Royal Oaks Manor-bradbury Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Duarte, California.
- Location
- 1763 Royal Oaks Drive, Duarte, California 91010
- CMS Provider Number
- 555503
- Inspections on file
- 37
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Royal Oaks Manor-bradbury Oaks during CMS and state inspections, most recent first.
A resident with cognitive impairment and significant care needs did not receive hospice-ordered Boost nutritional supplement or diclofenac sodium topical gel for pain management, as these orders were not included in the facility's active medication and nutrition orders. The omissions were confirmed by nursing staff and led to missed administration of prescribed therapies, despite the resident experiencing weight loss and requiring pain management.
Two residents with significant mobility needs experienced delays of up to an hour in staff response to call lights, with one family member intervening to assist with bathroom needs due to staff inaction. Staff interviews confirmed the expectation for immediate response, and Resident Council Meeting minutes documented ongoing concerns about untimely call light responses and unmet needs, contrary to facility policy.
The facility failed to develop comprehensive care plans for two residents, leading to potential gaps in care. One resident, with multiple diagnoses including anxiety disorder, lacked an activities care plan, while another resident with a hip fracture and edema had no care plan addressing their swelling. Observations confirmed the absence of necessary care plans, which were required by facility policy to guide staff in providing appropriate care.
The facility failed to attempt appropriate alternatives before using bedrails for two residents, potentially leading to accidents. One resident with dementia and another with multiple diagnoses were observed with siderails up, without documented attempts of alternatives like low beds. The facility's policy required such attempts and evaluations, which were not followed.
A facility failed to ensure accurate medical records for a resident by not documenting the administration of Hydrocodone-Acetaminophen in the MAR and not recording a change in condition for a skin rash. The Controlled Drug Record showed medication removal, but the MAR lacked corresponding entries. Additionally, a rash observed on the resident was not documented in the medical record, and the required change of condition evaluation was not completed.
The facility failed to maintain its infection prevention and control program, with deficiencies including staff not following enhanced barrier precautions, unclean shared restrooms, and improper handling of clean linen. Maintenance technicians entered a resident's room without PPE or hand hygiene, a restroom had a fecal smear on the toilet seat, and an unlabeled cleansing cream was found. Additionally, clean linen was observed touching the floor in the laundry room, all of which were acknowledged as breaches of infection control practices.
The facility failed to ensure call lights were within reach for two residents, violating their policy. One resident's call light was looped around a G-tube pump, and another's was tucked between the bed and wall, making them inaccessible. Both residents had cognitive impairments and required assistance, highlighting the importance of accessible call lights for safety and communication.
A resident with severe cognitive impairment and dependency on staff for ADLs was found with a dark brown substance under three fingernails, indicating a failure in grooming care. Despite the facility's policy requiring assistance with personal hygiene, the resident's nail care was neglected, as confirmed by staff interviews and observations.
A resident with multiple diagnoses, including anxiety disorder and psychosis, was not provided with activities that met their preferences, such as listening to music and going outside. Observations showed the resident mostly lying in bed, and records indicated no activities were provided for a period. The Activities Staff acknowledged the need for regular activities, but the facility failed to adhere to its policy of reflecting resident interests.
A resident with a history of a fractured femur and hypertension did not receive care in accordance with physician's orders for edema management. Despite orders for elastic stockings to reduce swelling, the resident was observed wearing regular socks, with both legs swollen. Staff interviews confirmed the oversight, and the facility's policy on applying anti-emboli stockings was not followed.
A facility failed to provide floor mats for a high-risk resident, as required by the care plan and physician's order. The resident, with diagnoses including cancer and mobility issues, was observed without floor mats, despite being at high risk for falls. A CNA and the DON confirmed the oversight, which deviated from the facility's fall prevention policy.
A facility failed to follow a pharmacist's recommendation for a gradual dose reduction of Seroquel for a resident with dementia, leading to potential unnecessary medication use. The resident, who was frequently observed asleep, had a care plan indicating a previous dose reduction, but no follow-up on the latest recommendation was documented. The facility's policy required gradual dose reductions unless contraindicated, which was not followed.
A resident with a history of anemia, hypertension, and GERD was administered Potassium Chloride ER without food, contrary to the facility's policy and pharmacist's recommendation. The medication was given at 9 a.m. while the resident had not eaten, potentially causing gastric irritation. The LVN acknowledged the error, and the DON emphasized the importance of following physician orders for medication administration.
A facility failed to properly store and label medications in Med Cart 2, affecting a resident with multiple diagnoses, including diabetes and dementia. Observations revealed medications without opened dates and insulin requiring refrigeration stored improperly. This deficiency could compromise medication effectiveness and resident safety.
A resident, who was eligible and consented to receive the influenza vaccine, did not receive it despite a physician's order and facility protocols allowing for its administration. The resident's medical records indicated the capacity to consent, and the facility's vaccination log confirmed the vaccine was not administered. This oversight was identified during a review by the Infection Prevention Nurse.
A resident with a fractured femur and dementia experienced severe pain, which was not promptly addressed due to a lack of communication between staff. The CNA did not report the resident's pain to the LVN, who was unaware of the situation until later. The LVN administered morphine but failed to assess the pain's location. The DON highlighted the need for immediate pain assessment and management, as outlined in the facility's policy.
A resident with a history of seizures and chronic atrial fibrillation fell and sustained a fracture when a CNA attempted to transfer them alone using a mechanical lift, contrary to the facility's policy requiring two-person assistance. The incident highlighted a significant deficiency in adherence to safety protocols and staff training.
A resident with dementia and high risk for falls and elopement fell and sustained fractures due to the facility's failure to implement care plan interventions and provide consistent supervision. The resident's care plan was not updated despite staff recognizing the need for one-to-one supervision.
Failure to Administer Hospice-Ordered Nutrition and Pain Management Therapies
Penalty
Summary
The facility failed to provide care and services as ordered by a hospice physician for a resident with a history of a displaced intertrochanteric fracture of the left femur and dysphagia, who was admitted with moderate cognitive impairment and required significant assistance with mobility. The facility did not include an order for Boost, a nutritional supplement, in the resident's active orders, despite it being present on the hospice agency's treatment list. There was no documentation that the Boost order was discontinued or placed on hold, and the omission was confirmed by nursing staff. The resident experienced a notable weight loss over a short period, and the care plan indicated the resident was on hospice for expected weight loss and overall decline. Additionally, the facility failed to include an order for diclofenac sodium topical gel, prescribed for osteoarthritis pain management, in the resident's drug therapy orders. The omission was identified during a review of the hospice agency's treatment list and confirmed by the MDS nurse. The resident, who had dementia and may not have been able to verbally report pain, was observed guarding the affected leg, which could indicate pain. The medication administration record showed the resident received morphine sulfate for severe pain on multiple occasions, but there was no evidence that the diclofenac was administered as ordered. Facility policy required coordination with hospice to meet the resident's care needs, including administering prescribed therapies.
Delayed Call Light Response for Residents Requiring Assistance
Penalty
Summary
The facility failed to ensure that call lights were answered immediately for two of three sampled residents. One resident, admitted with a right humerus fracture and a history of falls, required maximal assistance for mobility and was dependent for certain movements. The resident's family member reported that staff sometimes took up to an hour to respond to call lights, leading the family member to assist the resident with bathroom needs when staff were delayed. Another resident, admitted with a spinal fusion and muscle weakness, reported two separate incidents where it took staff an hour to respond to the call light, both during the day and at night. The resident stated that on those occasions, no staff came to check on their needs, which typically involved assistance to the bathroom. Interviews with facility staff, including a CNA and an LVN, confirmed that call lights are expected to be answered immediately due to the potential for emergencies. Resident Council Meeting minutes from two separate dates indicated ongoing concerns from residents about untimely responses to call lights, particularly during the overnight shift, and instances where residents' needs were not met even when call lights were answered. The facility's policy requires immediate response to call lights and completion of requests within five minutes if possible, but this standard was not consistently met as evidenced by resident and family reports.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, as required by their policy and procedure. Resident 23, who was admitted with multiple diagnoses including shortness of breath and anxiety disorder, did not have an activities care plan developed, which was necessary to guide the activities staff on the appropriate activities for the resident. Additionally, the resident's Minimum Data Set (MDS) indicated a moderately impaired cognition status, and the resident did not receive the influenza vaccine in the facility. The facility's policy required that a comprehensive care plan be developed within seven days of the MDS assessment and no more than 21 days after admission, which was not adhered to in this case. Similarly, Resident 6, admitted with a displaced intertrochanteric fracture of the left femur and other conditions, did not have a care plan addressing their edema, despite a physician's order for the application of elastic stockings to manage swelling. Observations revealed that Resident 6 had swollen and dependent legs, and the Licensed Vocational Nurse (LVN) confirmed that a care plan should have been in place to address the edema. The Director of Nursing (DON) acknowledged that a care plan should have been created to include the problem, goal, and interventions for Resident 6's edema. This oversight had the potential to result in the residents not receiving necessary care and services according to their specific needs.
Failure to Use Alternatives Before Bedrail Use
Penalty
Summary
The facility failed to use appropriate alternatives before resorting to the use of bedrails for two residents, which could potentially lead to accidents. Resident 12, who was admitted with dementia, muscle weakness, and difficulty walking, was observed with quarter siderails up on both sides of the bed. The Minimum Data Set (MDS) indicated that Resident 12 was unable to express ideas and understand verbal content. Similarly, Resident 23, admitted with multiple diagnoses including shortness of breath, anxiety disorder, and psychosis, was observed with upper side rails up on both sides of the bed. The MDS for Resident 23 showed moderately impaired cognition and a need for moderate assistance with bed mobility. The facility's Siderail Evaluation forms indicated that alternatives such as the use of a low bed should be attempted before using siderails. However, there was no documentation showing how the low bed was ineffective for Residents 12 and 23, nor were other alternatives attempted. The facility's policy required attempts to use alternatives and an interdisciplinary evaluation before the use of bedrails, which was not followed. The MDS Nurse acknowledged the lack of documentation and stated that siderails could pose hazards, especially for residents with dementia, due to the risk of entrapment.
Inaccurate Medical Records and Undocumented Change in Condition
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, specifically regarding the Medication Administration Record (MAR) and documentation of a change in condition. The resident's Controlled Drug Record indicated that Hydrocodone-Acetaminophen was removed on several occasions, but the MAR did not reflect the administration of this medication on certain dates. This discrepancy was acknowledged by the Director of Nursing (DON) during a review, who noted that licensed nurses are required to document medication administration in the MAR. The facility's policy mandates that the individual administering the medication must record specific details in the resident's medical record, which was not adhered to in this case. Additionally, the facility failed to document a change in the resident's condition regarding the development of a skin rash. The resident was observed with a red scabbed rash on the right arm and elbow, which was itchy and had spread from the elbow to the lower arm. Despite this, there was no change of condition evaluation form in the resident's medical record, and the Long Term Evaluation Progress Notes did not mention the rash. The Treatment Nurse (TN) stated that a new rash should be assessed, and the physician and Infection Prevention Nurse (IPN) should be notified, but this process was not followed. The facility's policies on administering medications and charting and documentation require that all services provided to the resident, including any changes in their medical condition, be documented in the medical record. The failure to document the administration of medication and the change in the resident's condition resulted in an inaccurate MAR and the potential for medication errors and inadequate care for the resident's skin rash.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during a survey. In one instance, two maintenance technicians entered a room with signage indicating enhanced barrier precautions (EBP) without wearing personal protective equipment (PPE) or performing hand hygiene. While inside, one technician adjusted a resident's bed, coming into direct contact with the bed linens, and both technicians exited the room without performing hand hygiene. This failure to adhere to EBP and hand hygiene protocols was acknowledged by the technicians and the infection preventionist, who emphasized the importance of these measures in preventing the transmission of infections. Additionally, the facility did not ensure the cleanliness of shared restrooms used by residents. In one restroom, a certified nursing assistant observed a large brownish fecal smear on the toilet seat, which was acknowledged as a health risk and cross-contamination concern. Another restroom contained an unlabeled bottle of cleansing cream, which a licensed vocational nurse confirmed should have been labeled to prevent cross-contamination. These observations highlight lapses in maintaining sanitary conditions and proper labeling of personal items in shared spaces. The facility also failed to handle clean linen properly in the laundry room. During an observation, laundry aides were seen removing dried laundry from dryers and placing it into hampers, with some linens touching and dragging on the floor. This was noted as a breach of infection control practices, as the floor was considered dirty. The infection preventionist reiterated the importance of maintaining hygienically clean linen to prevent environmental contamination. These deficiencies collectively indicate a lack of adherence to established infection control policies and procedures, potentially compromising resident safety.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which is a violation of their policy and procedure titled 'Answering Call Light.' For Resident 39, the call light was found looped around the G-tube feeding pump, out of the resident's reach, during an observation with the Director of Staff Development. The Director confirmed that the call light should be within reach to allow the resident to call for help when needed. Resident 39's care plan also specified that the call light cord should be placed within easy reach, but this was not adhered to. Resident 39 was admitted with multiple diagnoses, including anxiety disorder and a need for assistance with personal care. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and a dependency on assistance for all activities of daily living. Despite these needs, the call light was not accessible, potentially delaying necessary care and services. Similarly, Resident 300's call light was not within reach, as it was observed hanging from the upper bed rail, tucked between the wall and the bed mattress. Resident 300, who had severe cognitive impairment and required substantial assistance with activities of daily living, was unaware of the call light system and relied on staff entering the room for assistance. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, emphasized the importance of call lights for resident safety and communication, yet the facility's policy to ensure call lights are accessible was not followed.
Failure to Provide Adequate Grooming for a Resident
Penalty
Summary
The facility failed to ensure proper grooming for a resident, identified as Resident 18, who was observed with a dark brown substance under three fingernails of the left hand. This observation was made during a survey, and the resident was noted to have been admitted to the facility with diagnoses including anxiety and osteoarthritis. The Minimum Data Set (MDS) assessment indicated that Resident 18 had severely impaired cognitive skills and was dependent on staff for all activities of daily living (ADLs). Despite this dependency, the resident's grooming needs were not adequately met, as evidenced by the condition of the fingernails. During an interview, a Certified Nursing Assistant (CNA) suggested that the substance under the fingernails could be due to the resident scratching staff. The Director of Staff Development confirmed that daily ADL care should include nail care, among other personal hygiene activities. The facility's policy on ADLs, dated March 2018, stated that residents unable to perform these activities independently should receive necessary services to maintain grooming and hygiene. The failure to provide adequate nail care for Resident 18 represents a deficiency in meeting the resident's grooming needs.
Failure to Provide Activities for Resident's Needs
Penalty
Summary
The facility failed to provide activities to meet the needs of a resident, identified as Resident 23, which potentially affected their emotional and psychosocial wellbeing. Resident 23 was admitted with multiple diagnoses, including shortness of breath, anxiety disorder, and psychosis. The Minimum Data Set (MDS) indicated that Resident 23 had moderately impaired cognition but was usually able to understand and express ideas. The resident expressed a high interest in activities such as listening to music, going outside for fresh air, and participating in religious services. However, observations from November 12 to November 14, 2024, showed that Resident 23 was mostly lying in bed, either asleep or watching TV, with no engagement in preferred activities. The Activity Program Attendance records from November 1 to November 12, 2024, revealed that no activities were provided to Resident 23 from November 1 to November 9, 2024. The Activities Staff (AS) acknowledged that activities should be provided at least three times a week and that they were responsible for visiting residents who did not attend group activities. However, during the absence of the Activities Director, the AS was responsible for group activities, and Resident Assistant 1 (RA 1) was tasked with room visits, which included handing out chronicles and turning on TVs. The facility's policy indicated that activities should reflect resident interests, but this was not adhered to, leading to the deficiency in meeting Resident 23's activity needs.
Failure to Follow Physician's Orders for Edema Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema in accordance with the physician's order. The resident, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture of the left femur and essential primary hypertension, had a physician's order for the application of elastic stockings to both lower extremities once a day for compression. However, during observations on two separate occasions, the resident was found wearing regular socks instead of the prescribed elastic stockings, and both legs were swollen and dependent. Interviews with the resident and staff revealed that the facility did not discuss the resident's swollen legs with them, and the resident had to request staff assistance to elevate their legs. A Licensed Vocational Nurse confirmed that the resident had pitting edema and that the physician's order for elastic stockings was not followed. The Director of Nursing acknowledged that one of the interventions for edema was to elevate the extremities and follow the physician's orders. The facility's policy on applying anti-emboli stockings was not adhered to, which was intended to minimize edema and improve circulation.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure that floor mats were in place for a resident identified as high risk for falls, as indicated in the resident's physician's order, care plan, and the facility's policy and procedure on managing falls and fall risk. The resident, who was admitted with diagnoses including malignant neoplasm of the ascending colon, difficulty walking, and muscle weakness, was observed without floor mats in their room, despite being at high risk for falls. This oversight was confirmed during an interview with a CNA, who acknowledged that the resident should have had floor mats in place as part of their fall prevention interventions. The Director of Nursing (DON) also confirmed that staff should follow physician orders regarding safety equipment like floor mats to ensure resident safety and reduce the potential for fall-related trauma. The resident's care plan and physician's order both specified the use of floor mats, and the facility's policy emphasized implementing a resident-centered fall prevention plan. Despite these directives, the absence of floor mats in the resident's room was a clear deviation from the established care plan and facility policy, potentially compromising the resident's safety.
Failure to Implement Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to follow the pharmacist's recommendation to perform a gradual dose reduction (GDR) for Seroquel, an antipsychotic medication, for a resident diagnosed with dementia, muscle weakness, and difficulty in walking. The resident was admitted on 5/10/2024, and the Minimum Data Set (MDS) dated 8/15/2024 indicated severe cognitive impairment. Observations revealed the resident was frequently asleep in bed, and staff noted the resident slept all the time, even when seated in a chair. The resident's care plan for behavior related to psychosis indicated the last GDR was on 6/17/2024, when the Seroquel dose was reduced from 37.5 mg to 25 mg. The Medication Regimen Review (MRR) conducted between 9/1/2024 and 9/17/2024 recommended evaluating the current dose and considering a dose reduction, but there was no documentation of the physician's response to this recommendation. The Infection Prevention Nurse (IPN) confirmed the lack of documentation and stated that the Director of Nursing was responsible for following up on the MRR recommendations. The facility's policy on psychotropic medication use, dated July 2022, required gradual dose reductions unless clinically contraindicated, but this was not adhered to in this case.
Improper Administration of Potassium Chloride ER
Penalty
Summary
The facility failed to ensure the correct administration of Potassium Chloride ER for one resident, which was not in accordance with the facility's policy and procedure. The resident, who was alert and oriented, had a medical history including anemia, hypertension, and GERD. The facility's Consultant Pharmacist recommended that the potassium supplement be administered with food or after meals with a full glass of water or fruit juice to minimize gastrointestinal upset. However, the Medication Administration Record indicated that the medication was administered daily at 9 a.m. without ensuring the resident had eaten. During an observation, a Licensed Vocational Nurse administered the medication to the resident while they were in bed with an untouched breakfast tray, indicating the resident had not eaten. The nurse acknowledged that the medication should have been given with food to prevent stomach irritation. The Director of Nursing confirmed that medications should be administered as ordered by the physician to ensure their effectiveness. The facility's policy on administering medications emphasized that medications should be given safely, timely, and as prescribed, which was not followed in this instance.
Improper Storage and Labeling of Medications in Med Cart
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in one of the medication carts, Med Cart 2. During an observation, it was found that several medications and biologicals were not labeled with the opened date, which is crucial for determining their expiration. Specifically, an opened bottle of Magnesium Citrate and PreserVision Eye Vitamin & Mineral were found with opened dates but were past the one-year usage period. Additionally, containers of test strips and a glucose control solution were found without opened dates, contrary to the manufacturer's instructions to discard them six months after opening. The report highlights that two unopened Insulin Aspart Flexpens, which require refrigeration, were found inside Med Cart 2 with a sticker indicating they should be refrigerated. LVN 1 acknowledged the importance of labeling and proper storage, stating that the insulin should have been refrigerated to maintain its effectiveness. The lack of proper labeling and storage could potentially lead to the administration of ineffective medications, compromising the health and safety of residents, including Resident 33, who was receiving insulin from this cart. Resident 33, who was affected by this deficiency, had multiple diagnoses, including type 2 diabetes mellitus with diabetic polyneuropathy, COPD, and unspecified dementia. The resident's cognitive skills were moderately impaired, requiring supervision for daily decision-making. The facility's policies and procedures were reviewed, indicating that medications should be labeled with expiration dates and stored according to guidelines, including refrigeration when necessary. However, these procedures were not followed, leading to the identified deficiency.
Failure to Administer Influenza Vaccine to Consenting Resident
Penalty
Summary
The facility failed to administer the influenza vaccine to a resident who was eligible and had consented to receive it. The resident, identified as Resident 23, was admitted with multiple diagnoses, including shortness of breath, anxiety disorder, and unspecified fever. Despite having the capacity to understand and sign forms, as indicated in the resident's History and Physical, and a physician's order allowing the administration of the flu vaccine, the resident did not receive the vaccine. This oversight was confirmed during a review of the resident's Minimum Data Set and the facility's vaccination log, which showed that the resident had not been vaccinated. The facility's policy and procedure on vaccination, revised in October 2019, stated that all residents should be offered vaccines unless medically contraindicated or already vaccinated. The policy allowed for the administration of vaccines per physician-approved protocols after assessing medical contraindications. However, despite these guidelines, the resident did not receive the flu vaccine, as confirmed by the Infection Prevention Nurse during an interview and record review. This failure to administer the vaccine placed the resident at greater risk for acquiring or experiencing complications from the flu.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was experiencing significant pain. The resident, admitted with a displaced intertrochanteric fracture of the right femur and dementia, was observed crying out in pain multiple times. Despite the resident's clear expressions of pain, the Certified Nursing Assistant (CNA) did not report the resident's condition to the Licensed Vocational Nurse (LVN), as the resident had previously stated they did not want pain medication. This lack of communication resulted in the LVN being unaware of the resident's pain until later, when the resident rated their pain as 10 out of 10. Upon being informed, the LVN administered morphine sublingually but admitted to forgetting to assess the location of the pain, which is crucial for understanding its cause. The Director of Nursing (DON) emphasized the importance of prioritizing pain assessment and management, indicating that the CNA should have informed the nurse immediately. The facility's policy on pain management stresses the need for a multidisciplinary approach, recognizing and addressing pain based on professional standards and the resident's care plan, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided two-person physical assistance during a transfer using a mechanical lift. The resident, who had a history of seizures and chronic atrial fibrillation, required extensive assistance with bed mobility and transfers due to decreased functional mobility and impaired balance. Despite the care plan indicating the need for two-person assistance, the CNA attempted the transfer alone, resulting in the resident falling forward from the lift and sustaining a fracture in the neck of the humerus, causing severe pain and requiring hospital transfer for further evaluation and treatment. The incident occurred when the CNA used the Sara lift to transfer the resident from the toilet to the wheelchair without the assistance of another staff member. The CNA admitted to routinely performing such transfers alone, contrary to the facility's policy and procedures, which mandate the use of two staff members for mechanical lift transfers. The resident's knees buckled during the transfer, leading to the fall and subsequent injury. Interviews with other staff members, including another CNA and a Licensed Vocational Nurse (LVN), confirmed that the standard practice and facility policy required two staff members to operate the Sara lift safely. The Director of Nursing (DON) reiterated the importance of following the facility's policy for using the Sara lift with two staff members to ensure resident safety and prevent injuries. The facility's policies on using mechanical lifting devices and managing fall risks clearly stated the need for two nursing assistants to safely move a resident with a mechanical lift. The failure to adhere to these policies directly contributed to the resident's fall and injury, highlighting a significant deficiency in the facility's adherence to safety protocols and staff training.
Failure to Implement Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia and assessed at high risk for falls and elopement received appropriate care and services to prevent a fall. The resident's care plan interventions related to repetitive wandering behavior and attempts to leave the facility unattended were not implemented. Additionally, the care plan was not updated when staff recognized the need for one-to-one supervision due to frequent elopement attempts and the facility's fear that the resident might leave unnoticed. On the day of the incident, the resident fell while running toward the front lobby and attempting to leave the facility, resulting in a left distal radius fracture and a right humerus fracture. The resident was transferred to a general acute care hospital, where a cast was placed on the left arm and a sling on the right arm. Despite the resident's known high risk for falls and elopement, interventions such as frequent visual checks and outdoor walks were not consistently implemented. Interviews with staff revealed that the resident was known to be very confused and frequently wandered, making it difficult to monitor the resident when staff were busy with other tasks. The Director of Nursing confirmed that the resident's care plan interventions were not documented as implemented. The facility's policies and procedures for safety and supervision of residents and dementia care were not followed, leading to the resident's fall and subsequent injuries.
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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