Palm Terrace Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 11162 Palm Terrace Lane, Riverside, California 92505
- CMS Provider Number
- 555365
- Inspections on file
- 20
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Palm Terrace Care Center during CMS and state inspections, most recent first.
Surveyors observed that kitchen staff stored wet, dirty pans stacked together and failed to properly store a torn bag of powdered milk, which was only covered with tape and leaking product. The Dietary Supervisor and Registered Dietitian confirmed these practices did not meet facility policy or food safety standards, exposing residents to potential food contamination.
A deficiency was identified when pests, including a roach, spiders, and ants, were observed in the kitchen's dry food storage area, along with spiderwebs on metal carts. The Dietary Supervisor and Registered Dietician confirmed that pests should not be present and that their presence could contaminate food. Facility policies require food storage and service areas to be kept clean and free from pests.
Multiple residents reported experiencing long waits, sometimes up to an hour, for staff to respond to call lights, particularly during the night shift. Staff interviews confirmed that complaints about delayed responses were received, and the DON acknowledged that the facility's policy required call lights to be answered within five minutes. Despite these expectations, residents' needs for assistance with daily activities were not consistently met in a timely manner, leading to frustration and dissatisfaction.
On two reviewed days, the facility did not meet the required minimum CNA direct care service hours per patient day, as confirmed by record review and staff interviews. The shortfall was attributed to CNA turnover, and the facility's policy mandates sufficient staffing to meet resident care needs.
The facility failed to follow infection control protocols in three cases: a resident's annual TB test was not properly completed and documented; another resident's incentive spirometer was not stored in a labeled plastic bag as required; and a physical therapist did not wear PPE while providing care to a resident on Enhanced Barrier Precautions. These lapses were confirmed by facility staff and were not in accordance with established policies.
A resident with depression and diabetes was not served lunch at the same time as others at her table, resulting in a 30-minute delay while she waited and observed others eating. Staff interviews confirmed the meal was mistakenly placed on a different cart, and both the AD and LVN acknowledged this was a dignity issue. The DON stated that meals should be served simultaneously to all residents at a table, in accordance with facility policy on dignity and respect.
Surveyors found that two residents' rooms and a bathroom had areas of peeled paint on the walls and door frame, which was confirmed by both the Maintenance Supervisor and Administrator as not meeting the facility's standards for a homelike environment.
A resident with documented hearing loss and use of a left hearing aid was inaccurately assessed in the MDS, which stated the resident had adequate hearing and did not use a hearing aid. Both the MDS Nurse and DON confirmed the assessment did not reflect the resident's true status, contrary to facility policy and RAI manual guidance.
A resident with documented hearing loss and a non-functioning hearing aid did not receive a required audiology consultation, despite multiple staff recognizing the need and facility policy mandating such referrals. The resident's records consistently indicated hearing impairment and the need for evaluation, but no audiology services were provided.
A resident with missing teeth and difficulty chewing was not provided a timely dental consultation or referral for dentures, despite a physician's order and documented need. Staff interviews confirmed the expectation for referral, and facility policy requires coordination of dental evaluations, but this was not carried out.
A resident with Parkinson's disease who was on a mechanical soft, no added salt diet was not provided with necessary adaptive eating equipment, such as a plate divider, during mealtime. The resident was observed having difficulty keeping food on the plate, resulting in food spilling onto the floor. Staff interviews confirmed that the resident should have been evaluated and provided with appropriate assistive devices, in accordance with facility policy.
The facility failed to ensure proper cleaning procedures for food preparation surfaces and equipment, potentially risking foodborne illness for residents. Additionally, dietary staff did not adhere to prescribed pureed diets, serving chunky pasta to residents requiring smooth consistency, posing risks of aspiration and choking.
The facility failed to properly store medications in emergency medication supply containers (EKITs), leading to potential medication errors. Two EKITs were found with multiple different unit-dose medications mixed together in each compartment, including medications with similar-sounding names. The Consultant Pharmacist confirmed that medications should be stored separately to ensure safety and accuracy, aligning with facility policy and ISMP guidelines.
The facility failed to provide the correct food texture for residents on a pureed diet, serving chunky noodles instead of a smooth consistency. This was confirmed by a test tray and interviews with dietary staff, highlighting the risk of choking and aspiration for residents with difficulty swallowing.
The facility failed to maintain sanitary food preparation and storage practices, with staff not following proper cleaning procedures and a cook not covering his mustache. The kitchen had cracked tiles, missing grout, peeling paint, rusted shelves, and buildup on equipment, increasing the risk of contamination.
A facility failed to ensure a resident's Advance Directive (AD) was included in their medical record, despite the resident's acknowledgment of having one. The Social Service Director confirmed the AD should have been obtained and accessible, as per facility policy, but it was not available.
A resident did not receive milk and pureed soup as per their dietary preferences during a lunch meal. The Dietary Supervisor confirmed the omission and noted no alternative was offered. Facility policies require adherence to food preferences and checking meal trays for completeness, which was not followed in this instance.
A resident on a pureed diet was served a regular texture salad, contrary to physician orders, posing a risk of aspiration and choking. Additionally, the resident received a lower-calorie supplement than prescribed, potentially affecting weight gain. These discrepancies were confirmed by facility staff and highlighted a failure to adhere to dietary orders.
A Treatment Nurse in an LTC facility failed to change gloves and perform hand hygiene during wound care for a resident with a Stage 4 pressure ulcer, leading to a breach in infection control protocols. The resident had a local skin infection, and the facility's policy required specific steps for wound care, which were not followed.
Improper Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and sanitation practices in the kitchen, as observed by surveyors. Four large metal pans, including a perforated pan, were found stacked on a bottom shelf while still wet and with visible food debris and dripping water. The Dietary Supervisor confirmed that these pans were not clean and should not have been stored wet or with debris. The Registered Dietitian also stated that pans should be cleaned, dried, and stored properly to prevent cross-contamination. Additionally, a 50-pound bag of nonfat dry powdered milk was found in the facility's outside kitchen storage with an open tear, covered only by clear tape, and with food product seeping out. Both the Dietary Supervisor and Registered Dietitian confirmed that such damaged packaging should not be used, as it could allow pests to enter and contaminate the food. These findings were not in accordance with the facility's policies or the 2022 Federal Food Code, which require food-contact surfaces to be clean and food to be protected from contamination.
Pest Infestation Observed in Kitchen Food Storage Area
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen, as evidenced by the presence of pests in the dry food storage pantry. During an observation in the kitchen's dry food storage room, a roach, spiders, and ants were found on the floor, and spiderwebs were seen on metal carts. The Dietary Supervisor confirmed that pests should not be present in the dry food storage room and acknowledged that their presence could lead to contamination of food. Further interviews with the Dietary Supervisor and the Registered Dietician confirmed that the expectation was for the kitchen to be free of pests and that staff should report any pest sightings. Both staff members stated that pests could contaminate food, potentially making residents sick. Review of facility policies indicated that all food storage and service areas should be kept clean and free from insects, rodents, and other sources of contamination, in accordance with the 2022 Federal Food Code and facility procedures.
Failure to Answer Call Lights Promptly for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner for six residents, as evidenced by multiple resident interviews, staff interviews, and record reviews. Several residents reported waiting extended periods, sometimes up to an hour, for staff to respond to their call lights, particularly during the night shift. Residents described feeling frustrated and anxious due to these delays, and some reported that their requests were simple, such as needing a blanket or water, but staff would sometimes acknowledge the call and not return. These concerns were communicated to staff and administration, but residents indicated that their complaints were not addressed. Medical records and assessments confirmed that the affected residents had varying degrees of physical and cognitive needs, with most being cognitively intact and requiring assistance with activities of daily living such as toileting, bathing, and mobility. Staff interviews corroborated the residents' accounts, with CNAs and an RN acknowledging that complaints about long call light wait times had been received, especially during the night and afternoon shifts. The DON confirmed that the facility's expectation was for call lights to be answered within five minutes and that all staff, including administration, were responsible for responding to call lights. The DON also acknowledged receiving complaints about long wait times and recognized the potential impact on residents' well-being. A review of facility policies and job descriptions indicated that staff were required to answer call lights promptly and provide routine checks to ensure residents' needs were met. Despite these policies, the documented experiences of the residents and staff interviews demonstrated that the facility did not consistently meet its own standards for timely response to call lights, resulting in unmet needs and resident dissatisfaction.
Failure to Meet Minimum CNA Staffing Requirements
Penalty
Summary
The facility failed to provide sufficient certified nursing assistant (CNA) staffing to meet the required minimum of 2.4 direct care service hours per patient day (DHPPD) on two specific days in March and April 2025. Record review and interviews with the Director of Staff Development (DSD) and Director of Nursing (DON) confirmed that on March 1 and April 5, the actual CNA direct care hours fell below the mandated threshold, with 2.36 and 2.32 hours respectively. The DON attributed the shortfall to turnover among nightshift CNAs and acknowledged that the facility's goal was to consistently meet staffing requirements. The facility's policy requires adequate staffing to provide care and services for all residents in accordance with the facility assessment.
Infection Control Deficiencies: TB Screening, Device Storage, and PPE Use
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in three separate instances. For one resident, the Infection Preventionist (IP) did not ensure that the annual tuberculin skin test (TB test) was properly completed. The test was administered, but there was no documentation of the result being read after three days, as required by facility policy. Both the IP and the Director of Nursing (DON) confirmed that the test should have been repeated if the result was not read, in accordance with the facility's tuberculosis control plan. In another case, a resident's incentive spirometer was observed stored on top of a nightstand rather than in a labeled plastic bag as required by facility policy. The resident stated she did not have a plastic bag for storage, and the registered nurse (RN) confirmed that the device should have been kept in a plastic container. The IP and DON both acknowledged that improper storage of the spirometer could lead to respiratory infection, and the facility's policy specified that the device should be stored in a labeled plastic bag between uses. Additionally, a physical therapist (PT) was observed providing therapy to a resident on Enhanced Barrier Precautions (EBP) without wearing the required personal protective equipment (PPE). The resident had a PEG tube and was at risk for infection, with orders and care plans specifying the need for EBP and PPE during high-contact care activities. Both the IP and DON confirmed that the PT should have worn PPE in accordance with the facility's infection control policy.
Resident Not Served Meal with Peers, Dignity Compromised
Penalty
Summary
A deficiency occurred when a resident was not served lunch at the same time as other residents at her table. On the observed date, the resident, who was seated in a wheelchair with two other residents in the dining room, was not provided her meal while the others were served and began eating. The resident was seen waiting and inquired about her food, eventually receiving her meal approximately 30 minutes after the others. Staff interviews confirmed that the resident's meal tray had been mistakenly placed on a different cart and was intended for room service, resulting in the delay. Both the Activity Director and Licensed Vocational Nurse acknowledged that meals should be served in an organized manner to ensure no resident is left out, and that this incident was a dignity issue. The resident involved had a history of depression and diabetes mellitus and was documented as mentally capable of understanding her surroundings. The Director of Nursing stated that staff are expected to serve trays simultaneously to all residents at a table and follow a system to prevent such oversights. The facility's policy on dignity and privacy requires all residents to be treated with kindness, dignity, and respect. The failure to serve the meal in a timely and equitable manner led to the resident feeling forgotten and potentially affected her psychosocial well-being.
Failure to Maintain Homelike Environment Due to Peeling Paint
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and homelike environment for residents, as evidenced by the presence of peeled paint in multiple resident rooms. Specifically, peeled paint was noted on the wall at the right side of one resident's bed and on the side of the wall next to another resident's bed. Additionally, areas of peeled paint were observed at the bathroom door frame in a resident room. These environmental deficiencies were directly observed during multiple walkthroughs by surveyors and confirmed during a concurrent observation with the Maintenance Supervisor. Interviews with the Maintenance Supervisor and the Administrator confirmed that maintaining painted, clean, and smooth walls is part of their responsibility to ensure a homelike environment. The facility's policy on providing a homelike environment was also reviewed, which emphasizes the importance of maintaining areas that reflect a homelike atmosphere. The failure to address the peeling paint in resident rooms and bathrooms resulted in an environment that did not meet the facility's stated standards for comfort and homelikeness.
Inaccurate MDS Coding for Resident with Hearing Loss
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident with hearing loss was accurately coded. The resident was admitted with a diagnosis of right ear hearing loss and used a hearing aid in the left ear. Multiple records, including the inventory sheet and social service summary, documented the presence and use of a left hearing aid and noted moderate hearing difficulty. However, the MDS assessment incorrectly indicated that the resident was not using a hearing aid and had adequate hearing ability. During interviews, both the MDS Nurse and the Director of Nursing acknowledged that the MDS assessment did not accurately reflect the resident's actual hearing status and should have been coded as moderately impaired with hearing. The facility's policy and the Resident Assessment Instrument (RAI) manual require that assessments accurately reflect the resident's status, which was not followed in this instance.
Failure to Provide Audiology Consultation for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide an audiology consultation for a resident with documented hearing loss. Upon observation and interview, the resident was noted to have difficulty hearing staff even while using a left hearing aid, which was reported as not functioning properly. Multiple staff members, including a CNA, RN, Social Service Director, and DON, acknowledged the resident's ongoing hearing difficulties and the need for an audiology referral. The resident's records, including the admission record, order summary, care plan, and social service summary, all indicated hearing impairment and the need for audiology evaluation, yet no evidence was found that such a referral or evaluation was completed. The facility's policy required social services to coordinate and monitor audiology evaluations, but this process was not followed for the resident in question. The lack of action resulted in the resident continuing to experience hearing difficulties without appropriate intervention, as documented in both staff interviews and record reviews. The deficiency was identified through direct observation, interviews with staff, and review of the resident's medical and care records.
Failure to Provide Timely Dental Consultation and Services
Penalty
Summary
The facility failed to ensure that a dental consultation was provided for a resident who was reviewed for dental care. During an observation and interview, the resident was noted to have missing upper and lower teeth and expressed a desire for dentures, stating he had not been seen by a dentist and had difficulty chewing solid food. Record review showed a physician's order for a dental consult with follow-up treatment as needed, and a previous dental assessment indicated multiple missing teeth and root tips with treatment recommended. The resident was found to be cognitively intact and capable of understanding his care needs. Interviews with facility staff, including the Social Service Director and Director of Nursing, confirmed that the resident should have been referred for dental services to address his needs. The facility dentist also stated that he would have seen the resident promptly if a referral had been made. Facility policy requires social services to coordinate and monitor dental evaluations, but this process was not followed for the resident, resulting in the lack of necessary dental care.
Failure to Provide Assistive Eating Equipment for Resident with Parkinson's Disease
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary assistive eating equipment, specifically a plate divider, to a resident with Parkinson's disease who required such adaptive devices during mealtime. During observation, the resident was seen struggling to keep food on her plate, resulting in food falling onto the floor. The resident expressed difficulty with the provided utensils, and both the LVN and DON acknowledged that a plate guard should have been supplied to assist with eating. The resident was on a mechanical soft, no added salt diet and was mentally capable of understanding her needs. Record review confirmed the resident's diagnosis and dietary requirements, and interviews with facility staff revealed that the resident had not been evaluated or referred for adaptive equipment as outlined in the facility's policy. The Director of Rehabilitation stated that staff should have referred the resident for an evaluation to determine the need for adaptive devices, and the facility's policy indicated that adaptive equipment should be provided as needed, with occupational therapy involvement recommended for assessment.
Deficiencies in Dietary Services and Food Preparation
Penalty
Summary
The facility failed to ensure that dietary staff followed proper cleaning procedures for food preparation surfaces and equipment, which could potentially lead to foodborne illness for all 64 sampled residents. Observations and interviews revealed that food service workers, including CK 1, CK 2, and CK 3, used sanitizer to clean prep table surfaces and stationary equipment, contrary to the facility's procedure that required washing with a warm detergent solution, rinsing with clear water, and then sanitizing. The Dietary Supervisor confirmed the use of sanitizer, and the facility's policy emphasized the importance of sanitation training for employees. Additionally, the facility did not adhere to prescribed dietary requirements for residents on pureed diets. CK 1 served chunky pasta to 10 residents who required a pureed diet, posing risks of aspiration and choking. A test tray conducted with the Dietary Supervisor confirmed the presence of chunks in the pureed noodles, and the Registered Dietitian stated that pureed diets should be smooth with no chunks. The job description for cooks included preparing food for therapeutic diets according to planned menus and standardized recipes, which was not followed in this instance.
Improper Storage of Medications in EKITs
Penalty
Summary
The facility failed to ensure that medications in emergency medication supply containers (EKITs) were stored safely and organized properly. During an inspection, it was observed that two EKITs contained multiple different unit-dose medications mixed together in each compartment. Specifically, one EKIT labeled Nonantibiotic EKIT #1 (A-L) had 13 compartments for 48 different medications, and the other labeled Nonantibiotic EKIT #2 (M-W) had 17 compartments for 40 different medications. Medications were placed alphabetically, and some compartments contained medications with similar-sounding names, such as citalopram, carvedilol, and carbidopa/levodopa, which were stored together. The Consultant Pharmacist confirmed that medications in EKITs should be compartmentalized, with each medication stored separately to ensure safety and accuracy in medication administration. The facility's policy on medication storage emphasized that medications should be stored safely and free of clutter. Additionally, guidelines from the Institute for Safe Medication Practices (ISMP) recommend storing medications with look-alike and sound-alike names in separate locations to prevent errors. The facility's failure to adhere to these guidelines and policies increased the potential for medication errors and delays in administering the correct medication.
Inappropriate Food Texture Served to Residents on Pureed Diet
Penalty
Summary
The facility failed to provide the appropriate food texture for 10 residents who were on a physician-prescribed pureed diet. During a meal service on May 8, 2024, these residents were served chunky noodles instead of the required smooth consistency. This was confirmed through a test tray conducted by the surveyor and the Dietary Supervisor, who both observed that the pureed noodles contained chunks and did not meet the necessary smooth consistency. The Dietary Supervisor acknowledged the potential risks associated with serving chunky noodles to residents on a pureed diet, including choking and aspiration. Further interviews and document reviews supported these findings. A Registered Dietitian confirmed that a pureed diet should be smooth with no chunks, emphasizing the risks of choking and aspiration for residents with difficulty chewing and swallowing. The review of the Physician Prescribed Diet Orders confirmed that the affected residents were indeed on a pureed diet. Additionally, the facility's recipe for pureed starches and the Regular Pureed Diet Definition from the Diet Menu both specified that the texture should be smooth and moist, aligning with the requirements that were not met during the observed meal service.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Food service workers did not adhere to the facility's cleaning procedures for food preparation surfaces and stationary equipment. Specifically, the staff used sanitizer alone to clean these areas, contrary to the proper procedure of washing, rinsing, and sanitizing. This deviation from protocol was confirmed through interviews with the dietary staff and registered dietitians, who acknowledged the risk of cross-contamination due to improper cleaning practices. Additionally, the facility did not maintain proper hygiene standards for kitchen staff, as evidenced by a cook not covering his mustache during meal preparation. This was against the facility's dress code policy, which requires facial hair to be restrained to prevent cross-contamination. The dietary supervisor and registered dietitian confirmed that the cook should have adhered to this policy. The physical condition of the kitchen also contributed to the deficiency. Observations revealed cracked tiles, missing grout, peeling paint, and rusted storage shelves, all of which hindered effective cleaning and sanitation. Furthermore, there was a buildup of grease on the fire hoods, grime inside the microwave, dust on the grid divider, and buildup on the ice machine pipes. These conditions were acknowledged by the dietary supervisor and registered dietitian, who emphasized the need for smooth, cleanable surfaces to prevent contamination.
Failure to Include Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's Advance Directive (AD) was available and accessible in the resident's medical record. This deficiency was identified during a review of the records for a resident who was admitted to the facility and had indicated the existence of an AD. Despite the resident's acknowledgment of having an AD, there was no documented evidence of the AD being included in the medical record. During an interview with the Social Service Director (SSD), it was confirmed that the SSD was responsible for the formulation and follow-up of ADs. The SSD acknowledged that the resident's AD should have been obtained and placed in the medical record, but it was not available. The facility's policy, dated December 2023, required that a copy of any advance directives be included in the medical records, but this procedure was not followed in this instance.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically for milk and soup, during a lunch meal. On May 7, 2024, Resident 39 did not receive the 4 oz. of milk and pureed soup as indicated on their Meal Tray Ticket, which was based on the resident's diet physician order and food preferences. This was confirmed during a dining room observation and interview with both the resident and a Certified Nurse Assistant (CNA). The Dietary Supervisor (DTR) acknowledged that the resident did not receive the specified items and noted that no alternative was offered when soup was unavailable. The Dietary Supervisor explained that residents' food preferences are updated regularly and entered into a tray card system to generate meal tray tickets. The Registered Dietitian emphasized the importance of honoring food preferences to prevent unplanned weight loss. A review of the facility's policies indicated that food preferences should be adhered to within reason, and meal trays should be checked to ensure nothing is missing. Despite these policies, the failure to provide the requested items to Resident 39 was a clear deviation from the established procedures.
Failure to Follow Physician's Dietary Orders
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was on a pureed diet and required a specific oral nutrition supplement. During a dining observation, the resident was served a regular texture salad instead of the prescribed pureed diet. This was confirmed by the Activities Supervisor, Activities Assistant, Dietary Supervisor, Director of Staff Development, and a Registered Dietitian, all of whom acknowledged the error and the potential risk of aspiration and choking due to the resident's difficulty in chewing regular texture foods. The facility's policies on diet orders, menu planning, and meal service were reviewed, indicating that meals should meet the nutritional needs of residents as per physician orders. Additionally, the resident was given a Boost Glucose Control supplement instead of the prescribed Boost, which contained fewer calories than ordered. This discrepancy was noted during a dining room observation and confirmed by the Dietary Supervisor and Director of Nursing. The facility's policy stated that diet orders prescribed by the physician should be provided accurately, but the resident received a supplement with fewer calories, potentially affecting their ability to gain weight. The facility's failure to follow the physician's dietary and supplement orders was documented, highlighting the importance of adhering to prescribed nutritional plans.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during wound care for a resident with a pressure injury. During an observation, the Treatment Nurse (TN) did not change gloves or perform hand hygiene after removing a soiled wound dressing and before cleaning the resident's wound with normal saline. This lapse in protocol was acknowledged by the TN during an interview, where he admitted to not following good infection control practices. The resident involved, identified as Resident 64, was admitted with a Stage 4 pressure ulcer in the sacral region and a local infection of the skin and subcutaneous tissue. The facility's policy on wound treatment, dated January 2024, clearly outlines the steps for proper wound care, including hand hygiene and glove changes, which were not followed in this instance. The Director of Nursing confirmed that the TN should have adhered to these procedures to prevent cross-contamination and infection.
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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