform and document information on how to formulate an advance directive for four residents, violating their rights. Interviews revealed that residents were not informed about advance directives, and staff acknowledged the lack of documentation. The facility's policy requires informing residents of their rights to establish an advance directive, but this was not consistently followed.
The facility failed to maintain a safe and comfortable environment for residents, as evidenced by cold room temperatures, exposed wiring, and malfunctioning equipment. Two residents experienced discomfort due to cold rooms, while another resident's room had holes with exposed insulation and wiring. Additionally, a resident faced issues with a broken bed and poor TV reception, affecting their comfort and quality of life.
Two residents in the facility received incorrect oxygen flow rates, contrary to physician orders. One resident with COPD was given 2.5 LPM instead of the ordered 2 LPM, while another resident with multiple health issues had an oxygen flow rate set at 3 L/min instead of 2 L/min. Additionally, the second resident's oxygen tubing was not labeled with the date, risking infection. These actions were against the facility's policy and procedure for oxygen administration.
A facility failed to properly store and label medications, with two inhalers lacking open and expiration dates, and two medication refrigerators operating outside the recommended temperature range. This affected medications for several residents, risking their potency and effectiveness. Observations and interviews confirmed these deficiencies, highlighting the need for adherence to storage and labeling policies.
The facility's cook staff failed to accurately measure milk and margarine for pureed rice, affecting 12 residents on a pureed diet. Cook 1 used incorrect measuring techniques, leading to potential inconsistencies in nutrient content. The RD acknowledged the importance of following recipes but had not verified staff measurements. The DON noted the absence of a policy for pureed food preparation, while Cook 2 described a different measurement approach.
The facility failed to maintain safe and sanitary food preparation and storage practices. Observations included unlabeled potatoes and thawing beef kabobs, a dietary aide not washing hands after scratching their ear, and dust on the ceiling above a fan in the food storage room. These deficiencies posed a risk of foodborne illnesses to residents.
A resident in an LTC facility did not have a completed POLST on file, despite being admitted with multiple serious health conditions. The resident was cognitively intact and had expressed a DNR preference, but the lack of a POLST meant their end-of-life wishes might not be honored in an emergency. The facility's policy required timely completion of such documents, but the POLST remained incomplete for a month, which was acknowledged as unacceptable by the ADON.
The facility failed to maintain effective infection control, with issues such as improper storage of nebulizer mouthpieces, catheter bags on the floor, and lack of Enhanced Barrier Precautions for residents with wounds. Additionally, oxygen tubing was found on the floor, and opened medical supplies were improperly stored, posing infection risks.
The facility failed to maintain secure handrails in the hallways, increasing fall risk for residents. Observations revealed broken and loose handrails, with missing parts exposing metal brackets and screws. The Maintenance Supervisor acknowledged the risk and noted the use of the TELS System for repair notifications, but obsolete parts hindered replacements. Facility policies emphasized a safe environment, yet the handrails were not adequately maintained.
Two residents were transferred to the hospital without receiving written information about the facility's bed hold policy, despite verbal notifications. The facility's policy required written notice, but it was not provided, leading to potential confusion and disputes over bed availability.
The facility failed to implement comprehensive care plans for several residents, leading to potential risks and unmet needs. A resident with a Foley catheter lacked a care plan, increasing infection risk. Another resident's visual needs were unmet due to missing glasses, risking injury. Two residents on anticoagulants lacked care plans for monitoring side effects, highlighting the need for individualized care plans.
A facility failed to update a resident's care plan after a stage two pressure ulcer had healed, leaving active treatment interventions in place. Staff interviews revealed that accurate care plans are crucial for guiding resident care, and the Director of Nursing acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy requires regular evaluation and revision of care plans.
A resident with reduced mobility and no cognitive deficits experienced discomfort due to long, jagged toenails, as the facility failed to provide proper toenail care. Despite policies requiring routine care, staff did not adequately trim, file, or document the resident's toenail care, leading to potential risks of injury or infection.
A resident's foley catheter tubing was improperly managed, being wrapped around her prosthetic leg, posing a risk of falls or injury. Staff interviews revealed a lack of training and adherence to facility policies, highlighting a deficiency in ensuring resident safety.
A resident was administered mirtazapine for several months without documented attempts at a gradual dose reduction (GDR), despite no recorded depressive episodes. The facility's policy requires quarterly evaluations and documentation of GDR assessments, which were not followed.
A resident in an LTC facility was administered potassium chloride 20MEQ by RN 1 without following the manufacturer's instructions. The medication was given without a meal and the resident was allowed to lie down immediately after, contrary to guidelines. The resident had a history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease, and was cognitively intact.
An LVN at an LTC facility failed to perform necessary assessments and inaccurately documented care for a resident who was hospitalized. The LVN recorded vital signs, pain assessments, and enteral feeding interventions that were not provided while the resident was in a general acute care hospital. This resulted in an inaccurate clinical record, as confirmed by the ADON and DON, who stated the documentation was unacceptable and illegal.
A facility failed to ensure accurate documentation by an LVN, who recorded care for a resident while they were hospitalized. The resident, with multiple health conditions, was transferred to a hospital for shortness of breath, yet the LVN documented vital signs, pain assessments, and enteral feeding as if the resident were still in the facility. Interviews with the ADON and DON confirmed the documentation was inappropriate and illegal, as it falsely indicated care was provided. The LVN admitted to the mistake, acknowledging the failure to accurately document the resident's care.
The facility's kitchen was found in unsanitary conditions with debris, buildup, and dead cockroaches present. Observations revealed a golden-colored buildup behind the stove, debris on the floor in various areas, and a black substance on the pantry storage counter. The presence of dead cockroaches was also noted, indicating a failure to maintain cleanliness and pest control as per the facility's guidelines and FDA Food Code.
The facility failed to maintain an effective pest control program, evidenced by dead cockroaches in the kitchen and other areas. Staff confirmed awareness of the issue, and pest control reports indicated ongoing live cockroach activity despite treatments. The facility did not adhere to FDA Food Code requirements for pest prevention and cleanliness.
A resident developed a preventable Stage 3 pressure ulcer due to the facility's failure to implement the prescribed skin integrity care plan, including daily and weekly skin assessments. The resident, who had multiple diagnoses and moderate cognitive deficits, was admitted without pressure ulcers but later readmitted to an acute hospital with a Stage 3 ulcer. Staff interviews confirmed the care plan was not followed, and the Director of Nursing acknowledged the facility's failure to adhere to its skin integrity policy.
Unequal Treatment in Transfers, Discharges, and Services Based on Payment Source
Penalty
Summary
The facility failed to treat all residents equally regarding transfer, discharge, and the provision of services, regardless of their payment source. This deficiency indicates that some residents may have experienced differences in how they were transferred, discharged, or received services based on their payment method. The report specifically notes the lack of equal treatment but does not provide further details about individual residents or specific incidents.
Failure to Provide Restorative Nursing Services Post-PT Discharge
Penalty
Summary
The facility failed to provide necessary restorative nursing assistant (RNA) services to a resident after the discontinuation of physical therapy (PT) services. The resident, who was discharged from PT on March 6, 2024, did not receive the prescribed range of motion (ROM) exercises until February 4, 2025, resulting in a lapse of nearly 11 months. This failure potentially contributed to the development of a contracture in the resident's right hand, as observed by the occupational therapist during a reevaluation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was initially receiving PT and occupational therapy (OT) services to address functional limitations and prevent further decline. Despite the PT discharge summary indicating a good prognosis with consistent staff follow-through, the transition to RNA services was not executed. The RNA program, which was supposed to maintain the resident's current level of function, was not implemented due to a lack of coordination and communication between the PT and RNA staff. Interviews with facility staff revealed that the process for transitioning residents from PT to RNA services was not followed. The RNA did not receive the necessary restorative therapy referral form from the PT, and the MDS Coordinator was not informed of the need for RNA services. The Director of Nursing acknowledged the breakdown in the process and the importance of following through with PT recommendations to maintain residents' activities of daily living (ADLs).
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate daily staffing information, specifically the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs). During an observation, it was noted that the Census and Direct Care Services Hours Per Patient Day (DHPPD) form did not include these details. The Assistant Staff Development Coordinator (ASDC) admitted that the posted form did not reflect the actual hours worked and that the detailed hours were only available on a separate worksheet not accessible to residents or their families. This omission prevented residents and their families from having access to the actual direct care staff hours and the total number of staff providing care daily. In an interview, the Administrator acknowledged that the DHPPD form lacked the necessary information about RN and LVN hours and confirmed that this information should have been posted. The Administrator was unaware of the requirement by the Centers for Medicare & Medicaid Services (CMS) to post such information. The facility used a form provided by the California Department of Public Health (CDPH), but it did not meet the CMS requirements. This oversight resulted in a deficiency as it failed to provide transparency to residents and their families regarding the staffing levels and hours worked by direct care staff.
Failure to Provide Dignity Bags for Catheter Drainage
Penalty
Summary
The facility failed to ensure dignity for two residents by not providing dignity bags for their foley catheter drainage bags, leaving the urine visible to anyone entering their rooms. For Resident 3, observations on multiple occasions revealed that the catheter bag was uncovered, and staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The Director of Nursing confirmed that Resident 3's right to dignity was violated due to the lack of a privacy bag. Similarly, Resident 305 was observed with an uncovered catheter bag while lying in bed. The resident, who was cognitively intact, was unaware if the urinary bag was covered when outside the room. Staff members, including a CNA and an LVN, stated that a dignity cover should have been used to protect the resident's privacy and dignity. The facility's policies on resident rights and dignity emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide written information on how to formulate an advance directive for four residents, which is a violation of their rights. The deficiency was identified through interviews and record reviews, revealing that the facility did not document information on how to obtain an advance directive in the residents' charts. This oversight could potentially prevent the residents' wishes from being followed if they become unable to make decisions. Interviews with residents revealed that they were not informed about the option to formulate an advance directive. For instance, one resident stated that the facility did not discuss advance directives with her, and another resident mentioned that he had provided a copy of his advance directive to the facility, but it was not documented in his medical record. The facility's staff, including the Licensed Vocational Nurse and the Social Services Director, acknowledged that there was no documentation of discussions about advance directives with the residents. The facility's policy and procedure documents indicate that residents should be informed of their rights to establish an advance directive upon admission. However, interviews with staff members, including the Director of Nursing and the Assistant Director of Nursing, revealed that the facility did not consistently follow these procedures. The Social Services Director and other staff members admitted that there was no documentation to show that residents were offered assistance with formulating an advance directive, highlighting a systemic issue in the facility's handling of advance directives.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. Two residents, identified as Resident 34 and Resident 57, experienced discomfort due to cold room temperatures at night. Despite complaints to the staff, the room temperatures were not maintained within the recommended range of 71-81 degrees Fahrenheit. The Maintenance Supervisor admitted to checking room temperatures only during the day and not at night, which contributed to the residents' discomfort and potential health risks. Another deficiency was observed in Resident 42's room, where a large hole and a smaller hole with exposed insulation and wiring were found behind the bed. The holes posed potential environmental hazards, including the risk of electrocution. Despite the presence of these hazards, no maintenance order was placed in the TELS system to address the issue, and the holes remained partially unaddressed for some time. The Maintenance Assistant and Supervisor acknowledged the oversight and the potential risks associated with the exposed wiring and uncovered outlets. Additionally, Resident 305 experienced issues with a malfunctioning bed and poor television reception, which affected the resident's comfort and quality of life. The bed was stuck in a seated position, and the TV channels were not clear due to antenna issues. Although the Maintenance Supervisor was aware of the problems, there was a lack of timely and effective repairs, as indicated by the absence of recent maintenance requests in the TELS system. These deficiencies highlight the facility's failure to provide a homelike environment and ensure the safety and comfort of its residents.
Oxygen Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, Resident 112 and Resident 306, regarding the administration of oxygen. Resident 112, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), emphysema, and obstructive sleep apnea, was observed receiving oxygen at a rate of 2.5 liters per minute (LPM) instead of the ordered 2 LPM. This discrepancy was noted over several days, and the registered nurse (RN) acknowledged the error, stating that the oxygen order was not followed. The Director of Nursing (DON) confirmed that the resident received more oxygen than ordered, which could be detrimental to the resident's health. Resident 306, who was admitted with multiple diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), Parkinson's disease, and congestive heart failure, was observed with an oxygen flow rate set at 3 L/min instead of the prescribed 2 L/min. The Licensed Vocational Nurse (LVN) confirmed that the oxygen saturation was at 96% and did not require oxygen at the time, indicating that the physician's order was not followed. Additionally, Resident 306's oxygen tubing was not labeled with the date it was placed, which is a requirement to prevent infection and ensure timely changes of the equipment. The facility's policy and procedure for oxygen administration require checking the physician's order for the correct flow rate and method of administration, as well as labeling and changing the oxygen tubing regularly. The failure to follow these procedures for both residents put them at risk for potential health complications, including infection and respiratory issues. The Assistant Director of Nursing (ADON) emphasized the importance of following physician orders and maintaining proper labeling to prevent such risks.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label drugs and supplies in accordance with acceptable standards of practice. Two inhalers, belonging to two residents, were not labeled with an open date or expiration date. This oversight was confirmed during observations and interviews with LVNs and the Director of Infection Prevention. The lack of labeling could lead to the administration of expired medications, which may not be effective and could potentially cause adverse reactions. The facility's policy requires medications to be labeled with open and expiration dates to ensure their potency and effectiveness. Additionally, the facility did not maintain proper temperature control in two of its medication refrigerators. Observations revealed that the temperatures in these refrigerators were outside the recommended range of 36°F to 46°F. Medications stored in these refrigerators, belonging to three residents, were at risk of losing their potency due to improper storage conditions. Interviews with the ADON and DON confirmed that the refrigerators were out of range for several hours, and the medications stored within them were discarded and replaced. The facility's policy on the storage and expiration of medications emphasizes the importance of maintaining appropriate temperature and sterility conditions. The failure to adhere to these guidelines resulted in the potential degradation of medications, which could lead to ineffective treatment and adverse reactions for the residents involved. The report highlights the need for regular inspections and compliance with storage requirements to ensure the safety and efficacy of medications administered to residents.
Inaccurate Measurement of Ingredients in Pureed Diets
Penalty
Summary
The facility's cook staff failed to accurately measure milk and margarine while preparing a pureed rice recipe for 12 residents on a pureed diet. During an observation, Cook 1 used a 1/2 cup metal measuring cup three times to measure 1.5 cups of milk, but the milk did not level to the top edge of the measuring cup each time. Additionally, Cook 1 used a round plastic measuring cup to measure margarine, which left open areas between the block of margarine and the measuring cup wall, resulting in an inaccurate measurement. Cook 1 added a total of 2 additional cups of 2% milk to achieve the targeted pudding texture for the pureed rice. Cook 1 acknowledged the importance of following the recipe to ensure the correct consistency and nutrient content. The Registered Dietician (RD) confirmed the importance of following pureed recipes to achieve the right consistency and stated that additional milk would not significantly increase protein content or harm residents. However, the RD had not verified whether staff were properly measuring ingredients. The Director of Nursing (DON) stated that the facility did not have a policy for pureed food preparation but expected cooks to follow recipes. Cook 2, who also prepared pureed rice, described a different measurement approach, using a cylinder plastic measuring cup for milk and melted margarine for easier blending. The facility's job descriptions emphasized the importance of preparing food according to standardized recipes and ensuring high-quality food provision.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as observed during a survey. A box of potatoes was found in the kitchen without a label indicating the received date or use-by date. The Dietary Manager (DM) acknowledged that the potatoes were not dated and stated that all food should be labeled to ensure kitchen staff are aware of how long food has been on the shelf. The Registered Dietician (RD) also confirmed that unlabeled or undated foods pose a risk of serving expired or spoiled food to residents, potentially leading to foodborne illnesses. Additionally, a dietary aide was observed scratching their ear and continuing to handle clean cups without washing their hands. The DM stated that staff should wash their hands after touching their head or face to prevent cross-contamination. The RD emphasized the importance of handwashing to promote infection control and food safety practices, noting that failure to do so could result in residents acquiring foodborne illnesses. Further observations revealed that thawing frozen beef kabobs in the walk-in refrigerator were not labeled with a prepared by or use-by date. The DM admitted that the kabobs should have been labeled and dated, as this practice helps prevent the use of old food that could be contaminated. Dust was also identified on the ceiling above the fan in the food storage room, which the DM stated could affect temperature control and lead to spoiled food. The Supervisor of Maintenance acknowledged the responsibility to clean the fan and ceiling, noting that dust in the storage room could create a fire hazard and potentially contaminate food, leading to foodborne illnesses for residents.
Incomplete POLST for Resident in LTC Facility
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST). The POLST, which contains critical medical orders for end-of-life care, was not completed for the resident, who had been admitted to the facility from an acute care hospital with multiple diagnoses including MRSA, Parkinson's disease, schizoaffective disorder, congestive heart failure, and depression. The resident was observed to be cognitively intact with a BIMS score of 15, indicating the ability to make informed decisions about their care. During the review of the resident's records, it was found that there was no completed POLST on file, which was confirmed by the Medical Records Administrator (MRA). The MRA acknowledged the importance of the POLST in emergencies to ensure the resident's treatment preferences, such as DNR status, are honored. The Assistant Director of Nursing (ADON) also emphasized the significance of the POLST in respecting the resident's wishes for medical interventions. The facility's policy required timely completion and auditing of health records, but the POLST had remained incomplete for a month, which was deemed unacceptable by the ADON.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Resident 34's nebulizer mouthpiece was found on top of the machine next to a urinal, which was not stored in a bag as required to prevent cross-contamination. This oversight was acknowledged by both the Licensed Vocational Nurse and the Director of Infection Prevention, who confirmed that the improper storage posed a risk for respiratory infections. Resident 37's foley catheter bag and tubing were observed on the ground, which is against the guidelines for catheter maintenance. The Registered Nurse and the Director of Staff Development both recognized that this practice increased the risk of cross-contamination and infection. Similarly, Resident 152's urinal was found on a bedside table with food and personal items, which was not sanitary and posed a risk for infection, as noted by the Certified Nursing Assistant. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with surgical wounds, as observed with Residents 152 and 305. Licensed nurses did not use gowns during wound care, and therapy staff did not follow EBP when assisting Resident 306 with Activities of Daily Living. Additionally, Resident 505's oxygen tubing was found on the floor, which was not stored properly, increasing the risk of contamination. The facility's storage practices were also deficient, as evidenced by an opened debridement tray found in a treatment cart and staff personal belongings stored in a utility supply room, both of which posed potential infection control issues.
Failure to Maintain Secure Handrails in Hallways
Penalty
Summary
The facility failed to ensure that corridors were equipped with firmly secured handrails on each side, which increased the risk of falls for residents using the handrails for assistance with walking. During an observation in the Station 2 Hallway, a handrail was found to be broken and loose, and another was missing a curved piece of wood, exposing the metal bracket and screws. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged that broken and loose handrails posed a risk of injury to residents. The Maintenance Supervisor stated that the facility used the TELS System to notify the maintenance department of repair needs, and any staff member could access this system. Despite being notified of the broken handrails, the curved ends were obsolete and could not be replaced. The facility's policy and procedure documents emphasized the importance of maintaining a safe, clean, and comfortable environment, with regular facility rounds and oversight by the Executive Director, Director of Nursing, and Maintenance/Housekeeping Supervisor. However, the failure to maintain the handrails in good condition was a deviation from these policies.
Failure to Provide Written Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to two residents, Resident 3 and Resident 455, during their transfers to the hospital. Resident 3 was transferred to the hospital without receiving a written notice of the facility's bed hold policy, despite verbal notifications being made to the resident's responsible party (RP). Interviews with the Licensed Vocational Nurses (LVN) and the Admissions Coordinator (AC) revealed that while verbal communication occurred, no physical documentation of the bed hold policy was provided, which is a requirement according to the facility's policy and procedure. Resident 455, who was cognitively intact, also did not receive a written bed hold policy upon transfer to the hospital. The Social Services Director (SSD) and LVN confirmed that the resident was not provided with the policy, as it was not standard practice for residents with non-Medi-Cal insurance. The facility's policy and procedure documents did not clearly mandate the provision of a physical copy of the bed hold policy upon transfer, leading to this oversight. The Director of Nursing (DON) acknowledged the importance of providing the bed hold policy to ensure residents and their representatives understand the terms and can ask questions if needed. The facility's failure to provide the necessary documentation could lead to confusion and disputes regarding bed availability and the terms of the bed hold, as the residents were not adequately informed in writing as required by the facility's own policies.
Deficiencies in Care Plan Implementation in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential risks and unmet needs. Resident 37 did not have a care plan developed for an indwelling Foley catheter, which was necessary due to a neurogenic bladder. This oversight was attributed to a breakdown in communication among staff, resulting in the absence of a care plan that could guide staff in monitoring and managing the catheter, potentially increasing the risk of infection and compromising the resident's safety. Resident 26's care plan interventions for visual needs were not implemented, resulting in the resident not wearing glasses for five days. This failure was due to staff not following the care plan, which required ensuring the resident wore glasses when up. The absence of glasses increased the risk of injury and decreased participation in activities of daily living, as the resident struggled with vision-related tasks and required assistance from staff. Residents 409 and 86 did not have care plans addressing the use of anticoagulants, which are critical for monitoring potential side effects such as bruising and bleeding. The lack of a care plan for Resident 409 meant that the resident did not receive education on anticoagulant side effects or complications, while Resident 86's care plan lacked monitoring interventions for bleeding or bruising. These deficiencies highlighted the importance of having individualized care plans to ensure appropriate monitoring and education for residents on anticoagulant therapy.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan for a resident, identified as Resident 120, after a stage two pressure ulcer had healed. The care plan still contained active treatment interventions for the ulcer, which had already resolved. This oversight was discovered during a review of Resident 120's records, which showed that the pressure ulcer had healed on January 15, 2025, but the care plan dated December 2, 2024, had not been updated to reflect this change. Interviews with staff, including CNAs and an LVN, revealed that care plans are essential for guiding resident care, and if they are not accurate, specific care for the resident could be missed. The Director of Nursing (DON) confirmed the importance of accurate care plans for communicating resident needs and acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy and procedure on comprehensive care plans, dated December 2017, indicated that resident progress should be regularly evaluated and care plans revised as appropriate. The DON stated that the care plan for Resident 120 should have been resolved by the end of the nurse's shift on the day the wound was considered healed.
Failure to Provide Proper Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for Resident 28, resulting in long, jagged, and uncomfortable toenails. Resident 28, who was admitted with a displaced intertrochanteric fracture of the right femur and required assistance with personal care due to muscle weakness and reduced mobility, reported discomfort from her toenails. Despite having no cognitive deficits, she relied on staff for toenail care, which was inadequately performed, leaving her toenails sharp and uneven. Interviews with staff, including CNAs and LVNs, revealed that routine toenail care was expected to be performed twice a week with each shower, including trimming, filing, and cleaning. However, Resident 28's toenails were observed to be long and jagged, with the right big toenail growing at an angle into the toe, causing discomfort. The staff acknowledged the risk of long, jagged toenails leading to potential injury or infection, yet the care was not documented or performed as required. The facility's policies and training materials emphasized the importance of proper toenail care to prevent infection and maintain hygiene. Despite this, the documentation on the Shower Day Inspection form indicated that Resident 28's routine toenail care was not completed. The Director of Nursing and other staff members confirmed the expectations for toenail care and the failure to meet these standards, as evidenced by the condition of Resident 28's toenails.
Improper Foley Catheter Management Poses Risk to Resident
Penalty
Summary
The facility failed to ensure a resident was free from accidents when the resident's foley catheter tubing was wrapped around her prosthetic right lower leg while she was sitting in her wheelchair. This situation posed a risk of causing a fall or injury to the resident, either by tripping her during a transfer or by the catheter being pulled from her bladder. The resident, who was cognitively intact, was unaware of the tubing being wrapped around her leg and acknowledged the potential danger it posed. Interviews with staff revealed that the catheter was identified as a trip hazard, and it was noted that the physical therapy assistant who transferred the resident was not trained on the proper placement of the catheter. The Director of Staff Development and other staff members acknowledged that the catheter should not have been wrapped around the resident's leg and that the facility's policies and procedures regarding falls management and incident management were not followed. The facility's Incident Management Policy emphasizes the need to provide a safe environment and reduce the incidence of reoccurrence, which was not adhered to in this case.
Failure to Document Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident was administered mirtazapine, a medication used to treat depression, from November 2, 2024, to February 6, 2025, without any documented attempts at a gradual dose reduction (GDR). The resident, who was admitted with diagnoses of depression and anxiety, received mirtazapine daily despite having no recorded depressive episodes. The Licensed Vocational Nurse (LVN) acknowledged that the resident would have benefitted from a GDR and confirmed that no GDR attempt was documented. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the last medication review was conducted in November 2024, but no GDR was recommended. The SSD admitted to not properly documenting the doctor's recommendation regarding a GDR, which would have explained why a GDR was not performed. The facility's policy on psychotropic medication management requires the interdisciplinary team to evaluate the necessity of such medications quarterly, including documentation of GDR assessments, which was not adhered to in this case.
Medication Administration Error for Potassium Chloride
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 556, was free from significant medication errors. The error occurred when RN 1 administered potassium chloride 20MEQ to Resident 556 without following the manufacturer's instructions. The instructions specified that the medication should be taken with a meal and that the resident should avoid lying down for at least 10 minutes after administration. However, RN 1 gave the medication at around 10:10 a.m., after the resident had breakfast at 7:30 a.m., and allowed the resident to lie back down immediately after taking the medication. Resident 556, who was cognitively intact with a BIMS score of 15, had a medical history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease. The Assistant Director of Nursing confirmed that RN 1 did not adhere to the manufacturer's guidelines, which could have affected the medication's absorption and effectiveness. The facility's policy emphasized the importance of verifying medication instructions to prevent errors, but this was not followed in this instance.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for a resident when an LVN did not perform necessary assessments and continued to document on the resident's clinical record during a period when the resident was admitted to a general acute care hospital. The LVN documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions that were not provided from December 25 to December 30, 2021, while the resident was hospitalized. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. The resident had been admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. On December 25, 2021, the resident was transferred to the hospital due to shortness of breath. Despite the resident's absence from the facility, the LVN documented various medical interventions and assessments as if they had been performed, which was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. The ADON and DON acknowledged that the documentation by the LVN was unacceptable and illegal, as it falsely indicated that services and treatments were provided when they were not. The LVN admitted to the mistake, stating that her electronic signature was on the Medication Administration Record (MAR) and that she was responsible for the inaccurate documentation. The facility's policy and procedure documents emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a licensed nurse performed accurate assessments and documentation for a resident who was admitted to a general acute care hospital. The Licensed Vocational Nurse (LVN 1) documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions for Resident 1 from December 25 to December 30, 2021, despite the resident being hospitalized during this period. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. Resident 1 had multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. The resident was transferred to the hospital on December 25, 2021, due to shortness of breath. Despite this, LVN 1 continued to document care and treatments as if the resident were still in the facility, including enteral feeding orders and pain management interventions. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that LVN 1's documentation was inappropriate and illegal, as it falsely indicated that care was provided when the resident was not present in the facility. LVN 1 admitted to the mistake, acknowledging that her electronic signature was on the Medication Administration Record (MAR) and that she failed to accurately document the resident's care. The facility's policies and procedures emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Unsanitary Kitchen Conditions and Pest Presence
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was a golden-colored buildup and debris accumulation behind the stove, and the floor in various areas, including next to the water inlet, behind the ice machine, and between the pantry and kitchen, was littered with soiled napkins, straws, beverage cups, wrappers, and food debris. The pantry floor had a dark granular substance and a dark glob, while the floor underneath the pantry wire storage rack was scattered with debris such as utensils, jelly cups, brown paper bags, napkins, a hairnet, and saltine crackers in plastic wrap. Additionally, a one-foot length of vinyl baseboard molding was found peeled off and on the floor in the pantry, and the pantry storage counter holding five-gallon water jugs had a black substance buildup. The presence of pests was also noted, with two dead cockroaches found under the food preparation table, one beneath the three-compartment sink area, and another caught in a web near the ceiling by the dishwasher. These unsanitary conditions were confirmed by both the Dietary [NAME] and the Dietary Manager during observations and interviews. The facility's Employee Handbook and the Food and Drug Administration's Food Code emphasize the importance of maintaining clean work areas and controlling pests, which the facility failed to adhere to, potentially risking foodborne illness among residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple dead cockroaches in critical areas such as the kitchen floor beneath the food preparation area, the three-compartment sink, and behind the hallway ice machines. These observations were made during a survey, and interviews with staff confirmed awareness of the cockroach problem. The Dietary Manager and Dietary staff validated the presence of dead cockroaches in the kitchen and pantry areas, acknowledging the importance of cleanliness, which was not maintained. The facility's pest control company had previously treated the kitchen and other areas with roach gel bait, as indicated in service tickets from August 2024. However, the problem persisted, with live cockroach activity noted in the pest control reports. The Food and Drug Administration's Food Code requires that food establishments be protected against pests by sealing openings and maintaining cleanliness, which the facility failed to uphold, leading to the deficiency.
Failure to Implement Skin Integrity Care Plan
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as a moderate risk for developing pressure ulcers, did not develop such ulcers. The nursing care plan, which included daily and weekly skin assessments, was not implemented from 1/6/24 to 1/19/24. This failure resulted in the resident developing a preventable Stage 3 pressure ulcer on the sacrum area. The resident was admitted to the facility with no pressure ulcers or open skin and was later readmitted to an acute hospital with a Stage 3 pressure ulcer due to the facility's negligence in following the care plan. The clinical record review revealed that the resident had multiple diagnoses, including acute respiratory failure, generalized muscle weakness, hypertension, mild cognitive impairment, pneumonia, and morbid obesity. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive deficits. Despite the facility's policy requiring routine skin assessments and an interdisciplinary care plan to maintain skin integrity, these measures were not followed. The resident's skin was not assessed daily or weekly, leading to the late recognition of the pressure ulcer. Interviews with staff, including a CNA and RN, confirmed that the resident's skin integrity care plan was not implemented. The CNA, who was new and assigned to the resident, did not receive proper instructions or documentation regarding the resident's skin assessment. The RN and Assistant Directors of Nursing (ADONs) acknowledged the failure to conduct the required skin assessments. The Director of Nursing (DON) admitted that the facility did not follow its policy on skin integrity, contributing to the development of the Stage 3 pressure ulcer.
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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