Pittsburg Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburg, California.
- Location
- 535 School Street, Pittsburg, California 94565
- CMS Provider Number
- 055677
- Inspections on file
- 20
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pittsburg Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with dementia and PTSD, who was totally dependent on staff and severely cognitively impaired, was physically abused when a CNA forcefully pushed the resident's face back into a wheelchair, as witnessed by two student nurses. The incident was later reported to facility leadership, and staff interviews confirmed the handling was inappropriate and abusive.
The facility did not ensure RN coverage for eight hours a day, seven days a week, as required. Staffing schedules from January to April 2023 showed missing RN coverage on several dates. The DON confirmed these gaps and acknowledged the risk of poor RN supervision, potentially endangering resident health and safety.
The facility failed to discuss and document Advanced Directives for three residents, as indicated by missing or unmarked information on their POLST forms. The Social Services Director confirmed the lack of documentation and follow-up during care conferences, contrary to the facility's policy.
The facility failed to maintain a homelike environment for three residents due to an inaccurate wall clock and damaged overbed tables. A CNA confirmed the clock's incorrect time, and the DON acknowledged potential confusion for residents. Two residents had chipped overbed tables, posing injury risks, with the Environmental Services Supervisor reporting the issue a month prior without action. The Administrator confirmed replacements were only made for non-functional tables, and an LVN noted the absence of a service request for replacement.
Two residents were given melatonin at 4:00 p.m., contrary to their prescribed orders to take it at bedtime. The facility's DON stated this was due to an early sleeping schedule, but the CP did not recommend this timing. The residents and their representatives were not informed, and the facility's policy on medication administration was not followed.
The facility failed to conduct proper assessments and obtain informed consent before installing bed rails for three residents. One resident's family was not informed of alternatives, and the facility did not document any alternative measures. Another resident's care plan lacked specific goals for safe bed rail use, and the facility backdated a physician's order. The third resident was not reassessed for safe bed rail use, and the facility used inappropriate bed rails provided by hospice.
Two residents with Type 2 diabetes were administered Metformin without meals, contrary to prescribed orders, resulting in an 8% medication error rate. An LVN gave the medication without food due to timing issues, despite the facility's policy requiring adherence to medication orders.
The facility failed to ensure safe medication storage and labeling, with issues including ice buildup in the medication refrigerator, improper storage of a resident's glucagon with eye medications, and an unlabeled eyewash bottle stored with oral medications. The Facility Maintenance Director had not maintained the refrigerator as required, and staff were unaware of proper storage protocols, leading to potential medication errors.
The facility failed to follow its policy on timecard adjustments, altering an RN's hours 16 months later without verification. The RN's hours were changed from four to eight on three weekends, despite her working only one hour to administer IV antibiotics. Discrepancies in documentation and mismatched signatures were found, and the facility's policy requiring timely salary adjustments was not followed.
The facility failed to maintain infection control practices in the laundry room and during glucometer use. Observations showed lint accumulation in dryer compartments, which were not cleaned as required, posing fire and infection risks. Additionally, an LVN improperly cleaned a glucometer with an alcohol pad instead of the approved disinfectant wipes, increasing infection spread risk. Facility policies and manufacturer's instructions for cleaning were not followed.
A resident with major depressive disorder was served pureed breakfast in plastic cups, which was deemed undignified by staff. An LVN transferred the food from plates to cups due to the need to return trays to the kitchen. Both the LVN and DON acknowledged this practice did not respect the resident's dignity, contrary to the facility's policy.
A facility failed to ensure a family representative made an informed decision about bed rails for a resident with severely impaired cognition. The Admission Coordinator, a non-licensed professional, obtained consent without proper training or documentation of alternatives. The Director of Nursing acknowledged the resident could not use the rails voluntarily, and the family representative was not informed of alternatives by the physician.
A resident with multiple health conditions died in the facility, but the Death in Facility Tracking Record was not completed or submitted to CMS as required. The MDSC admitted the oversight, which led to outdated payment information and quality measure data.
A facility failed to accurately assess and code a resident for Pneumonia in the MDS, leading to an incorrect active diagnosis. Observations and interviews confirmed the resident showed no symptoms of Pneumonia, and the MDS Coordinator found no supporting documentation. This resulted in an inaccurate reflection of the resident's medical condition.
A resident with schizophrenia was not given a required PASRR Level II evaluation due to unresponsiveness from facility staff, despite being identified as Level I positive for Serious Mental Illness. The Medical Record Director and Director of Nursing were unaware of the need for this evaluation, which should have been processed immediately according to facility policy.
A facility failed to monitor and document behaviors and side effects for a resident prescribed Sertraline for uncontrollable scratching. Despite the resident's inability to communicate, there was no documentation of behavior monitoring or side effects, contrary to the facility's policy on psychotropic medication use. This oversight risked the resident's individualized care.
A facility failed to provide storage for food brought by family members for a resident, leading to disappointment. Interviews revealed that there was no refrigerator available for storing such food, and residents were instructed to consume it immediately or have it discarded. The facility's policy indicated that outside food could be stored, but this was not implemented, affecting a resident with intact cognition who wished to save food brought by her son.
A facility failed to maintain accurate medical records when the DON backdated a physician order for bed rails for a resident admitted with post-hemorrhagic anemia. The order was created on one date but backdated to an earlier date without informing the MD, leading to inaccuracies in the resident's medical records. The Administrator was unaware of this action, which could result in document falsification.
The facility failed to meet the required minimum square footage per resident in 12 rooms, providing only 75.1 sq. ft. per resident instead of the mandated 80 sq. ft. Despite this, observations indicated sufficient space for care, no interference from equipment, and no resident complaints or safety concerns.
Physical Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) physically abused a resident by forcefully and aggressively pushing the resident's face back into a wheelchair. This incident was directly witnessed by two student nurses, who observed the CNA using his whole hand to push the resident's face, resulting in a whiplash motion. The CNA appeared frustrated while repositioning the resident, who repeatedly leaned forward in the wheelchair. The student nurses were disturbed by the event and later reported it to facility leadership. The resident involved had a history of dementia and post-traumatic stress disorder (PTSD), was totally dependent on staff for activities of daily living, and was severely cognitively impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of 0 out of 15. The resident was unable to verbalize needs and exhibited tremors. Staff interviews confirmed that the resident required two-person assistance for safe repositioning and that the CNA's method of handling was inappropriate and could have caused harm. Interviews with facility leadership, including the administrator and director of nursing, confirmed that the CNA's actions were considered abusive and demeaning. The administrator noted that the CNA had previously been investigated for suspected physical abuse, though it was unsubstantiated at that time. The facility's policy emphasized the right of residents to be free from abuse and the importance of maintaining a culture of compassion, particularly for those with cognitive or behavioral issues.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for eight hours a day, seven days a week, as required. A review of the facility's licensed staffing schedules from January 2023 through April 2023 revealed that there were no RNs scheduled to work the required hours on specific dates: January 7 and 30, February 5, and April 22, 29, and 30. This deficiency was confirmed through an interview with the Director of Nursing (DON), who acknowledged the lack of RN coverage on these dates. The DON also stated that the absence of RN coverage posed a risk of poor oversight of RN supervision, which could potentially endanger the health and safety of residents and hinder their ability to reach their highest practicable level of well-being.
Failure to Discuss and Document Advanced Directives
Penalty
Summary
The facility failed to ensure that the Advanced Directives for three residents were properly discussed and documented. For Resident 10, the Minimum Data Set indicated mild cognitive impairment, and the Physician Orders for Life-Sustaining Treatment (POLST) form lacked information on the presence of an Advanced Directive. During an interview, the Social Services Director (SSD) confirmed that there was no documentation of discussions regarding Advanced Directives with Resident 10's responsible party. Similarly, Resident 4's POLST indicated that Advanced Directive information was marked as not available, and Resident 8's POLST was unmarked. The SSD assumed the absence of an Advanced Directive when the POLST was unmarked and stated that follow-ups were supposed to occur during care conferences. However, the Multidisciplinary Care Conference forms for Residents 4 and 8 showed that their Advanced Directives were not followed up. The facility's policy required informing residents or their responsible parties about Advanced Directives during admission, but this was not documented for these residents.
Deficiencies in Homelike Environment and Equipment Maintenance
Penalty
Summary
The facility failed to provide a homelike environment for three residents due to two main issues. Firstly, the wall clock in the shared room of three residents displayed an incorrect time, which was confirmed by a CNA who noted the clock needed a battery change. The Director of Nursing acknowledged that a non-functioning clock could cause confusion and disorientation among residents. The facility's policy on maintaining a homelike environment was reviewed, indicating the expectation for a safe and comfortable setting. Secondly, the overbed tables for two residents were found to be chipped and unfurnished with rough edges, posing a risk of injury. The Environmental Services Supervisor had reported the need for replacement to the Administrator a month prior, but no action had been taken. The Administrator confirmed that replacements were only made when tables were non-functional or damaged. A Licensed Vocational Nurse noted the risk of injury due to the residents' frail skin and the absence of a written service request for table replacement in the Maintenance Binder.
Improper Administration of Melatonin
Penalty
Summary
The facility failed to administer melatonin to two residents, Resident 35 and Resident 23, according to professional standards and prescribed orders. Resident 35 was ordered to take melatonin 30 minutes before bedtime as needed, while Resident 23 was to take it nightly at bedtime. However, both residents were routinely given melatonin at 4:00 p.m., which was not in accordance with their prescribed orders. This discrepancy was observed during medication pass observations and confirmed through record reviews of the residents' Medication Administration Records and hospital transfer documents. The Director of Nursing stated that the facility had implemented an early sleeping time for all residents, which led to the early administration of melatonin. However, the facility's Consultant Pharmacist clarified that the pharmacy did not recommend administering melatonin at 4:00 p.m. and emphasized that it should be given later in the evening to avoid safety issues. Interviews with Resident 23 and the Family Representative of Resident 35 revealed that they were not informed about the early administration of melatonin, and Resident 23 expressed a preference for taking it later. The facility's policy required medications to be administered according to orders and to consult with a physician if a dosage was believed to be inappropriate, which was not adhered to in this case.
Failure to Properly Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to conduct accurate assessments and evaluations before installing bed rails for three residents. For Resident 36, the facility did not attempt to use any alternatives prior to the installation of bed rails and failed to obtain informed consent from the family representative. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and total dependence on staff for bed mobility, yet the facility did not document any alternative measures or a proper informed consent process. The Director of Nursing (DON) acknowledged the lack of documentation regarding alternative attempts and informed consent. For Resident 40, the facility's Bed Rail Assessment (BRA) indicated the need for bed rails due to unsteady gait, but there was no evidence of alternative measures being considered. The care plan lacked specific goals and interventions for safe bed rail use. Observations showed that half side rails were used, contrary to the quarter size evaluated, and the facility did not reassess the resident for proper bed rail use upon admission. The DON admitted to backdating a physician's order for bed rails, indicating a lack of proper documentation and assessment. Resident 24 was admitted with a diagnosis of cerebral infarction and was totally dependent on staff for bed mobility. The BRA indicated the need for side rails, but like Resident 40, there was no documentation of alternative measures or a specific care plan for bed rail use. Observations confirmed the use of half side rails, and the facility failed to reassess the resident for safe bed rail use. The DON acknowledged the inaccurate assessment and lack of documentation regarding the use of bed rails, which were provided by the hospice agency.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that two residents, Resident 22 and Resident 38, received their medications without error, resulting in a medication error rate of 8%. Both residents had a diagnosis of Type 2 diabetes mellitus and were prescribed Metformin 1000 mg to be taken twice daily with meals to prevent gastrointestinal upset. During a medication pass observation, LVN 5 administered Metformin to both residents without offering food or a meal, contrary to the prescribed orders. LVN 5 acknowledged the error, stating that the medication was given without meals because of the timing of her rounds and the residents' readiness. The Consultant Pharmacist confirmed that Metformin should be taken with meals to prevent stomach discomfort. The Director of Nursing also stated that the medication should have been administered with meals to avoid affecting the residents' blood sugar levels. The facility's policy on administering medications requires adherence to prescribed orders, including timing, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage and labeling practices, as observed during a survey. The medication refrigerator freezer was found to have multiple ice packs and a thick accumulation of ice with a yellowish color. The Infection Preventionist (IP) was unaware of the reason for the ice buildup, and the Facility Maintenance Director (FMD) admitted that the refrigerator had not been cleaned or maintained since June 2024, despite the facility's policy requiring monthly cleaning. The FMD noted that the freezer door was not closing properly due to the ice buildup, which could lead to temperature changes affecting the medications stored inside. The Consultant Pharmacist (CP) confirmed that improper closure of the freezer door could cause defrosting and potentially alter medication labels. Additionally, Resident 25's glucagon, an injectable emergency medication, was improperly stored with eye medications, and an unlabeled bottle of eyewash was found with liquid oral medications. Licensed Vocational Nurse (LVN) 3 was unaware of the glucagon's presence due to its placement at the back of the drawer and did not know the owner of the unlabeled eyewash. LVN 3 also admitted to not knowing the facility's protocol for medication storage. The IP and CP both stated that medications should be stored separately by route to prevent infection spread and medication errors. The facility's policy indicated that drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling before storage.
Failure to Adhere to Timecard Adjustment Policy
Penalty
Summary
The facility administration failed to adhere to its policy and procedure regarding timecard adjustments for a Registered Nurse (RN). The issue arose when the RN's timecard was adjusted 16 months after the fact, changing her recorded hours from four to eight on three specific weekend days in April 2023. This adjustment was made in August 2024 without proper verification, as the Payroll Director (PD) altered the hours based on information from the Director of Staff Development (DSD), who claimed the RN worked eight hours but did not punch in correctly. However, the RN stated she only worked one hour on those weekends to administer IV antibiotics and was paid for four hours, as agreed with the facility. Further investigation revealed discrepancies in the documentation, including mismatched signatures on missed punch forms and inconsistencies between the RN's timecard and paycheck. The Director of Nursing (DON) and DSD acknowledged these discrepancies, with the DON denying recent involvement in signing the missed punch forms. The facility's policy requires salary adjustments to be reported within 30 days, but this was not followed, leading to the deficiency. The Administrator was unaware of who created the missed punch forms, and the RN confirmed she was paid correctly last year, further highlighting the administrative oversight.
Infection Control Lapses in Laundry and Glucometer Use
Penalty
Summary
The facility failed to maintain proper infection control practices in two key areas: the laundry room and the use of a glucometer. In the laundry room, an observation revealed that the lint trap compartments of two dryers were full of lint, which should have been cleaned every two hours according to the Environmental Services Supervisor (ESS). The ESS admitted that there was no documentation to confirm regular cleaning and maintenance of the dryers, which posed a potential fire hazard. The Infection Preventionist (IP) noted that excessive lint could also lead to respiratory diseases or infections among residents. The facility's policy on laundry and bedding, dated September 2022, emphasized the importance of maintaining laundry equipment according to the manufacturer's instructions to prevent microbial contamination. In another instance, a Licensed Vocational Nurse (LVN) failed to properly clean and disinfect a glucometer after use. The LVN used an alcohol pad for less than five seconds to wipe the glucometer after checking a resident's blood sugar, instead of using the facility's approved disinfectant wipes, Micro-Kill One Germicidal Alcohol Wipes. The IP stated that the proper procedure involved using one wipe to clean all areas and another to disinfect, ensuring the device remained wet for one minute to kill germs. The facility's policy on obtaining a fingerstick glucose level, dated October 2011, and the glucometer's owner's manual both outlined specific cleaning and disinfecting procedures that were not followed, increasing the risk of infection spread.
Resident Served Food in Plastic Cups, Violating Dignity
Penalty
Summary
The facility failed to treat a resident with dignity and respect by serving her pureed breakfast in plastic cups. The resident, who was diagnosed with major depressive disorder, was observed eating her meal in plastic cups while sitting in bed. When questioned, the resident expressed confusion about why her food was served in this manner. The Licensed Vocational Nurse (LVN) present during the observation identified the food as grits but was unable to identify another item, and explained that the resident ate from plastic cups because she was a slow eater. Further interviews revealed that another LVN transferred the food from plates to plastic cups because the breakfast trays and plates needed to be returned to the kitchen. This LVN acknowledged that serving food in plastic cups was not dignified. The Director of Nursing (DON) also confirmed that this practice did not treat the resident with dignity. The facility's policy on dignity, revised in August 2009, states that residents should be treated with dignity and respect at all times, which includes maintaining and enhancing their self-esteem and self-worth.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to ensure that the family representative (FR) of a resident made an informed decision regarding the use of bed rails. The facility did not provide or maintain a record of an accurate assessment of the resident's medical needs, nor did it document alternative attempts that failed to meet the resident's needs or alternatives considered but not attempted. Instead, a non-licensed professional, the Admission Coordinator (AC), was designated to obtain informed consents for the use of bed rails during the admission process. This led to the FR being unaware of the medical necessity and alternative options available instead of using bed rails. The resident in question had severely impaired cognition and was totally dependent on staff for activities of daily living. The care plan indicated the use of side rails as ordered, and a physician order specified the use of bilateral 1/4 siderails for bed mobility. However, the Director of Nursing (DON) acknowledged that the resident could not hold onto the side rails voluntarily and that they were used more for comfort rather than necessity. The DON also stated that the facility was not required to obtain informed consent if the bed rails were not used as restraints, and that the physician was responsible for obtaining such consent. Despite this, there was no documentation of any alternatives being used or a physician obtaining informed consent prior to the installation of the bed rails. The FR stated that she signed the consent upon the resident's admission after being informed by front desk staff about the use of bed rails to prevent falls. However, she did not recall any discussion with the resident's physician about alternatives or other medical reasons for using bed rails. The AC, who was responsible for obtaining informed consent, admitted to not having received official training on the process and was not a licensed medical professional. The facility's policy required staff to inform the resident or representative about the benefits and potential hazards associated with bed rails and to obtain informed consent, which was not adequately followed in this case.
Failure to Submit Death in Facility Tracking Record
Penalty
Summary
The facility failed to complete and submit the Death in Facility Tracking Record to the Centers for Medicare & Medicaid Services (CMS) for a resident who died in the facility. This oversight was identified during a review of the resident's records and an interview with the Minimum Data Set Coordinator (MDSC). The resident, who had been admitted with multiple diagnoses including Cervical Disc Disorder, Malignant Neoplasm of Prostate, Combined Systolic and Diastolic Heart Failure, and Chronic Obstructive Pulmonary Disease, passed away in the facility. The MDSC acknowledged that the Death in Facility Tracking Record was missed and not completed for submission. The facility's policy on MDS Submission Timeframes requires that resident assessments be conducted and submitted in accordance with federal and state guidelines. According to the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the Death in Facility Tracking Record must be completed within 7 days of a resident's death and submitted within 14 days. The failure to adhere to these guidelines resulted in the resident's specific payment information and quality measure data being outdated.
Inaccurate MDS Coding for Pneumonia Diagnosis
Penalty
Summary
The facility failed to accurately assess and code a resident for a diagnosis of Pneumonia in the quarterly Minimum Data Set (MDS). The MDS was incorrectly coded to indicate an active diagnosis of Pneumonia, despite the resident not having this condition. This error was identified through observation, interviews, and record reviews, which revealed that the resident did not exhibit any symptoms of Pneumonia, such as respiratory distress or cough, during the assessment period. Interviews with the Certified Nursing Assistant and Licensed Vocational Nurse confirmed that the resident had not shown signs of Pneumonia recently. The MDS Coordinator also acknowledged that there was no documentation in the resident's nursing progress notes to support the diagnosis of Pneumonia during the look-back period. The facility's policy on maintaining accurate medical records was not adhered to, resulting in an outdated and inaccurate reflection of the resident's medical condition.
Failure to Complete PASRR Level II Evaluation for Resident with Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 15, completed a Preadmission Screening and Resident Review (PASRR) Level II evaluation, which is a federal requirement for individuals with serious mental disorders or intellectual disabilities. Resident 15, who was diagnosed with schizophrenia, was readmitted to the facility and was identified as Level I positive for Serious Mental Illness (SMI) during a PASRR screening. Despite this, the necessary Level II evaluation was not scheduled because facility staff were unresponsive to multiple communication attempts within 48 hours of the Level I screening. Interviews with the Medical Record Director (MRD) and the Director of Nursing (DON) revealed a lack of awareness regarding the need for a Level II evaluation for Resident 15. The MRD, responsible for processing PASRR, was unaware of the attempted screening, while the DON acknowledged that the evaluation should have been processed immediately due to the Level I positive result. The facility's policy and procedure on PASRR screening indicated that residents on antipsychotic medications should be evaluated for appropriateness, but this was not adhered to in Resident 15's case.
Failure to Monitor Sertraline Use and Side Effects
Penalty
Summary
The facility failed to monitor and document specific behaviors and side effects related to the use of Sertraline for a resident who was being treated for uncontrollable scratching. The resident, who was unable to communicate her needs or understand others, was observed to have a habit of scratching herself. Despite being prescribed Sertraline for generalized anxiety disorder manifested by uncontrollable scratching, there was no documentation of behavior monitoring or side effects from the medication. Interviews with facility staff, including a CNA and an LVN, revealed that there was a lack of awareness and documentation regarding the resident's behavior and any changes since the initiation of Sertraline. The facility's policy on psychotropic medication use emphasized the need for adequate monitoring for efficacy and adverse consequences, which was not adhered to in this case. This oversight placed the resident at risk of not receiving individualized care to address her medical, mental, and psychosocial needs.
Failure to Provide Storage for Resident's Outside Food
Penalty
Summary
The facility failed to provide storage for food brought by family members for residents, specifically affecting one resident, Resident 14. During interviews, it was revealed that the facility did not have a refrigerator available for storing such food, and residents were instructed to consume the food immediately or have it discarded. Certified Nursing Assistant (CNA) 1 confirmed that there was no place to keep leftover food, and the Administrator stated that the facility did not reheat food brought by family and any remaining food was thrown away. This lack of storage led to Resident 14 feeling disappointed as she could not save food brought by her son for later consumption. Resident 14, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, expressed her disappointment during an interview, stating that she would like to save food brought by her son. The facility's policy, dated 2018, indicated that food brought from outside could be stored in the facility kitchen, nursing station's refrigerator, or in residents' personal refrigerators. However, the Registered Dietitian (RD) confirmed that there was no refrigerator available for this purpose, contradicting the facility's policy.
Inaccurate Medical Record Due to Backdated Physician Order
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident when a physician order for bed rails was backdated without verification. The order was created on August 27, 2024, but was backdated to April 13, 2024, by the Director of Nursing (DON) without informing the Medical Doctor (MD). This action resulted in an inaccurate reflection of the physician's orders for the use of bed rails for the resident. The resident was admitted with a diagnosis of post-hemorrhagic anemia and was observed with half-sized bed rails provided by a hospice agency. During a review of the resident's electronic health record, it was found that the DON created and backdated the order due to the absence of an order in the system. The DON acknowledged the mistake, stating that the order should have been dated on the day it was received. The facility's Administrator was unaware of this action and stated that backdating could lead to document falsification.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide residents with the required minimum square footage per resident in multiple occupancy rooms. Specifically, 12 out of 20 rooms were identified as having less than the mandated 80 square feet per resident. Each of these rooms, numbered 3, 4, 5, 7, 9, 10, 12, 15, 17, 18, 19, and 20, measured a total of 225.36 square feet and housed three residents, resulting in only 75.1 square feet per resident. This deficiency was observed during a survey conducted on August 26, 2024, with the Facility's Maintenance Director. Despite the deficiency in room size, observations from August 25 to August 28, 2024, indicated that there was sufficient space for the provision of care, and no heavy equipment was stored in the rooms that could interfere with residents' care. Each resident had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns reported as a result of the decreased space in the affected rooms. A recommendation for a room size waiver was made.
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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