San Jose Healthcare & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 75 N. 13th Street, San Jose, California 95112
- CMS Provider Number
- 055388
- Inspections on file
- 25
- Latest survey
- June 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at San Jose Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not receive scheduled evening medications on time due to a failure to communicate changes in nursing assignments. Confusion among LVNs about who was responsible for the resident's care led to delayed administration of medications, including insulin, and incomplete documentation of medication times.
The facility failed to ensure proper use of bed rails for six residents, lacking care plans, physician's orders, or informed consent. This oversight was confirmed by the DON and violated the facility's policy, potentially placing residents at risk of entrapment and injury.
The facility's kitchen staff failed to properly test the dish machine sanitizer, using an incorrect method that involved dipping a test strip directly into the water. This practice was confirmed by the RD and DM, but contradicted by a dish machine vendor technician who stated the correct procedure involves using a cleaned plate or the inside walls of the dish machine. This failure risked exposing 51 residents to foodborne illness.
The facility failed to maintain sanitary conditions in the kitchen, with a dirty sink drainage pipe and unlabeled or expired food items, posing potential food contamination risks for residents. The sink drainage pipe was not included in the cleaning schedule, and food items like sugar-free gelatin and non-dairy creamer were improperly labeled or stored, contrary to facility policies.
The facility failed to ensure proper infection control procedures, as staff did not perform hand hygiene before patient contact or meal handling, and did not clean equipment before wound care. These lapses were acknowledged by the staff involved, contrary to CDC guidelines and facility policies.
A resident with dementia and other health conditions experienced verbal abuse when a Dietary Manager shouted at them for expressing hunger. The incident was witnessed by a state surveyor, who observed the manager attempting to close the door on the resident while shouting. Facility policies emphasize respectful treatment of residents, which was not followed in this case.
A resident's dignity was compromised during wound care when an LVN exposed the resident's back and buttocks by opening the room door without covering them. The LVN called for assistance twice without ensuring the resident's privacy, contrary to the facility's policy on resident rights.
The facility failed to obtain informed consent for psychotropic medications for three residents, compromising their right to be fully informed about their care. Incomplete documentation and missing signatures were noted for medications like Risperidone and Valproic Acid, contrary to facility policy.
A resident with Parkinson's, schizoaffective disorder, and dementia was left with unattended medication despite not being approved for self-administration. A nurse confirmed leaving the medication without observing the resident taking it, contrary to facility policy requiring licensed nurse administration.
The facility failed to follow physician orders and resident care plans for three residents. A resident did not receive prescribed dietary items, another did not have necessary physical supports applied, and a CNA was unaware of a resident's dialysis site, leading to potential care issues.
A facility failed to ensure complete medication administration for a resident via a gastrostomy tube. An LVN prepared and administered 12 medications, but residue remained in 6 medication cups, indicating incomplete dosing. The LVN acknowledged the issue, and the DON confirmed the resident did not receive the full prescribed dose, contrary to the facility's medication administration policy.
The facility failed to store and label medications properly, as observed during an inspection. An unopened bottle of Latanoprost eye drops and a Humalog insulin vial were not refrigerated as required, and a Breo Ellipta inhaler lacked an open date. RN E confirmed these storage and labeling errors, which violated the facility's policy to follow manufacturer's recommendations.
Two residents with intact cognition signed arbitration agreements without understanding them, as the facility failed to explain the agreements during admission. The admission director acknowledged the oversight, which violated the facility's policy requiring clear explanation of such agreements.
The facility did not meet the required minimum space of 80 square feet per resident in 10 bedrooms, with some rooms providing as little as 69 square feet per resident. Despite this, nursing care and services were not negatively impacted, and no complaints were reported by residents or staff.
A resident with skin infections did not receive prescribed medications due to a failure in the facility's medication management. Despite the medications being delivered, nurses documented them as on order and did not administer them, potentially compromising the resident's health.
A facility failed to maintain complete and accurate medical records for a resident when a nurse did not document notifying the physician about multiple medications that were not administered. The resident had orders for several topical medications, which were not documented as given on certain days. The nurse confirmed the medications were not administered due to unavailability and admitted to not documenting the physician notification, contrary to facility policy.
The facility failed to adhere to professional standards of practice when two residents were involved in an altercation. Staff did not complete necessary documentation or notify relevant parties, and a skin assessment was not performed. Additionally, there was no follow-up documentation after a resident's room change, contrary to facility policy. These deficiencies could negatively impact resident well-being.
The facility failed to notify the Ombudsman of discharges and transfers for three residents, as required by policy and state regulations. A resident was discharged without proper notification to the Ombudsman, and two other residents were transferred to an acute hospital without documentation of notification. The facility's policy mandates notification to the Ombudsman, which was not adhered to, as confirmed by the lack of documentation and confirmation.
The facility did not follow its Oxygen Therapy policy for two residents with chronic respiratory failure. One resident's nasal cannula was not labeled or dated, contrary to the policy requiring weekly changes and labeling. Another resident's room lacked a 'No Smoking' sign, which is required where oxygen is administered. These deficiencies were confirmed by an LPN and had the potential to compromise resident safety.
Failure to Communicate Nursing Assignment Results in Delayed Medication Administration
Penalty
Summary
The facility failed to establish and communicate which licensed nurse was responsible for providing care to a resident during the evening shift. On the specified date, there was confusion among the nursing staff regarding the assignment of care for the resident. Although the monthly nursing assignment indicated that one LVN was scheduled to provide care, it was requested that this nurse not care for the resident, and another LVN was supposed to assume responsibility. However, this change was not communicated to the replacement nurse, resulting in a lack of clarity about who was responsible for the resident's care during that shift. As a result of this miscommunication, the resident did not receive scheduled medications, including lactobacillus, metformin, metoprolol, and insulin lispro, at the appropriate times. The insulin was administered almost two hours late by the nurse supervisor, and the administration times for the other medications were not documented. The resident had multiple diagnoses, including dementia, diabetes mellitus, hypertensive heart disease, and heart failure, which required timely medication administration. The facility's policies required medications to be administered within one hour before or after the scheduled time, which was not followed in this instance.
Failure to Ensure Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed rails for six residents, which included not having care plans, physician's orders, or informed consent for their use. Specifically, residents 31, 33, and 35 did not have care plans for the use of siderails. Residents 42 and 49 lacked both a physician's order and a care plan for siderails. Resident 37 was missing a consent, a physician's order, and a care plan for the use of siderails. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged the lack of necessary documentation and care planning. The facility's policy, NP120 Bed Rails, requires an evaluation of the resident's need for bed rails, informed consent from the resident or their representative, and the development of a care plan regarding their use. The absence of these critical steps had the potential to place residents at risk of entrapment and injury, as the proper procedures for assessing and documenting the need for bed rails were not followed. Observations on a specific date confirmed that these residents had bilateral siderails without the required documentation and planning.
Improper Testing of Dish Machine Sanitizer
Penalty
Summary
The facility failed to ensure that the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice. During an observation, the kitchen staff incorrectly demonstrated how to test the dish machine sanitizer by dipping a test strip directly into the water from the dish machine. This method was confirmed by the Registered Dietician and Dietary Manager as their standard practice. However, a dish machine vendor technician specialist clarified that the correct procedure involves using a cleaned plate or the inside walls of the dish machine to test the sanitizer, not directly dipping the strip into the water. The facility's policy and procedure documents, which were not provided upon request, indicated that the dish machine should be used according to the manufacturer's guidelines. This failure had the potential to expose 51 residents to contaminants in food, increasing the risk of foodborne illness.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, leading to potential food contamination risks for 51 residents. During an initial kitchen tour, it was observed that the sink drainage pipe had a buildup of whitish to yellowish substances, and the sink faucet was dripping and could not be turned off completely for one or two weeks. The Dietary Manager confirmed that the drainage pipe was not included in the cleaning schedule, and a work order had been requested for the faucet. The Regional Registered Dietician verified that the cleaning log did not include the sink and drainage pipe, and it was recommended to add the sink to the cleaning log. The facility's policy and procedure indicated the maintenance of sanitation and safety standards, which were not adhered to in this instance. Additionally, during the kitchen tour, it was found that food items were improperly stored. A container of sugar-free gelatin was labeled with a past use-by date, and an opened non-dairy creamer and lettuce salad mix were stored without labeled open dates. The Registered Dietician confirmed that refrigerators were checked every morning and that the non-dairy creamer should be labeled with the date it was opened. The lettuce salad mix was wilted and needed to be discarded. The facility's policy required all food items to be labeled and dated, which was not followed, leading to potential food safety issues.
Infection Control Lapses in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed by staff, as observed in several instances. Licensed Vocational Nurse D did not perform hand hygiene before checking the vital signs of Resident 21, despite acknowledging the necessity of such a practice. This oversight was noted during an observation and interview, where LVN D confirmed the lapse in protocol. The Centers for Disease Control and Prevention (CDC) guidelines recommend hand hygiene immediately before patient contact, which was not adhered to in this case. Additionally, during a dining observation, Certified Nursing Assistant C did not sanitize her hands before feeding Resident 40. Similarly, Licensed Vocational Nurse A and Registered Nurse F failed to wash or sanitize their hands before opening meal plate lids to check residents' meals. These actions were acknowledged by the staff involved, who admitted to not following the facility's policy requiring hand hygiene before meal distribution. Furthermore, LVN A did not clean scissors before using them to cut a granufoam dressing and vacuum-assisted closure tape for Resident 31's wound, which was also against CDC recommendations for infection control during wound care.
Verbal Abuse Incident Involving Resident's Hunger
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a staff member shouted at the resident and did not acknowledge the resident's statement of hunger. The incident involved a resident with a history of unspecified dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, and major depressive disorder. The resident, who had a moderate cognitive impairment, was observed by a state surveyor holding a kitchen door slightly open and stating they were hungry. The Dietary Manager was seen shouting at the resident to go to their room and attempted to close the door on the resident. This interaction was witnessed by the surveyor, who noted that the Dietary Manager stopped shouting once they noticed the surveyor's presence. The facility's policies and job descriptions emphasize the importance of treating residents with respect and protecting their rights. However, during interviews, it was revealed that the Dietary Manager did not provide an appropriate response to the resident's statement of hunger. The Regional Registered Dietician and the Director of Nursing both indicated that staff should respond to residents' needs respectfully and appropriately. The facility's documents also prohibit rude or unprofessional behavior towards residents, highlighting a failure to adhere to these standards in this incident.
Resident Dignity Compromised During Wound Care
Penalty
Summary
The facility failed to uphold the dignity of a resident during a wound treatment procedure. The incident involved a licensed vocational nurse (LVN) who, while attending to a resident's wound care, exposed the resident's back and buttocks to the room door. The resident was lying in bed with the curtain fully open and the door closed. During the procedure, the LVN discovered that the resident had a bowel movement and, without covering the resident, opened the door to call a certified nursing assistant (CNA) for assistance. The LVN repeated this action when further help was needed, again without covering the resident. The LVN later acknowledged that she should have covered the resident before opening the door. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to properly obtain informed consent for psychotropic medications for three residents, which compromised their right to be fully informed about their care and treatment. Resident 20 had a physician's order for Risperidone, but the informed consent documentation was incomplete, lacking details such as medication name, dose, frequency, indications, side effects, and possible adverse reactions. Additionally, the verification of informed consent for Risperidone was missing a date and a nurse's signature. The facility's policy requires informed consent to be obtained prior to treatment, but this was not adhered to in this case. Resident 4's clinical record showed a physician's order for Valproic Acid to manage mood disorder, but there was no informed consent for this medication. The DON confirmed the absence of informed consent for Valproic Acid, although there was one for Seroquel. Similarly, Resident 28's informed consent documentation for Risperidone was incomplete, missing critical information such as medication name, dose, frequency, indications, side effects, and possible adverse reactions. The verification of informed consent for Risperidone also lacked a date and a nurse's signature. These deficiencies indicate a failure to ensure residents or their responsible parties were fully informed about their treatment options.
Medication Mismanagement for Non-Approved Self-Administration
Penalty
Summary
The facility failed to ensure that medications were not left unattended at the bedside for a resident who was not approved to self-administer medications. Resident 4, who has diagnoses including Parkinson's Disease, schizoaffective disorder, and dementia with agitation, was observed with a medication cup containing five pills left on her breakfast tray. The resident stated that staff routinely leave her medications for her to take on her own, despite not being approved for self-administration. During an interview, a registered nurse confirmed that she left the medication in the resident's room after the resident indicated she would take it later. The nurse did not stay to observe whether the resident took all of the prescribed medications. The Director of Nursing confirmed that Resident 4 was not approved for self-administration of medications. The facility's policy requires that medication be administered by a licensed nurse and upon the order of a physician or licensed independent practitioner.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to provide necessary care and services for three residents, as observed during a survey. Resident 3 did not receive yogurt, tofu, orange, and tangerine with his meals as ordered by the physician. This was confirmed by the registered dietician and the director of nursing, who acknowledged that the physician's order should be followed. The facility's policy indicated that resident preferences should be reflected in the medical record and tray-card and updated in a timely manner. Resident 21 did not have rolled towels applied to his hands or offloading boots on his lower extremities as ordered by the physician. This was observed during multiple shifts, and the licensed vocational nurse acknowledged the oversight. Additionally, CNA C was unaware of Resident 23's dialysis site, incorrectly stating it was on his chest, and mentioned taking blood pressure on the arm with an AV shunt, which contradicts the facility's policy prohibiting such procedures on the arm with an AV shunt.
Incomplete Medication Administration via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that medications were fully administered as prescribed for a resident during a medication pass administration. During the observation, a Licensed Vocational Nurse (LVN) prepared the resident's medications for administration via a gastrostomy tube. The LVN crushed each medication separately, placed them into individual medicine cups, and added approximately 10 milliliters of water per cup. After confirming that the resident had 12 medications, the LVN administered each medication separately, flushing the gastrostomy tube with 10 milliliters of water between doses. However, medication residue remained in 6 of the 12 medication cups after administration. In a concurrent interview, the LVN confirmed that residue remained in the six medication cups and acknowledged that more water should have been added to ensure all medication was administered. The Director of Nursing later acknowledged that the resident did not receive the full prescribed dose because medications remained in the medication cups. The facility's policy indicated that medications and treatments should be administered as prescribed to ensure compliance with dose guidelines.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications and biologicals according to manufacturer instructions and facility policy, as observed during an inspection of the medication cart in Station 2. Specifically, an unopened bottle of Latanoprost eye drops for a resident was found in the top drawer of the medication cart instead of being refrigerated as required by the pharmacy label. Additionally, an inhaler, Breo Ellipta, for another resident was opened but lacked an open date on the label, which is necessary to ensure proper tracking of the medication's usage. Furthermore, an unopened Humalog insulin vial for a third resident was stored in the medication cart rather than being refrigerated as indicated by the pharmacy label. During an interview, Registered Nurse E confirmed that the Latanoprost eye drops and Humalog insulin vial should have been refrigerated until opened, and the Breo Ellipta inhaler should have been labeled with an open date upon first use. The facility's policy, dated April 2008, mandates that medications and biologicals be stored safely, securely, and properly, following manufacturer's recommendations, which was not adhered to in these instances.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to two residents, Resident 23 and Resident 31, during their admission process. Both residents, who had intact cognition as indicated by their Minimum Data Set assessments, signed the arbitration agreements without a full understanding of what they entailed. Resident 23 was admitted and signed the agreement on January 20, 2025, while Resident 31 signed on January 22, 2025. During interviews conducted on March 5, 2025, both residents stated that they were not informed about the arbitration agreement and simply signed the documents provided to them by the facility. The admission director, who was responsible for overseeing the arbitration agreements, stated in an interview on March 7, 2025, that she would ensure the agreements were explained to residents. However, the facility's policy, AD 17 Arbitration Agreements, dated May 26, 2023, clearly required that the agreement be explained to residents in a manner they understand, including in a language they comprehend. This policy was not followed, leading to the deficiency where residents signed the agreements without proper explanation or understanding.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 10 bedrooms met the required minimum space of 80 square feet per resident. The specific room measurements were recorded, showing that several rooms had less than the required space, with some rooms accommodating three residents with as little as 69 square feet per resident. Despite this deficiency, observations during the survey indicated that nursing care and services were not negatively impacted by the shortage of space. Interviews with residents and staff revealed no complaints or concerns regarding the lack of space.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, which had the potential to compromise the resident's health and well-being. The resident, who was admitted with diagnoses including cellulitis and other skin disorders, had physician orders for several topical medications to be applied multiple times a day. However, the medication administration record (MAR) and treatment administration record (TAR) for the resident showed that these medications were not documented as administered on specific dates. Instead, the nurses documented a code indicating that the medications were on order, suggesting they were not available for administration. Interviews with the licensed nurses responsible for administering the medications revealed that they were unable to find the medications in the facility and thus did not administer them. Despite their documentation indicating the medications were on order, a review of the facility's delivery records confirmed that the medications had been delivered before the first doses were due. This discrepancy between the delivery records and the nurses' documentation highlights a failure in the facility's medication management process, as the medications were available but not administered as prescribed.
Incomplete Medical Record Documentation for Medication Administration
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for a resident when there was no documentation that the nurse notified the resident's physician of multiple medications that were not administered. The resident, who was admitted with diagnoses including cellulitis and other skin disorders, had physician orders for several topical medications to be applied multiple times a day. However, on specific dates, these medications were not documented as administered in the resident's medication administration record (MAR) and treatment administration record (TAR). During an interview, a licensed nurse confirmed that he did not administer the medications because he could not find them in the facility. Furthermore, there was no documentation in the resident's medical record indicating that the nurse notified the physician about the missed medications. Although the nurse stated he had notified the physician, he admitted to not documenting this communication, acknowledging that documentation was required. The facility's policy on medical record completion emphasized the importance of prompt, complete, and accurate documentation, including notifying physicians about changes in a resident's condition.
Failure to Document and Follow Up After Resident Altercation and Room Change
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents involved in an altercation. Staff did not complete an SBAR communication tool, nor did they notify the physician and responsible party when the altercation occurred. Additionally, a licensed nurse failed to perform a skin assessment on one resident after the incident, and neither resident was placed on alert charting for close monitoring and documentation for 72 hours following the altercation. These actions were not in line with the facility's policies, which require documentation and notification in such incidents. Furthermore, the facility did not follow up with one resident after a room change, failing to document the resident's adjustment to the new room and interactions with the new roommate. The facility's policy mandates that social services or a designee should assess and document the resident's adjustment for three days following a room change. The lack of documentation and follow-up in these instances had the potential to negatively affect the residents' health, safety, and well-being.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of discharges and transfers for three residents, which is a requirement under the facility's policy and state regulations. Resident 1 was discharged from the facility after her insurance issued a last covered date, but there was no documentation that the Ombudsman was notified of her discharge. The Director of Nursing (DON) attempted to provide evidence of notification but was unable to produce a fax confirmation or any documentation indicating that the Ombudsman was informed. An Ombudsman office representative confirmed that they had not received notifications of transfers and discharges from the facility since July 2023. Similarly, Residents 2 and 3 were transferred to an acute hospital, but there was no documentation in their medical records indicating that the Ombudsman was notified of these transfers. The facility's policy requires that a Notice of Transfer and Discharge be provided to the resident, responsible party, and Ombudsman 30 days prior to the transfer or discharge, or as soon as practicable in emergency situations. The facility did not adhere to this policy, as evidenced by the lack of documentation and confirmation of notification to the Ombudsman.
Failure to Follow Oxygen Therapy Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its Oxygen Therapy policy for two residents who required oxygen therapy. Resident 4, diagnosed with chronic respiratory failure, was observed receiving oxygen via a nasal cannula that was neither labeled nor dated. According to the facility's policy, nasal cannulas should be changed weekly and labeled with the date of change. During an interview, a licensed nurse confirmed the oversight, acknowledging that the nasal cannula was not labeled with a date, which is a requirement per the facility's policy. Additionally, Resident 5, also diagnosed with chronic respiratory failure, was observed receiving oxygen without a 'No Smoking' sign posted in or at the entrance of her room. The facility's policy mandates that 'No Smoking' signs be prominently displayed wherever oxygen is stored or administered. Observations confirmed the absence of such signage, and a licensed nurse verified this deficiency, stating that the signs should be posted for residents using oxygen. These lapses in following the facility's policy had the potential to compromise the residents' health and safety.
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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