Pioneer House
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 415 P Street, Sacramento, California 95814
- CMS Provider Number
- 555542
- Inspections on file
- 33
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Pioneer House during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, documented as lacking decision-making capacity and assessed as high risk for elopement, refused the wander management system (WMS), yet the care plan did not include specific interventions to monitor safety, address the mental illness diagnosis, or reduce elopement risk. Progress notes showed the resident was restless, agitated, and on high elopement risk, but staff did not document monitoring strategies. When the resident was discovered missing, an LPN did not announce Code Pink, administration was not notified for more than two hours, and police were notified several hours later, contrary to facility policy requiring immediate Code Pink, prompt administration notification, and police notification if the resident was not located after 30 minutes. Staff interviews confirmed the absence of WMS use, difficulty monitoring residents leaving the floor, and lack of a Code Pink announcement, while the DON acknowledged the missing care plan interventions and the failure to follow the elopement procedures.
A resident with extensive burn wounds and homelessness was discharged without arrangements for home health nursing, food, or transportation for follow-up care. The facility did not contact community resources, provide written instructions, or ensure the resident could manage her medical needs post-discharge. Staff interviews confirmed the lack of individualized discharge planning and failure to meet the resident's health and safety needs.
A resident with severe cognitive impairment and a history of wandering was not wearing a required wander guard device for multiple shifts, despite physician orders and care plan directives. Staff failed to ensure the device was in place or to document its absence, resulting in the resident leaving the facility unsupervised and being found by law enforcement miles away without the device.
A resident with severe cognitive impairment and a history of aggression wandered unsupervised, entering other residents' rooms and physically assaulting two residents, resulting in pain, injury, and fear. Staff and residents reported that the aggressive resident was not adequately monitored, despite known risks and prior incidents, and the facility failed to protect residents from abuse as required by policy.
A resident with encephalopathy and dysphagia was not provided the therapeutic diet ordered by their physician, receiving a pureed meal instead of the prescribed soft and bite-sized texture. This discrepancy was confirmed by facility staff, including a CNA, LN, and the DON, highlighting a failure to adhere to the facility's policy on therapeutic diets.
A resident with multiple health conditions requiring substantial assistance for ADLs was unsafely discharged to a room and board facility without confirming necessary in-home supportive services (IHSS). The facility's SSD and DON failed to verify the availability of IHSS, relying instead on the resident's self-assessment and the room and board representative's understanding. This oversight led to the resident being unable to care for themselves, resulting in hospitalization.
A facility failed to complete and provide an inventory of personal belongings sheet to a resident upon admission, as required by policy. The resident, admitted with anxiety, confirmed that no inventory was conducted, and no copy was given. The DON acknowledged the lack of documentation, which could lead to the resident's belongings being lost or stolen.
A resident with a history of aggression and inappropriate behavior verbally threatened and physically assaulted another resident, causing injury and distress. Another resident experienced multiple episodes of sexual inappropriateness from the same resident. Despite awareness of the resident's behaviors, the facility failed to implement effective interventions to ensure the safety of the affected residents.
A facility failed to document the admission weight of a resident with dysphagia and severe protein-calorie malnutrition, as required by physician orders. The absence of this documentation was confirmed by the ADON, DON, and NC, and the facility could not provide their policy for Admission Assessment despite requests.
A resident, dependent on staff for grooming and hygiene due to cerebral infarction and muscle weakness, did not receive scheduled showers as per their care plan. The resident's care plan required bathing at least twice a week, but records showed only two showers were provided over a specified period. Facility staff confirmed the oversight, acknowledging the failure to adhere to the resident's care plan.
The facility failed to store medications in their original containers for 16 residents, as observed with unlabeled pills in plastic cups in a medication cart. A Licensed Nurse confirmed the safety concern, and the DON highlighted the risk of incorrect identification. Facility policy mandates medications remain in original packaging.
The facility failed to maintain food safety and sanitation standards, affecting 42 residents. Expired and unlabeled food items were found in the kitchen, and there were no temperature logs for certain storage areas. Ice and water dispensers were unclean, and food tray lids were improperly stored on a dirty oven top. The Dietary Manager confirmed these deficiencies.
The facility failed to maintain proper infection control practices, including housekeeping staff not changing gloves, lack of handwashing in the laundry room, and no corrective action for positive legionella tests. LN 1 and CNAs did not perform hand hygiene when passing lunch trays, and LN 1 did not follow Enhanced Barrier Precautions for a resident with spina bifida and paraplegia.
A resident's right to retain personal possessions was violated when their cell phone was taken without permission after they used it to call 911 due to unresponsive staff. The facility failed to investigate or document the incident, and the phone's whereabouts remain unknown, despite policies requiring prompt investigation of such issues.
A resident reported an incident of sexual and physical abuse to an LN, resulting in a bruise, but the facility failed to investigate or report the allegation. Interviews revealed staff were unaware of the abuse protocol, and the DON and ADM were not informed. The facility's policy requires immediate reporting and investigation, which was not followed, leaving the resident feeling unsafe.
A resident was served meals in polystyrene containers with plastic utensils without any documented orders or dietary instructions, leading to feelings of neglect and diminished self-worth. The DON and DM confirmed the lack of orders for this practice, acknowledging it as a dignity issue. The facility's policy on resident rights, which includes the right to a dignified existence, was not followed.
The facility failed to maintain secured handrails in the corridors of Unit A and Unit B, as required by regulations. Observations showed a resident with impaired cognition and difficulty walking using a walker in a corridor without handrails, and two other residents navigating another corridor also lacking handrails. The Maintenance Supervisor confirmed the handrails were removed for painting and repairs, with no timeline for reinstallation. The DON acknowledged the increased risk of falls and injuries due to the absence of handrails and admitted the facility lacked a policy for handrails.
The facility failed to ensure that call lights were within reach for two residents, placing them at risk of not being able to ask for assistance. The call lights were found bundled up in a basket above the bedside dresser, out of reach. Staff confirmed the call lights were out of reach and stated they usually place them within reach for resident safety. The facility's policy indicated call lights should be accessible when residents are in bed.
Failure to Prevent Elopement and Follow Elopement Procedures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement measures to prevent an avoidable elopement for a resident with schizoaffective disorder who was assessed as high risk for elopement and lacked decision-making capacity. The resident’s Wandering Risk Assessment identified a high elopement risk, and physician orders and admission documentation indicated the resident did not have capacity to understand choices and make decisions. The care plan documented that the resident was non-compliant with the wander management system (WMS) and was a fall risk, but it did not include nursing interventions for monitoring safety or reducing elopement risk, nor did it address the resident’s schizoaffective disorder or how related behaviors would be monitored. Progress notes documented that the resident refused the WMS and was on high elopement risk, with restlessness and agitation, but staff did not document monitoring interventions or best practices to keep the resident safe from elopement. On the date of the incident, a licensed nurse documented at 7:35 p.m. that the resident was not found in the facility, but there was no documentation that a Code Pink was announced as required by the facility’s elopement emergency procedures. The same nurse documented at 10:05 p.m. that the DON was notified the resident had left the facility, indicating an administration notification delay of more than two hours. A later progress note at 3:17 a.m. showed the DON faxed notification to the police department, exceeding the policy requirement to notify police if the resident is not located after 30 minutes. Staff interviews revealed that residents outside smoking after the main entrance doors locked at 5 p.m. needed to ring a doorbell for re-entry and that one CNA could not tell when residents left the floor if busy elsewhere and confirmed the resident did not wear a WMS and no Code Pink was heard. The DON confirmed the resident lacked capacity, was high risk for elopement, that the care plan did not address the mental illness diagnosis, and that there were no interventions for monitoring safety when the WMS was not worn. The facility’s policies required identification of residents at risk for wandering/elopement, inclusion of safety strategies in the care plan, and initiation of the elopement/missing resident emergency procedure, including announcing Code Pink, notifying administration, and notifying police if the resident was not located after 30 minutes.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who was homeless and required ongoing care for multiple burn wounds. The resident, admitted with third-degree burns covering 20-29% of her body, muscle wasting, mobility disorders, and MRSA carrier status, was discharged without proper arrangements for home health nursing services, food, or transportation to follow-up medical appointments. The case manager/social worker did not contact homeless shelters or home health agencies, nor did she provide the resident with written discharge instructions or information for follow-up care. The resident was only verbally informed of her discharge the day before and was not advised of her right to appeal the discharge. The discharge plan was not individualized or reviewed with the resident, and the facility did not ensure that the resident's needs and preferences were met. The administrator attempted to secure a motel room for three nights but did not make a reservation or arrange for food, nursing care, or a long-term shelter solution. There was no documentation of a discharge plan or communication with the resident regarding the plan. The facility's own policy required a discharge summary and plan to be developed and reviewed with the resident and family at least 24 hours before discharge, but this was not followed. Interviews with facility staff, including the DON and wound nurse, revealed a lack of awareness and preparation for the resident's discharge needs. The wound nurse acknowledged that the resident would not be able to care for wounds on her back and had not provided any education or training for wound care. The facility's failure to coordinate post-discharge care, secure appropriate shelter, and provide necessary information and resources resulted in a discharge process that did not address the resident's health and safety needs.
Failure to Ensure Use of Wandering Device for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate supervision and ensure that a resident at high risk for elopement was wearing a required wandering device, as ordered by the physician and outlined in the care plan. The resident, who had severe cognitive impairment with a BIMS score of 4/15, a history of dementia, falls, and spinal fracture, was known to wander and exhibit exit-seeking behaviors. Staff interviews confirmed that the resident was supposed to wear a wander guard on the left ankle, which would trigger an alarm if the resident approached an exit. However, documentation in the Medication Administration Record (MAR) indicated that the resident was not wearing the device for six consecutive shifts prior to the incident. On the day of the incident, the resident was able to leave the facility unsupervised and without staff knowledge. The absence of the wandering device was confirmed by both staff and the resident's responsible party, who reported not seeing the device on the resident prior to the elopement. The resident was later found by law enforcement more than two miles from the facility, without the wandering device, and was returned to the facility. The facility's own policies required identification of residents at risk for wandering and implementation of safety interventions, including the use of a wander guard, but these were not followed in this case. Record reviews and staff interviews further revealed that nurses were expected to check and document the presence of the wandering device each shift, and to immediately replace it if missing. Despite these expectations, there was no documentation or action taken to ensure the device was in place during the period leading up to the resident's elopement. The failure to follow physician orders, care plan interventions, and facility policy directly led to the resident's unsupervised exit from the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two residents experiencing pain, injury, and fear for their safety. One resident with severe cognitive impairment, Alzheimer's disease, and a history of behavioral disturbances was known to wander unsupervised and had prior incidents of aggression. This resident entered another resident's room, touched personal belongings, ate food, and became physically aggressive when confronted, swinging her arms and making physical contact that resulted in redness on the other resident's neck. The affected resident, who had intact cognition and a history of depression and chronic pain, reported feeling abused and expressed fear, leading him to avoid activities and remain in his room for safety. In a separate incident, the same resident with cognitive impairment approached another resident in the dining room, touched her belongings, and slapped her on the back of the head when she tried to intervene. The resident who was struck, who had moderate cognitive impairment, hemiplegia, and mental health diagnoses, complained of pain and expressed feeling unsafe and wanting to leave the facility. Witnesses, including another resident and staff, confirmed the aggressive behavior and noted that the resident responsible for the incidents was not monitored at all times, despite being on special monitoring due to her known wandering and aggression. Staff interviews revealed that the facility did not provide sufficient supervision to prevent the aggressive resident from entering other residents' rooms or causing harm. Multiple staff members and residents reported that the aggressive resident frequently wandered unsupervised and that staff were often too busy to monitor her continuously. The facility's policy stated that residents have the right to be free from abuse, including abuse by other residents, but the observed incidents and staff accounts demonstrated a failure to uphold this standard.
Failure to Provide Correct Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician for one of the sampled residents, who was admitted with diagnoses including encephalopathy and dysphagia. The physician's order specified a regular diet with soft and bite-sized texture, but the resident received a meal with a pureed food item and a tray card indicating a mince moist diet. This discrepancy was confirmed during observations and interviews with a Certified Nurse Assistant (CNA), a Licensed Nurse (LN), a kitchen staff member, and the Director of Nursing (DON). The facility's policy on therapeutic diets, which requires that diet orders match the terminology used by the food and nutrition services department, was not followed. The DON acknowledged that the diet provided did not match the physician's order, and the kitchen staff confirmed that the mince moist and soft, bite-sized diets are different orders. This failure had the potential to impact the resident's nutritional status, as the diet provided did not align with the resident's treatment plan and preferences.
Unsafe Discharge of Resident Without Adequate Support
Penalty
Summary
The facility failed to provide a safe discharge for a resident who was discharged to a room and board facility that did not meet their care needs. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, and a right leg above the knee amputation, required substantial assistance for activities of daily living (ADLs) such as toileting, showering, dressing, bed mobility, and transfers. Despite this, the resident was discharged without ensuring that the necessary in-home supportive services (IHSS) were in place, leading to the resident living in an unsafe environment. Interviews and record reviews revealed that the Social Service Director (SSD) and the Director of Nursing (DON) did not confirm the availability of IHSS before the resident's discharge. The SSD relied on the resident's self-assessment and the room and board representative's (RBR) understanding that IHSS would be provided, but did not verify this information. The resident's Minimum Data Set (MDS) indicated a need for substantial assistance, yet the discharge plan did not adequately address these needs, resulting in the resident being unable to care for themselves and eventually requiring hospitalization. The facility's policy and procedure for preparing a resident for discharge were not followed, as the post-discharge plan was not adequately developed or confirmed. The SSD did not document discussions with the RBR regarding the resident's functional abilities and the room and board's capacity to provide care. The lack of documentation and confirmation of IHSS services contributed to the unsafe discharge, as the resident was left without the necessary support to manage their ADLs independently.
Failure to Provide Inventory of Personal Belongings
Penalty
Summary
The facility failed to ensure that an inventory of personal belongings sheet was completed and a copy was provided to a resident upon admission. This deficiency was identified for one of the three sampled residents, who was admitted with a diagnosis that included anxiety. The review of the resident's Admission Record indicated that the Inventory of Personal Effects sheet, dated shortly after admission, lacked the resident's signature on the 'Certification of Receipt' portion. Furthermore, there was no documented evidence in the resident's closed record, nurse's notes, or admission record that the resident signed the inventory sheet or received a copy upon admission. During a telephone interview, the resident confirmed that an inventory of belongings was not conducted upon admission, and a copy of the inventory sheet was not provided. The Director of Nursing (DON) acknowledged that the facility could not provide documentation that the resident received a copy of the inventory sheet. The facility's policy and procedure for admitting residents, dated September 2013, required that all personal items be inventoried, recorded, and signed by the resident or a family member, with a copy provided to them. This failure had the potential for the resident's personal belongings to be lost or stolen.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, who had a known history of verbal aggression and sexual inappropriateness. Resident 3 was verbally threatened and physically assaulted by Resident 1, resulting in physical injury and emotional distress. Despite Resident 1's history of aggression, there was no documented evidence that the resident had been referred or evaluated by a psychiatrist as ordered by the physician. Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1. The facility's care plan for Resident 2 did not contain any interventions to ensure the resident's safety, despite the resident's report of feeling uncomfortable and dirty due to Resident 1's actions. The facility's staff, including the Assistant Director of Nursing, were aware of Resident 1's behaviors but failed to take adequate measures to protect Resident 2. Interviews with staff and residents revealed that Resident 1 had a history of inappropriate behavior, including making sexual advances towards staff and residents. Despite this, the facility did not implement effective interventions to prevent further incidents. The facility's policy on safety and supervision of residents was not adequately followed, leading to the failure to protect Residents 2 and 3 from abuse.
Failure to Document Admission Weight for Resident
Penalty
Summary
The facility failed to follow physician orders for a resident when the resident's weight was not measured at admission. The resident was admitted with diagnoses including dysphagia and severe protein-calorie malnutrition. A review of the resident's Order Summary Report (OSR) dated 10/31/24 indicated an order for an admission weight, which was not documented. During an interview and record review with the Assistant Director of Nursing, Director of Nursing, and Nurse Consultant, it was confirmed that there was no admission weight recorded for the resident, and thus no way to track potential weight loss. Additionally, the facility was unable to provide their policy and procedure for Admission Assessment, which should include documentation of a resident's admission weight, despite requests made on 11/26/24 and 11/27/24.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living (ADLs) independently, received the necessary services to maintain grooming and personal hygiene. The resident, admitted with diagnoses including cerebral infarction and muscle weakness, was dependent on staff for grooming and hygiene care and required assistance from one to two staff members for bathing. The resident's care plan indicated a preference for showers and required bathing at least twice a week. However, a review of the resident's bathing tasks revealed that the resident only received showers on two occasions within a specified period, with no bathing tasks completed for over a week. During an interview and record review, facility staff, including the Assistant Director of Nursing, Director of Nursing, and Nurse Consultant, confirmed the resident's dependency on staff for hygiene needs and acknowledged the failure to provide showers as scheduled. The facility's policy on supporting ADLs emphasized the necessity of providing appropriate care and services for residents unable to carry out ADLs independently.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in their original containers and in a safe manner for 16 sampled residents. During an observation and interview with a Licensed Nurse (LN) at Medication Cart 1, it was found that there were three 30 mL plastic cups in the top drawer, each containing two or more unlabeled and unidentified items. The LN confirmed that the plastic cups were not labeled and contained various pills, including a pink pill, a red liquid-gel pill, two orange-colored pills, and seven red and white liquid-gel pills. The LN acknowledged that medications should not be removed from their original packaging, citing this as a safety concern. In a subsequent interview with the Director of Nursing (DON), it was confirmed that medications are not to be removed from their original packaging, as this poses a safety hazard. The DON emphasized that the next nurse taking over the medication cart would not know what these pills are, highlighting the potential for incorrect identification and misuse. A review of the facility's policy and procedure on Medication Labeling and Storage indicated that medications and biologicals should be stored in their original packaging, and only the issuing pharmacy is authorized to transfer medications between containers. The policy also states that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and medications may not be transferred between containers.
Food Safety and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner for 42 residents. During an inspection, an expired half-gallon of milk, opened salad dressing, and creamer containers without open dates were found in the kitchen refrigerators. Additionally, full egg crates were found without received or expiration dates labeled. The Dietary Manager confirmed these observations and acknowledged that the items should have been labeled and the expired milk discarded. Furthermore, there were no temperature monitoring logs for the resident food freezer section and the dry storage room, which the Dietary Manager confirmed should have been in place. The inspection also revealed that the ice and water dispensers in the dining room were not clean, with white and brown residue observed on the surfaces. The Dietary Manager confirmed the unclean state of the dispensers. Additionally, lids used for covering prepared food on the steam table were stored on top of an unclean oven top, which was observed to have a dusty sticky residue. The Dietary Manager acknowledged the unclean surface and the improper storage of food tray lids. These findings indicate a failure to adhere to the facility's policies and procedures for food safety and sanitation.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to potential cross-contamination and infection risks. Housekeeping staff were observed dipping contaminated gloves into mop bucket sanitizing solution without changing gloves, which was confirmed by the housekeeper and the infection preventionist as cross-contamination. Additionally, the laundry room lacked a handwashing station, and staff did not use gowns when handling dirty laundry, failed to sanitize equipment after handling dirty laundry, and did not perform hand hygiene after glove removal or between resident room visits. Contaminated clothes hangers were also hung back on the clean linens cart. The facility was unable to provide evidence of timely corrective action following positive legionella tests in the water systems. A review of the facility's water management plan revealed a positive legionella testing report, but no evidence of corrective action or retesting was available. The infection preventionist confirmed that interventions and retesting were expected but not documented. Licensed Nurse 1 and Certified Nursing Assistants 2 and 3 did not perform hand hygiene when going in and out of residents' rooms while passing lunch trays. Additionally, LN 1 did not follow Enhanced Barrier Precautions when providing wound care for a resident with spina bifida and paraplegia, who had nephrostomy tubes and a sacral wound. The infection preventionist confirmed that staff should have worn gowns during high-contact care activities, as indicated by the Enhanced Barrier Precautions policy.
Failure to Maintain Resident's Right to Personal Possessions
Penalty
Summary
The facility failed to ensure a resident's right to retain and use personal possessions, specifically a cell phone, was maintained. The resident, who was admitted with diagnoses including intracerebral hemorrhage and hemiplegia, reported that their cell phone was taken away after they used it to call 911 due to unresponsive nursing staff at night. The resident was unaware of the current location of the cell phone. Interviews with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON) confirmed that the resident was admitted with a cell phone and chargers, but the SSD admitted to not following up on the whereabouts of the phone after it was reportedly taken by firefighters. The facility's policies and procedures, which were reviewed, indicate that residents are allowed to retain personal possessions and that any complaints of misappropriation should be promptly investigated. However, the SSD and the Director of Nursing (DON) both acknowledged that they did not know the current location of the resident's cell phone, and no documentation was found regarding the outcome or location of the phone. The facility's failure to investigate and document the incident violated the resident's rights as outlined in their policies and procedures.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident, identified as Resident 21, who reported an incident of sexual and physical abuse to a Licensed Nurse (LN). Resident 21, who was admitted with diagnoses including intracerebral hemorrhage and hemiplegia, expressed feeling unsafe and neglected within the facility. The resident reported to LN 4 that two CNAs were involved in the alleged abuse, which resulted in a bruise on the resident's hand. Despite being a mandated reporter, LN 4 did not take appropriate action to report the sexual abuse allegation, considering it a non-emergency situation. Interviews with facility staff revealed a lack of understanding and execution of the facility's abuse reporting protocol. CNA 4 indicated she would report incidents to a nurse or supervisor but was unsure about the availability of an abuse binder. LN 2 stated she would notify the DON and ADM, check the policy for abuse reporting, and inform the state authorities, but was unaware of the location of the abuse binder. The DON and ADM were not informed of the incident and were unaware of the abuse allegation until the surveyor's review. The facility's policy requires all reports of abuse to be immediately reported to the administrator and relevant authorities, with thorough investigations conducted by management. However, the policy was not followed in this case, as the ADM, who is the abuse coordinator, was not notified, and no investigation was initiated. The failure to adhere to the policy resulted in the incident not being reported or investigated, leaving Resident 21 feeling unsafe and unsupported.
Resident Served Meals in Polystyrene Containers Without Justification
Penalty
Summary
The facility failed to provide an environment that supported the quality of life for one resident, identified as Resident 21, by serving meals in polystyrene containers with plastic utensils. This was observed during a visit to Resident 21's room, where the resident expressed dissatisfaction and a lack of understanding as to why meals were served in this manner. The resident felt neglected and expressed feelings of hopelessness, indicating a negative impact on their self-worth and well-being. Upon review of Resident 21's records, it was confirmed by both the Director of Nursing (DON) and the Dietary Manager (DM) that there were no physician orders or dietary instructions specifying the use of polystyrene containers and plastic utensils for this resident. The DON acknowledged that this practice was a dignity issue, potentially making the resident feel singled out. The facility's policy on Resident Rights, which emphasizes the right to a dignified existence and participation in care planning, was not adhered to in this instance.
Absence of Secured Handrails in Facility Corridors
Penalty
Summary
The facility failed to ensure that the corridors in Unit A and Unit B had firmly secured handrails, as required by the California Code of Regulations. This deficiency was identified through observations, interviews, and record reviews. During an observation, a resident with severely impaired cognition and difficulty walking was seen using a walker in the Unit A corridor, which lacked secured handrails. The resident confirmed the absence of handrails and expressed that having them would enhance safety by providing support for balance. Further observations revealed that two residents were seen navigating the Unit B corridor, which also lacked secured handrails. The Maintenance Supervisor confirmed that the handrails had been removed over three weeks prior for painting and repairs, with no clear timeline for reinstallation. The Director of Nursing (DON) acknowledged that the handrails had been absent for over a month and admitted to not having a specific date for their return. Additionally, the facility did not have a policy or procedure in place regarding handrails. The absence of handrails in the facility's corridors posed a potential risk of increased falls and injuries for residents using these areas. The DON, who started working at the facility after the handrails were removed, agreed that the lack of handrails heightened the risk of falls and injuries. The facility's failure to comply with the regulation requiring firmly secured handrails in corridors was evident, as confirmed by the observations and interviews conducted during the survey.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and easily accessible for two residents, placing them at risk of not being able to ask staff for assistance. Resident 2, who has dementia, a history of falling, and glaucoma, and Resident 4, who has dementia, chronic kidney disease stage 3, and hypertension, were observed to have their call lights bundled up and placed in a black basket above the bedside dresser, out of their reach. During an interview, a Certified Nurse Aide confirmed the call lights were out of reach and stated that they usually place the call lights within reach so that residents feel safe and can call for assistance. The Administrator also confirmed that staff are expected to always place the call lights within reach of the residents. The facility's policy and procedure on answering call lights indicated that call lights should be accessible to residents when in bed.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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