Shasta Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Weed, California.
- Location
- 445 Park Street, Weed, California 96094
- CMS Provider Number
- 055807
- Inspections on file
- 25
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Shasta Healthcare during CMS and state inspections, most recent first.
A resident who was admitted without a pressure injury developed a sacral PI that worsened from Stage 2 to Stage 4 with infection due to staff failing to notify the attending physician of changes, delaying treatment, and performing wound debridement without physician orders. The lack of timely communication and adherence to wound care protocols led to the resident's hospitalization for an infected PI, sepsis, and osteomyelitis, and the resident later died in the hospital.
A resident with a sacrum fracture and Stage 4 pressure injury left AMA to a location three hours away without a physician's order, proper documentation, or discussion of risks and alternatives. The facility did not offer an AMA form, failed to notify the physician or APS, and did not document or discuss safer discharge options. The resident was hospitalized with an infection shortly after leaving.
A resident developed a pressure injury that progressed from Stage 2 to Stage 4 with infection, but the care plan was not updated to reflect these changes or necessary interventions. Despite facility policy requiring care plan revisions after significant changes in condition, the care plan remained outdated, leading to inconsistent and delayed treatment.
Nursing staff did not notify the physician when a resident's sacral pressure injury worsened and performed conservative sharp wound debridement without a physician's order. The wound progressed from Stage 2 to unstageable and then to Stage 4 with infection, and the resident was later hospitalized for sepsis and osteomyelitis. These actions were not in accordance with facility policy or state regulations.
A resident with multiple medical conditions, who was cognitively intact, was subjected to verbal abuse when a CNA admitted to using inappropriate language out of frustration. The incident was reported to the DON, who confirmed the staff member's admission and the facility's policy requiring respectful treatment of residents.
The facility failed to implement its Legionella Water Management Program, with no recent water testing conducted. Additionally, an LVN did not follow hand hygiene and medication handling protocols, handling medications with bare hands and administering pills that fell on the cart to a resident with a history of hypertension and anxiety.
A facility failed to secure a computer screen on a medication cart, leaving residents' PHI visible. The nurse responsible was not present, and the cart was unattended. Staff interviews confirmed the policy to lock screens, but it was not followed, resulting in a breach of confidentiality.
The facility failed to prepare for a scheduled EMR outage, resulting in the inability to access MARs, TARs, and Physician's Orders for 41 residents. Nursing staff could not administer medications or treatments, leading to residents missing critical medications. The administration admitted to not having a backup system or policy for such outages, and outdated paper charts compounded the issue.
A resident with dementia and a history of wandering was not properly assessed or monitored for elopement risks in an LTC facility. Despite multiple elopements, including one where the resident was found injured near a highway, the facility lacked a formal system to monitor at-risk residents. The alarm system was inadequate, and staff failed to provide consistent supervision, contributing to the resident's repeated elopements.
Failure to Prevent and Manage Pressure Injury Progression
Penalty
Summary
A resident was admitted to the facility without a pressure injury (PI) and subsequently developed a PI on the sacrum during their stay. The PI was first identified as a Stage 2 injury, but over the course of 18 days, it progressively worsened to an unstageable PI and then to a Stage 4 PI with signs of infection. Throughout this period, nursing staff, including the wound care nurse (WCN/RN) and a registered nurse (RN A), failed to notify the resident's attending physician (AP) of the changes in the PI's condition, despite facility policy requiring physician notification for significant changes in a resident's condition. Documentation showed that the AP was not informed of the PI's worsening status until six days after it was first identified as a Stage 2 injury, by which time the injury had already deteriorated further. The WCN/RN performed a conservative sharp wound debridement (CSWD) on the resident's PI without obtaining a physician's order, and there was no documentation that the AP was notified about the procedure or the continued deterioration of the wound. Interviews with staff confirmed that the AP was not kept informed of the PI's progression or the lack of healing, and the AP stated that if they had been aware of the worsening condition, they would have referred the resident to a wound care physician. The AP also confirmed that no specific orders were given for the CSWD procedure. The facility's documentation and staff interviews revealed a breakdown in communication and failure to follow established policies regarding notification and wound care management. Two days after discharge from the facility, the resident was admitted to an acute care hospital with an infected PI, sepsis, and osteomyelitis of the sacrum. Hospital records indicated that the resident's family sought hospital care due to the non-healing and foul-smelling wound. The resident passed away at the hospital ten days later. The failure to provide timely and appropriate wound care, notify the physician of significant changes, and obtain necessary orders for wound procedures directly contributed to the resident's worsened condition and subsequent hospitalization.
Failure to Ensure Safe Discharge for Resident Leaving Against Medical Advice
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who left against medical advice (AMA). The resident, who had a sacrum fracture and a Stage 4 pressure injury, left the facility with family members to a location three hours away, rather than returning to her home in a nearby town as documented. There was no physician's order for the discharge, and the medical director was not notified of the resident's departure. The discharge summary inaccurately stated the resident's destination, and the facility did not complete or offer an AMA form to the resident or her family. There was no documentation of any discussion with the resident or her family regarding the risks and implications of leaving the facility AMA or the suitability of the discharge location. The facility also failed to document any discussion of alternative, more appropriate discharge options, nor did they record that such options were offered and refused. Interviews with family members confirmed that no alternatives or consequences were explained to them prior to the resident's departure. Additionally, the facility did not conduct an investigation or determine if a referral to Adult Protective Services (APS) was necessary, as required by their policy when a resident is discharged to a potentially unsafe setting. Staff interviews confirmed that these steps were not taken, and the director of nursing acknowledged that the required notifications and documentation were not completed. The resident was admitted to an acute care hospital within two days of leaving the facility with an infection.
Failure to Update Care Plan Following Worsening Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated in response to significant changes in the resident's condition, specifically the worsening of a pressure injury (PI) to the sacrum. The resident was admitted without any pressure injuries and was cognitively intact. Initial assessments and documentation showed no PIs, but subsequent records indicated the development of a Stage 2 PI, which progressed to an unstageable PI and then to a Stage 4 PI with signs of infection, including eschar and slough. Despite these changes, the care plan was not updated in a timely manner to reflect the resident's current status, treatments, or interventions. Interviews and record reviews confirmed that the care plan had not been revised after the initial update, even as the PI worsened. The Wound Care Nurse and the Director of Nursing both acknowledged that the care plan did not reflect the resident's deteriorating condition or the necessary interventions. Facility policy required care plans to be reviewed and revised when there was a significant change in a resident's condition, but this was not followed, resulting in inconsistencies and delays in treatment for the resident's pressure injury.
Failure to Notify Physician and Obtain Orders for Wound Care Procedures
Penalty
Summary
Nursing staff failed to demonstrate competency in wound care management and in responding to changes in a resident's condition, as required by facility policy and state regulations. Specifically, a registered nurse and the wound care nurse did not notify the attending physician when a resident's sacral pressure injury worsened from Stage 2 to an unstageable wound, and later showed signs of infection. Documentation and interviews confirmed that the physician was not informed of these significant changes in the resident's condition, despite facility policy requiring such notification for significant changes. Additionally, the wound care nurse performed conservative sharp wound debridement (CSWD), an invasive procedure, on the resident's unstageable pressure injury without obtaining a physician's order. Both the wound care nurse and the director of nursing stated that they believed a physician's order was not necessary for this procedure, contrary to state regulations and facility policy, which require treatments to be administered only on the order of an authorized person. There was also no evidence that the physician was notified of the worsening wound or the procedure performed. The resident, who had been admitted with a sacrum fracture and was cognitively intact, developed a pressure injury during her stay that progressed in severity without appropriate physician notification or intervention. Within two days of leaving the facility, the resident was hospitalized for sepsis and osteomyelitis of the sacrum, conditions secondary to the infected pressure injury. These failures resulted in a delay in treatment and contributed to the worsening of the resident's wound.
Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) verbally abused a resident by using inappropriate language. The resident, who was cognitively intact and had diagnoses including diverticulitis, type 2 diabetes, depression, and complications of a colostomy, reported to the Director of Nursing (DON) that the CNA had cursed at her. The incident was documented in the resident's progress notes, and the resident expressed reluctance to discuss the matter further. An internal investigation was conducted, during which the CNA admitted to being frustrated with the resident and confirmed that she used the term 'bulls**t' when speaking to her. The facility's abuse prevention policy explicitly states that residents have the right to be free from abuse and that staff are expected to treat residents with respect. The DON confirmed the CNA's admission and acknowledged the expectation for respectful treatment of residents.
Deficiencies in Water Management and Medication Handling
Penalty
Summary
The facility failed to implement its Legionella Water Management Program as outlined in its policy. The Maintenance Director, who had been employed for a year, confirmed that he had not tested the water for Legionella, and the Director of Nursing was unable to find records of the last water testing. The Administrator admitted that the facility had changed maintenance staff and that Legionella testing was not included in their orientation, leading to uncertainty about when the last test was conducted. This oversight in water management had the potential to affect all residents in the facility. Additionally, the facility did not adhere to its hand hygiene and medication handling policies during medication administration. An LVN failed to wash or sanitize her hands before preparing medications for a resident with a medical history of hypertension, atrial fibrillation, angina, and anxiety disorder. The LVN handled medications with bare hands and administered pills that had fallen on the medication cart. Interviews with staff, including another LVN, the Infection Preventionist, and the DON, confirmed that the facility's protocols required hand hygiene and proper handling of medications, which were not followed in this instance.
Failure to Secure Medication Cart Computer Screen
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information (PHI) by not securing a computer screen on a medication cart. During an observation, the surveyor noted that the computer on the medication cart was left unlocked, displaying Resident #28's list of medications and other residents' PHI. The nurse responsible for the medication cart was not present, and the cart was left unattended and out of the nurse's visual field. The nurse was later found in the dining room and acknowledged that she could not see the medication cart from her location and would have another staff member lock the screen. Interviews with staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), the Director of Nursing (DON), and the Administrator, confirmed that the facility's policy required computer screens on medication carts to be locked when not in use or out of the nurse's view. The staff had been educated on this policy to protect residents' PHI. However, the failure to lock the computer screen on the medication cart resulted in a breach of confidentiality, as sensitive information was left visible and accessible to unauthorized individuals.
Failure to Prepare for EMR Outage Leads to Medication and Treatment Lapses
Penalty
Summary
The facility failed to ensure an alternative system was in place for accessing resident Medication Administration Records (MARs), Treatment Administration Records (TARs), and Physician's Orders during a scheduled Electronic Medical Record (EMR) system outage. The EMR system administrator had notified the facility of a planned outage, but the facility did not take any preparatory actions. As a result, the nursing staff was unable to administer medications or perform treatments for all 41 residents, as they had no access to the current physician's orders. Interviews with residents revealed that they did not receive their medications during the outage. One resident expressed anxiety over not receiving heart medications, while another was concerned about constipation due to missed stool softeners. A third resident experienced pain from untreated gout. Nursing staff confirmed the inability to access current MARs, TARs, and Physician's Orders, and the facility's paper charts contained outdated information from April 2024. The facility's administration acknowledged the lack of a backup system and the absence of a policy for EMR outages. The Director of Nursing Services admitted to not reading EMR outage warnings and failing to print current Physician's Orders for several months. The Business Office Manager noted that EMR outage alerts were ignored, as previous outages were brief. The Medical Director and Pharmacist were informed of the outage but indicated that medication card labels were not reliable for administering medications.
Inadequate Monitoring and Assessment of Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure adequate assessment and monitoring of a resident at risk for unsafe wandering and elopement. Resident 1, who had a history of dementia, anxiety disorder, and other medical conditions, was not assessed for wandering or elopement risks upon admission. Despite exhibiting wandering behavior, no care plan was developed to address these risks. The facility's policy required such assessments and care plans, but these were not implemented for Resident 1. Resident 1 eloped from the facility on multiple occasions. On one occasion, she was found by police in a ditch near a highway with injuries, including a scratched face and bruised chin. The facility's alarm system was inadequate, as it did not differentiate between residents, staff, or visitors, and the alarm sound was low due to needing new batteries. Staff interviews revealed that there was no formal system to monitor residents at risk of elopement, and the existing alarm system was insufficient to alert staff effectively. The facility's staff, including the DON and CNAs, acknowledged the lack of proper monitoring and supervision for Resident 1. Despite being aware of the resident's elopement risk, the facility did not implement consistent one-to-one supervision or use tracking devices as indicated in the care plan. The facility's failure to develop and implement appropriate interventions and monitoring systems contributed to Resident 1's repeated elopements and subsequent injuries.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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