Sacramento Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 5255 Hemlock Street, Sacramento, California 95841
- CMS Provider Number
- 056073
- Inspections on file
- 27
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Sacramento Post-acute during CMS and state inspections, most recent first.
A resident with prior pelvic fractures and hip pain, requiring substantial/maximal assistance for transfers, was transferred from bed to a shower chair by CNA students and their instructor after CNA staff had instructed them to wait for help and provided a gait belt. The instructor and students proceeded without calling for assistance, and multiple accounts from the resident, a witness, and staff described the resident slipping to the floor onto her knees, complaining of pain, and showing redness and discoloration on her lower legs, with a male student lifting her from the floor before any nurse was notified. The gait belt was later found unused on a table, and although the resident reported being dropped and expressed anxiety about falling again, facility leadership acknowledged there was no documented fall assessment, IDT review, or formal investigation, contrary to the facility’s written accident/incident policy requiring prompt investigation and reporting of all such events.
The facility failed to maintain food safety and sanitation standards, affecting 62 residents. Expired food items were found, and the kitchen had cleanliness issues, including unclean equipment and residue on surfaces. Temperature monitoring in storage areas was inadequate, with no logs for the dry storage room and missing thermometers in the freezer. The ice maker also had residue, indicating poor maintenance.
The facility failed to maintain the reach-in meat freezer in safe operating condition, with observed cracks on door seals and ice buildup near the fan. This was confirmed by the RD, and the facility's manual indicated the need for proper maintenance. The FDA Food Code 2022 requires equipment to be kept in repair, impacting food safety for 62 residents.
The facility failed to meet professional standards of care for three residents. A resident did not receive ordered suprapubic catheter and coccyx skin care, another resident's physician was not notified of high gastrostomy tube residuals, and a third resident received restorative nursing services without active orders. These deficiencies were confirmed through interviews and record reviews.
The facility failed to maintain infection control practices, as a resident's nephrostomy bag was observed touching the floor without a placement date, and two residents' CAM respiratory equipment lacked replacement dates. The Infection Preventionist and Respiratory Therapist confirmed these lapses, which were against the facility's policies.
A resident on hospice care with severe cognitive impairment suffered a significant skin tear during a brief change by a CNA, who allegedly handled him roughly. Despite the resident's distress and the severity of the injury, the incident was not reported to the appropriate authorities as required by the facility's policy.
A resident on hospice care sustained a degloving injury allegedly due to rough handling by a CNA. The facility failed to follow its policy for investigating abuse allegations, lacking interviews with the resident, witnesses, and staff, and did not document a thorough investigation. This placed the resident at risk for further harm.
A resident with a hydrocodone allergy was mistakenly given Norco instead of Percocet, leading to an unmonitored allergic reaction for 20 hours. The error was not reported immediately by the LPN, contrary to facility policy, resulting in a delay in addressing the resident's adverse effects.
A resident with a hydrocodone allergy was mistakenly given Norco, leading to itching and shortness of breath. The error occurred due to a nurse's distraction while preparing medications. The facility lacked a care plan addressing this medication error, contrary to its policy requiring defined goals and objectives for resident care.
A resident with a hydrocodone allergy was mistakenly given Norco, a medication containing hydrocodone, instead of the prescribed Percocet. The error occurred when a licensed nurse became distracted during medication preparation. The resident experienced itching and shortness of breath, and the error was confirmed by the facility's Infection Preventionist.
A resident with paralysis and PTSD was unable to reach the call light, which was hanging off the bed. This was confirmed by a CNA and the ADON, who acknowledged that the call light should have been within easy reach, as per the facility's policy.
Failure to Safely Supervise Transfer and Investigate Alleged Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate and sufficient supervision during a transfer and to ensure the environment was free from accident hazards for a cognitively intact resident with significant prior pelvic fractures and hip pain. The resident had a history of a serious pelvic ring and pubic ramus fracture following a fall and required substantial/maximal assistance for bed-to-chair transfers per the MDS. On the morning in question, CNA 1 informed a CNA instructor that the resident preferred a bed bath due to hip pain and instructed the instructor to call him for assistance before attempting the first out-of-bed transfer. Despite this, the CNA instructor and CNA students proceeded to transfer the resident from bed to a shower chair without calling CNA 1 for help. According to CNA 1, he left his gait belt in the room for the instructor to use and then left to care for another resident. He later heard a commotion and, upon returning, heard the resident repeatedly saying she had been dropped. CNA 1 observed redness on the resident’s lower legs and heard complaints of leg and back pain, and he saw the gait belt lying on a table across the room, leading him to suspect it had not been used during the transfer. The resident reported that three female students and their instructor attempted to transfer her, that she warned them she was going to fall, and that the instructor reassured her they had her before her legs buckled and she fell onto her knees on the floor. The resident stated the group could not lift her, and a male student entered and picked her up from the floor to the shower chair before CNA 1 arrived. An anonymous witness reported being present in the room and stated that four CNA students and the instructor were assisting with the resident’s shower and that, when the resident complained of pain, the instructor told the group to hurry with the transfer. The witness stated the resident slipped toward the ground, yelled that she was being dropped, and ended up on the floor on her legs, with one leg bent backward on her knee. The witness further stated there were no staff present and that no nurse was notified before the resident was picked up from the floor by the male student. Documentation on the shower sheet noted slight redness and discoloration at the resident’s lower legs, signed by CNA 1 and an LVN. Facility leadership, including the DSD and DON, acknowledged conflicting accounts about whether the resident fell, confirmed that the resident and at least one CNA student reported a fall, and stated that no fall assessment, IDT meeting, or documented investigation was completed, despite facility policy requiring investigation and reporting of all accidents and incidents. A physician progress note documented that the resident expressed anxiety about being in the facility because she reported being dropped during a transfer that morning and stated she was scared of falling again. During a record request, the facility was unable to provide any documentation that an investigation of the alleged fall had been conducted, even though the facility’s written policy on accidents and incidents required prompt investigation and reporting of all such events by the nurse supervisor/charge nurse or department director, including specific data elements on an incident/accident report form.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe and sanitary manner, affecting 62 residents who received food from the kitchen. During an inspection, expired food items, specifically bread crumb containers, were found on the kitchen shelf. The Registered Dietitian (RD) confirmed the expiration of these items, which was against the facility's policy that no food should be kept longer than its expiration date. Additionally, the facility's kitchen was found to have several cleanliness issues. An unclean appliance attachment cap with dark residue was observed on the steam table, and the oven top was covered in dust-like particles. A metal wire rack used for storing clean water pitchers was also found with dark residue. Pans with hard black residue were available for use, and the RD acknowledged that this buildup could affect food quality and safety. The facility's policy required all equipment to be clean and maintained in good repair, which was not adhered to. The facility also failed to monitor temperatures in storage areas adequately. The dry storage room had no documented temperature monitoring, and the freezer section of the refrigerator lacked a thermometer and temperature logs. The ice maker's dispensing mechanism was found with dark residue, indicating inadequate cleaning. These findings were contrary to the facility's policies, which required regular temperature checks and maintenance of cleanliness in all equipment and storage areas.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the reach-in meat freezer in safe operating condition, as observed during a survey. The freezer was found with two cracks on the door seals, each under 1/2 inch in length, and ice buildup was noted near the fan at the top of the freezer. These observations were confirmed by the Registered Dietitian during an interview. The facility's freezer installation and operations manual, although undated, indicated that door gaskets should be cleaned with a mild soap solution to extend their life. Additionally, the FDA Food Code 2022 specifies that equipment should be maintained in a state of repair, with components such as doors and seals kept intact and adjusted according to the manufacturer's specifications. The failure to maintain the freezer in proper condition decreased the facility's potential to ensure food safety and quality for 62 residents who consumed meals prepared by the facility.
Failure to Meet Professional Standards in Nursing Care
Penalty
Summary
The facility failed to ensure that nursing care met professional standards for three residents. For Resident 63, the nursing staff did not perform suprapubic catheter care and coccyx skin care as ordered. The resident was admitted with conditions including benign prostatic hyperplasia, diabetes mellitus type II, and moderate malnutrition, which increased the risk for complications. Despite orders to check the catheter every shift and apply barrier cream to the coccyx, documentation showed that care was not completed on multiple dates in September 2024. Interviews with staff confirmed the lack of documentation and care. Resident 36's medical record did not indicate that the physician was notified as ordered when the gastrostomy tube residual exceeded 250 ml. The resident, who had a history of stroke and was dependent on tube feeding, had orders to notify the physician if residuals were high. However, on several occasions in September 2024, there was no documented evidence that the physician was informed, as confirmed by the Assistant Director of Nursing during a record review. For Resident 53, restorative nursing services were provided without active prescriber orders. The resident, admitted with muscle weakness and hemiplegia, had a discontinued order for RNA services since September 2023. Despite this, RNA services continued to be provided, as confirmed by the Director of Nursing and the Director of Rehabilitation. The facility's policy required services to be provided in accordance with physician orders, which was not followed in this case.
Infection Control Deficiencies in Equipment Management
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by two specific incidents involving residents. In the first incident, a resident with a nephrostomy bag was observed with the antimicrobial privacy bag touching the floor, and the bag was not labeled with a placement date. This was confirmed by the Infection Preventionist, who acknowledged that the bag should be kept off the floor and dated to ensure timely replacement. The facility's policy on catheter care emphasized the importance of keeping catheter tubing and drainage bags off the floor to prevent urinary tract infections. In the second incident, two residents receiving tracheostomy care had their Continuous Air Mist (CAM) respiratory equipment not labeled with replacement dates. The Respiratory Therapist confirmed that the tracheostomy mask, corrugated tubing, and humidifier bottle for these residents were not dated, which was against the facility's expectations for equipment management. The Director of Nursing also confirmed that all parts of the CAM system should be labeled with replacement dates, as per the facility's policy on preventing ventilator-associated pneumonia.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an incident of alleged abuse involving a resident who was treated roughly during a brief change, resulting in a significant skin tear. The incident was reported anonymously, indicating that the resident acquired an avulsion injury to the right upper extremity when a CNA allegedly grabbed him by the arm. The resident expressed that the CNA was so strong that she tore the last piece of skin he had. Despite the severity of the incident, the Director of Nursing (DON) and the administrator did not report it, and there was an insistence on rewording documentation to avoid implications of physical abuse. The resident involved was on hospice care and had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 5. He was able to make medical decisions and understand his rights and responsibilities. The resident was described as needing assistance with various activities of daily living. On the day of the incident, the wound nurse documented the resident's tearful and painful state, with the resident repeatedly questioning why the CNA treated him like a rag doll. The wound nurse also took pictures of the injury and notified the physician. Interviews with staff confirmed that the incident was reported to the charge nurse and the DON, but no further action was taken to report the incident to the appropriate authorities. The facility's policy required immediate reporting of suspected abuse to the administrator and other officials, but this protocol was not followed. The resident was unable to be interviewed later as he had expired.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to follow its policy and procedure to investigate an allegation of abuse involving a resident who sustained a degloving injury to the right forearm and wrist. The incident was reported by an anonymous staff member, who indicated that the injury occurred during a brief change when a CNA allegedly handled the resident roughly. Despite the resident's claims of rough treatment, the facility did not initiate a proper investigation as per their policy. The resident, who was on hospice care and had severe cognitive impairment, was able to communicate and expressed distress over the incident, repeatedly questioning why the CNA treated him in such a manner. The wound nurse documented the resident's statements and the nature of the injury but did not record any further information or conduct a comprehensive investigation. The facility's investigation report, which was supposed to be documented in an IDT note, lacked essential elements such as interviews with the resident, witnesses, and staff, as well as observations of the resident's interactions with others. The facility's policy required a thorough investigation of all allegations, including interviews with relevant parties and documentation of findings. However, the investigation report did not meet these requirements, and there was no evidence of a five-day follow-up investigation report. The failure to conduct a proper investigation placed the resident at risk for further harm and did not comply with the facility's own procedures for handling allegations of abuse.
Failure to Promptly Notify Physician and Monitor Resident After Medication Error
Penalty
Summary
The facility failed to promptly notify the physician or implement timely monitoring for a resident who was administered Norco, a narcotic medication containing hydrocodone and acetaminophen, despite having hydrocodone listed as an allergy. This oversight resulted in the resident not being monitored for an allergic reaction for approximately 20 hours. The resident, who was admitted in early 2023 with diagnoses including Multiple Sclerosis, a stage four pressure ulcer, and paraplegia, experienced itching and shortness of breath after receiving the medication in error. The error occurred when a licensed nurse, while distracted during medication administration, mistakenly gave Norco instead of the prescribed Percocet. The nurse realized the mistake during a medication count but failed to report it immediately, only informing the charge nurse the following day. The facility's policy requires immediate reporting and monitoring of medication errors, but no documentation or monitoring was conducted on the day of the incident. The Infection Preventionist confirmed the lack of documentation and emphasized the expectation for immediate reporting to address any adverse effects.
Failure to Implement Care Plan for Medication Allergy
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who was administered Norco, a narcotic medication containing hydrocodone, despite having hydrocodone listed as an allergy. This oversight occurred for a resident admitted in early 2023 with multiple diagnoses, including Multiple Sclerosis, a stage four pressure ulcer, and paraplegia. The resident, who is his own responsible party, experienced itching and shortness of breath after receiving the medication, which was documented in the physician's progress notes. The incident was attributed to a licensed nurse who administered the narcotic by mistake, as she was distracted while preparing another resident's medications. A medication error report confirmed that the resident received Norco instead of the prescribed Percocet. During a review, it was found that there was no care plan addressing the medication error, which was confirmed by the Infection Preventionist. The facility's policy on care plans emphasizes the importance of having defined goals and objectives accessible to all disciplines, which was not adhered to in this case.
Medication Error: Administration of Norco to Resident with Hydrocodone Allergy
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications when a licensed nurse administered Norco, a narcotic medication containing hydrocodone and acetaminophen, to a resident who had hydrocodone listed as an allergy. This error occurred despite the resident's face sheet and order summary report clearly indicating the hydrocodone allergy. The resident, who was admitted in early 2023 with diagnoses including Multiple Sclerosis, a stage four pressure ulcer, and paraplegia, experienced itching and shortness of breath after receiving the incorrect medication. The medication error was confirmed by the facility's Infection Preventionist and was documented in a medication error report. The licensed nurse involved admitted to the mistake, stating that she was distracted while preparing medications and inadvertently administered Norco instead of the prescribed Percocet. The facility's policy on medication errors defines such incidents as deviations from physician orders or professional standards and requires monitoring for adverse consequences and prompt notification of significant errors.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to maintain a resident's communication within the facility when the resident's call light was not within reach. Resident 1, who was admitted in 2023 with diagnoses including paralysis of the legs and lower body and post-traumatic stress disorder (PTSD), was observed on 4/18/24 stating that he was unable to reach the call light, which was hanging off the left side of the bed. This observation was confirmed by Certified Nursing Assistant 1 (CNA 1) and the Assistant Director of Nursing (ADON), both of whom acknowledged that the call light should have been within easy reach of the resident. The facility's policy, dated 9/2003, also indicated that the call light should be within easy reach of the resident when they are in bed or confined to a chair.
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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