Regents Point - Windcrest
Inspection history, citations, penalties and survey trends for this long-term care facility in Irvine, California.
- Location
- 19191 Harvard Avenue, Irvine, California 92612
- CMS Provider Number
- 555295
- Inspections on file
- 19
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regents Point - Windcrest during CMS and state inspections, most recent first.
Multiple residents were found with elevated bed side rails in use without required physician orders, informed consent, or proper assessments. Staff confirmed that necessary steps such as interdisciplinary evaluation, entrapment risk assessment, and documentation of alternatives were not consistently completed. Facility policy requiring these steps was not followed, and medical records for several residents showed missing or incomplete documentation related to bed rail use.
Cold beverages, including various juices, were served to all residents at temperatures above the facility's required standard of 41°F or below. The CDM confirmed that the measured temperatures ranged from 42.6°F to 43.8°F, which did not meet the policy for cold TCS food holding during meal service.
Surveyors found that the kitchen had significant sanitation failures, including a dirty stove hood, damaged and unclean utensils, heavily marred cutting boards, and improperly dried blenders. These issues were confirmed by dietary staff and affected all residents receiving food from the kitchen.
The facility did not fully assess all required bed entrapment zones for several residents using side rails, as documentation and staff interviews confirmed that only some zones were evaluated. Residents affected included those with cognitive impairment, physical limitations, and high fall risk, and the facility's own forms and procedures did not reflect complete assessments as required by policy.
The facility did not provide or document written information about advance healthcare directives for two residents, including one with severe cognitive impairment. Staff failed to complete required forms, document discussions, or provide resources as outlined in facility policy, and these omissions were confirmed by interviews with the case manager, DSD, SSD, and DON.
A resident with severe cognitive impairment and a high risk for falls did not have a physician-ordered floor mattress in place as a safety precaution. Despite care plan interventions and staff acknowledgment of the need for the mattress, it was observed leaned against the wall rather than at the bedside while the resident was in bed.
A resident with a PICC line did not have required measurements of external catheter length and arm circumference documented during dressing changes, as required by facility policy. Nursing staff confirmed these assessments were not performed or included in the care plan or physician's orders, and the DON verified the deficiency.
Multiple residents requiring respiratory support did not receive care in accordance with physician orders or facility policy. One resident's CPAP machine lacked a physician's order, care plan, and documented maintenance, with cleaning performed only by the resident and family. Another resident's oxygen cannula was found on the floor, and two residents received oxygen therapy that did not match physician orders or lacked required safety signage. Staff interviews and record reviews confirmed these failures in documentation, equipment care, and adherence to prescribed therapy.
A resident receiving enoxaparin injections did not have injection sites rotated as required, resulting in skin discoloration that was not assessed or reported. Additionally, oxycodone administration was documented on the controlled drug record but not on the MAR, leading to incomplete reconciliation of a controlled substance. Staff and leadership confirmed these deficiencies during interviews and record reviews.
Surveyors found that the medication error rate exceeded 5% after a nurse failed to administer metformin with a meal as ordered for a resident with diabetes, and another resident did not receive a calcium citrate supplement on time due to pharmacy delivery delays. These errors were confirmed through observation, interviews, and record review.
A facility's assessment did not include active participation from direct care staff, their representatives, residents, or family members, as required by updated CMS guidance. Additionally, the assessment lacked a contingency plan for staffing needs. These deficiencies were confirmed by the Administrator during document review and interview.
Multiple breaches in infection control were observed, including a CNA placing a urinal near beverages and failing to change gloves or perform hand hygiene, personal belongings stored with clean linen, and an LVN not following hand hygiene protocols during wound care for a resident with a sacrococcyx pressure injury. Staff and supervisors acknowledged these failures, which were not in accordance with facility policies.
A resident with mild cognitive impairment and an indwelling urinary catheter was repeatedly observed with an uncovered urinary catheter drainage bag, both in bed and in a wheelchair. Staff confirmed that the drainage bag was not covered with a privacy bag as required by facility policy, and the care plan lacked an intervention to ensure the bag was covered. Interviews with a CNA, LVN, and the DON verified the deficiency in maintaining the resident's dignity.
A resident with an indwelling urinary catheter had incomplete documentation of urine output in the medical record, despite physician orders and facility policy requiring intake and output to be recorded every shift. Nursing staff and the DON confirmed that several entries were missing from the Treatment Administration Record.
A facility failed to monitor a resident's psychosocial wellness after an alleged financial abuse incident. The care plan required monitoring by nursing and social services staff for three days, but notes were missing for two days, indicating non-compliance. The DSD confirmed the resident should have been monitored as per the care plan.
The facility failed to ensure accurate MDS assessments for two residents. One resident receiving hospice care was not marked as such in the MDS, and another resident with serious mental illness was incorrectly coded as not requiring a level II PASARR evaluation. Both the MDS Coordinator and the DON acknowledged these oversights.
The facility failed to complete a PASARR evaluation for a resident after a new diagnosis of schizophrenia and prescription of Risperdal. Staff interviews confirmed that a new PASARR should have been conducted to determine if the resident would benefit from additional services.
The facility failed to follow physician orders for a resident with diabetes and hypotension by not notifying the physician of elevated blood glucose levels and administering midodrine despite high SBP. Interviews confirmed these lapses, with staff acknowledging the failure to adhere to orders.
The facility failed to ensure proper infection control practices during catheter care and glucometer use. A CNA did not change gloves after catheter care, and an RN did not disinfect a glucometer after use on two residents. Both actions were against facility policies and confirmed by multiple staff members.
A resident with a history of pneumonitis, atrial fibrillation, and rheumatoid arthritis did not receive a follow-up pneumococcal vaccine despite consent being given. Facility staff were unaware of the oversight, and both the Administrator and DON confirmed the resident should have received the vaccine.
Failure to Obtain Orders, Consent, and Assessments for Bed Rail Use
Penalty
Summary
Surveyors identified that the facility failed to follow required protocols for the use of bed side rails for multiple residents. Observations revealed that several residents were found in bed with elevated bilateral side rails without evidence of a physician's order, informed consent, or proper assessments documented in their medical records. In several cases, residents had cognitive impairments or lacked capacity to make decisions, yet there was no documentation of family or representative involvement in the consent process. Staff interviews confirmed that the necessary steps, such as obtaining a physician's order, conducting entrapment and bed rail assessments, and securing informed consent, were not consistently completed prior to the application of side rails. Medical record reviews for the affected residents showed missing or incomplete documentation, including absent physician orders for side rail use, lack of informed consent forms, and incomplete interdisciplinary team (IDT) evaluations. In some instances, side rail evaluations indicated that side rails were not indicated for the resident, yet the rails were still in use. Additionally, some residents' records lacked documentation of the risks and benefits discussion or the rationale for side rail use, and in certain cases, the IDT meeting documentation was incomplete or missing required signatures from care team members such as the physician or social worker. The facility's own policies and procedures require that alternatives to bed rails be attempted first, and if unsuccessful, a comprehensive assessment, interdisciplinary evaluation, and informed consent must be completed before side rails are used. Despite these requirements, the facility failed to ensure compliance, resulting in the use of side rails without proper authorization or assessment for nine sampled residents and one non-sampled resident. These failures were confirmed through staff interviews and record reviews, and were found to be inconsistent with both facility policy and federal safety alerts regarding the risks of bed rail entrapment.
Cold Beverage Temperatures Exceed Safe Holding Standards
Penalty
Summary
The facility failed to ensure that cold beverages served to residents were maintained at the required appetizing and safe temperatures. During a tray line observation, the Certified Dietary Manager (CDM) measured the temperatures of various juices, including cranberry juice, orange juice, and a mixed juice, and found them to be between 42.6 and 43.8 degrees Fahrenheit. These temperatures exceeded the facility's policy requirement that cold Time/Temperature Control for Safety (TCS) foods be held at 41 degrees Fahrenheit or below. The CDM acknowledged that the beverages were not at the appropriate temperature prior to being served to residents, despite being placed in a bucket of ice for cooling. All 45 residents in the facility consumed food and beverages prepared in the kitchen, according to the Diet Type Report.
Widespread Kitchen Sanitation Failures and Unsafe Food Contact Surfaces
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations during a kitchen tour. The hood over the stove was found to have black, dirt residue, and the Dietary Aide confirmed this condition. Facility policy required the Maintenance Department to clean such equipment, but this was not done, resulting in unsanitary conditions above the food preparation area. Kitchen utensils and equipment were observed to be in poor condition, with several items cracked, chipped, melted, discolored, or otherwise damaged. These included blenders, serving spoons, spatulas, scoops, and cutting tools. The Dietary Aide verified that these items were in use and stored as clean, despite their compromised surfaces, which made them difficult or impossible to clean properly. Facility policies and USDA Food Code require utensils and food-contact surfaces to be smooth, cleanable, and in good repair, but these standards were not met. Additionally, many utensils and kitchenware items stored as clean were found to have visible food residue, watermarks, crusted debris, and fuzzy film. Cutting boards were heavily marred, discolored, and had deep grooves, making them unsanitary and difficult to clean. Heavy-duty blenders were stored while still wet, with water visible inside and on the lids, contrary to facility policy and food code requirements for air drying. All of these deficiencies were acknowledged by the Dietary Aide and the Director of Dining Services, and affected all residents consuming food prepared in the kitchen.
Failure to Complete Full Bed Entrapment Assessments for Residents Using Side Rails
Penalty
Summary
The facility failed to ensure that entrapment assessments for bed systems were accurately completed for multiple residents. Specifically, the Bed System Measurement Device Test Results Worksheet used by the facility did not include or document assessments for Zones 6 and 7, which are critical areas identified by the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. This omission was confirmed through review of facility documentation and interviews with the Maintenance Supervisor, who acknowledged that these zones were not reflected or assessed on the forms for several residents. Observations revealed that numerous residents were found in beds with elevated bilateral side rails, and their medical records showed a range of cognitive and physical impairments, including severe cognitive impairment, fluctuating decision-making capacity, and physical limitations such as osteoporosis and high fall risk. Despite these vulnerabilities, the required entrapment assessments for all seven zones were not completed or documented for these residents. In several cases, staff interviews confirmed a lack of awareness or understanding of the entrapment assessment process, and the documentation consistently showed only Zones 1 to 4 were assessed. The facility's policy and procedure required that bed frames, mattresses, and bed rails be checked for compatibility and entrapment risk, and that maintenance staff routinely inspect all beds and related equipment. However, the actual practice did not align with these requirements, as evidenced by the incomplete assessments and lack of documentation for Zones 6 and 7. This deficiency was identified for nine sampled residents and one non-sampled resident, all of whom had beds with side rails in use, and was verified through direct observation, record review, and staff interviews.
Failure to Provide and Document Advance Directive Information for Residents
Penalty
Summary
The facility failed to provide written information regarding the right to formulate advance healthcare directives for two residents, as required by its own policies and procedures. For one resident, the medical record did not contain evidence that written information about advance directives was provided upon admission, despite documentation indicating the resident had executed an advance directive. The case manager, responsible for gathering advance directives, was unable to produce documentation of discussions or provision of information regarding advance directives for this resident, and the required staff signature was missing from the acknowledgment form. For another resident, who was readmitted with severe cognitive impairment as indicated by a BIMS score of zero, the medical record showed an incomplete POLST form and an acknowledgment that the resident wished to execute an advance directive. However, there was no documentation that resources or follow-up were provided to the resident's family member, and no advance directive was available in the medical record. The social services designee confirmed that the process and resources provided for executing an advance directive must be documented, and acknowledged that this was not done. Interviews with facility staff, including the case manager, director of staff development, social services designee, and DON, confirmed that the expected processes for providing information, documenting discussions, and assisting with advance directives were not followed or documented for these residents. The lack of documentation and incomplete forms were verified by staff during the survey.
Failure to Implement Physician-Ordered Fall Precaution for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls was free from accident hazards, as required by both physician order and facility policy. Specifically, the resident, who had severe cognitive impairment, Alzheimer's disease, dementia, and poor safety awareness, was supposed to have a floor mattress placed at the bedside as a fall precaution. Despite a care plan and a physician's order for the use of a floor mattress, observations revealed that the mattress was not in place while the resident was in bed; instead, it was found leaned against the wall. Medical record review confirmed the resident's high fall risk and the need for the floor mattress intervention. Staff interviews corroborated that the mattress should have been in place at all times when the resident was in bed, especially given the resident's history of attempting to get out of bed and a previous fall incident. The failure to implement this safety intervention as ordered constituted a deficiency in providing adequate supervision and accident hazard prevention.
Failure to Document PICC Line Measurements During Dressing Changes
Penalty
Summary
The facility failed to provide necessary care and services for the maintenance of a peripherally inserted central catheter (PICC) line for one resident. Specifically, the facility did not obtain or document the required measurements of the external catheter length and arm circumference during dressing changes, as outlined in their own policy and procedure for central venous catheter care. The resident's care plan and physician's orders also lacked directives to measure and record these parameters, and there was no evidence in the treatment administration records that these assessments were performed. Interviews with nursing staff confirmed that while they were aware of the need to monitor for infection and perform dressing changes, they did not include the required measurements in their assessments or documentation. The resident involved had a PICC line placed in the facility for IV antibiotic administration and was observed with the line in place and a dressing dated from a previous week. Both the licensed vocational nurse (LVN) and registered nurse (RN) acknowledged that the measurements were not taken or documented, and the director of nursing (DON) verified these findings. The absence of these documented assessments had the potential to delay the identification of PICC line-related complications for the resident.
Deficiencies in Respiratory Care and Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services for several residents requiring oxygen therapy and CPAP support. For one resident using a CPAP machine, there was no documented physician's order, no care plan, and no evidence of care or maintenance of the device in the medical record. The resident reported that she and her family were solely responsible for cleaning and maintaining the CPAP machine, with no involvement from facility staff. Observations and interviews confirmed that staff were aware of the device but did not ensure its care or proper documentation, and the device was not cleaned according to manufacturer guidelines. For another resident, the oxygen nasal cannula was found on the floor while the oxygen concentrator was running, indicating improper administration and storage of oxygen equipment. The facility's policy required that oxygen tubing not be placed on the floor and be kept in a bag when not in use, but this was not followed. Additionally, another resident was observed receiving oxygen at a higher flow rate than ordered by the physician, and staff were incorrectly documenting compliance with the physician's order in the system. There was also a failure to post required oxygen signage on the door for a resident receiving oxygen therapy, as required by facility policy. These deficiencies were identified through observations, interviews with staff and residents, and review of medical records and facility policies. The failures included lack of physician orders, care plans, proper documentation, adherence to prescribed oxygen flow rates, and compliance with infection control and safety protocols for respiratory equipment.
Failure to Rotate Injection Sites and Incomplete Controlled Substance Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not rotating injection sites for enoxaparin, an anticoagulant medication, as required by facility policy. Documentation showed that the medication was repeatedly administered to the same area of the resident's upper arms over several days, rather than rotating sites as directed. This resulted in the resident developing bluish to greenish discoloration on the right upper arm, which was observed during an interview and not previously assessed, monitored, or reported to the physician or family representative as required. Additionally, the facility did not ensure accurate reconciliation and documentation of a controlled substance, oxycodone HCl IR, for the same resident. The medication was documented as administered on the Controlled Drug Record but was not recorded on the electronic Medication Administration Record (MAR). Staff interviews confirmed that the medication was removed from the bubble pack and given to the resident, but the administration was not properly documented in the MAR immediately after, as required by facility policy. The resident involved had no capacity to exercise rights or sign necessary documents and was receiving enoxaparin for DVT prophylaxis and oxycodone for pain management. Facility staff, including LVN, RN, and DON, verified the findings during interviews and record reviews, confirming that both the failure to rotate injection sites and the failure to accurately document controlled medication administration occurred.
Medication Error Rate Exceeds 5% Due to Administration and Delivery Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During medication administration, one licensed nurse did not follow physician orders for a resident prescribed metformin for diabetes mellitus. The nurse administered the metformin tablet at 9:22 AM, while the resident had eaten breakfast at 8:00 AM, contrary to the order specifying the medication should be taken with meals. The nurse confirmed the medication was not given as directed with the meal. Additionally, another resident did not receive a prescribed calcium citrate supplement on time following admission because the medication had not yet been delivered by the pharmacy. The nurse stated that all medication orders are sent to the pharmacy upon admission and are usually delivered the same day, but in this instance, the supplement was not available for administration. These events were observed and verified through interviews and medical record reviews.
Facility Assessment Lacks Required Stakeholder Involvement and Staffing Contingency Plan
Penalty
Summary
The facility failed to ensure that its Facility Assessment included the active involvement of required individuals, such as direct care staff, direct care representatives, residents, residents' representatives, and family members, in its development. Review of the Facility Assessment dated 3/12/25 showed no evidence of participation from these groups. This omission was confirmed during an interview and document review with the Administrator, who acknowledged the lack of involvement from these stakeholders and was aware of the updated CMS guidance requiring such participation. Additionally, the Facility Assessment did not include a contingency plan for staffing needs, as required by the revised CMS guidance. The Administrator verified that the assessment lacked this component and had not been updated to reflect the latest requirements. The absence of both stakeholder involvement and a staffing contingency plan was identified through document review and staff interview, indicating noncompliance with current regulatory expectations.
Infection Control Breaches in Resident Care, Laundry, and Wound Treatment
Penalty
Summary
The facility failed to maintain its infection prevention and control program as evidenced by multiple observed breaches in infection control practices. In one instance, a certified nursing assistant (CNA) placed a resident's urinal containing urine on top of the overbed table near uncovered cups of water and juice. The CNA then removed the urinal, discarded its contents, rinsed it, and returned it to the same location, all while wearing the same gloves. The CNA continued to use the contaminated gloves to move the overbed table and put socks on the resident, without performing hand hygiene or changing gloves. Both the CNA and the infection preventionist (IP) acknowledged that the urinal should not have been placed on the overbed table and that proper hand hygiene was not performed. Another deficiency was observed in the facility's laundry area, where a laundry aide's personal belongings, including a black backpack and jacket, were stored with clean linen in the clean linen room. Both the laundry aide and the housekeeping supervisor confirmed that personal items should not be stored with clean linen, as per facility policy. The administrator also verified that the clean linen area must be kept clean and free of personal belongings. Additionally, a licensed vocational nurse (LVN) failed to perform appropriate hand hygiene during wound care for a resident with a sacrococcyx pressure injury. The LVN was observed touching the resident's thigh after handling a trash can with the same gloves, removing gloves and donning new ones without hand hygiene, and completing the wound care procedure without changing gloves or performing hand hygiene between steps. The LVN acknowledged that proper infection control practices, including handwashing after touching dirty surfaces, were not followed. The director of nursing (DON) confirmed that the facility's policy requires hand hygiene and glove changes during such procedures.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Drainage Bag
Penalty
Summary
Facility staff failed to maintain the dignity of a resident with an indwelling urinary catheter by not covering the urinary catheter drainage bag with a privacy bag. Multiple observations over several days showed the resident in bed and in a wheelchair with the drainage bag uncovered and visible at the side of the bed or under the wheelchair. The facility's policy on dignity requires staff to promote and protect resident privacy, including bodily privacy during personal care and treatment procedures. However, the resident's care plan did not include an intervention to cover the urinary catheter drainage bag with a privacy bag. The resident, who had mild cognitive impairment and required total assistance for urinary catheter care, had a physician's order for catheter care every shift and to change the catheter bag as needed. Staff interviews confirmed that the drainage bag was not covered and that it should have been, according to facility expectations. The Director of Nursing also verified that the expectation was for the drainage bag to be covered to maintain resident dignity.
Incomplete Documentation of Urine Output for Catheterized Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, specifically regarding the documentation of urine output for a resident with an indwelling urinary catheter. According to the facility's policy on Output Measuring and Recording, urine output should be recorded in milliliters in the resident's medical record every shift. However, a review of the resident's Treatment Administration Record (TAR) revealed missing documentation of urine output on several dates and shifts, despite physician orders requiring intake and output monitoring every shift and catheter care. During interviews, both a registered nurse and the Director of Nursing confirmed the presence of the indwelling catheter and acknowledged the incomplete documentation. They verified that the nurses were responsible for measuring and recording the urine output in the TAR, and confirmed the specific dates and shifts where documentation was missing. The administrator also verified these findings during a subsequent interview.
Failure to Monitor Resident's Psychosocial Wellness After Alleged Financial Abuse
Penalty
Summary
The facility failed to adequately monitor a resident's psychosocial wellness following an allegation of financial abuse. The care plan for the resident, who was admitted to the facility on an unspecified date, included specific interventions to address the alleged financial abuse. These interventions required monitoring by nursing staff and social services staff for three days, assisting the resident in developing a meaningful activity program, notifying relevant authorities and the resident's responsible party, and observing the resident for signs of depression or anxiety. However, the facility did not adhere to these interventions as required. Upon review, it was found that the psychosocial monitoring notes from the social services staff were missing for two days following the incident, and there was no nursing progress note for one of those days. This lack of documentation indicates that the resident was not monitored for the psychosocial effects of the alleged abuse as outlined in the care plan. The Director of Staff Development confirmed these findings, acknowledging that the resident should have been monitored for 72 hours by both nursing and social services staff.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for two residents. Resident #34 was admitted with multiple diagnoses, including chronic obstructive pulmonary disease and malignant neoplasm of the skin. Despite being admitted to hospice care as indicated by physician orders and the care plan, the MDS assessment did not reflect this status. Both the MDS Coordinator and the Director of Nursing acknowledged that hospice care should have been marked on the MDS assessment, but it was overlooked, resulting in an inaccurate MDS assessment for Resident #34. Resident #3, who was admitted with diagnoses including psychosis, major depressive disorder, and dementia with psychotic disturbance, was incorrectly coded in the MDS assessment as not being considered by the state level II PASARR process to have a serious mental illness. Documentation from the State of California-Health and Human Services Agency indicated that a level II mental health evaluation was required and specialized services were recommended. The MDS Coordinator and the Director of Nursing both confirmed that the MDS should accurately reflect the resident's mental health status, but it did not, leading to an inaccurate assessment for Resident #3.
Failure to Complete PASARR Evaluation for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for a resident after a newly evident serious medical illness diagnosis of schizophrenia. The resident, who was admitted with diagnoses including major depressive disorder and dementia, was later found to have schizophrenia and was prescribed Risperdal, an antipsychotic medication. Despite this significant change in the resident's medical condition, no PASARR evaluation was conducted to determine if the resident would benefit from additional services. Interviews with facility staff, including the MDS Coordinator, Director of Nursing, and the Administrator, confirmed that a new PASARR should have been completed when the resident was prescribed the antipsychotic medication. The staff acknowledged that the nurse who received the order should have notified the MDS Coordinator to submit a new PASARR. The failure to complete the PASARR evaluation was identified through a review of the resident's medical records, care plan, and physician's orders.
Failure to Follow Physician Orders for Blood Glucose and Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure staff followed the physician's orders for a resident with type 2 diabetes mellitus and hypotension. Specifically, the staff did not notify the physician when the resident's blood glucose level exceeded 300 mg/dL and did not hold a medication when the resident's systolic blood pressure (SBP) was greater than 140 mmHg. The resident had an order for midodrine to be held if the SBP was above 140 mmHg and an order for insulin lispro with instructions to notify the physician if the blood glucose level was above 300 mg/dL. Despite these orders, the resident received midodrine when the SBP was 148 mmHg, and the physician was not notified when the blood glucose level reached 347 mg/dL. Interviews with the Licensed Vocational Nurse (LVN) and the Medical Doctor (MD) confirmed these lapses in following the physician's orders. The LVN did not recall administering the midodrine outside the prescribed parameters and admitted to not notifying the physician about the elevated blood glucose level. The MD expressed concerns about the lack of notification regarding the elevated blood glucose level and emphasized the importance of following physician orders. The Director of Nursing and the Administrator also stated their expectations that nursing staff should adhere to physician orders.
Infection Control Deficiencies in Catheter Care and Glucometer Use
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the provision of catheter care and the use of a glucometer. Specifically, a Certified Nurse Assistant (CNA) did not change gloves after completing catheter care for a resident with severe sepsis and chronic kidney disease, and continued to perform other tasks such as placing a new incontinence brief and changing the resident's bed pad without changing gloves. This was acknowledged by the CNA, the Director of Nursing, the Administrator, and the Infection Preventionist, all of whom confirmed that gloves should be changed when moving from a dirty to a clean task. Additionally, a Registered Nurse (RN) failed to disinfect a glucometer after using it to check the blood glucose levels of two residents. The RN did not clean the glucometer after each use and placed it back on the medication cart. Interviews with the RN, the Director of Staff Development, the Director of Nursing, and the Administrator confirmed that the glucometer should be cleaned with germicidal wipes after each use to prevent cross-contamination. The RN was unaware of the proper cleaning procedure, believing it was the responsibility of the night shift nurse.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to ensure a pneumococcal vaccine was administered to a resident after consent was received. The facility's policy, revised in March 2022, mandates that all residents are offered pneumococcal vaccines to prevent pneumonia/pneumococcal infections. Resident #25, admitted on 05/02/2023, had a history of pneumonitis due to inhalation of food and vomit, permanent atrial fibrillation, and rheumatoid arthritis. The resident's immunization report indicated they received a pneumococcal vaccine on 07/18/2017, and consent for a follow-up vaccine was given on 10/16/2021. However, there was no record of the resident receiving the follow-up vaccine after consent was obtained. During interviews, both the Licensed Vocational Nurse (LVN) and the Director of Staff Development were unaware of why the resident did not receive the vaccine. The Administrator and the Director of Nursing confirmed that the resident should have received the pneumococcal vaccine once consent was received. The failure to administer the vaccine as per the facility's policy and the received consent constitutes the deficiency identified in the report.
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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