Sherwood Oaks Post Acute Care, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Bragg, California.
- Location
- 130 Dana Street, Fort Bragg, California 95437
- CMS Provider Number
- 056483
- Inspections on file
- 28
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sherwood Oaks Post Acute Care, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep the kitchen clean and sanitary for 31 residents, with dried liquids and food debris on floors under and around refrigerators and a stove, and a dust-covered fan blowing onto clean utensils in the dish room. The Dietary Manager acknowledged the floors did not meet cleanliness expectations and could attract pests and cause illness, but could not state when the floors were last cleaned. The kitchen cleaning log listed various equipment-cleaning tasks for dietary staff but did not include floor cleaning, and a staff member reported that floor cleaning was not her job, that the floors were not cleaned the previous night, and she did not know who was responsible, despite a facility policy requiring kitchen floors to be mopped at least once daily.
A resident at high risk for falls, with multiple medical conditions and cognitive impairment, fell and sustained a hip fracture due to inadequate supervision and preventive measures. The resident's care plan required staff assistance for transfers and close observation, but these were not effectively implemented. Contributing factors included the discontinuation of medication managing hallucinations and the family's decision to stop overnight supervision, leaving the resident without necessary support.
A resident with severe cognitive impairment was not protected from abuse when another resident with moderate cognitive impairment placed the first resident's hand on her genital area without consent. The incident was observed by a nurse who intervened, but the affected resident experienced emotional distress. The facility failed to document and monitor the situation adequately, and care plans were not updated as required.
A facility failed to submit a written report of an abuse investigation within 5 working days after an incident involving two residents with cognitive impairments. One resident attempted inappropriate contact with another, which was immediately addressed by staff. However, due to a lack of awareness of reporting requirements, the necessary documentation was not sent to the Department on time.
A resident with severe dementia and aggressive behaviors hit another resident on the thigh, causing pain. Despite having a care plan to manage her behavior, the resident was seated near another resident, leading to the incident. Staff intervened after the event, but the facility failed to prevent the abuse as per their policy.
The facility failed to immediately report an alleged abuse incident where a resident hit another resident. The incident was reported to the Department the following day, contrary to the requirement to report within two hours. The facility's abuse prevention policy lacked a specific reporting timeframe, and the DON was unaware of the two-hour reporting requirement.
The facility failed to have a dedicated full-time DON, with the current DON also serving as MDS coordinator and floor nurse. This compromised oversight and resident care, as the DON was responsible for medication administration and other duties. Interviews and record reviews showed the DON's extensive workload, with no active efforts to fill the vacant DON role since 2022.
The facility did not submit required PBJ data to CMS for the first quarter of 2024. The Administrator Assistant was unaware of the submission process, and the Director of Nursing was unfamiliar with PBJ reporting. The facility lacked a policy for PBJ reporting, and the Administrator could not confirm submission of the data.
The QAPI program at an LTC facility failed to identify several deficiencies, including a resident self-administering medications without assessment, missing narcotics not being investigated, and inadequate protocols for residents who are hard of hearing. Additionally, oral care was inconsistent, staffing requirements were not met, and significant weight changes in a resident were not reported. There was also a lack of staff training on care planning and infection control practices were inadequate.
The facility failed to identify and address multiple instances of abuse and neglect, including withholding food from a resident, neglecting to change soiled briefs, and verbal abuse by a staff member. Despite reports and observations of inappropriate behavior, the administration did not recognize these actions as abuse, creating an environment where residents' rights were violated and they were fearful of reporting further issues.
The facility failed to report multiple instances of abuse by an unlicensed staff member, who exhibited inappropriate behavior towards residents. Despite documented disciplinary actions, the Administrator did not notify the Department, creating an environment where residents were fearful of reporting negative behaviors. Interviews revealed that the staff member yelled at residents and acted unprofessionally, but the Administrator considered these incidents as personnel matters rather than abuse.
The facility failed to notify the Office of the State LTC Ombudsman about the discharge or transfer of four residents, including one discharged to home and three transferred to acute care facilities. The Social Services Assistant and Administrator showed confusion and lack of clarity regarding the notification process, and the facility's policies were outdated, leading to non-compliance with federal regulations.
The facility failed to ensure timely and collaborative completion of basic care plans (BCP) for residents, with the Director of Nursing (DON) being the sole individual involved in the process. The Interdisciplinary Team (IDT) did not review or implement the BCPs to meet residents' immediate care needs, and residents or their responsible parties were not involved or provided with BCP summaries. This lack of involvement and communication could compromise resident safety and care quality.
A resident with moderately impaired cognition did not receive regular oral care, as required by the facility's policy. Observations showed a buildup of material on the resident's tongue, and documentation confirmed that oral care was not provided after meals. Staff interviews verified the lack of oral care, which was not documented or performed consistently.
A resident experienced significant weight changes that were not reported to the physician or RD, contrary to facility policy. The resident, with severe cognitive impairment and dependency on staff for eating, lost 12.8 pounds and later gained 17.8 pounds over several months. Despite the facility's policy requiring re-weighing and reporting of such changes, these actions were not taken, posing potential health risks.
The facility failed to provide adequate staffing, leading to long wait times for residents needing assistance. Residents reported feeling scared and frustrated due to delayed responses to call lights. The facility did not meet the required DHPPD and CNA hours for most days in April and several days in May, impacting the quality of care. Staff acknowledged the short staffing and its potential risks, including delayed care and increased falls.
The facility failed to ensure staff competency in Baseline Care Plans (BCP) and Trauma Informed Care (TIC), as revealed through staff interviews. Key personnel, including the Director of Staff Development and various licensed and unlicensed staff, were unaware of BCP requirements and TIC principles. The facility's competency checklists and in-service training did not cover these areas, potentially compromising resident care and safety.
The facility failed to post nurse staffing information in a visible and accessible location, keeping it in a binder behind the nursing station counter. The staffing information was incomplete, lacking NHPPD data and signatures from the DON. Staff interviews revealed a lack of awareness about the requirement for visible posting and daily NHPPD calculations.
The facility failed to securely store discontinued controlled medications, leading to missing narcotics and unauthorized access. Additionally, medication labeling did not match doctor's orders, and a resident was allowed to self-administer OTC medications without proper assessment or physician's order, posing safety risks.
The facility failed to provide palatable food, as residents reported issues with taste, texture, and temperature. Observations confirmed mushy vegetables and tough meat, leading to potential nutritional problems if residents declined meals.
The facility failed to maintain proper infection control and hygiene practices. Clean linens were transported uncovered, exposing them to contamination. Staff did not consistently perform or offer hand hygiene before and after meals, risking cross-contamination. Additionally, urinals with urine were improperly managed, affecting infection control and resident dignity.
A facility failed to coordinate a Level II PASARR for a resident with mental illness after a positive Level I PASARR result, leading to a delay in necessary medical evaluation and care. The oversight involved not adhering to federal requirements to ensure proper placement and care planning for individuals with mental disorders.
A resident in a LTC facility was not assisted with using his CPAP machine every night, as staff failed to help him with the mask due to his hand dexterity issues. The resident's room setup made it difficult for him to access the CPAP, and a planned room transfer had not occurred. Additionally, there was no physician order specifying the CPAP settings, and a no smoking sign was missing from the resident's room, contrary to facility policy.
A resident with intact cognition and multiple diagnoses, including diabetes and muscle weakness, was not provided access to necessary hearing services. Despite requests, no audiologist referral was made, and hearing aids were not checked, leading to communication difficulties. Staff interviews revealed a lack of protocol for addressing hearing impairments, contributing to the oversight.
A resident with Multiple Sclerosis and contractures in both ankles did not receive the ordered ROM exercises due to the absence of a Restorative Nursing Assistant (RNA) for about two months. The facility's Restorative Nursing Program requires daily services to maintain patients' function, but interviews confirmed that no ROM exercises were conducted, potentially worsening the resident's condition.
Unsanitary Kitchen Conditions and Inadequate Floor-Cleaning Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a clean and sanitary condition for a census of 31 residents. During a kitchen observation, surveyors noted dried liquids on the floor in front of the refrigerator and visible food crumbs and dried food debris under the refrigerators, stove, and along the baseboards, with debris extending along the wall-floor seam into multiple areas. In the dish room, a fan with a buildup of dark-colored dust was observed blowing directly onto clean utensils and other clean dishes on the clean side of the dishwasher deck. The Dietary Manager, when shown the debris under the refrigerators and stove, stated that evening staff were supposed to clean the floor but was unable to say when the floor was last cleaned and acknowledged the floor did not meet his expectations of cleanliness. The Infection Preventionist also acknowledged the visibly soiled floors and observed the fan blowing toward clean utensils. A review of the kitchen cleaning assignment and log for the month showed daily cleaning tasks for morning and evening cooks and a dietary aide, including cleaning equipment such as the coffee machine, refrigerators, microwave, housekeeping closet, utility carts, trash cans, and stove, but did not list cleaning the kitchen floors. During an interview, a staff member stated that cleaning the floors was not her job and confirmed the floors were not cleaned the previous night, and she could not identify who was responsible for regular floor cleaning. The facility’s policy titled “General Cleaning of Food & Nutrition Services Department,” dated 2023, required that kitchen floors be mopped at least once per day and described the correct sweeping and mopping procedure. The Dietary Manager stated that floors that were not clean and sanitary could attract pests and cause illness to residents.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to prevent an avoidable fall for Resident 3, who was assessed as high risk for falls. Resident 3 was found on the floor by the bathroom after attempting to transfer and ambulate without staff assistance and supervision. This incident resulted in Resident 3 sustaining a left femoral neck fracture, requiring surgical repair. The deficiency was identified through interviews and record reviews, highlighting the lack of adequate supervision and preventive measures for a resident with known fall risks. Resident 3 was admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, schizoaffective disorder, heart failure, and diabetes. The Minimum Data Set indicated that Resident 3 was moderately cognitively impaired and required one-person staff assistance for toileting and mobility. Despite being identified as a high fall risk, the facility's interventions, such as keeping the bed in the lowest position and using fracture mats, were insufficient to prevent the fall. The resident's care plan included staff assistance for transfers and close observation for unsafe actions, but these measures were not effectively implemented. Several factors contributed to the fall, including the discontinuation of Seroquel, which managed Resident 3's hallucinations and delusions, and the family's decision to stop providing overnight supervision. The Director of Nursing acknowledged that Resident 3 had a history of climbing out of bed and was moved closer to the nurse's station after the family ceased their overnight presence. However, the facility did not provide a one-to-one sitter due to staffing limitations, leaving Resident 3 without the necessary supervision to prevent the fall.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident placed the first resident's hand on her genital area without consent. This incident involved two residents, both with cognitive impairments. The first resident, who was admitted with severe cognitive impairment due to dementia and other medical conditions, was seated in a hallway when the second resident, who also had dementia and moderate cognitive impairment, engaged in inappropriate behavior. The incident was observed by a licensed nurse who intervened immediately to separate the residents. Despite the intervention, the first resident experienced emotional distress, as evidenced by tears in his eyes. The facility's documentation revealed that the first resident had a BIMS score indicating severe cognitive impairment, while the second resident had a BIMS score indicating moderate cognitive impairment. The second resident's care plan included interventions to prevent inappropriate sexual touching, but these measures were not effectively implemented at the time of the incident. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, revealed that there was a lack of documentation and monitoring for emotional distress and behaviors following the incident. The facility's policies and procedures for abuse prevention, investigation, and documentation were not adequately followed, contributing to the deficiency. The Director of Nursing acknowledged that a care plan for the first resident should have been created following the incident, but it was not, highlighting a gap in the facility's response to the event.
Failure to Timely Report Abuse Investigation
Penalty
Summary
The facility failed to provide a written report of the results of an abuse investigation to the Department within 5 working days following an incident involving two residents. Resident 1, who was admitted with severe cognitive impairment and other medical conditions, was involved in an incident where Resident 2, who also had cognitive impairments, attempted to place Resident 1's hand on her genital area. This incident was observed by a licensed nurse who intervened immediately. Resident 1, who has dementia and severe cognitive impairment, was unable to recall the incident when questioned. Similarly, Resident 2, who has moderate cognitive impairment, did not remember the incident and showed no distress when interviewed. Despite the immediate separation of the residents and notification of relevant parties, the facility did not submit the required investigation report to the Department within the stipulated timeframe. The Director of Staff Development, acting as the licensed nurse during the incident, and the Social Services Director, who completed the investigation report, were both unaware of the requirement to submit the report within 5 working days. This lack of awareness led to the failure to comply with the facility's policy and procedure on abuse investigations, which mandates timely reporting to the state survey and certification agency.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when Resident 1, who had severe memory issues and exhibited aggressive behaviors, hit Resident 2 on the thigh with her fist. Resident 1's medical records indicated she had severe dementia with agitation and was on antipsychotic medication. Her care plan included interventions to manage her aggressive behavior, such as redirecting her away from others and ensuring she was not in a position to strike other residents. Despite these measures, Resident 1 was seated near Resident 2 in the hallway, leading to the incident where she struck Resident 2 after a verbal exchange. Resident 2, who also had severe cognitive impairments and was easily distracted, was seated in her wheelchair near Resident 1. During the incident, Resident 1 verbally engaged Resident 2 and, upon not receiving a response, hit her, causing Resident 2 to express pain. Unlicensed Staff A witnessed the event and intervened by telling Resident 1 not to hit others and taking her back to her room. The facility's policy aimed to maintain an abuse-free environment by assessing and addressing behavior problems, but this incident indicates a failure to implement these measures effectively.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged resident abuse incident immediately, which involved a resident hitting another resident who was sitting nearby. The incident occurred on 11/10/24 at 4:18 p.m., but the report was not sent to the Department until 11/11/24 at 4:52 p.m. and received on 11/12/24 at 8:00 a.m. During a review of records and an interview on 12/23/24, it was found that the facility's abuse prevention policy did not specify a timeframe for reporting suspected abuse incidents. The Director of Nursing (DON) was unaware of the requirement to report alleged abuse incidents within two hours after the allegation is made, as informed by the Department. The facility's policy stated that all suspected violations of abuse should be immediately reported to appropriate state agencies as required by law.
Lack of Dedicated Full-Time Director of Nursing
Penalty
Summary
The facility failed to have a dedicated full-time Director of Nursing (DON), which is a requirement for ensuring proper oversight and management of nursing staff and resident care. The current DON was also fulfilling multiple roles, including that of the MDS coordinator and a floor nurse responsible for administering medications. This multi-faceted role compromised the ability to provide dedicated oversight as a full-time DON, potentially putting residents at risk. Interviews with the DON and the Director of Staff Development (DSD) revealed that the DON was responsible for passing medications to residents every weekday, in addition to handling pharmacy-related tasks, admissions, and discharges. The DON had been in this position since 2022, with no active efforts observed to fill the vacant DON role. The DSD occasionally assisted with medication administration to allow the DON to focus on other duties, but the workload remained overwhelming. A review of multiple residents' MDS records and Medication Administration Records showed that the DON was consistently involved in medication administration and MDS documentation over an extended period. This included administering medications to several residents on numerous days each month, further highlighting the extensive responsibilities shouldered by the DON. The facility was unable to provide a policy on the DON job description, indicating a lack of formal guidance for the role.
Failure to Submit PBJ Data to CMS
Penalty
Summary
The facility failed to electronically submit Payroll Based Journal (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) as required every quarter. The Certification and Survey Provider Enhanced Reporting system (CASPER) report indicated that there was no staffing information submitted for the first quarter of 2024. During interviews, the Administrator Assistant (AA) admitted to not knowing how to submit the PBJ report and mentioned that another staff member from a sister facility was responsible for submitting the facility's PBJ information. The Administrator confirmed that PBJ staffing information should be reported quarterly but was unable to provide evidence that the information was submitted for the first quarter. Additionally, the facility lacked a policy for PBJ reporting, and the Director of Nursing (DON) was unaware of PBJ reporting requirements. The AA acknowledged the importance of PBJ reporting for monitoring nursing hours but did not understand the implications of failing to report to CMS timely.
QAPI Program Fails to Identify Multiple Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Program (QAPI) failed to identify several quality deficiencies. One resident was found to be self-administering and storing medications in his room without a self-administration assessment or physician notification. Additionally, there was a lack of management oversight regarding missing narcotics, which were not investigated or reported to the appropriate agencies until discovered by a surveyor. The facility also lacked protocols for addressing residents who were hard of hearing, as evidenced by a resident who had not been referred to an audiologist. Oral care was not consistently provided, with one resident found to have poor oral hygiene. The facility failed to meet the required direct care staffing hours for several days, and there was no Restorative Nursing Assistant program for over two months. Significant weight fluctuations in a resident were not properly monitored or reported to the physician or dietitian. Furthermore, there was a lack of staff training on baseline care planning and trauma-informed care, and the interdisciplinary team did not collaborate effectively on care plans. Hand hygiene protocols were not followed, and infection control practices were inadequate, as evidenced by improper handling of residents' urinals. These deficiencies were not discussed in the QAPI meetings, preventing the committee from addressing and developing corrective plans.
Failure to Identify and Address Abuse and Neglect
Penalty
Summary
The facility failed to identify and address multiple instances of abuse and neglect involving residents. One incident involved an unlicensed staff member withholding food from a resident due to the resident's behavior. Another incident involved staff neglecting to change soiled briefs, resulting in skin breakdown for an unidentified resident. Additionally, a staff member verbally abused a resident, identified as Resident 19, by yelling at them in a hostile and angry tone. Interviews with various staff members and a complainant revealed a culture of fear and intimidation within the facility. The complainant indicated that residents and staff were reluctant to report issues due to fear of retaliation and the potential closure of the facility. High staff turnover and a lack of advocacy for residents were also noted. Despite multiple reports and observations of inappropriate behavior by Unlicensed Staff C, including yelling at residents and neglecting their care, the facility's administration did not recognize these actions as abuse or neglect. The facility's policy on reporting abuse was not effectively implemented, as evidenced by the failure to address the reported incidents. The Administrator and other staff members, including the DON and DSD, were aware of the issues but did not take appropriate action to protect the residents. The Administrator's investigation concluded that the incidents were personnel matters rather than abuse, despite evidence to the contrary. This lack of action and failure to recognize abuse created an environment where residents' rights were violated, and they were fearful of reporting further abusive behaviors.
Failure to Report Abuse by Unlicensed Staff
Penalty
Summary
The facility failed to identify and report three instances of abuse involving an unlicensed staff member, referred to as Unlicensed Staff C, who exhibited inappropriate behavior towards residents. Despite documented disciplinary actions on specific dates, the Administrator did not notify the Department of these incidents. This failure to report created an environment where residents' rights were violated, and they were fearful of reporting negative behaviors due to potential retaliation. Interviews and record reviews revealed multiple instances of misconduct by Unlicensed Staff C. A complainant reported that there were ongoing issues between staff and residents, with a specific incident occurring around late January. Resident 87, who had no cognitive impairment, was aware of staff incidents but chose not to discuss them. Unlicensed Staff A overheard Unlicensed Staff C yelling at a resident, and Licensed Staff B reported that Unlicensed Staff C's behavior was unprofessional and disrespectful towards residents and visitors. Despite these reports, the Administrator did not consider these actions as abuse or neglect. The facility's policy on reporting abuse was not followed, as the Administrator failed to report the incidents to the appropriate authorities. The policy clearly defines verbal and mental abuse and mandates immediate reporting of any suspected abuse. However, the Administrator deemed the incidents as personnel matters rather than abuse, leading to a lack of proper investigation and reporting. This oversight resulted in a failure to protect residents from potential harm and maintain a safe environment.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman regarding the discharge or transfer of four residents, which is a requirement to ensure residents are informed of their rights and options. Specifically, Resident 85 was discharged to home, while Residents 86, 87, and 88 were transferred to acute care facilities. The Social Services Assistant (SSA) expressed confusion about which discharges required notification to the Ombudsman, indicating a lack of clarity in the facility's procedures. The Administrator also failed to ensure proper notification, particularly in cases where residents were transferred to a higher level of care, such as Resident 86, who was transferred and returned on different dates without Ombudsman notification. The facility's policy and procedure documents were outdated and did not clearly indicate the requirement to notify the Ombudsman office. The Administrator acknowledged the oversight and mentioned that weekend discharges and transfers to higher levels of care posed challenges due to limited staff availability. The report highlights that the facility's current practices and policies did not align with federal regulations, as evidenced by the outdated reference tag in their policy documents. This lack of compliance with notification requirements potentially deprived residents of advocacy and information about their rights during transfers and discharges.
Deficiencies in Timely and Collaborative Care Planning
Penalty
Summary
The facility failed to ensure timely completion of basic care plans (BCP) for residents, which are essential for promoting continuity of care and communication among staff to enhance resident safety. Specifically, the BCPs were not completed in a timely manner for one out of four sampled residents, and the Interdisciplinary Team (IDT) did not review the physician's orders or implement the BCP to meet the residents' immediate care needs for all four sampled residents. This lack of timely and collaborative care planning had the potential to compromise resident safety and the quality of care provided. The report highlights that the Director of Nursing (DON) was the sole individual involved in completing the BCPs for the residents, without the collaboration of the IDT, which includes various healthcare professionals. Additionally, the residents or their responsible parties were not involved in the development of the BCPs, nor were they provided with a summary of the BCPs. This lack of involvement and communication could lead to residents not receiving the necessary care tailored to their specific needs and conditions. The report provides specific examples of residents affected by these deficiencies. For instance, one resident with severe cognitive impairment and dependency on staff for eating had a BCP completed late and without IDT collaboration. Another resident, who required maximum assistance with activities of daily living, also had a BCP completed solely by the DON, without input from the IDT or the resident's responsible party. These failures in care planning processes were confirmed through interviews with facility staff, who acknowledged the importance of IDT involvement and the provision of BCP summaries to residents and their representatives.
Failure to Provide Regular Oral Care
Penalty
Summary
The facility failed to ensure regular oral care for Resident 31, who was dependent on staff for oral hygiene due to moderately impaired cognition. Observations revealed a buildup of whitish yellowish material on Resident 31's tongue, indicating a lack of oral care. Interviews with the Director of Staff Development (DSD) and other staff confirmed that oral care was not documented or provided after meals, as required by the facility's policy. The absence of oral care documentation suggested that the care was not performed, which was verified by multiple staff members. Resident 31's point of care documentation from early May to late May showed that oral care was not provided after breakfast. The Director of Nursing (DON) confirmed that oral care should be performed every shift, but the documentation indicated otherwise. The facility's policy on Activities of Daily Living (ADL) required appropriate support and assistance with hygiene for residents unable to perform ADLs independently, which was not adhered to in this case.
Failure to Report Significant Weight Changes
Penalty
Summary
The facility failed to report significant weight changes of a resident to the physician and Registered Dietician (RD), which is a deficiency in maintaining the resident's health. Resident 6 experienced a weight loss of 12.8 pounds or 7.6% between April and May 2023, and a weight gain of 17.8 pounds or 11.5% between May and September 2023. These changes were not communicated to the physician or RD, which could have put the resident at risk for adverse health outcomes. The Director of Nursing (DON) acknowledged the lack of notification and the absence of documentation for re-weighing the resident to confirm the weight changes. Resident 6, who was admitted with diagnoses including Parkinsonism, feeding difficulties, and muscle weakness, was dependent on staff assistance during meals. The Minimum Data Sheet Assessment indicated severely impaired cognition. Despite the facility's policy requiring weight changes of 5% or more to be rechecked and reported, the significant weight changes were not addressed promptly. Interviews with the DON, Administrator, and licensed staff confirmed the oversight and the potential health risks associated with unreported weight changes. The facility's policy on weight assessment and intervention, revised in 2008, outlines the need for multidisciplinary care planning involving the physician, nursing staff, and dietician for significant weight changes. However, the policy was not followed in this case, as evidenced by the lack of immediate re-weighing and notification to the physician and RD. The Administrator and staff interviews highlighted the importance of reporting such changes to prevent health risks, yet the necessary actions were not taken for Resident 6.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by complaints from six sampled residents and a review of staffing records. Residents reported long wait times for assistance, with some waiting up to an hour for staff to respond to call lights. The facility did not meet the required direct care service hours per patient per day (DHPPD) and Certified Nursing Assistant (CNA) hours for the majority of days in April and several days in May 2024. This shortfall in staffing led to residents feeling scared and frustrated, fearing that no one would be available to assist them in case of a medical emergency. Interviews with residents and staff further highlighted the impact of inadequate staffing. Residents expressed concerns about the lack of timely assistance, with some stating that they had to go to the nursing station to find help. Staff members, including licensed and unlicensed personnel, acknowledged the short staffing and its potential consequences, such as delayed care, increased risk of falls, and late responses to call lights. The Director of Nursing and other staff members confirmed that the facility was not meeting the minimum DHPPD requirements, which could compromise the quality of care provided to residents. The facility's policy on emergency staffing situations was reviewed, but it was undated and did not appear to be effectively implemented. The policy aimed to ensure appropriate nursing staff levels to care for residents, but the consistent failure to meet staffing requirements suggests that the policy was not adequately addressing the staffing issues. The deficiency in staffing was a significant concern, as it directly affected the residents' safety and well-being, leading to a decrease in the quality of care provided at the facility.
Lack of Staff Competency in Baseline Care Plans and Trauma Informed Care
Penalty
Summary
The facility failed to ensure that its staff possessed the necessary competencies and skills to meet the needs of residents, specifically in the areas of Baseline Care Plans (BCP) and Trauma Informed Care (TIC). Interviews with various staff members, including the Director of Staff Development (DSD), licensed and unlicensed staff, the Infection Preventionist (IP), and the Activity Director (AD), revealed a lack of awareness and understanding of BCPs and TIC. The DSD admitted to not knowing what a BCP was or the required timeframe for its completion, which should be within 24 hours of admission. Similarly, the DSD and other staff members were unaware of TIC and had not received any in-service training on the subject. The deficiency was further highlighted by the absence of BCP and TIC in the facility's Registered Nurse and Certified Nursing Competency Checklists, as well as in the DSD's mandatory in-service topics. Staff members expressed a desire for training on TIC to provide safe and effective care for residents with trauma histories. The lack of knowledge and training in these critical areas could potentially compromise the safety and well-being of residents, as staff are not equipped to develop timely care plans or provide trauma-informed care.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Observations and interviews revealed that the staffing information was kept in a binder behind the counter at the nursing station, making it inaccessible. Additionally, the staffing information was found to be incomplete, as it lacked the nursing home patient per day (NHPPD) data and was not signed by the Director of Nursing (DON) or a designee. Staff members, including the Director of Staff Development (DSD) and Licensed Staff, confirmed the absence of visible staffing information and the lack of daily NHPPD calculations. Interviews with various staff members, including the Administrator Assistant (AA) and the DON, indicated a lack of awareness regarding the requirement to post staffing information visibly and the necessity of daily NHPPD calculations. The AA admitted to calculating NHPPD only every two weeks during the pay period and keeping the information in a binder behind the nursing station counter. The DON was unaware of the need for visible posting and did not sign off on NHPPD information. The facility's policy and procedure for nurse staffing posting were requested but not provided, further highlighting the deficiency in compliance with staffing information regulations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all controlled discontinued medications were stored securely and that only authorized licensed staff, such as the Director of Nursing (DON), had access to the storage. During an observation, it was found that discontinued controlled medications, including narcotics, were not properly secured, and an unauthorized licensed staff nurse had direct access to the locked storage for discontinued medication. The DON admitted to storing discontinued controlled medications in a black tin can box that was not securely vaulted, and discrepancies were found in the reconciliation sheets for medications like Norco and Percocet, indicating missing tablets. Additionally, the facility did not accurately label individual medications according to the doctor's orders. The labels from the pharmacy did not indicate the route and duration as ordered by the doctor, which could lead to medication administration errors. The Pharmacist Manager acknowledged the labeling issue but did not provide a policy or procedure for medication labeling. Furthermore, the facility failed to ensure the safety of a resident who was self-administering medications. The resident had over-the-counter (OTC) medications stored in his room without a physician's order or a self-administration assessment. The DON and other staff members confirmed that there was no assessment or physician's order for the resident to self-administer or store medications, posing a safety risk to the resident and others in the facility.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to provide residents with palatable food, as evidenced by multiple resident interviews and observations. Residents reported that the food was often mushy, lacked taste, and was sometimes served cold. Specific complaints included canned vegetables being mushy, a lack of fresh food, and meals primarily consisting of frozen items and pasta dishes. These issues were corroborated by a test tray evaluation conducted by surveyors, who found the zucchini mushy and the barbecued beef tough in texture. Further interviews with residents revealed dissatisfaction with the texture and quality of the meat served, with descriptions comparing it to leather and noting difficulty in cutting and chewing. The deficiency in food quality had the potential to lead to nutritional problems if residents chose not to eat the meals provided by the facility.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that clean linens were transported in a manner that promoted cleanliness and protection from dust and soil. During an observation, an unlicensed staff member was seen transporting clean bed linens and towels using an uncovered laundry cart, leaving them exposed to potential contamination. The staff member acknowledged the requirement to use a covered cart but admitted to forgetting in this instance. The facility's Infection Preventionist and Administrator confirmed the expectation that linens should be covered during transport, aligning with CDC guidelines for handling clean linen. The facility also failed to ensure proper hand hygiene practices were followed by staff and offered to residents before and after meals. Observations revealed that staff did not perform hand hygiene before assisting residents with meals, nor did they offer hand hygiene to residents. Interviews with residents and staff confirmed inconsistencies in hand hygiene practices, which were not in compliance with the facility's policy. The Director of Staff Development and other staff members emphasized the importance of hand hygiene to prevent cross-contamination and infection. Additionally, the facility did not appropriately manage urinals containing urine, which were found hung on a resident's walker and left on a bedside table. This practice was identified as inappropriate for infection control and resident dignity. Staff interviews confirmed that leaving urinals in such locations was not acceptable and posed risks for spillage and infection. The facility's policy indicated that if a resident preferred to keep a urinal at the bedside, it should be checked frequently and noted in the care plan, which was not done in these cases.
Failure to Coordinate Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate the Level II Preadmission Screening and Resident Review (PASARR) for a resident after a positive result from the Level I PASARR. This oversight involved Resident 17, who was admitted with a mental illness. The Level I PASARR evaluation, dated 08/10/21, indicated the need for a Level II PASARR mental health evaluation from the Department of Health Services, which was not coordinated by the facility. As a result of this failure, there was a delay in the evaluation by a medical doctor for mental illness, leading to a delay in the necessary care and services for Resident 17. The report highlights the federal requirement for Level II PASARR to ensure individuals with mental disorders or intellectual disabilities are not inappropriately placed in long-term care facilities. The regulatory health and safety codes emphasize the importance of incorporating PASARR recommendations into resident assessments and care planning, which was not adhered to in this case.
Failure to Assist Resident with CPAP Use and Lack of No Smoking Signage
Penalty
Summary
The facility failed to ensure that a resident was using his continuous positive airway pressure (CPAP) machine every night as prescribed. The resident, who had intact cognition and required maximum assistance with activities of daily living, reported that he had not used his CPAP regularly for months because staff did not assist him in wearing the CPAP mask. The resident had difficulty putting on the mask due to issues with hand strength and dexterity, and the CPAP machine's location in his room made it challenging for him to access it. Despite a plan for a room transfer to facilitate easier access to the CPAP, this had not occurred, and staff often told the resident to put on the mask himself. The Director of Nursing (DON) confirmed that the resident had a CPAP machine and acknowledged that nurses should have assisted him in using it every night. The DON was unaware of the resident's non-compliance with CPAP use and could not explain why the room change had not been implemented. Licensed staff and the Infection Preventionist (IP) emphasized the importance of having a physician order specifying the CPAP settings and assisting the resident with the CPAP mask if requested. The absence of a physician order with the correct CPAP settings was noted, and the DON verified that the order lacked essential components such as oxygen concentration and flow settings. Additionally, the facility failed to post a no smoking sign in the resident's room, despite the use of a CPAP machine. Both licensed staff and the IP confirmed the absence of the signage and highlighted its importance in preventing accidents and fire risks. The facility's policy and procedure for CPAP/BiPAP support required reviewing the physician's order for oxygen concentration and flow and posting a no smoking sign in the resident's room, which was not followed in this case.
Failure to Provide Hearing Services for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 1, gained access to necessary hearing services. Despite Resident 1's repeated requests to see an audiologist, no referral was made, and no appointment was scheduled. The resident's hearing aids were not checked for functionality, leading to difficulties in hearing spoken words. This oversight was confirmed through observations and interviews with the resident, who expressed frustration over the lack of action taken to address her hearing issues. Resident 1 was admitted to the facility with diagnoses including hyperlipidemia, type 2 diabetes mellitus, and muscle weakness. Her cognitive status was intact, as indicated by a BIMS score of 14. Despite needing assistance with activities of daily living, the resident was not provided with the necessary support to address her hearing impairment. Interviews with various staff members, including the Director of Nursing, Social Services Director, and other licensed staff, revealed a lack of protocol and action regarding the resident's hearing needs. The staff acknowledged the resident's hard of hearing condition and the associated risks of miscommunication, frustration, and potential safety issues. However, there was no evidence of a referral to an audiologist or any attempt to ensure the resident's hearing aids were functioning. The facility's policy on supporting activities of daily living did not specifically address the needs of residents with hearing impairments, contributing to the oversight in Resident 1's care.
Failure to Provide Ordered ROM Exercises for a Resident
Penalty
Summary
The facility failed to provide Range of Motion (ROM) exercises for one of the sampled residents, Resident 23, as ordered by her physician and outlined in her comprehensive care plan. Resident 23, who has a principal diagnosis of Multiple Sclerosis and suffers from contractures in both ankles and paraplegia, was supposed to receive passive ROM exercises with her upper extremities 2-3 times per week. However, due to the absence of a Restorative Nursing Assistant (RNA) for approximately two months, these exercises were not performed. Interviews with staff and the resident confirmed that no ROM exercises had been conducted during this period. The deficiency was further highlighted by the facility's own Restorative Nursing Program document, which mandates daily performance of such services to maintain patients' optimum level of function. Despite this requirement, the facility did not have an RNA available, and the Director of Nursing could not recall the duration of this absence. Resident 23 expressed that neither the former RNA nor the Certified Nursing Assistants (CNAs) had been performing the ROM exercises, and she noted that the CNAs lacked the knowledge and time to do so. This oversight had the potential to lead to the development or worsening of contractures, affecting the resident's health and well-being.
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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