Santa Maria Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Maria, California.
- Location
- 820 West Cook Street, Santa Maria, California 93458
- CMS Provider Number
- 055563
- Inspections on file
- 31
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Santa Maria Post Acute during CMS and state inspections, most recent first.
A resident did not receive their routine Alprazolam medication due to a failure in the facility's medication ordering process. The admitting nurse was unaware of the requirement to fax orders for controlled substances, leading to the medication not being delivered. The nursing staff did not adequately follow up to resolve the issue, resulting in the resident's distress and eventual discharge against medical advice.
A facility failed to follow physician orders for a resident's pain medication, resulting in a delay and incorrect frequency of administration. Hydrocodone was prescribed to be given every 4 hours as needed, but the facility ordered it two days late and recorded it for every 6 hours. This was confirmed by the DON, who noted the order should have been submitted on the specified day.
A resident with dementia and other health issues eloped from a facility due to inadequate supervision and a malfunctioning wander guard system. The resident, who had a wander guard bracelet on their wheelchair, was able to leave the facility unnoticed and was found five blocks away. Testing revealed the wander guard alarm only activated intermittently, and staff were unaware if it sounded during the elopement.
A resident's behavior escalated due to a delay in medication administration, and staff failed to use de-escalation techniques. The resident, upset and cursing, attempted to grab a phone at the nurse's station, resulting in a skin tear. Despite being trained in de-escalation, the LPNs involved did not address the resident's needs promptly, leading to the deficiency.
A facility failed to ensure a functioning call light system for a resident. During an observation, the resident reported that staff did not respond when the call light was pressed. It was found that the call bell was unplugged, resulting in no response or indication outside the room. A CNA confirmed the issue, and the facility's policy requires call lights to be plugged in and functioning.
The facility failed to maintain food safety standards during lunch tray preparation and did not follow the recommended sanitization schedule for its ice machine. A dietary aide/cook did not change gloves or perform hand hygiene while preparing food, potentially contaminating it. Additionally, the ice machine had not been sanitized within the six-month interval recommended by the manufacturer's manual, as confirmed by the maintenance supervisor and Director of Nursing.
The facility failed to provide 24-hour nursing staff, with no RNs assigned on specific dates as per the PBJ report. The Administrator confirmed the absence of RNs, potentially impacting resident care.
A facility failed to obtain informed consent for Xanax administration for a resident. During a review, it was found that the physician's order for Xanax lacked documentation of informed consent, and the DON could not locate a consent form in the resident's chart. The facility's policy requires healthcare practitioners to obtain and document informed consent for psychotherapeutic medications, which was not adhered to in this case.
The facility did not make the most recent recertification survey results from August 2022 available to residents, family members, and legal representatives. The survey binder at the entrance check-in counter was missing these results, and the DON was unaware of the survey. The ADM confirmed the results were in his office, not in the accessible binder, contrary to the facility's policy.
The facility failed to develop comprehensive care plans for two residents regarding their medication use. A resident prescribed Xanax for anxiety and another on Apixaban for anticoagulation did not have care plans addressing these medications. The DON confirmed the absence of these care plans, which is against the facility's policy requiring comprehensive, person-centered care plans.
A resident with a pronounced foot drop was non-compliant with wearing bilateral splints, and this non-compliance was not documented or communicated beyond the Rehab Director. The care plan was not updated to reflect the resident's current condition, including the need for off-loading heels to prevent pressure ulcers. Additionally, the resident received inconsistent RNA therapy, with no documentation explaining the discrepancies. The facility's policy required comprehensive care plans, but the resident's plan did not meet these standards.
A facility failed to administer medications on time for a resident with CHF, did not carry out a physician's order for lab tests for a resident with multiple health issues, and neglected to complete post-dialysis assessments for a resident with end-stage renal disease. These deficiencies were confirmed by the DON and involved registry nurses and other staff.
The facility failed to administer medications correctly for three residents. A resident received an incorrect dose of Acetaminophen, another was given Levothyroxine after breakfast instead of on an empty stomach, and a third resident did not receive Magnesium Oxide and Acamprosate as prescribed, with discrepancies noted between the nurse's documentation and the resident's account.
A facility failed to conduct a Medication Regimen Review (MRR) for Xanax for a resident, as required by their policy. The resident had a physician's order for Xanax, but the MRR did not include a review for its continued use beyond 14 days. The Director of Nursing confirmed the absence of a pharmacist review, which is a requirement under the facility's policy for Consultant Pharmacist Services.
A facility failed to ensure a practitioner's justification for the continued use of Xanax beyond 14 days for a resident. During a review with the DON, it was found that the resident had an order for Xanax 0.25 mg every 8 hours as needed for anxiety and panic, but there was no documentation justifying its use beyond 14 days. The facility's policy requires documentation for extending PRN orders for psychotropic medications beyond 14 days, which was not followed in this case.
The facility had a medication error rate of 14.81%, exceeding the acceptable limit. A nurse administered incorrect dosages and timing of medications to three residents. One resident received less Acetaminophen than prescribed, another was given Levothyroxine after eating, and a third did not receive Magnesium Oxide and Acamprosate as ordered, despite the resident's willingness to take them.
The facility failed to properly label and store medications and biologicals, including an opened Sodium Chloride solution without a date label, out-of-range refrigerator temperatures without corrective actions, and improper storage of lemon glycerin swab sticks in a freezer. Additionally, medications were found in a sink, and glucometer strips lacked an open date label, all confirmed by LNs during interviews.
The facility failed to implement a water management program to prevent Legionella and other waterborne pathogens. The Administrator and DON admitted there was no system to test and track these pathogens, and the facility's assessment did not address a water management program. Despite having policies indicating the need for such a program, it was not in place, potentially exposing residents to harmful pathogens.
The facility failed to maintain a safe and functional environment for two residents. One resident's bed was not working, hindering their ability to feed themselves, and the issue was not addressed despite being reported. Another resident had a frayed bed control wire and an extension cord near their head. The facility's policies require routine inspections to ensure equipment safety.
A resident with a history of a right heel DTI and other medical conditions was admitted with a brace on the right lower extremity, which caused additional pressure injuries. Despite an email allowing modification of the immobilizer, the facility did not act promptly, leading to the worsening of the initial DTI and the development of three additional wounds. The facility's failure to follow its policy and procedure for pressure injuries resulted in increased pain and an additional hospital stay for the resident.
The facility failed to report a resident's unwitnessed fall from a wheelchair in the dining room, which resulted in injuries requiring EMS and an ER visit. The Administrator stated that no report was filed because the resident did not return from the hospital. This was against the facility's policy requiring such incidents to be reported within 24 hours and a written report within 48 hours.
The facility failed to provide an environment free from restraints when all four side rails of a resident's bed were raised without consent. Despite the facility's policy against using bedrails as restraints, a CNA raised the side rails to prevent the resident from getting out of bed due to a history of falls. Both the DON and Administrator confirmed that this practice is considered a restraint and should not have occurred.
Failure to Provide Routine Medication
Penalty
Summary
The facility failed to ensure that a routine medication, Alprazolam 2 mg, was available for a resident, resulting in the resident not receiving the scheduled medication and experiencing distress. The deficiency occurred when the admitting nurse sent the medication list electronically to the pharmacy but was unaware that a fax was required for controlled medications like Alprazolam. The pharmacist confirmed that controlled medications need to be faxed unless the order is sent directly by the prescriber. The resident was admitted in the evening, and the medication was missing from the delivery, which was not immediately addressed. The nursing staff did not follow up adequately to resolve the issue. The nursing progress notes indicated that the medication did not arrive, and there was no documentation of further attempts to contact the physician for an alternative medication until the following day. The resident's representative was upset and signed the resident out of the facility against medical advice. The facility's policy required special procedures for ordering controlled substances, which were not followed, leading to the deficiency.
Failure to Follow Physician Orders for Pain Medication
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in a delay and incorrect administration of pain medication. Specifically, Hydrocodone was prescribed for the resident's back pain to be administered every 4 hours as needed, according to the discharge medication list from the hospital. However, the facility did not order the medication until two days after the physician's orders were given, and the medication was recorded with an incorrect frequency of every 6 hours as needed. This discrepancy was confirmed during a review with the Director of Nursing, who acknowledged that the order should have been submitted to the pharmacy on the day the physician specified. The facility's policy requires that drug orders be recorded on the physician's order sheet in the resident's chart, which was not followed in this instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Wander Guard System
Penalty
Summary
The facility failed to ensure adequate supervision for a resident identified as being at risk for elopement, resulting in the resident eloping from the facility without staff knowledge. The resident, who had a history of unspecified dementia, hypertension, osteoporosis, major depressive disorder, and adjustment disorder, was admitted to the facility with a physician's order for a wander guard due to increased confusion and poor judgment. Despite the implementation of a wander guard system, the resident was able to leave the facility unaccompanied and was found five blocks away. The facility's wander guard system was not functioning reliably, as observed during an interview and test conducted with the Director of Nursing and the administrator. The wander guard door alarm, which was supposed to sound every time a resident with a wander guard bracelet passed through, only activated three out of six times during a test. Additionally, the resident's wander guard was found on the wheelchair rather than on the resident's wrist or leg, which may have contributed to the failure of the alarm system to detect the resident's exit. Interviews with staff revealed that the resident had expressed intentions to leave the facility to watch a game, indicating a potential risk for elopement. However, there was no documentation of regular testing of the wander guard system, and staff were unaware if the alarm had sounded during the resident's elopement. The lack of reliable alarm function and inadequate supervision allowed the resident to leave the facility unnoticed, posing a potential risk for harm.
Failure to Utilize De-escalation Techniques for Resident
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when their behavior escalated, and de-escalation techniques were not utilized. The incident involved a resident who was upset due to a delay in receiving their medication. The resident was observed cursing and reaching over the nurse's station to grab the phone while a licensed nurse (LN 1) was on a call. LN 1 did not employ any de-escalation techniques and continued with the call, resulting in the resident sustaining a skin tear on their left arm. Another licensed nurse (LN 2) was also involved, as she continued with her medication pass without addressing the resident's escalating behavior or providing the medication sooner. Interviews with the staff revealed that the resident was alert and oriented but difficult to please at times. The Director of Nursing (DON) acknowledged that de-escalation techniques should have been utilized by both LN 1 and LN 2, as staff are trained in these techniques. The facility's policy emphasizes a commitment to compassion and caring, particularly for residents with behavioral issues, which was not adhered to in this situation. The failure to employ de-escalation techniques and address the resident's needs in a timely manner led to the deficiency.
Failure to Ensure Functioning Call Light System
Penalty
Summary
The facility failed to ensure a functioning call light system for a resident, which was identified during an observation and interview. The resident reported that staff did not respond when the call light was pressed, and upon testing, it was found that there was no response, no ringing sound, and the light outside the room was not illuminated. The call bell was observed to be unplugged from the wall. A certified nursing assistant confirmed the call light was not functioning and stated it should always be plugged in. The facility's policy, reviewed with the administrator, indicated that call lights should be plugged in and functioning at all times.
Food Safety and Ice Machine Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to food safety standards during lunch tray preparation and ice machine sanitization. A dietary aide/cook (DAC) was observed not following proper hygiene and sanitary practices while preparing lunch trays. The DAC measured food temperatures with gloved hands and continued to handle various kitchen items without changing gloves or performing hand hygiene. Additionally, the DAC rested a plate against her body, allowing her apron and ID badge to touch the edge of the plate, potentially contaminating the food. The certified dietary manager (CDM) confirmed these practices were inappropriate and acknowledged the need for frequent glove changes and hand hygiene to prevent food contamination. The facility also failed to follow the recommended sanitization schedule for its ice machine. The ice machine's sanitization was last performed on 3/18/24, which was not within the six-month interval recommended by the manufacturer's manual. The maintenance supervisor (MS) confirmed the lapse in the sanitization schedule and could not provide any service records or invoices indicating sanitization after the last recorded date. The Director of Nursing (DON) also confirmed the ice machine had not been sanitized within the recommended timeframe, which could lead to potential contamination as per the FDA Food Code.
Failure to Provide 24-Hour Nursing Staff
Penalty
Summary
The facility failed to provide nursing staff on a 24-hour basis to meet the needs of residents, as evidenced by the absence of assigned Registered Nurses (RNs) on specific dates. During a review of the Payroll Based Journal (PBJ) report for Quarter 1, 2024, and Quarter 2, 2024, it was found that there were no RNs assigned on several infraction dates, including Sundays and other weekdays. This lack of staffing was confirmed during an interview with the facility Administrator, who acknowledged the absence of assigned RNs on the specified dates. This deficiency had the potential to result in residents not receiving necessary care.
Lack of Informed Consent for Xanax Administration
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of the medication Xanax for a resident. During an interview and record review with the Director of Nursing (DON), it was found that the physician's order for Xanax, prescribed as 0.25 mg every 8 hours as needed for anxiety and panic, lacked documentation of informed consent. The DON was unable to locate any consent form in the resident's chart that indicated the resident or their representative had been educated on the risks and benefits of Xanax. The facility's policy and procedures on informed consent for psychotherapeutic medications require the healthcare practitioner ordering such medication to obtain and document informed consent. However, this procedure was not followed, leading to the potential for the resident to be administered Xanax without being informed of its risks and benefits.
Failure to Provide Access to Recent Survey Results
Penalty
Summary
The facility failed to provide the most recent recertification survey results to residents, family members, and legal representatives. During an observation at the entrance check-in counter, it was found that the survey binder was missing the recertification survey results and plan of correction from the survey conducted in August 2022. The Director of Nursing (DON) was unaware of the August 2022 survey and confirmed that the most recent survey results in the binder were from July 2021. The Administrator (ADM) acknowledged that the August 2022 survey results were in his office and not in the survey binder accessible to residents. The facility's policy and procedure, dated April 2007, requires that the most recent survey results and plans of correction be maintained in a binder located in an area frequented by residents.
Failure to Develop Comprehensive Care Plans for Medications
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which was identified during a survey. For Resident 44, there was no care plan addressing the use of Xanax, a medication prescribed to control anxiety and panic attacks. During an interview and record review with the Director of Nursing (DON), it was confirmed that the care plan for behavior monitoring and continuous use of Xanax was missing from Resident 44's records. Similarly, Resident 17, who has a medical history of anemia and atrial fibrillation, was prescribed Apixaban, an anticoagulant medication. However, the facility did not develop a care plan for the use of this medication. During a review of Resident 17's clinical records, it was found that there was no documented care plan for the use of Apixaban, which was acknowledged by the DON. The facility's policy and procedures require the interdisciplinary team to develop comprehensive, person-centered care plans, but this was not adhered to in these cases.
Failure to Update Care Plan for Non-Compliant Resident
Penalty
Summary
The facility failed to ensure the timely revision and update of a comprehensive care plan for a resident, which resulted in an inaccurate care plan. The resident was observed with a pronounced foot drop and was non-compliant with the use of bilateral lower extremities splints, as they would remove and discard them. Despite this non-compliance, there was no documentation of the resident's refusal or non-compliance, and the information was only verbally communicated to the Rehab Director, who did not report it further. The care plan did not reflect the resident's current condition, including the need for off-loading the heels to prevent pressure ulcers, and the foot drop was not documented as a change of condition. The resident was supposed to receive 30 minutes of restorative nursing assistant (RNA) therapy, but records showed inconsistent therapy times, with several instances of reduced or no therapy provided. There was no documentation explaining the discrepancies in therapy duration or the resident's refusal. The facility's policy required comprehensive, person-centered care plans with measurable objectives, but the care plan for this resident was not updated to reflect their current needs and non-compliance, leading to a potential risk of inadequate care.
Medication Administration and Assessment Failures
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards for Resident 403. The resident had a doctor's order for Furosemide, a medication used to manage congestive heart failure, to be given twice daily at specific times. However, the medication was consistently administered late on multiple occasions throughout November 2024, with delays ranging from over an hour to more than five hours. There was no documentation explaining the reasons for these delays, and the Director of Nursing confirmed that the nurses involved were registry nurses. The facility's policy required medications to be administered within 60 minutes of the scheduled time, which was not adhered to. For Resident 50, the facility did not carry out a physician's order for laboratory tests. The resident, who had multiple diagnoses including hypertensive heart disease and chronic kidney disease, was supposed to have a CBC and CMP conducted due to symptoms of a swollen abdomen with tenderness. Despite a verbal order being received and documented, the tests were not performed, and no lab results were found. Both the Minimum Data Set coordinator and a licensed nurse confirmed the absence of lab results and the failure to execute the physician's order. Resident 34, who required regular dialysis due to end-stage renal disease, did not receive proper post-dialysis assessments. The facility's policy required vital signs and assessments of dialysis access sites to be completed after each dialysis session. However, records showed that these assessments were incomplete on several occasions. The Director of Nursing confirmed that the nursing staff did not fulfill the expected documentation requirements for post-dialysis care, leaving critical health assessments unrecorded.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper administration of medications for three residents, leading to potential deficiencies in pharmaceutical services. For one resident, Acetaminophen was administered incorrectly, with only 325 mg given instead of the prescribed 650 mg. This discrepancy was observed during a medication administration session. Another resident received Levothyroxine after breakfast, contrary to the recommended administration on an empty stomach, as per the drug reference handbook used by the facility. Additionally, a third resident did not receive Magnesium Oxide and Acamprosate as prescribed. The licensed nurse documented these medications as refused, citing reasons such as stomach upset and the resident's desire to discontinue Acamprosate. However, upon interview, the resident denied experiencing stomach issues or refusing the medications, indicating a discrepancy between the nurse's documentation and the resident's account.
Failure to Conduct Medication Regimen Review for Xanax
Penalty
Summary
The facility failed to ensure a Medication Regimen Review (MRR) was conducted for Xanax, a medication prescribed to control anxiety and panic attacks, for one of the sampled residents. The deficiency was identified during an interview and record review with the Director of Nursing (DON), where it was found that the resident had a physician's order for Xanax oral tablet 0.25 mg, dated 10/30/24. However, the MRR dated November 2024 did not include a review for the continued use of Xanax beyond 14 days. The DON confirmed the absence of a pharmacist review for Xanax. The facility's policy and procedure titled 'Consultant Pharmacist Services Provider Requirements' mandates that the medication regimen of each resident be reviewed at least monthly, or more frequently under certain conditions. It also requires communication of potential or actual problems detected, as well as recommendations for changes in medication therapy to the responsible prescriber and facility leadership. The failure to adhere to these guidelines resulted in the deficiency noted in the report.
Lack of Justification for Extended Use of Xanax
Penalty
Summary
The facility failed to ensure there was a practitioner's justification for the continued use of Xanax beyond 14 days for one of the sampled residents. During an interview and record review with the Director of Nursing (DON), it was found that Resident 44 had an order for Xanax 0.25 mg to be taken every 8 hours as needed for anxiety and panic. However, there was no documentation in the physician's progress notes justifying the need for the continuous use of Xanax beyond the 14-day limit. The DON acknowledged the absence of provider justification for the continued use of the drug beyond the specified period. The facility's policy and procedure on psychotropic medication use, dated July 2022, indicated that PRN orders for psychotropic medications are limited to 14 days. If the prescriber or attending physician believes it is appropriate to extend the order beyond 14 days, they must document the rationale for extending its use. This policy was not adhered to in the case of Resident 44, leading to the potential for the resident to receive an unnecessary medication and experience complications due to the medication.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 14.81 percent error rate during medication administration for three residents. For Resident 403, a licensed nurse administered only 325 mg of Acetaminophen instead of the prescribed 650 mg. For Resident 404, Levothyroxine was given after breakfast, contrary to guidelines that it should be taken on an empty stomach. For Resident 202, the nurse did not administer Magnesium Oxide and Acamprosate as ordered, citing the resident's refusal due to stomach upset, which the resident later denied.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during a survey. An opened one-liter bottle of 0.9% Sodium Chloride solution was found without an open date label, making it impossible to determine when it should be discarded. Additionally, temperature logs for medication refrigerators showed multiple instances of out-of-range temperatures without any documentation of corrective actions taken. A box of lemon glycerin swab sticks was improperly stored in a freezer, despite instructions indicating they should not be frozen. Furthermore, two plastic bags containing both labeled and unlabeled medications were found in the medication storage room sink, with no clear understanding of why they were there or what should be done with them. The survey also revealed an opened container of glucometer strips in a medication cart without an open date label, contrary to instructions that require discarding the strips 60 days after opening. These deficiencies were confirmed through interviews with licensed nurses, who acknowledged the issues but were unsure of the appropriate actions to take. The facility's policies and procedures for medication storage and disposal were reviewed, highlighting the lack of adherence to established guidelines, which could potentially lead to ineffective and unsafe medication administration.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a water management program to prevent the growth of Legionella and other waterborne pathogens in their water system. During an interview and record review, the Administrator and Director of Nursing admitted that the facility did not have a system in place to test and track for Legionella and other harmful pathogens. The facility's assessment did not address a water management program, and the Administrator confirmed that no water testing had been conducted to ensure the absence of Legionella or other pathogens in the water system. The facility's policy and procedure documents, dated September 2022, indicated that a water management program should be part of the infection control program, overseen by a water management team. However, these procedures were not followed, as evidenced by the lack of a water management program or team. The CDC guidelines encourage healthcare facilities to develop comprehensive water management programs to reduce the risk of Legionella growth and transmission, but the facility did not adhere to these guidelines, potentially exposing residents to harmful pathogens.
Facility Fails to Maintain Safe and Functional Environment for Residents
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for two residents. In one instance, a resident's bed was not in working order, making it difficult for the resident to feed themselves as the head of the bed could not be elevated. The maintenance supervisor was informed of the issue by a night shift CNA four days prior, but the bed had not been repaired, and the resident was not moved to an available functional bed. The maintenance supervisor indicated that the nursing department should have moved the resident to the other bed. In another instance, an extension cord with six sockets was found on a bedside table near a resident's head, and the bed control switch had a frayed wire within easy reach of the resident. Both the director of nursing and the maintenance supervisor confirmed these findings during an observation. The facility's policies and procedures require the maintenance department to ensure that equipment is maintained in a safe and operable manner, including routine inspections of residents' beds and their components for safe operating conditions.
Failure to Prevent Worsening of Pressure Injuries
Penalty
Summary
The facility failed to prevent the worsening of a Deep Tissue Injury (DTI) and the development of additional pressure injuries in a resident. The resident, who had a history of a right heel DTI, a spiral fracture of the right tibia, Type II Diabetes, and hemiplegia, was admitted with a brace on the right lower extremity. The brace, which was not to be modified or removed until a follow-up with an orthopedic surgeon, caused irritation and pressure ulcers on the heel and ankle. Despite an email from Central Coast Orthopedics allowing modification of the immobilizer, the facility did not act promptly, leading to the worsening of the initial DTI and the development of three additional wounds. The resident's wound assessments showed a progression from a single DTI on the right heel to additional wounds on the lateral, posterior, and medial right ankle. The facility's records indicated that the resident experienced significant pain and non-compliance with positioning due to the brace. The brace was eventually removed after it was found to be causing significant pressure and eschar formation on the resident's skin. Despite the worsening condition, the facility continued with the same treatment orders without revising the care plan in a timely manner. The Director of Nursing confirmed that the facility's policy and procedure for pressure injuries were not followed. The facility failed to evaluate the resident's clinical condition and risk factors adequately, implement appropriate interventions, monitor the impact of interventions, or revise interventions as needed. This lack of adherence to policy resulted in the resident's DTI worsening and the development of additional pressure injuries, leading to increased pain and an additional hospital stay.
Failure to Report Resident Fall with Injury
Penalty
Summary
The facility failed to comply with the state requirement of reporting unusual occurrences by not reporting a fall with injury to the Department for one of the sampled residents. The clinical record indicated that the resident sustained an unwitnessed fall from a wheelchair in the dining room, resulting in injuries that required emergency medical services and a transfer to the emergency room. During an interview, the Administrator stated that no report was filed because the former Administrator did not report the fall to the California Department of Public Health, as the patient did not return to the facility from the hospital and therefore was not given a diagnosis. The facility's policy and procedure on Unusual Occurrence Reporting required such incidents to be reported via telephone within twenty-four hours and a written report to be sent within forty-eight hours, which was not followed in this case.
Failure to Provide an Environment Free from Restraints
Penalty
Summary
The facility failed to provide an environment free from restraints for one of the sampled residents when all four side rails of the resident's bed were raised. The facility's policy and procedure on the use of restraints, dated April 2017, explicitly stated that practices preventing resident mobility, such as using bedrails to keep a resident from voluntarily getting out of bed, are considered restraints and are not permitted. Despite this policy, Resident 1's consent form dated July 30, 2019, indicated that the resident did not consent to the use of side rails. However, during an observation on March 21, 2024, Resident 1 was found in bed with all four side rails up. Interviews with facility staff revealed that the Certified Nursing Assistant (CNA) had raised all four side rails to prevent Resident 1 from getting out of bed due to the resident's history of falls. The Director of Nursing (DON) confirmed that staff should not use bed side rails to prevent residents from getting out of bed as they are considered restraints. The Administrator also acknowledged that having all four bed side rails up is considered a restraint and that Resident 1 should not have had the side rails up as the resident did not consent to their use.
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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