River Walk Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 1100 West Morton Avenue, Porterville, California 93257
- CMS Provider Number
- 555658
- Inspections on file
- 36
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at River Walk Care Center during CMS and state inspections, most recent first.
A resident was admitted with bruising to both forearms, and a subsequent skin assessment documented a right forearm bruise of approximately 6 cm by 5 cm. The bruise was monitored only through the initial ordered period, after which no further re-assessments were documented even though the bruise remained present. During interview and record review, the treatment nurse confirmed that facility practice was to re-assess bruises after the monitoring order ended to ensure they were not new or worsening, and acknowledged that this re-assessment did not occur. Review of the facility’s skin assessment policy showed that head-to-toe skin assessments were required on admission, daily for three days, and weekly thereafter, but this process was not followed for the ongoing bruise.
Surveyors found that expired and unlabeled food items were present in storage areas, including bread, desserts, and dairy products, and that opened frozen foods were left exposed and undated. The steam table used for meal service was observed with food debris and had not been cleaned as required. Dietary staff confirmed these practices did not follow facility policies for food labeling, storage, and sanitation.
A resident with severe cognitive impairment and a history of falls related to toileting needs did not receive scheduled toileting and bowel/bladder retraining as outlined in the care plan. Despite being at high risk for falls and dependent for toilet transfers, the intervention was not consistently implemented or documented, and some CNAs were unaware of the care plan requirements. This failure resulted in the resident attempting to toilet independently, experiencing multiple falls, and ultimately sustaining a hip fracture that required hospitalization and surgery.
A resident developed bluish discoloration and edema in the left foot, which was documented by multiple LVNs over several days without notifying the physician, despite facility policy requiring such notification for significant changes. The physician was only informed after the resident's family requested hospital evaluation, at which point a nondisplaced fracture was discovered.
A resident with multiple wounds was discharged from the hospital with orders for a follow-up at a wound healing clinic to resume grafix and wound vac therapy. Facility staff, including the wound nurse and DON, were unaware of the order and could not find documentation that the appointment was scheduled, despite facility policy requiring implementation of hospital transfer orders.
A resident with a history of spontaneous hip dislocations experienced a dislocated hip, but staff did not complete the required SBAR form or monitor the resident for changes in condition as per facility policy. Although the physician and family were notified and the resident was eventually sent to the ER for further evaluation, documentation and monitoring procedures were not followed, as confirmed by the DON.
A resident with diabetes and osteomyelitis did not have their physician notified when blood sugar readings exceeded 400, as required by physician orders, and missed several doses of prescribed intravenous antibiotics for a bone infection, with no documentation to confirm administration. The DON confirmed the lack of required notifications and documentation.
A resident with diabetes who was prescribed a consistent carbohydrate and no added salt diet was served vanilla mousse pudding with chocolate chips, contrary to physician orders and the facility's dietary guidelines. Staff confirmed the error, and facility policy requires adherence to prescribed therapeutic diets.
A resident with significant medical history was not provided with a recommended restorative nursing program or with ordered PT and OT services. Staff failed to enter physician orders, develop a care plan, or implement the restorative program, and therapy services were not delivered due to insurance issues and communication lapses. This resulted in a documented decline in the resident's bed mobility and functional abilities.
A resident with multiple wounds did not consistently receive wound care treatments and monitoring as ordered by the physician, as evidenced by missing documentation on the TARs over several months. The DON confirmed that without documentation, it could not be determined if the treatments were completed. Facility policy required all wound care to be recorded, but this was not done, potentially impacting the resident's wound healing.
A resident's blood glucose levels were not checked timely as ordered by the physician, leading to potential inaccuracies in readings and insulin administration. Despite the resident's preference and facility protocol requiring checks before meals, logistical issues and delays resulted in late checks, confirmed by the DON and LVN.
A facility failed to complete a medication administration competency assessment for an RN hired three months prior, as required by their policy. The RN confirmed the lack of assessment, and the DON acknowledged the oversight, which could lead to medication errors and unmet care needs.
A resident with dementia and a history of elopement left the facility unsupervised and was found a mile away. Despite being identified as high risk for elopement, the resident was able to exit the facility without staff noticing. Interviews revealed that staff were unaware of the resident's whereabouts until another resident reported the elopement. The facility's policy on supervision was not adequately followed.
A resident with significant cognitive impairment and high fall risk experienced multiple falls over six months, resulting in serious injuries. The facility failed to update the care plan or implement new interventions after each fall, and recommendations from medication reviews were not followed. The lack of adherence to protocols and failure to conduct IDT meetings contributed to the resident's repeated falls.
The facility did not follow its policy on Advance Directives, resulting in 26 out of 30 residents lacking documented directives in their medical records. Interviews revealed that residents and family members were often unaware of or did not recall completing these forms. The Admission Coordinator confirmed the absence of Advance Directives and acknowledged the lack of documentation and process to ensure residents' wishes were recorded.
A resident's bed linen was observed with brown stains, identified as feces, and had not been changed for two days. Housekeeping and CNA staff confirmed the issue, and the Infection Preventionist stated that the linen should have been changed immediately. The facility's policy requires soiled laundry to be handled as potentially contaminated.
A resident with a history of stroke and hemiplegia, dependent on staff for oral hygiene, did not receive adequate oral care as per the facility's policy. Observations showed the resident's lips and teeth were covered with a brown film, and their lips were dry and cracked. Interviews with staff and family confirmed neglect in oral care provision, despite the care plan requiring oral care every shift.
A resident with a G-tube experienced deficiencies in enteral feeding procedures at the facility. The enteral nutrition feeding bottle was not labeled with the necessary information, and the enteral tubing was disconnected with the three-way valve left open, causing stomach contents to leak onto the resident's skin. These issues were acknowledged by the LVN and DON, who confirmed that the facility's policies were not followed.
A facility failed to implement pharmacy recommendations for a resident after multiple falls, as identified in several Interim Medication Regimen Reviews (IMRRs). The IMRRs recommended conducting tests and monitoring vital signs, but the Director of Nursing (DON) could not provide evidence of implementation. The facility's policy requires acting on such recommendations to prevent medication-related issues, but this was not done, potentially leaving staff unaware of adverse consequences.
A resident with hand contractures was not provided with adaptive equipment to drink water independently, despite facility policies and assessments indicating the need. Observations showed the resident's water cup was out of reach, and staff confirmed the resident's difficulty in accessing water. The facility's failure to adhere to its ADL policy resulted in the resident's dependency on staff for hydration.
The facility failed to ensure staff were adequately trained on the elopement binder, leading to a lack of awareness among CNAs about residents at high risk for elopement. Interviews revealed that CNAs were either unaware or relied on informal communication to identify at-risk residents. The Administrator noted that only a small fraction of staff attended the last in-service training on elopement risk, highlighting a significant gap in training and communication.
A CNA in an LTC facility failed to treat a resident with dignity and respect by using foul language and dismissive gestures, leading to the resident's agitation. The resident, diagnosed with Lewy body Dementia and severely impaired cognition, was unable to respond appropriately to questions. The incident was witnessed by two other staff members, and the CNA admitted to the inappropriate behavior, which violated the facility's policy on Resident Rights.
Failure to Re-Assess and Monitor Ongoing Forearm Bruise
Penalty
Summary
The facility failed to ensure services met professional standards of quality when nursing staff did not re-assess and monitor a resident’s right forearm bruise after the initial monitoring period ended. The resident was admitted with discoloration (bruising) to both forearms, and a skin re-assessment the following day documented a right forearm bruise measuring approximately 6 cm by 5 cm. The treatment record for the month showed that the bruise was monitored only until a monitoring order was completed on 1/23/26, after which no further re-assessments were documented, despite the bruise still being present. During interview and concurrent record review, the treatment nurse confirmed the resident had been admitted with the right forearm bruise, acknowledged that facility practice was to re-assess skin bruises after completion of the monitoring order to ensure they were not new or worsening, and verified that the bruise remained present but was not re-assessed as required. Review of the facility’s undated Skin Assessment policy indicated that a full body, head-to-toe skin assessment was to be conducted on admission/re-admission, daily for three days, and weekly thereafter, which was not followed for this resident’s ongoing bruise.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, labeling, and sanitation practices. In the dry food storage room, a package of hamburger buns was found with a date indicating it was 12 days old, exceeding the facility's guideline of using bread within five to seven days. In the walk-in refrigerator, several food items, including bowls of apple crisp, containers of pudding, mixed fruit, and sliced cheese, were not labeled or dated. Additionally, a large container of orange juice was labeled with an outdated date, and a container of tomato soup and a half-gallon of buttermilk were found past their recommended use or expiration dates. The Dietary Supervisor confirmed that these items should have been labeled, dated, and disposed of according to facility policy. Further observations in the walk-in freezer revealed opened boxes of chopped spinach, beef steaks, and broccoli that were left open to air and lacked open dates. In the kitchen, the steam table used for keeping food hot during meal service was found with food debris on and between the compartments, as well as inside them. The Registered Dietitian acknowledged that the steam table should have been wiped down at least once daily and as needed, and that the covers should be washed daily. Review of facility policies confirmed requirements for labeling, dating, and proper storage of food, as well as maintaining cleanliness of kitchen equipment, which were not followed in these instances.
Failure to Implement Scheduled Toileting and Bowel/Bladder Retraining for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident who was at high risk for falls and had a history of falls related to toileting needs. The resident had severe cognitive impairment, was dependent for toilet transfers, and was frequently incontinent. The care plan included scheduled toileting and bowel and bladder retraining, with specific instructions to offer toileting assistance every two hours and as needed. Despite these interventions being documented in the care plan, there was no evidence that the bowel and bladder retraining was consistently implemented or documented. The resident experienced multiple unwitnessed falls while attempting to use the bathroom independently, as documented in progress notes. Staff interviews revealed that some CNAs were unaware the resident was on a bowel and bladder retraining program, and the required task was not properly triggered in the point of care (POC) system for documentation. The Director of Nursing confirmed that the retraining intervention was not correctly implemented in the POC prior to the resident's final fall. The lack of consistent implementation and documentation of the scheduled toileting intervention contributed to the resident continuing to attempt independent toileting, resulting in repeated falls. On one occasion, the resident fell after going to the bathroom independently and sustained an acute left femoral neck fracture, which required hospitalization and surgical repair. The facility's policies required comprehensive, person-centered care plans with measurable objectives and timetables, as well as monitoring and documentation of interventions. However, the failure to implement and document the bowel and bladder retraining as outlined in the care plan led to the resident's continued risk and eventual serious injury.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify the physician when a resident developed bluish discoloration to the left foot, as documented in multiple progress notes over several days. Despite repeated observations of the discoloration and edema by various LVNs, there was no evidence that the physician was informed until the resident's daughter requested hospital evaluation. The facility's own policy required physician notification for significant changes in a resident's condition, such as clinical complications or deterioration in health, but this was not followed. As a result, the resident's nondisplaced fracture of the left great toe went unrecognized by the facility until after the delayed notification and subsequent hospital evaluation. Interviews with nursing staff confirmed that the discoloration was observed and documented, but the physician was not notified in a timely manner. The Assistant Director of Nursing also acknowledged the lack of timely physician notification, consistent with the facility's policy.
Failure to Schedule Wound Clinic Follow-Up per Physician Order
Penalty
Summary
The facility failed to follow a physician's order for a resident who was discharged from the hospital with multiple wounds, including an unstageable wound to the right buttocks and stage 3 wounds to the left buttock and sacrum. The discharge instructions specified that the resident should have a follow-up appointment at a wound healing clinic to resume grafix (skin graft) and wound vac therapy. However, interviews with the wound nurse, a registered nurse, and the Director of Nursing revealed that there was no documented evidence that this follow-up appointment was scheduled. The review of the resident's clinical record and order summary confirmed the presence of the physician's order for the wound clinic follow-up, but staff were unaware of the order and could not find any documentation that the appointment was made. The facility's policy indicated that written transfer orders from a hospital should be implemented without further validation, yet this order was not carried out. This lapse had the potential for the resident's wound to worsen.
Failure to Complete SBAR and Monitor Resident After Hip Dislocation
Penalty
Summary
The facility failed to follow its policy and procedure for managing a change in condition for one of three sampled residents who experienced a dislocated hip. Specifically, staff did not complete an SBAR (Situation, Background, Appearance, Review and Notify) form to notify the physician of the change in condition, nor did they monitor the resident for changes after the dislocation was identified. Progress notes indicated that the dislocation was discovered via X-ray, and the physician was notified, but there was no documentation of detailed observations or use of the SBAR communication tool as required by facility policy. Additionally, the resident, who had a history of spontaneous hip dislocations, continued to experience pain and was eventually sent to the emergency room for further evaluation and treatment at the request of the family. The Director of Nursing confirmed during interview and record review that there was no completed SBAR or evidence of monitoring for the resident following the dislocation. The facility's policy required nurses to gather and document pertinent information using the SBAR form and to record changes in the resident's condition in the medical record, which was not done in this case.
Failure to Follow Physician Orders for Blood Sugar Notification and Antibiotic Administration
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with diabetes and osteomyelitis. Specifically, the resident had multiple blood sugar readings greater than 400, as documented in the Medication Administration Records (MAR) over several months. Despite physician orders to notify the physician if blood sugar exceeded 400, there was no documentation that the physician was notified on any of these occasions. The Director of Nursing (DON) confirmed that there was no evidence of physician notification as required by the orders. Additionally, the same resident was prescribed ceftriaxone to treat a chronic bone infection (osteomyelitis) in the left ankle and foot. The MAR indicated that the resident did not receive the antibiotic on three specific dates, and there was no documentation to confirm administration. The DON acknowledged that if medication administration was not documented, there was no way to verify that the resident received the prescribed treatment. Facility policies reviewed indicated that medications should be administered and documented according to prescriber orders, and that staff should report issues affecting diabetes management.
Therapeutic Diet Not Followed for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a therapeutic menu was followed for one of three sampled residents who was prescribed a consistent carbohydrate (CCHO) and no added salt (NAS) diet for diabetes management. According to the resident's physician orders and the dietary spreadsheet, the resident was to receive vanilla mousse without chocolate chips. However, during observation, the resident was served vanilla mousse pudding with chocolate chips, which was confirmed by a CNA. The Dietary Services Supervisor acknowledged that the resident should not have been served the dessert with chocolate chips. The facility's policy requires that menus for therapeutic diets comply with physician orders and the diet manual, which was not followed in this instance.
Failure to Provide Restorative Nursing and Therapy Services Resulting in Decline
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, type 2 diabetes mellitus, and a history of transient ischemic attack, was not provided with a restorative nursing program as recommended by physical therapy upon discharge from PT services. The physical therapist recommended a bed mobility restorative program to maintain the resident's current level of function and prevent decline, but there was no evidence that physician orders for the program were entered, nor was there documentation that the program was implemented. Interviews with staff confirmed that the restorative nursing program was not provided, and no care plan was developed for it. Additionally, the resident did not receive physical therapy and occupational therapy evaluations and treatments as ordered by the physician on two separate occasions. Although an OT evaluation was completed, no subsequent OT or PT treatments were provided due to insurance coverage issues, and the resident was dropped from therapy services. The lack of therapy interventions and restorative nursing support led to a documented decline in the resident's bed mobility and functional abilities, as evidenced by subsequent MDS assessments showing increased dependence and impairment in range of motion. Facility policy required that staff and physicians assess and respond to changes in resident function, collaborate on care plans, and ensure appropriate rehabilitative or restorative interventions. However, communication failures between nursing and therapy staff resulted in missed opportunities to intervene when the resident's condition declined. The DON and DOR acknowledged that the necessary programs and treatments were not implemented as ordered or recommended, and documentation supporting the provision of these services was absent.
Failure to Follow Physician Orders for Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that physician orders for wound care were followed for a resident with multiple wounds, including diabetic blisters, surgical scars, and areas of skin breakdown. Review of the Treatment Administration Records (TARs) over several months revealed that wound care treatments and monitoring were not consistently documented as completed according to physician orders. Specific dates showed blanks on the TARs, indicating that required treatments and monitoring for wounds, such as cleansing, application of medications, and pressure relief interventions, may not have been performed as ordered. The resident had a complex medical history involving wounds on the abdomen, heels, sacrum, and lower extremities, with orders for daily wound care, use of specialized support surfaces, and regular monitoring for signs of infection or worsening condition. Despite these orders, the TARs for multiple months contained numerous instances where documentation was missing for wound care treatments and monitoring. The Director of Nursing confirmed that if the treatment was not documented, there was no way to verify whether it had been completed. Facility policies required that all wound care provided be recorded in the resident's medical record, including the type of care, date and time, and the name and title of the person performing the care. The lack of documentation and potential omission of ordered treatments had the potential for the resident's wounds to worsen, as there was no assurance that the necessary care was provided as prescribed.
Failure to Timely Check Blood Glucose Levels
Penalty
Summary
The facility failed to ensure professional standards of care for a resident when blood glucose levels were not checked timely as ordered by the physician. The resident, who had intact cognition with a BIMS score of 15, reported that her blood sugar was supposed to be checked four times a day, before each meal and at bedtime. However, the resident stated that the RN often checked her blood sugar either while she was eating or after she had finished, resulting in higher readings and subsequent administration of more insulin. This was confirmed by the Licensed Vocational Nurse, who stated that the facility protocol and physician's order required blood sugar checks prior to each meal to avoid inaccurate readings. A review of the resident's medication administration record from late February to early March revealed multiple instances where blood sugar checks were conducted late, ranging from over an hour to nearly five hours past the scheduled time. The Director of Nursing confirmed these findings and acknowledged that the checks were not performed as ordered. The RN mentioned that the resident preferred to have her blood sugar checked before dinner, but logistical issues, such as the resident being in the dining area far from her room, contributed to the delays. The facility's policy on insulin administration emphasized the importance of checking blood glucose per physician order or facility protocol, which was not adhered to in this case.
Failure to Complete Medication Administration Competency Assessment
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) underwent a medication administration competency assessment, which is a requirement for all nursing staff upon hire according to the facility's policy. The RN was hired on December 30, 2024, and had been working at the facility for approximately three months without this assessment being completed. During an interview, the RN confirmed that he had not been assessed for medication administration competency. The Director of Nurses (DON) also confirmed the absence of this assessment in the RN's employee file, acknowledging that it was the facility's practice to complete such assessments upon hire. This oversight had the potential to lead to medication errors and unmet care needs.
Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with dementia, who was at high risk for elopement and had a history of elopement. The resident was able to leave the facility without staff awareness, as noted in a progress note dated 11/2/24. The resident was found approximately one mile away from the facility by a staff member who brought him back. The resident's elopement risk was documented in evaluations dated 5/1/24, 7/19/24, and 10/11/24, and the resident had a moderate cognitive impairment as indicated by a BIMS score of 12 on a quarterly MDS dated 9/13/24. Interviews with staff revealed that on 11/2/24, a CNA was unable to locate the resident within the facility, and the resident was eventually found walking on the side of the road. Another resident had observed the elopement, noting that the resident pushed the door open and left the facility. The facility's policy on safety and supervision emphasized the importance of resident supervision based on individual needs and environmental hazards, which was not adequately followed in this case.
Failure to Update Care Plans and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to its policy and procedure on comprehensive person-centered care plans for a resident, identified as Resident 341, who was at high risk for falls. Despite being diagnosed with metabolic encephalopathy, difficulty in walking, and muscle weakness, and having significant cognitive impairment, the facility did not update the resident's care plan following multiple fall incidents. The resident experienced several falls over a six-month period, resulting in serious injuries, including fractures to the left hip and shoulder, which required surgical intervention. The facility's Director of Nursing (DON) confirmed that after each fall, the care plan should have been updated, and new interventions should have been implemented. However, the care plan was not revised after several fall incidents, and there was no evidence of interdisciplinary team (IDT) meetings being conducted to address the root causes of the falls. Additionally, recommendations from interim medication regimen reviews (IMRR) were not implemented, and there was a lack of evidence of frequent rounding or monitoring as advised. The facility's policies on care plans and falls were not followed, as the staff failed to gather data, sequence events properly, and consider the relationship between the resident's problems and their causes. The facility did not monitor or document the resident's response to interventions intended to reduce falls, nor did they re-evaluate the situation when the resident continued to fall. This lack of adherence to protocols and failure to implement necessary interventions contributed to the resident's repeated falls and subsequent injuries.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding Advance Directives, as evidenced by the absence of Advance Directives in the medical records of 26 out of 30 sampled residents. This deficiency was identified through interviews and record reviews, revealing that many residents did not have documented Advance Directives, which are crucial for understanding and respecting their healthcare wishes. The Admission Coordinator (AC) acknowledged the importance of Advance Directives and confirmed that several residents, including Resident 341, Resident 292, and others, did not have these documents in their records. Additionally, some residents, like Resident 63, had incomplete or unsigned Advance Directives, further indicating a lapse in the facility's process. Interviews with residents and family members highlighted a lack of awareness and documentation regarding Advance Directives. For instance, Resident 292 and Family Member 1 did not recall being offered or signing an Advance Directive. Resident 63, despite having an Advance Directive with her initials, did not remember completing the form or her wishes. The AC admitted that the form had not been available when she started working at the facility and that there was no documentation of the process to ensure residents or their representatives were asked about Advance Directives. The facility's policy, dated 2022, emphasizes the resident's right to formulate an Advance Directive, but the lack of adherence to this policy was evident in the findings.
Failure to Change Soiled Bed Linen
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Laundry and Bedding, Soiled,' when a resident's bed linen was observed with brown stains. During an observation and interview, a family member noted that the bed linen had been dirty for two days, expressing discomfort with the situation. Housekeeping staff confirmed the presence of dried brown spots on the linen and stated that it was the responsibility of the Certified Nursing Assistant (CNA) to change the bed linen. Further interviews revealed that the CNA identified the brown spots as feces and acknowledged the need for the linen to be changed. The Infection Preventionist also confirmed that the bed linen should have been changed immediately, as dirty linen is unacceptable. The facility's policy indicates that soiled laundry should be handled and processed according to best practices for infection prevention and control, treating all used laundry as potentially contaminated.
Failure to Provide Adequate Oral Care for Dependent Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for supporting activities of daily living, specifically oral care, for a resident who was unable to perform these tasks independently. The resident, who had a history of stroke with hemiplegia and was fed via a gastrostomy tube, was dependent on staff for oral hygiene. Despite the care plan indicating the need for oral care every shift, observations revealed that the resident's lips and teeth were covered with a brown film, and their lips were dry and cracked, indicating neglect in oral care provision. Interviews with staff and family members further highlighted the deficiency. A Licensed Vocational Nurse acknowledged that oral care should have been completed earlier in the day, while a family member reported consistently finding the resident's mouth in a crusted state. The Director of Nursing confirmed that oral care should be performed multiple times daily for residents not taking anything by mouth, with moisturizing required at least every two hours. The facility's policy, dated March 2018, mandates that residents unable to perform activities of daily living independently receive necessary services, including oral hygiene, in accordance with their care plan.
Deficiencies in Enteral Feeding Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedure for enteral feedings, resulting in two deficiencies for a resident with a gastrostomy tube (G-tube). The first deficiency involved the failure to label the enteral nutrition feeding bottle with the resident's name, date, or time, as observed during an inspection. This oversight was acknowledged by the Licensed Vocational Nurse (LVN) present, who admitted uncertainty about when the bottle was hung. The Director of Nursing (DON) confirmed that the bottle should have been labeled according to the facility's policy, which mandates documentation of the initials, date, and time the formula was hung. The second deficiency was observed when the enteral tubing was disconnected from the G-tube site, and the three-way valve was left open, causing stomach contents to leak onto the resident's abdomen and clothing. This was noted by the LVN, who recognized the potential harm to the resident's skin integrity. The DON stated that the valve should have been closed whenever the feeding tube was disconnected. The facility's policy emphasizes the importance of preventing misconnection errors and maintaining skin integrity by keeping the exit site clean and dry, and regularly inspecting tubing connections.
Failure to Implement Pharmacy Recommendations After Resident Falls
Penalty
Summary
The facility failed to implement pharmacy recommendations for a resident after multiple falls, as identified during a review of the resident's Interim Medication Regimen Reviews (IMRRs) dated over several months. The IMRRs consistently recommended conducting a basic metabolic panel (BMP), thyroid-stimulating hormone (TSH) test, monitoring blood pressure (BP) and heart rate (HR), and checking orthostatic blood pressures every shift for three days. Additionally, the IMRRs advised notifying a medical doctor if the resident experienced orthostasis. Despite these recommendations, the Director of Nursing (DON) was unable to provide evidence that these actions were implemented. The facility's policy and procedure for Medication Regimen Review and Reporting, dated September 2018, outlines the necessity of acting upon resident-specific medication regimen review recommendations to prevent, identify, report, and resolve medication-related problems. However, the facility did not follow through on these recommendations for the resident, which could have left staff unaware of potential adverse consequences from the resident's medication regimen. This oversight was confirmed during an interview and record review with the DON, who acknowledged that the IMRR recommendations should have been implemented.
Failure to Provide Adaptive Equipment for Resident with Hand Contractures
Penalty
Summary
The facility failed to provide necessary adaptive equipment for a resident, identified as Resident 52, who required assistance with drinking water due to contractures in both hands. Observations and interviews conducted over several days revealed that Resident 52's water cup was consistently placed out of reach, and the resident expressed difficulty in drinking without spilling. Despite the resident's condition, which was documented in the Minimum Data Set (MDS) and Care Plan, indicating a need for partial assistance and an adaptive device, no such device was provided. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and the Minimum Data Set Nurse (MDSN), confirmed the resident's inability to independently access water due to hand contractures. The Occupational Therapist (OT) also noted that the resident should have been evaluated for adaptive devices. The facility's policy on Activities of Daily Living (ADL) emphasized the provision of care and services to maintain residents' abilities, yet this was not adhered to in the case of Resident 52, leading to the resident's dependency on staff for hydration.
Inadequate Staff Training on Elopement Risks
Penalty
Summary
The facility failed to ensure that staff were adequately in-serviced on the elopement binder, which is crucial for identifying residents at high risk for elopement. During a review of the Elopement Binder, it was found that several residents were identified as high risk for elopement. However, interviews with various Certified Nursing Assistants (CNAs) revealed a lack of awareness regarding which residents were at risk. CNA 1 was unaware of the residents at risk, while CNA 2 believed all residents were at risk. CNA 3 stated there was no way to know who was at risk without a meeting or in-service, and CNA 4 relied on word of mouth for this information. CNA 5 mentioned needing to ask other staff about the residents at risk. This indicates a significant gap in communication and training regarding elopement risks. The Administrator acknowledged that only 19 out of approximately 100 employees attended the last in-service training on elopement risk, which was deemed unacceptable. The facility's policy and procedure on elopements and wandering residents emphasized the need for a systematic approach to managing residents at risk, including adding interventions to care plans and communicating these to staff. Despite this policy, the lack of consistent training and communication led to staff being unaware of the elopement binder's existence or its contents, potentially compromising resident safety.
Resident Dignity and Respect Violation by CNA
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a Certified Nursing Assistant (CNA 1) used foul language and dismissive gestures towards the resident. This incident was witnessed by two other staff members, CNA 2 and CNA 3, during the night shift. CNA 1 was reported to have used offensive language and shooed the resident away with her hands, which resulted in the resident becoming agitated. The resident, who has a diagnosis of Lewy body Dementia and a severely impaired cognition score, was unable to respond appropriately to questions during an observation. The incident was documented in the Nurses Notes, where it was noted that CNA 1 used inappropriate language towards the resident at around 10:45 p.m. CNA 2 and CNA 3 confirmed the use of foul language and disrespectful behavior by CNA 1. CNA 1 admitted to using foul language and shooing the resident away, acknowledging that it was inappropriate. The facility's policy and procedure on Resident Rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this case.
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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