Parkway Hills Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in La Mesa, California.
- Location
- 7760 Parkway Drive, La Mesa, California 91942
- CMS Provider Number
- 055078
- Inspections on file
- 40
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Parkway Hills Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain a safe and homelike environment, with hallway floors taped and missing sections creating tripping hazards, and a wobbly handrail posing risks to residents and staff. Two residents, one using a cane and another with a history of falls, expressed concerns about these conditions. The maintenance director acknowledged the issues, which predated his employment, and admitted to lacking a routine schedule for checking handrails.
The facility failed to staff an RN for at least 8 hours a day for 18 days between January and March 2024. Despite having sufficient LNs and CNAs, the facility could not retain RN services and had no staffing waivers. The DON highlighted the importance of an RN for managing staff and resident care. The absence of an RN had the potential to compromise resident care quality.
A long-term care facility experienced a 50% medication error rate during a medication pass observation. Errors included a nurse failing to administer full doses to a resident via a G-tube, another nurse delaying a resident's morning medications by over three hours, and a third nurse unable to administer a diabetes medication due to unavailability. The errors involved medications critical for managing conditions like seizures, hypertension, and diabetes.
Three residents in a LTC facility experienced significant medication errors. A resident did not receive the full dosage of medications through a G-tube due to improper administration. Another resident's morning medications were administered over three hours late, including critical medications for diabetes and hypertension. A third resident did not receive a diabetes medication because it was unavailable in the medication cart. These errors highlight issues in medication administration and availability.
The facility failed to ensure kitchen staff were competent in operating and documenting the use of low-temperature dishwashers. Observations revealed dishwashers were unsure of proper procedures for taking temperature and chlorine samples, leading to inaccurate logs and potential risks of foodborne illness. The Dietary Manager acknowledged the need for accurate documentation to ensure proper machine functioning.
The facility failed to provide palatable and flavorful meals, potentially affecting residents' meal intake and health. Residents reported issues such as bland, cold, and repetitive food, with some dietary needs not being met. A test tray observation confirmed the lack of seasoning and unsatisfactory texture in meals, highlighting a deficiency in food quality.
The facility failed to store soy sauce and teriyaki glaze as per manufacturer's instructions, requiring refrigeration after opening. Additionally, the low-temperature dishwasher did not reach the necessary rinsing temperature for sanitization, with staff unsure of proper temperature recording procedures. These issues could increase the risk of foodborne illness.
A resident's MDS was inaccurately coded regarding their pneumococcal vaccination status, leading to incorrect data submission to the federal database. Despite consenting to vaccines, the resident did not receive an updated pneumonia vaccine, as confirmed by the IP nurse and the resident. The DON acknowledged the error, stating the MDS should reflect accurate assessment per the RAI manual.
A resident with obstructive sleep apnea had a care plan that was not updated to include specific details about their CPAP machine's settings and cleaning procedures. Observations showed the CPAP machine was present but not in use, and staff interviews confirmed the resident used the machine at night. The facility's policy required detailed care plans, but this was not reflected in the resident's documentation, leading to a deficiency.
Two residents in the facility did not receive necessary assistance with nail care, despite facility policies requiring weekly trimming during showers. One resident, with hemiplegia and hemiparesis, had long, untrimmed nails with debris, while another resident with dementia had long, jagged nails. Staff interviews revealed a lack of action due to uncertainty and fear of causing harm, leading to a deficiency in care.
A resident with obstructive sleep apnea used a CPAP machine without a documented physician's order for its settings, leading to potential inappropriate care. The resident brought her own CPAP machine, and staff were unaware of the preprogrammed settings. The facility's policy required documentation of CPAP settings but lacked guidance on obtaining a physician's order.
A resident with a history of epilepsy and moderate cognitive deficits had an unlabeled medication cup left unattended on their bedside table. A nurse admitted to leaving the medications, which included Clonazepam and Depakote, because the resident did not want to take them immediately. Facility staff acknowledged that medications should not be left unattended due to risks of divergence and choking hazards.
The facility failed to maintain infection control procedures for three residents, including not changing oxygen tubing weekly for two residents and improper storage of a CPAP mask for another. The respiratory therapist was on emergency leave, leading to lapses in changing and labeling oxygen tubing. Additionally, a CPAP mask was not stored in a plastic bag as required, and there was no documentation of its cleaning. These deficiencies increased the risk of infection transmission.
The facility failed to offer and administer updated pneumococcal vaccines to two residents, despite having consent forms and CDC recommendations. One resident, cognitively intact with a history of pneumonia, was not offered the vaccine, while another resident with a G-tube and high-risk status had an incomplete consent form. The DON acknowledged the importance of vaccine administration, but the facility did not follow its policy, leading to the deficiency.
The facility did not meet the minimum square footage requirements for resident rooms, with some rooms providing less than the required 80 square feet per resident. Despite this, there was no observed adverse effect on residents' health or quality of life, and a waiver for the room size variance was recommended.
A resident with functional quadriplegia lacked adequate visual privacy during personal care due to insufficient curtain placement, allowing a roommate to view her when accessing the shared bathroom. The Maintenance Director acknowledged the issue and noted that adding a curtain would be a simple fix.
Unsafe and Unhomelike Environment Due to Poor Flooring and Handrail Conditions
Penalty
Summary
The facility failed to provide a safe and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The hallway floors were found to be in poor condition, with gray duct tape used to secure the flooring and missing sections creating uneven surfaces. This was particularly concerning for residents with mobility issues, such as one resident who used a cane and expressed concern about the potential for injury due to the unstable flooring. Another resident, with a history of falling, also expressed fear about the missing flooring near their room. The maintenance director acknowledged the taped flooring and missing sections, noting that these issues predated his employment. Additionally, a handrail outside a resident's room was observed to be wobbly and secured with a loose screw, posing a risk to residents and staff. A CNA confirmed the handrail's instability and the danger posed by the uneven flooring. The maintenance director admitted to not having a routine schedule for checking handrails and was unaware of the issue until it was pointed out. The facility's policy on providing a safe and homelike environment was not adhered to, as evidenced by these observations.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days between January 1, 2024, and March 31, 2024. This deficiency was identified through a review of the PBJ Staffing Data Report and CASPER Report 1705, which indicated that no RN hours were recorded for 19 days within the specified period. The Staffing Coordinator confirmed that on specific dates in January, February, and March, there was no RN scheduled for at least 8 hours. Despite having sufficient Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) on those days, the facility was unable to retain RN services and had no waivers for staffing. Attempts to use registry RNs were made, but the registry was found to be undependable. The Director of Nursing (DON) emphasized the necessity of having an RN on duty for at least 8 hours daily to manage staff, oversee resident care, and administer intravenous medications. The facility's policy on staffing mandates providing a sufficient number of skilled staff to meet resident care plans and facility assessments. The absence of an RN for the required hours had the potential to result in inadequate supervision and compromised quality of care for residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent medication errors of less than 5% during a medication pass observation involving three licensed nurses and three residents. Licensed Nurse 1 (LN 1) administered medications to Resident 37 via a gastronomy tube but omitted one medication and failed to administer the full dose of several medications. The medications were not fully dissolved, leaving remnants in the medication cups, which resulted in Resident 37 not receiving the complete dosage necessary for managing health complications such as seizures, hypertension, and anxiety. Licensed Nurse 2 (LN 2) did not administer Resident 31's morning medications as scheduled, resulting in a delay of over three hours. This included medications for diabetes, high blood pressure, depression, and nutritional supplements. The delay was attributed to LN 2's incorrect assumption that Resident 31 was with the rehabilitation therapy team, which was not the case. The delay in medication administration was highlighted by the electronic medication administration record, which indicated the medications were late. Licensed Nurse 3 (LN 3) was unable to administer Resident 33's Januvia, a medication for diabetes management, because it was not available in the medication cart. LN 3 was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The Director of Nursing emphasized the importance of administering medications according to the facility's policy to prevent complications and ensure resident safety. The facility's medication error rate was calculated at 50%, significantly exceeding the acceptable threshold.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. For Resident 37, a Licensed Nurse (LN) administered medications through a gastronomy tube but omitted one medication and did not ensure the full dose of medications was administered. The nurse was unsure of the medication being administered due to similar unlabeled medication cups and mixed all medications with the same syringe, leading to undissolved medication remnants. This resulted in Resident 37 not receiving the full dosage of medications necessary for managing epilepsy, hypertension, and mood stability. Resident 31 did not receive morning medications as scheduled because the nurse missed administering them, believing the resident was with the rehabilitation therapy team. The medications were administered more than three hours late, which included critical medications for diabetes, high blood pressure, and depression. The delay in administration was not acceptable, as it could lead to complications such as a hypertensive crisis or uncontrolled blood sugar levels. For Resident 33, the nurse was unable to administer Januvia, a medication for diabetes management, because it was not available in the medication cart. The nurse was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The absence of this medication could lead to hyperglycemia, highlighting the importance of ensuring medication availability and adherence to the facility's medication administration policy.
Incompetency in Dishwasher Operation and Documentation
Penalty
Summary
The facility failed to ensure that kitchen staff, specifically dishwashers, were competent in operating, documenting, and checking the water temperatures of two low-temperature dishwashers. This deficiency was identified through observations, interviews, and record reviews. During an observation, a dishwasher was seen taking a chlorine sample from the water exit site instead of directly from the dishes, and was unsure of where to take the temperature reading for the log. The temperature logged was 120 degrees Fahrenheit, but upon demonstration, the machine's thermometer showed 115 degrees Fahrenheit, and an independent reading showed 110 degrees Fahrenheit. The dishwasher was unaware of the appropriate temperature required. Further observations with the Dietary Manager revealed that the dishwashers were likely not taking accurate temperature readings, as the log showed consistent numbers despite different measurements. The Dietary Manager acknowledged that the machine was not reaching the appropriate temperature for rinsing and that manual washing would be necessary. Another dishwasher was also observed taking a chlorine sample incorrectly and was unaware of the proper procedure. The Dietary Manager admitted that the dishwashers should understand the importance of taking accurate temperatures and chlorine samples to ensure the machine's proper functioning and prevent foodborne illness.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and flavorful, which could potentially decrease meal intake and contribute to weight loss among residents. During a dining observation and interviews with residents, several concerns were raised about the quality of the food. Residents reported issues such as grilled cheese sandwiches not being cooked properly, dry macaroni and cheese, bland meat, cold food, and repetitive menu items like broccoli. Additionally, a vegetarian resident was served fish, and another resident on a renal diet received salty food. The facility's menu for the day included roast turkey with gravy and other items, but residents expressed dissatisfaction with the taste and temperature of the meals. A test tray observation conducted with the Dietary Manager (DM) and Registered Dietician (RD) revealed that the food served was bland and lacked seasoning. The temperatures of the dishes were taken, and while they were within safe ranges, the taste and texture were not satisfactory. The pureed diet meals had more seasoning compared to the regular diet meals. The DM acknowledged the importance of residents enjoying their meals to prevent weight loss and negative health impacts. The facility's policy on resident food preferences indicated that a variety of foods should be offered at each meal, but the observations and resident feedback suggested that this was not being effectively implemented.
Improper Food Storage and Dishwasher Temperature Issues
Penalty
Summary
The facility failed to store soy sauce and teriyaki glaze according to the manufacturer's recommendations, which required refrigeration after opening. During an observation and interview with the Dietary Manager (DM), it was found that opened containers of these sauces were stored in the dry storeroom, contrary to the instructions on the labels. The DM admitted to being unaware of the need for refrigeration for soy-based sauces and disposed of the sauces upon realizing the mistake. The facility's policy on food storage emphasized the importance of checking food labels to prevent serving spoiled or contaminated food, which could lead to foodborne illness. Additionally, the facility did not ensure that the low-temperature dishwasher reached the appropriate rinsing temperature for sanitization. An observation and interview with Dishwasher (DW) 11 revealed confusion about where to take temperature readings, with the DW incorrectly using a chlorine test strip for this purpose. The recorded temperature was below the required 120 degrees Fahrenheit, with independent measurements confirming this discrepancy. The DM acknowledged that the dishwashers might not have been taking accurate temperature readings and were likely recording incorrect data. The facility's policy required maintaining a temperature log to ensure the dishwashing machine operated within the manufacturer's guidelines to prevent the spread of foodborne illness through contaminated dishes.
Inaccurate MDS Coding for Resident's Vaccination Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident's vaccination status, leading to the submission of incorrect information to the federal database. Resident 31, who was readmitted to the facility with a history of congestive heart failure, was found to have an inaccurately coded MDS regarding their pneumococcal vaccination status. The resident's MDS indicated that their pneumococcal vaccination was up to date, despite the fact that an updated pneumonia vaccine had not been administered, as confirmed by the Infection Prevention (IP) nurse during a record review. Interviews and record reviews revealed that Resident 31 had consented to receive vaccines during the 2023-2024 vaccine season but was not offered or given an updated pneumonia vaccine. The resident confirmed receiving COVID-19 and flu vaccines but not the pneumonia vaccine. The Director of Nursing (DON) acknowledged the error, stating that the MDS should reflect an accurate assessment per the Resident Assessment Instrument (RAI) manual, which specifies coding the pneumococcal vaccination status as not up to date if the vaccine was not administered.
Failure to Update CPAP Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to update a resident-centered care plan for a resident with obstructive sleep apnea who required the use of a CPAP machine. The resident was admitted with a diagnosis of obstructive sleep apnea, and during an observation, the CPAP machine was noted to be present but not in use, with the mask placed on the bed. Interviews with staff revealed that the resident applied the CPAP mask at night and removed it in the morning. A review of the care plan by the Minimum Data Set Nurse revealed that it lacked specific details regarding the CPAP machine's settings and the cleaning procedures for the tubing and mask. The facility's policy on comprehensive person-centered care plans emphasized the need for detailed interventions derived from thorough assessments, but this was not reflected in the resident's care plan. The absence of documentation for these critical aspects of care indicated that they were not being addressed, leading to a deficiency in providing appropriate care and treatment for the resident.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents, Resident 43 and Resident 30, which was identified during a survey. Resident 43, who was admitted with hemiplegia and hemiparesis, had intact cognition but required substantial assistance with personal hygiene due to functional limitations in the upper extremity. Observations revealed that Resident 43 had long, untrimmed fingernails with debris underneath, and the resident reported that no one had cut his nails for a long time. Despite the facility's policy requiring weekly nail care, staff interviews indicated a lack of action due to uncertainty about the resident's health condition and fear of causing harm. Resident 30, diagnosed with dementia and muscle weakness, also had long and jagged fingernails. The resident expressed a desire for assistance with nail trimming, but observations over several days showed no change in the condition of the nails. Interviews with staff revealed that nail care was expected to be provided during shower days, but this was not done for Resident 30. The facility's policy allowed CNAs to trim fingernails unless the resident had diabetes, yet the necessary care was not provided. The facility's policy and procedure documents indicated that nail care should be performed weekly with showers and as needed. However, the failure to adhere to these guidelines resulted in the deficiency, as both residents did not receive the required assistance with nail care, potentially affecting their dignity and increasing the risk of infection and injury.
Lack of Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to ensure a physician's order for the settings of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with obstructive sleep apnea. The resident, who brought her own CPAP machine from home, did not have a documented physician's order specifying the CPAP settings. During an observation, the CPAP machine was seen on a plastic container beside the resident's bed, with the mask placed on the bed. Interviews with the licensed nurse and respiratory therapist revealed that the CPAP was used during sleep hours at preprogrammed settings, but there was no knowledge of what those settings were, nor was there an order to verify them. The resident expressed concern that staff might alter the CPAP settings, as they were not documented in the physician's order. The Director of Nurses confirmed that CPAP settings should be included in the physician's order to ensure staff are aware of the correct settings. A review of the facility's policy and procedure on CPAP/BIPAP support indicated the need to document mode and settings in the resident's medical record, but it did not provide guidance on obtaining a physician's order for the CPAP machine prior to its use.
Unsecured Medication at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications for a resident were secured and locked during a medication storage inspection. During an observation, a clear medication cup containing six medications was found unlabeled and unattended on the bedside table of a resident who had been readmitted to the facility with a history of epilepsy and moderate cognitive deficits. The resident stated that a licensed nurse had left the medication cup on the table for later consumption. A certified nursing assistant confirmed witnessing the medication cup on the table and noted that medications should not be left unattended for safety reasons. The licensed nurse admitted to leaving the medications at the resident's bedside because the resident did not want to take them at that time, and the nurse did not want to delay administering medications to other residents. The medications included Clonazepam, fenofibrate, fish oil, a multivitamin, vitamin D, and Depakote. Another licensed nurse and the Director of Nursing both stated that medications should not be left unattended due to the risk of medication divergence, potential medication errors, and the possibility of causing a choking hazard. The facility's policy on medication storage requires that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Infection Control Deficiencies in Oxygen Tubing and CPAP Mask Management
Penalty
Summary
The facility failed to implement and maintain infection control procedures for three residents, leading to potential risks of infection. For Residents 27 and 34, the facility did not adhere to its policy of changing oxygen tubing weekly. Resident 27, who has chronic respiratory failure, COPD, and congestive heart failure, was observed with oxygen tubing labeled from two weeks prior, and there was no consistent labeling or changing of the tubing. Similarly, Resident 34, with diagnoses including congestive heart failure and chronic respiratory failure, had oxygen tubing that was not changed weekly as required. The respiratory therapist, who was responsible for changing the tubing, was on emergency leave, and the task was not adequately covered by other staff, leading to lapses in the procedure. Resident 6, diagnosed with obstructive sleep apnea, had issues with the storage and maintenance of their CPAP mask. The mask was observed on the floor and not stored in a plastic bag as per infection control guidelines. The licensed nurse stated that the mask should be stored in a plastic bag when not in use, but the resident reportedly refused this practice, although the resident later denied such a refusal. The respiratory therapist did not document the cleaning of the CPAP mask and tubing, which was supposed to occur weekly, further contributing to the deficiency. The facility's policies and procedures, including those for infection control and CPAP/BIPAP support, were not adequately followed, leading to these deficiencies. The lack of proper labeling, changing, and storage of medical equipment increased the risk of infection transmission among residents and staff. Interviews with staff, including the respiratory therapist, licensed nurse, and director of nursing, confirmed the expectations and importance of these procedures, highlighting the lapses in adherence to the facility's infection control policies.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and administer an updated pneumococcal vaccine to two residents, Resident 31 and Resident 37, as per the Centers for Disease Control (CDC) recommendations. Resident 31, who was cognitively intact and had a history of congestive heart failure and pneumonia, was readmitted to the facility and had a consent form dated for the vaccine season. However, the vaccine was not administered, and the resident confirmed that he was not offered the updated pneumonia vaccine, although he would have consented if it had been offered. Resident 37, who had a history of epilepsy and required nutritional and medication administration through a G-tube, was also not offered the updated pneumonia vaccine. The consent form for Resident 37 was incomplete, with no indication of consent or refusal for the pneumonia vaccine. The Infection Prevention (IP) nurse acknowledged that the vaccine was not offered due to the incomplete consent form, despite the resident's high-risk status for pneumonia infections due to his health condition. The Director of Nursing (DON) confirmed the importance of offering and administering vaccines to all residents if consented. The facility's policy, revised in October 2023, stated that pneumococcal vaccines should be administered unless medically contraindicated, already given, or refused, in accordance with CDC recommendations. However, the failure to adhere to this policy resulted in the deficiency noted in the report.
Room Size Deficiency in Resident Accommodations
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in four of its 28 resident rooms. Specifically, rooms designated for two residents only provided 71.5 square feet per resident, falling short of the 80 square feet requirement. Additionally, a room accommodating three residents offered only 73.66 square feet per resident, and a room with four residents provided 76 square feet per resident. Despite these deficiencies, the variations in room size were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. The Department recommended the continuance of the room size variance/waiver for the affected rooms.
Inadequate Privacy Curtains Compromise Resident Privacy
Penalty
Summary
The facility failed to provide adequate visual privacy for a resident, identified as Resident 1, who was admitted with conditions including heart failure and functional quadriplegia, necessitating assistance with personal care. During an observation and interview, it was noted that the privacy curtain for Resident 1's bed did not extend to separate the walkway to the shared bathroom, allowing other residents to potentially view Resident 1 during personal care activities. Resident 1 expressed concerns about the lack of privacy, stating that if her roommate needed to use the bathroom while she was receiving care, the roommate would have a full view of her body due to the inadequate curtain placement. The roommate, identified as Resident 2, confirmed that accessing the bathroom required entering Resident 1's privacy curtain area, which would result in a clear view of Resident 1 during personal care. The Maintenance Director acknowledged the issue, stating that the current curtain setup did not prevent other residents from accessing the shared bathroom without breaching Resident 1's privacy. The director also mentioned that adding a curtain between Resident 1's bed and the walkway to the bathroom would be a simple solution. The facility's policy on confidentiality and personal privacy, revised in October 2017, emphasizes the importance of protecting residents' privacy during personal care, which was not upheld in this instance.
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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