River Bend Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Sacramento, California.
- Location
- 2215 Oakmont Way, West Sacramento, California 95691
- CMS Provider Number
- 055887
- Inspections on file
- 41
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at River Bend Nursing Center during CMS and state inspections, most recent first.
A resident with non‑traumatic intracerebral hemorrhage and H. pylori gastritis had an order for metronidazole 500 mg via PEG tube every 6 hours, but two scheduled doses were not administered. MAR review showed missed doses, and administration notes documented that the medication was pending pharmacy delivery. During surveyor interviews, the IP confirmed the doses were not given and identified that metronidazole was available in the medication e‑kit, which staff did not use. The DON stated the nurse should have used the ordered medication from the e‑kit, contrary to the facility’s medication administration policy requiring timely administration as prescribed.
The facility did not ensure that call light systems accommodated the needs of several dependent residents. Two residents with severe mobility impairments, including contractures and quadriplegia, were given standard call lights placed on their chests despite being unable to use them, and the DON stated the facility did not assess for or provide accessible call light options. Three additional residents, including individuals with respiratory failure, anoxic brain injury, and Parkinson’s disease, were observed in bed with their call lights on the floor and out of reach, which staff acknowledged as a safety concern. These practices conflicted with the facility’s own policy requiring that call lights be accessible to residents in bed.
A resident with hypotension and impaired cognition did not receive prescribed Midodrine HCl on several occasions when their SBP was below the ordered threshold. Nursing staff failed to administer the medication as ordered and did not notify the physician of the omissions, contrary to facility policy and expectations.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Residents lost the ability to perform ADLs without a documented medical reason, and the facility did not provide evidence that the decline was unavoidable due to a medical condition.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance to complete these tasks.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of environmental safety measures and insufficient supervision led to the identification of this issue.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Surveyors identified that an open container of glucometer test strips lacked an open date, and an eye drop medication in the medication room refrigerator had an illegible open date, making it unclear if it was still safe for use. Additionally, keys to controlled substance cabinets and the refrigerator were found unsecured, allowing unauthorized access. These findings were confirmed by nursing staff and were not in accordance with facility policy requiring secure storage and proper labeling of medications.
The facility failed to protect residents from scabies when three residents tested positive, and a recommended second round of treatment was not completed. Despite initial treatments, the Director of Nursing decided against a second round for all residents and staff, contrary to public health recommendations. This decision was made despite guidelines emphasizing comprehensive treatment to control outbreaks.
A resident's care plan was not updated in a timely manner after their skin condition worsened to a Stage 4 pressure ulcer. Despite physician orders for new interventions, the care plan was not revised until over a month later, contrary to facility policies. The DON acknowledged the change but did not see the need for additional interventions.
A resident with multiple diagnoses, including epilepsy, had electrodes placed for an EEG, but the facility failed to obtain follow-up care instructions, resulting in a missed appointment for electrode removal. The Director of Nursing removed the electrodes without proper guidance, causing scalp injuries. Communication lapses and lack of documentation contributed to the deficiency.
A resident with parkinsonism did not receive their prescribed Rytary medication on time due to a delay in delivery, leading to worsening symptoms. Interviews with staff and the resident highlighted concerns about medication availability, and the facility's policies on timely pharmacy services were not followed.
The facility compromised resident privacy by discarding meal tray tickets containing sensitive information into the general kitchen trash. A dietary aide was observed throwing these tickets away, which included resident names, room numbers, diet orders, and other personal details. The District Kitchen Supervisor confirmed this practice, acknowledging that the tickets should be shredded to maintain confidentiality, as per the facility's policy on resident rights.
The facility's kitchen staff lacked the necessary knowledge and competencies, leading to several deficiencies. A cook was unable to read freezer temperatures correctly, and a dietary aide could not state dishwashing machine temperatures. Additionally, a cook prepared pureed foods without a recipe, and incorrect scoop sizes were used for food portions, potentially affecting residents' nutrition and safety.
The facility failed to follow the prescribed recipe for pureed food for three residents on a pureed diet. A kitchen staff member used incorrect scoop sizes, leading to improper portion sizes for pureed potatoes and cream style corn. This error was identified during an observation and interview, with the staff member unaware of the correct scoop sizes. The District Kitchen Supervisor and Registered Dietitian emphasized the importance of following recipes and using proper measurements to ensure residents receive adequate nutrition.
The facility failed to prepare pureed bread according to a standardized recipe, affecting 20 residents on pureed diets. A cook was observed using unmeasured ingredients, resulting in a thick and sticky consistency. The Dietary Supervisor and Registered Dietitian confirmed the importance of following recipes to ensure nutritional adequacy and consistency, as outlined in the facility's policies.
A facility failed to meet food safety standards, affecting 54 residents. Issues included improper food labeling, expired items, inadequate storage temperatures, and structural and equipment deficiencies. Observations revealed unlabeled and expired food, improper storage temperatures, and a lack of air gaps in the produce sink. A chipped can opener blade and a staff member without a beard restraint were also noted, posing contamination risks.
A LTC facility failed to follow proper infection control practices, including a respiratory therapist not performing hand hygiene, an uncovered isolation trash can, improperly labeled oxygen equipment, a dirty air fan, and open trash containers in the dining room. These deficiencies were confirmed by staff and posed potential infection risks.
The facility failed to maintain a reach-in freezer in safe operating condition, with temperatures recorded at 16 and 20 degrees Fahrenheit, contrary to the policy requiring 0 degrees or below. The Dietary Supervisor confirmed the issue, noting the freezer might be broken and lacked scheduled maintenance. This failure risked bacterial growth and foodborne illness for 54 residents consuming facility-prepared meals.
The facility failed to provide a safe, clean, and comfortable environment, with issues such as missing window blind slats, non-functioning bulbs, and open trash containers in the dining room. A resident with PTSD and blindness was found in an unsanitary state, with a strong odor and a dirty room. Staff confirmed these deficiencies, which were not addressed due to communication lapses and lack of parts.
The facility failed to ensure that two contracted CNAs received the required in-service training, including dementia management and abuse prevention. The Director of Staff Development and the Director of Nursing could not provide documentation verifying the completion of the mandatory 12 hours of annual training. The facility relied on a staffing agency, which did not maintain records of training completion, leading to a potential compromise in the quality of care provided to residents.
The facility failed to uphold dignity and privacy for two residents, impacting their well-being. A resident with PTSD and depression experienced a breach of privacy when maintenance staff entered without knocking or identifying themselves. Another resident with PTSD and blindness was found neglected, with a strong body odor and a disheveled appearance, expressing feelings of being left in filth. These actions were contrary to the facility's policy on resident rights.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. One resident with PTSD experienced distress from loud door noises, which was not addressed despite complaints. Another resident with Alzheimer's and anxiety had no care plan for activities, resulting in isolation. The facility's policy requires timely care plan development, but this was not followed, posing potential risks to residents' well-being.
The facility failed to update care plans for two residents, one requiring an adaptive device for nutrition and another needing pain management. A resident with stroke and dysphagia did not have their care plan revised to include a two-handled cup, leading to the use of an incorrect sippy cup. Another resident with pain issues did not have their care plan updated to include a new Tramadol prescription, resulting in unmanaged pain. These oversights were confirmed by staff and highlighted a lack of adherence to the facility's policy on care plan revisions.
Two residents in an LTC facility were found with deficiencies in personal hygiene and grooming care. A resident with PTSD and blindness was observed in a disheveled state with a strong odor, despite not rejecting ADL assistance. Another resident with respiratory failure and traumatic brain injury had long, jagged fingernails, which were not trimmed as per facility policy. Staff acknowledged these issues, which were contrary to the facility's policies on maintaining hygiene and grooming.
Two residents did not receive scheduled in-room activity visits, leading to potential isolation and depression. One resident with cerebral infarction and quadriplegia had no documented visits despite a care plan for thrice-weekly visits. Another resident with Alzheimer's and anxiety disorder had only one documented visit since admission. The Activities Director confirmed the lack of visits, contrary to facility policy.
A facility failed to obtain necessary physician's orders and informed consent before using bed rails for a resident with memory impairment and other medical conditions. Observations confirmed the use of bed rails without proper documentation, violating the facility's policy on bed safety.
The facility failed to accurately document narcotic administration for two residents, leading to discrepancies between the Controlled Drug Record and the Medication Administration Record. This failure involved missing documentation for Norco and Oxycodone tablets, increasing the risk of narcotic diversion. The Director of Nursing confirmed the discrepancies and highlighted the importance of accurate documentation to ensure medication safety.
A resident with no cognitive impairment was served cream of wheat for breakfast despite requesting oatmeal, as indicated on their meal tray ticket. The Dietary Supervisor confirmed the error, acknowledging that the resident should have received oatmeal. The facility's policy requires alternate meal options, which was not followed in this case.
Two residents were not provided with necessary adaptive eating equipment as ordered by their physicians, potentially impacting their well-being. One resident, with a history of stroke and dysphagia, was given a sippy cup instead of a two-handled cup. Another resident, with encephalopathy and dysphagia, was given metal silverware instead of plastic utensils. The facility's policy emphasizes the need to evaluate and provide adaptive devices.
Failure to Administer Ordered Antibiotic When Available in Emergency Kit
Penalty
Summary
The facility failed to administer a prescribed antibiotic in accordance with professional standards and physician orders for one resident. The resident had been admitted with diagnoses including non‑traumatic intracerebral hemorrhage and H. pylori gastritis. The hospital After Visit Summary dated 3/17/26 showed metronidazole 500 mg every 6 hours, with the last hospital dose given at 12:12 p.m. The facility’s Order Summary Report starting 3/17/26 ordered metronidazole 500 mg via PEG tube every 6 hours for H. pylori gastritis. Review of the March 2026 MAR showed that the resident did not receive the scheduled metronidazole doses on 3/17/26 at 6 p.m. and 3/18/26 at 12 a.m. During interviews and concurrent record review, the Infection Preventionist confirmed that the medication had not been given, as documented in Administration Notes on 3/17/26 at 7:45 p.m. and 3/18/26 at 12:32 a.m., which indicated the medication was pending pharmacy delivery. In a medication room observation, the Infection Preventionist checked the emergency medication kit (e‑kit) and found it contained metronidazole, and stated the nurse should have used the e‑kit to administer the scheduled antibiotic if available. The DON also stated that the nurse should have used the ordered medication from the e‑kit. The facility’s undated “Administering Medications” policy stated that medications are to be administered in a safe and timely manner, as prescribed, and in accordance with prescribed orders, including any required time frame.
Failure to Provide Accessible and Reachable Call Lights for Dependent Residents
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences related to call light accessibility for multiple residents. Two residents with significant physical limitations, including one with bilateral hand contractures and another with quadriplegia, were assessed as dependent in activities of daily living. During observation, both residents had standard call lights placed on their chests despite their mobility issues, and a licensed nurse acknowledged not knowing how they would be able to use the call lights if they needed help. The DON confirmed that these residents were not provided with accessible call light systems and stated that the facility did not conduct assessments for accessible call lights, asserting that such residents could not press them anyway. The facility did not provide a policy or procedure for call light accessibility when requested, although its Resident Rights policy referenced residents’ right to a dignified existence. Additional deficiencies were identified for three other residents whose call lights were not within reach. One resident with respiratory failure and another with an anoxic brain injury were observed lying in bed with their call lights on the floor; the licensed nurse present confirmed the call lights were not within reach and acknowledged that call lights on the floor were a safety issue. Another resident with Parkinson’s disease was also observed in bed with the call light on the floor, and the respiratory therapist confirmed the call light was out of reach and that the resident would not be able to use it to get help. These observations were inconsistent with the facility’s written policy on answering call lights, which required that call lights be accessible to residents when in bed.
Failure to Administer Antihypotensive Medication as Ordered
Penalty
Summary
A resident with a history of hypotension and impaired cognition was admitted to the facility and had a physician's order for Midodrine HCl, an antihypotensive medication, to be administered twice daily when systolic blood pressure (SBP) was less than or equal to 120. Review of the Medication Administration Record (MAR) for February 2025 showed that the resident did not receive the prescribed medication on multiple dates when the SBP was below the threshold, as required by the physician's order. The medication was omitted without documentation of physician notification or clinical justification. Interviews with the DON and a licensed nurse confirmed that the expectation was to follow physician orders and to notify the physician if a medication was not administered. The licensed nurse acknowledged that the resident's SBP was below 120 on the missed dates and that the medication should have been given. Facility policy required medications to be administered as prescribed and for the prescriber to be contacted if there were concerns about the appropriateness of a dosage. These actions and inactions resulted in a significant medication error for the resident.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning, as required, and did not provide evidence that any decline in ADL abilities was unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not show appropriate justification for the decline in ADL performance.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for a resident who was unable to do so independently. The report notes that the required support for ADLs was not given to a resident in need, indicating a lapse in the provision of necessary care and assistance as required for residents unable to perform these tasks on their own.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. This lapse in maintaining a safe environment and providing necessary oversight directly contributed to the deficiency cited by surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. An open container of glucometer test strips was found on a medication cart without an open date, despite manufacturer instructions requiring use within six months of opening. The nurse present confirmed the omission and was unable to state the allowable usage period after opening. Additionally, an eye drop medication (latanoprost) stored in the medication room refrigerator was labeled with an open date that was not legible and predated the refill date, making it impossible to determine if it was still safe for use. The Assistant Director of Nursing confirmed that the medication should be used within six weeks of opening and that the observed container had exceeded this period. Further, keys to the controlled substance cabinets and refrigerator were found unsecured, hanging in a plastic bag on the wall of the medication storage room. A nurse confirmed that these keys provided access to controlled substances and were not secured as required. The Director of Nursing acknowledged that these practices did not comply with facility policy, which mandates that all drugs and biologicals be stored in locked compartments and that only authorized personnel have access to them. The policy also requires proper labeling of all medication containers and the return or destruction of outdated or improperly labeled drugs.
Failure to Implement Comprehensive Scabies Prophylaxis
Penalty
Summary
The facility failed to protect residents from acquiring scabies, a contagious skin infestation caused by mites, when three residents tested positive for scabies and facility-wide prophylaxis was not completed as recommended by public health authorities. The deficiency was identified through observation, interview, and record review, revealing that the facility did not follow through with the recommended second round of treatment for all residents and staff, which was advised to prevent further spread of the infestation. Resident 1, admitted in March 2023 with multiple diagnoses including cerebral infarction, ventilator dependence, tracheostomy, and heart failure, tested positive for scabies on December 13, 2024, and was treated with permethrin cream as ordered. Resident 2, admitted in September 2012 with respiratory failure, quadriplegia, seizures, and heart failure, also tested positive for scabies and received the prescribed treatment. Similarly, Resident 3, admitted in October 2022 with respiratory failure, paraplegia, pressure ulcer stage 4, and amputation of both legs above the knee, was treated for scabies following a positive test result. Despite these treatments, the facility did not implement a second round of prophylaxis for all residents and staff, as recommended by the Yolo County Public Health Officer. Interviews with facility staff, including the Nursing Supervisor, Infection Preventionist, and Director of Nursing, revealed that while initial treatments were administered, the decision not to conduct a second round of treatment for all residents and staff was made by the Director of Nursing, who deemed it a recommendation rather than a mandate. This decision was made despite the public health officer's strong recommendation for a second round of treatment to prevent recurrence and further spread of scabies within the facility. The facility's policy on infection prevention and control, as well as guidelines from the California Department of Public Health and Los Angeles County Public Health, emphasize the importance of comprehensive treatment to control outbreaks, which was not fully adhered to in this case.
Failure to Update Wound Care Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to update and revise the wound care plan in a timely manner for a resident whose moisture-related skin condition deteriorated into a Stage 4 pressure ulcer. The resident, who had been admitted with conditions including respiratory failure, muscle wasting, diabetes, and reduced mobility, was found to have a Stage 4 pressure ulcer on the sacrococcyx during a skin integrity review. Despite the reclassification of the wound from a shear injury to a pressure injury by a wound MD, and subsequent physician orders for specific wound care interventions, the care plan was not revised until over a month later. The care plan, initially created in May, was not updated to reflect the significant change in the resident's condition or the new interventions ordered by the physician on two separate occasions in September and October. The Director of Nursing acknowledged the change in the resident's condition but did not believe additional interventions were necessary at the time. This oversight was contrary to the facility's policies, which require care plans to be revised when there is a significant change in a resident's condition.
Failure to Follow Up on EEG Appointment Leads to Resident Injury
Penalty
Summary
The facility failed to provide care according to professional standards of practice for a resident who had electrodes placed for an EEG machine. The facility did not obtain instructions for follow-up care, resulting in a missed appointment for the removal of the electrodes. This oversight had the potential to cause scalp skin injuries when the electrodes were eventually removed at the facility. The resident, who had multiple diagnoses including dysphagia following a stroke, quadriplegia, and epilepsy, was admitted to the facility in June 2013. The resident was sent out for an EEG appointment, and upon return, there was no documentation or paperwork regarding follow-up care. The EEG department contacted the facility to request the return of the EEG machine, and the Director of Nursing removed the electrodes without proper instructions, leading to skin damage on the resident's scalp. Interviews with facility staff revealed a lack of communication and documentation regarding the follow-up appointment. The resident's family member had informed staff about the appointment, but this information was not conveyed to the appropriate personnel to arrange transportation. The facility's failure to ensure proper follow-up care and communication resulted in the resident developing pressure injuries on the scalp.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to maintain timely and appropriate pharmaceutical services for a resident diagnosed with parkinsonism, fibromyalgia, muscle wasting, atrophy, and difficulty walking. The resident was prescribed Rytary, an extended-release medication for parkinsonism, to be taken two capsules three times a day. However, the medication was unavailable for administration as ordered by the physician, leading to the resident experiencing worsening tremors, increased rigidity, loss of balance, confusion, and agitation due to not achieving the therapeutic dose. Interviews with the resident and facility staff revealed that the resident was concerned about running out of medication, and the pharmacy had not delivered the medication on time. The resident missed the scheduled dose, and the Director of Nursing acknowledged the failure to administer the medication as prescribed. The facility's policies and procedures emphasized the importance of providing routine and timely pharmacy services and ensuring medications are administered within one hour of their prescribed time, which were not adhered to in this case.
Improper Disposal of Meal Tray Tickets Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information by improperly disposing of meal tray tickets. During an observation and interview, a dietary aide was seen discarding meal tray tickets into the general kitchen trash while preparing breakfast trays. These tickets contained sensitive information, including resident names, room numbers, diet orders, food allergies, food preferences, and special dietary needs. The District Kitchen Supervisor confirmed this practice and acknowledged that the tickets should be shredded to protect resident privacy. The facility's policy on resident rights, dated December 2016, explicitly prohibits unauthorized release, access, or disclosure of resident information, underscoring the deficiency in maintaining confidentiality.
Deficiencies in Kitchen Staff Competency and Food Preparation
Penalty
Summary
The facility failed to ensure that kitchen staff possessed the necessary knowledge and competencies to perform dietary functions effectively. A cook was unable to correctly read the temperature in a reach-in freezer and did not know the required temperature for proper food storage, which is critical to prevent bacterial growth. Additionally, a dietary aide was unable to state the desired temperatures for a dishwashing machine and could not locate the temperature gauge, which is essential for ensuring that dishes are sanitized properly. Further deficiencies were observed when a cook prepared pureed foods without following a recipe, adding unmeasured amounts of ingredients, which could affect the nutritional content and consistency necessary for residents with swallowing difficulties. Another cook used incorrect scoop sizes to measure food portions, leading to residents receiving improper portion sizes. These actions were contrary to the facility's policies and procedures, which emphasize the importance of following standardized recipes and using correct portion sizes to ensure nutritional adequacy and consistency.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to adhere to the prescribed recipe for pureed food for three residents on a pureed diet, which was identified during an observation, interview, and record review. The deficiency was noted when a kitchen staff member used incorrect scoop sizes to measure food portions, specifically using a 3/8 scoop for pureed potatoes and a 1/4 scoop for pureed cream style corn, instead of the required #8 scoop (1/2 cup) as indicated in the facility's Diet Guide Sheet. This error in portion control had the potential to affect the nutritional intake of residents on a pureed diet, potentially leading to malnutrition and weight loss. During the investigation, it was revealed that the kitchen staff member was unaware of the correct scoop sizes, and the District Kitchen Supervisor emphasized the importance of using the proper scoop size to ensure residents receive adequate nutrition. The Registered Dietitian also confirmed that cooks should follow recipes and measure ingredients accurately. The facility's Policy and Procedure on Trayline Accuracy/Menu Compliance, dated 2010, highlighted the necessity of following menus and recipes as written to ensure adequacy and accuracy in portion control, underscoring the importance of having the correct scoops, ladles, and spoodles available for meal preparation.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that food was prepared in a manner that conserved nutritive value and palatability for 20 residents receiving a pureed diet. This deficiency was observed when a cook, identified as CK 2, was seen preparing pureed bread without following a recipe. CK 2 added unmeasured amounts of milk, bread, and water to a blender and then added an unmeasured amount of food thickener, relying on feel rather than a standardized recipe. This method of preparation resulted in a thick and sticky consistency of the pureed bread, which was confirmed during a test tray sampling by the Dietary Supervisor. The Registered Dietitian emphasized the importance of following recipes and measuring ingredients to ensure nutritional adequacy and consistency, especially for residents with swallowing difficulties. The facility's policy and procedure documents, including the Trayline Accuracy/Menu Compliance and Diet and Nutrition Care Manual, highlighted the necessity of using standardized recipes to maintain consistency in taste, appearance, and nutritional content. The failure to adhere to these guidelines posed a risk of inadequate nutrition and potential swallowing issues for the residents on pureed diets.
Food Safety Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 54 residents who received facility-prepared meals. During an initial kitchen tour, it was observed that proper food labeling was not followed for items stored in the freezers, refrigerator, dry storage, and spice shelf. Additionally, expired food items were found in these areas, and personal milk cartons were not stored at appropriate temperatures. The kitchen's reach-in freezers contained multiple boxes of food items that were exposed and open to the freezer environment, and a plastic container of brown sugar was not sealed properly. Furthermore, frozen foods were not stored at appropriate temperatures, and a steam table pan was found stored wet. The facility's kitchen also had structural and equipment issues that could compromise food safety. No air gaps were found in the produce sink, which could lead to wastewater contaminating produce. The kitchen can opener had a chipped blade, posing a risk of physical contamination in food. Additionally, a kitchen staff member was observed not wearing a beard restraint, which is necessary to prevent hair from contacting food and clean equipment. These deficiencies were confirmed through observations and interviews with the Dietary Supervisor, Registered Dietitian, and other kitchen staff. The facility's policies and procedures, as well as the US FDA Food Code, were reviewed and indicated that the facility did not comply with the required standards for food labeling, storage, and equipment maintenance. These failures had the potential to lead to foodborne illness for the residents receiving facility-prepared meals.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several instances. A respiratory therapist did not perform hand hygiene during a breathing treatment for a resident with chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The therapist was observed using the same gloves to handle tubing and then organizing the resident's equipment, which was confirmed as inappropriate by both the therapist and the Director of Nursing. In another instance, an isolation trash can in a resident's room was found overflowing and uncovered, exposing personal protective equipment. The licensed nurse confirmed the trash can was broken and should have been covered, a sentiment echoed by the Infection Preventionist and the Director of Nursing. Additionally, oxygen tubing and nebulizer facemasks for another resident were not properly labeled or were labeled with expired dates, which was verified by a certified nursing assistant and the Director of Staff Development. This oversight was acknowledged as a potential risk for respiratory infection by the Infection Preventionist and other staff members. Further deficiencies were noted with an air fan in a resident's room that was dirty and blowing directly towards the resident, which could lead to respiratory illness. This was confirmed by a certified nursing assistant and a licensed nurse, who acknowledged the responsibility to clean such equipment. Additionally, three trash containers in the dining room were found open and without lids during a meal, which was confirmed by a licensed nurse as a breach of infection control protocols.
Unsafe Freezer Temperatures in Facility Kitchen
Penalty
Summary
The facility failed to maintain one of its three reach-in freezers in safe operating condition, as observed during a survey. The freezer, located near the Dietary Supervisor's office, was found to be running at unsafe temperatures, with readings of 16 and 20 degrees Fahrenheit during two separate observations. The Dietary Supervisor confirmed these readings and acknowledged that the freezer should be colder. It was noted that the freezer had been last serviced in July 2024, but there was no scheduled maintenance, suggesting it might be broken. The facility's policy and procedure for food storage indicated that freezer temperatures should be maintained at 0 degrees Fahrenheit or below. Additionally, the policy for equipment maintenance required routine cleaning and maintenance in accordance with manufacturer's directions, with requests for maintenance or repair to be submitted as needed. The failure to maintain the freezer at the appropriate temperature had the potential to lead to the growth of bacteria and foodborne illness for all 54 residents consuming meals prepared by the facility.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, clean, and comfortable environment for its residents, staff, and the public. In the dining room, several issues were observed, including missing slats on window blinds, non-functioning fluorescent bulbs, and open trash containers without lids. These deficiencies were verified by various staff members, including a Restorative Nursing Aide, a Licensed Nurse, and the Activities Director. The Maintenance staff acknowledged the issues but indicated that they were not addressed due to a lack of parts and communication from previous administration. Resident 19 was found in a concerning state, with a strong odor emanating from both the resident and the room environment. The resident, who has a history of PTSD, blindness, and anxiety, was observed to be disheveled, half-naked, and wearing a dirty incontinence brief. The room was also noted to be unclean, with disorganized sheets and a dirty floor. The resident expressed dissatisfaction with the care received, indicating neglect in personal hygiene and room cleanliness. Interviews with staff, including a Licensed Nurse and the Director of Nursing, confirmed the unsanitary conditions and the need for a clean and comfortable environment. The facility's policy on maintenance service, which emphasizes maintaining the building in good repair and following infection control precautions, was not adhered to, leading to these deficiencies.
Deficiency in In-Service Training for Contracted CNAs
Penalty
Summary
The facility failed to ensure that two contracted Certified Nursing Assistants (CCNAs), identified as CCNA 15 and CCNA 16, received the required in-service training, including dementia management and abuse prevention, as mandated by the facility's policy. During interviews and record reviews, the Director of Staff Development (DSD) and the Director of Nursing (DON) were unable to provide documentation verifying that these CCNAs had completed no less than 12 hours of annual in-service training. The facility relied on a staffing agency to provide this documentation, but the agency was identified as a scheduling agency, which did not maintain records of training completion. The Administrator (ADM) confirmed that there was no way to verify if the in-service training was completed for the contracted CCNAs through the agency. The facility's policy, revised in May 2019, clearly stated the requirement for annual in-services to address specific skills and knowledge, including dementia management and abuse prevention. The lack of documentation and verification of training for CCNA 15 and CCNA 16 had the potential to significantly compromise the quality of services provided to the residents.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure dignity and privacy for two residents, impacting their emotional, mental, and psychosocial well-being. For Resident 52, who has PTSD, depression, and chronic pain, the deficiency occurred when a maintenance staff member entered the resident's room without knocking or identifying himself. This action was contrary to the facility's policy, which requires staff to knock, announce themselves, and ask for permission before entering a resident's room. Interviews with the maintenance staff and nursing staff confirmed the lack of adherence to this protocol, which left Resident 52 feeling that their dignity and privacy were not respected. Resident 19, who has PTSD, blindness, and anxiety, was found in a state of neglect, with a strong body odor and a foul-smelling environment. The resident was disheveled, half-naked, and wearing a dirty incontinence brief, with a dirty floor and disorganized sheets. Despite having moderate memory impairment, Resident 19 did not reject assistance with activities of daily living. The resident expressed feelings of being neglected and living in filth, which was verified by a licensed nurse who acknowledged the unhealthy and undignified condition. The facility's policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. Resident 52, who was admitted with PTSD, depression, and chronic pain, expressed concerns about loud door noises exacerbating her PTSD symptoms. Despite her complaints and the maintenance staff's awareness of the issue, no care plan was developed to address her emotional and environmental concerns. Interviews with staff revealed that the problem had been ongoing for months, yet no action was taken to move the resident or fix the door noise, and the Social Services Director was unaware of the issue. Resident 85, admitted with a lumbar vertebral fracture, Alzheimer's disease, and generalized anxiety disorder, did not have a care plan for activities. The resident was observed to remain in bed and not participate in activities, contrary to the initial assessment that recommended in-room visits three times a week. The Activities Director confirmed the absence of a care plan and acknowledged its importance in preventing isolation and depression. Despite the facility's policy requiring care plans to be developed within 24 hours of identifying a new issue, this was not done for Resident 85. The facility's policy on comprehensive, person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the failure to develop and implement care plans for Residents 52 and 85 indicates a lapse in adhering to this policy. Interviews with the Director of Nursing and other staff highlighted the expectation for immediate care plan development, yet this was not reflected in practice, leading to potential risks to the residents' well-being.
Failure to Update Care Plans for Adaptive Device and Pain Management
Penalty
Summary
The facility failed to revise the comprehensive care plan for two residents, leading to potential deficiencies in their care. Resident 18, who was admitted with conditions including stroke, diabetes, and dysphagia, had a nutrition care plan that was not updated to include the use of a two-handled cup as ordered by the physician. During an observation, it was noted that Resident 18 was provided with a sippy cup instead of the prescribed two-handled cup, which was confirmed by the nursing staff. The MDS Coordinator verified that the care plan did not include the necessary adaptive device, indicating a lack of revision and update. Resident 139, admitted with diagnoses such as stroke and COPD, had a pain care plan that was not updated to reflect a new medication order for Tramadol. Despite the resident expressing pain and the presence of a physician's order for pain management, the care plan lacked an intervention for the administration of the medication. Observations and interviews revealed that Resident 139 was experiencing pain and had not received the prescribed medication, with staff acknowledging the oversight in updating the care plan. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in these cases. The Director of Nursing emphasized the importance of addressing residents' needs promptly, yet the care plans for both residents were not updated to include necessary interventions, potentially impacting their well-being.
Deficiencies in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for two residents. Resident 19, who has diagnoses including PTSD, blindness, and anxiety, was found in a disheveled state with a strong foul-smelling odor in his room. Despite having moderate memory impairment and not rejecting assistance with activities of daily living, Resident 19 was observed in a dirty incontinence brief and expressed dissatisfaction with the care provided. A licensed nurse confirmed the resident's unclean condition and acknowledged it was unhealthy to leave him in such a state. Resident 29, diagnosed with respiratory failure, traumatic brain injury, and seizures, was observed with long and jagged fingernails. When asked, the resident indicated a desire to have his nails trimmed. A licensed nurse confirmed the nails were long and should be cut on shower days to prevent potential harm. The facility's policy indicated that nail care should include daily cleaning and regular trimming, and that residents should receive appropriate care to ensure their activities of daily living do not diminish unless unavoidable due to clinical conditions.
Failure to Provide Scheduled In-Room Activities
Penalty
Summary
The facility failed to meet the activity needs of two residents, leading to potential isolation and depression. Resident 37, who has a history of cerebral infarction, aphasia, and quadriplegia, was supposed to receive in-room visits three times a week as per their care plan. However, upon review, it was found that no documented activity visits had occurred. The Activities Director confirmed the lack of documented visits and acknowledged the importance of activities to prevent depression and isolation. Similarly, Resident 85, diagnosed with lumbar vertebral fracture, difficulty in walking, Alzheimer's disease, and generalized anxiety disorder, was also supposed to receive in-room visits three times a week. However, the electronic health record indicated only one documented visit since admission. The Activities Director confirmed this and emphasized the resident's need for companionship to avoid feeling alone. The facility's policy requires the Activity Director to schedule and ensure assistance for residents to attend activities, which was not adhered to in these cases.
Failure to Obtain Consent and Orders for Bed Rail Use
Penalty
Summary
The facility failed to follow proper procedures before using bed rails for a resident, identified as Resident 63. The resident was admitted with medical conditions including sequelae of cerebral infarction, muscle wasting and atrophy, and dysphagia, and was noted to have memory impairment. Observations on two separate occasions revealed that the bed rails were locked and in use without the necessary physician's orders, informed consent, or care plan in place. Licensed Nurse 5 confirmed the absence of these documents in the resident's medical record, which was corroborated by another licensed nurse during a concurrent review. The facility's policy and procedure on bed safety, dated December 2007, requires obtaining consent from the resident or their legal representative before using side rails, and informing them about the benefits and potential hazards. The policy also mandates that side rails should only be used when no other reasonable alternatives can be identified. However, the facility did not attempt appropriate alternatives, nor did it obtain the required physician's orders and informed consent prior to the use of bed rails for Resident 63, leading to a deficiency in compliance with the established procedures.
Narcotic Inventory Discrepancies
Penalty
Summary
The facility failed to maintain an accurate inventory of narcotics for two residents, Resident 66 and Resident 76, which increased the potential for diversion and hindered the ability to accurately monitor medication administration. Resident 66, admitted with cancer of the head and neck, had two instances where Norco tablets were removed from the medication card but not documented as administered in the Medication Administration Record (MAR). Similarly, Resident 76, diagnosed with muscular dystrophy, had four Oxycodone tablets removed without corresponding documentation in the MAR. The Director of Nursing (DON) confirmed the discrepancies between the Controlled Drug Record (CDR) and the MAR for both residents, acknowledging the lack of signatures on the MAR that matched the narcotic sheet. The DON emphasized the importance of accurate documentation to ensure residents receive their medications and acknowledged that inaccurate documentation increases the risk of narcotic diversion. The facility's policy on medication reconciliation aims to ensure medication safety by accurately accounting for residents' medications, but this was not adhered to in these cases.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident 9, who was admitted with acute and chronic respiratory failure with hypoxia, pneumonia, and muscle wasting and atrophy. Despite having a Brief Interview for Mental Score (BIMS) of 13, indicating no cognitive impairment, Resident 9's request to not be served cream of wheat for breakfast was disregarded. Instead, the resident was served cream of wheat, contrary to the meal tray ticket instructions which specified oatmeal with three butter packets. This incident was confirmed during an interview with the Dietary Supervisor, who acknowledged that Resident 9 should have received oatmeal as requested. The facility's policy and procedure titled 'Trayline Checklist' from 2010 was reviewed, which indicated that alternate meal options should be available, but this was not adhered to in this instance.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide necessary adaptive eating equipment for two residents, as ordered by their physicians, which could negatively impact their well-being and meal intake. Resident 18, who has a history of stroke, diabetes, hemiplegia, dysphagia, and muscle weakness, was not provided with a two-handled cup as specified in her care plan. During an observation, it was noted that Resident 18 was given a sippy cup instead, which was not in accordance with her meal ticket or care plan. The MDS Coordinator confirmed that the two-handled cup was not included as an intervention in the nutrition care plan. Similarly, Resident 73, who has encephalopathy, diabetes, dysphagia, and reduced mobility, was not provided with plastic eating utensils as indicated in her care plan. During a meal, Resident 73 was observed struggling to use metal silverware instead of the prescribed plastic utensils. The MDS Coordinator verified that the care plan included the use of plastic utensils, and the Director of Nursing emphasized the importance of providing adequate care and adaptive devices. The facility's policy on accommodating needs highlights the requirement to evaluate and review residents' needs for adaptive devices regularly.
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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