Sierra Vista Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 1715 South Cedar, Fresno, California 93702
- CMS Provider Number
- 555866
- Inspections on file
- 21
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Sierra Vista Healthcare during CMS and state inspections, most recent first.
A resident with acute encephalopathy, severe cognitive impairment, and a history of wandering eloped from the facility after staff failed to respond promptly to a triggered security bracelet alarm at the front door. The resident, who was independently mobile and assessed as high risk for elopement and falls, was later found at a family member's home and returned to the facility with the security bracelet still in place. Facility leadership confirmed that the alarm was not answered immediately, and several other residents at high risk for elopement were also present in the facility.
A resident with a fractured ankle and suspected surgical site infection did not receive a prescribed antibiotic because the physician's order, received via fax, was not provided to clinical staff as required. The breakdown in communication led to the resident missing the ordered treatment.
A resident with cognitive and physical impairments fell and fractured his hip after attempting to self-transfer from a bed with unlocked wheels. The bed had been moved by a CNA to assist the resident's roommate, and the wheels were not locked afterward. Staff interviews confirmed that bed wheels should be locked when residents are in bed.
The facility did not post the most recent survey results in an accessible location for residents and their representatives. A binder labeled CDPH Survey Results was missing the last recertification survey results. Interviews with the DON and ADM revealed a misunderstanding about the requirement to include survey results from 2022. The facility's policy on Resident Rights states that residents have the right to examine survey results, which was not met.
The facility failed to properly store and label medications, with two medication carts found unlocked and unattended, posing a risk of unauthorized access. A bottle of polyethylene glycol 3350 was left unattended on a cart, and an expired bottle of Lactulose was found in another cart, indicating lapses in adherence to storage and expiration policies.
The facility failed to maintain an infection prevention and control program, with deficiencies in sharps storage and oxygen equipment maintenance. Sharps containers were improperly stored in an accessible room, posing a risk of injury. Oxygen concentrator filters for several residents were dirty, and there was confusion about cleaning responsibilities. Additionally, a resident's oxygen tubing was not labeled with the change date, risking infection. These issues indicate a lack of adherence to infection control policies and inadequate staff training.
Five residents experienced a delay of up to 30 minutes in receiving their lunch trays while watching others eat, due to a lack of communication between nursing and dietary staff. This affected their dining experience and violated their right to dignity. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
The facility failed to implement resident-centered care plans for three residents, leading to potential risks and unmet medical needs. A resident lacked a care plan for prescribed medication, another had exposed bedrail padding despite a seizure risk, and a third had no care plan for a change in condition related to diarrhea. Staff acknowledged these oversights, which were confirmed through observations and interviews.
A resident with a fluid restriction order was allowed to consume more fluids than prescribed during a meal, leading to a deficiency in care. Staff acknowledged the oversight, and the facility's policy to check trays for correct diets was not effectively followed.
The facility exceeded the acceptable medication error rate with two incidents involving improper administration. An LVN gave a resident glucophage and methenamine without food, against instructions, risking GI distress. Another LVN mixed Polyethylene Glycol with insufficient water, leading to potential discomfort. Both errors were acknowledged by staff and highlighted the need for adherence to medication instructions.
A dietary staff member failed to check the internal temperature of pork loins before serving, as observed during a survey. The staff member admitted to not knowing the required temperature, and both the Dietary Service Manager and Dietitian confirmed the importance of this step to prevent foodborne illness. Facility policies and professional guidelines emphasize the necessity of using a food thermometer for safety.
The facility failed to ensure sanitary food preparation and storage, affecting 87 residents. A serving cart was found with a white powdered substance and other items, while a kitchen storage room had dirt, debris, and a missing baseboard. The Dietary Manager Supervisor, Registered Dietitian, and Administrator acknowledged the importance of cleanliness to prevent contamination and pest attraction.
A resident's POLST form was not completed and signed by a physician for over eleven days after admission, contrary to facility policy. Staff interviews indicated the form should have been completed upon admission and signed within 72 hours. The resident, with multiple diagnoses and moderate cognitive impairment, was automatically considered full code due to the incomplete form.
A resident's personal information was exposed when an LVN left a computer screen open and unattended, violating privacy protocols. Facility staff confirmed that this action breached HIPAA regulations and contradicted the facility's policy on maintaining residents' confidentiality.
Two residents experienced an unclean and cluttered environment due to one resident's food hoarding habits. Despite being cognitively intact, the resident continued to store various food items improperly, leading to potential risks of pest infestation and foodborne illness. Facility staff attempted to manage the situation through education and alternative storage solutions, but the resident often refused assistance.
A facility failed to accurately complete the PASRR for a resident admitted with unspecified psychosis and depression, who was on psychotropic medications. The PASRR from the hospital inaccurately indicated no need for Level II screening and no mental illness diagnosis, which was not corrected by the facility. The DON acknowledged the oversight, which could affect the resident's psychiatric care.
A resident with diabetes and other conditions had long, thick, and crooked toenails due to the facility's failure to ensure proper foot care. Despite the resident's refusal of podiatry visits, staff did not take further action to address the issue, which was contrary to the facility's foot care policy.
A resident with no cognitive impairment did not have his meal preferences documented, leading to him not eating his lunch due to a dislike for Italian food. Despite the facility's policy to accommodate preferences, staff failed to ensure meal tickets were accurate, resulting in the resident not receiving a meal he would eat.
A resident with psychosis and muscle weakness was not provided with the necessary built-up utensils on her meal tray, as required by her care plan. Despite the facility's policy and staff responsibilities, the dietary aides failed to ensure the correct utensils were placed, leading to the deficiency.
A resident with dementia, known for wandering, exited a facility unsupervised and was found in a rose garden during extreme heat, resulting in second-degree burns and an acute kidney injury. The resident, who had severe cognitive impairment and was a fall risk, required hospitalization for treatment. Staff interviews confirmed the resident needed constant supervision, which was not provided, leading to the incident.
Failure to Respond to Elopement Alarm Results in Resident Leaving Facility
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a security elopement alarm, resulting in a resident eloping from the facility. The resident had been admitted with acute encephalopathy, severe impairment affecting judgment, and a history of wandering and elopement. Assessments indicated the resident was independently mobile, at high risk for both elopement and falls, and had a physician's order for a security bracelet to be worn on the right ankle. The care plan included interventions such as applying the security bracelet and checking its function and placement per protocol. On the day of the incident, the resident was last seen by staff outside his room during breakfast service. When the resident could not be located, a search was initiated inside and outside the facility. The security bracelet alarm at the front door was triggered, but staff did not respond to the alarm in a timely manner. The resident was eventually found at a family member's home approximately one mile away and was returned to the facility. At the time of his return, the security bracelet was still in place and functioning. Interviews with facility leadership confirmed that the alarm at the front door was sounding but was not answered immediately, as the receptionist who typically monitors the area was not on duty at the time. The facility had six other residents identified as high risk for elopement, all with physician's orders for security bracelets due to wandering or exit-seeking behaviors. Facility policies required adequate supervision and timely response to alarms for residents at risk of elopement, but these protocols were not followed during the incident.
Failure to Administer Prescribed Antibiotic Following Physician Order
Penalty
Summary
A deficiency occurred when a resident who was admitted for aftercare following a fractured left ankle did not receive a prescribed antibiotic for a suspected surgical site infection. The surgeon ordered Bactrim DS to be administered twice daily for ten days, starting on 3/3/25, after a follow-up visit raised concerns about infection. However, the antibiotic was not administered as ordered. The failure was traced to a breakdown in the facility's process for handling physician orders received via fax. The surgeon's progress note, which included the antibiotic order, was faxed to the facility and received by medical records staff, but it was not provided to the clinical staff as required. The Director of Nursing confirmed that the process in place to start antibiotics within four hours of receiving an order was not followed, resulting in the resident not receiving the medication as prescribed.
Resident Falls Due to Unlocked Bed Wheels
Penalty
Summary
The facility failed to ensure a resident was free from injury when he attempted to self-transfer out of his bed with the bed's wheels unlocked, resulting in a fall and fracture to his left hip. The resident, who was cognitively intact but had impairments in both lower extremities and required substantial assistance for transfers, attempted to transfer himself to his wheelchair. During this attempt, the unlocked wheels caused the bed to move, leading to the fall. The resident had been admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies, bipolar disorder, and dementia. Despite being wheelchair-bound and needing maximal assistance for transfers, the resident attempted to transfer himself after a CNA had moved his bed to assist his roommate and forgot to lock the bed's wheels. This oversight was confirmed by the resident, who stated that the CNA had asked for permission to move the bed but did not lock the wheels afterward. Interviews with staff, including CNAs and nurses, confirmed that the bed's wheels should have been locked when the resident was in bed. The bed was found moved from its normal position, and the resident was discovered on the floor by a nurse. The staff acknowledged that the bed would not have moved if the brakes were locked, indicating a failure to follow safety protocols regarding bed wheel locks.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to all 91 residents, their families, and legal representatives. During an observation, a binder labeled CDPH Survey Results was found in a hallway near the main entrance, but it did not contain the results of the last recertification survey conducted on September 22. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the survey results were not included in the binder. The ADM mistakenly believed that only results from the previous year needed to be stored, and since the survey was conducted in 2022, it was not included. The facility's policy on Resident Rights, dated August 22, indicated that residents have the right to examine survey results, which was not upheld in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. Two of four medication carts were found unlocked and unattended by licensed nurses, which posed a risk of unauthorized access by residents, staff, and visitors. During observations, Licensed Vocational Nurses (LVNs) were seen leaving medication carts unlocked while attending to residents in their rooms, acknowledging that the carts should have been locked to prevent access to medications by unauthorized individuals. Additionally, a bottle of polyethylene glycol 3350 was left unattended on top of a medication cart, creating a potential risk for unauthorized access and misuse. The LVN responsible admitted to leaving the medication unattended and acknowledged the risk of it being accessed by residents, staff, or visitors. The Director of Nursing (DON) confirmed that leaving medications unattended on top of carts was against facility policy and posed a risk of unauthorized access and potential harm. Furthermore, an expired bottle of Lactulose was found in a medication cart, indicating a failure to adhere to the facility's policy of checking expiration dates before administering medications. The LVN and Assistant Director of Nurses (ADON) acknowledged that expired medications should not be present in the cart and could lead to ineffective treatment or harmful side effects. The facility's policies clearly stated that expired medications should be removed and destroyed, highlighting a lapse in adherence to these procedures.
Infection Control Deficiencies in Oxygen Equipment and Sharps Storage
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper storage of sharps containers in a room accessible to residents. The room contained five full sharps containers, one of which was uncovered, posing a risk of injury and cross-contamination. The room was used by an outside lab company, but the facility staff did not monitor or report the unsafe condition, despite the potential for residents to access the room and harm themselves. Another deficiency involved the maintenance of oxygen concentrators for multiple residents. Resident 58's oxygen concentrator filter was found covered in dirt, dust, and lint, which could introduce contaminants into the oxygen supply. Similarly, the oxygen concentrator filters for Residents 61 and 3 were covered with grayish-white material, indicating they were not cleaned regularly. There was confusion among staff about who was responsible for cleaning these filters, leading to a lack of proper maintenance and increased risk of respiratory issues for the residents. Additionally, Resident 345's oxygen tubing was not labeled with the date it was changed, which is necessary to ensure timely replacement and prevent respiratory infections. The facility's policies required nasal cannula tubes to be changed weekly and labeled with the date, but this was not adhered to, putting the resident at risk. These deficiencies highlight a lack of adherence to infection control policies and procedures, as well as inadequate staff training and communication regarding responsibilities for maintaining medical equipment.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified dining experience for five residents, as they were made to wait up to 30 minutes for their lunch trays while observing other residents eat. This incident involved Residents 68, 81, 245, 246, and 350, who were left without their meals in the dining room on two separate occasions. The delay in serving these residents was attributed to a lack of communication between the nursing and dietary staff, as the lunch trays for these residents were mistakenly sent to their rooms instead of the dining room. Resident 68, who has a severe cognitive deficit, and Resident 81, with a moderate cognitive deficit, were among those affected. Resident 245, with no cognitive deficit, and Resident 246, with a severe cognitive deficit, also experienced the delay. Additionally, Resident 350, who has no cognitive deficit, was affected, and a family member expressed discomfort with the situation. The staff's failure to communicate effectively resulted in these residents being served significantly later than others, impacting their dining experience. Interviews with various staff members, including CNAs, the Dietary Service Manager, the MDS Coordinator, and the Director of Nursing, revealed that the standard practice was to serve one table at a time. However, due to a lack of communication, the dietary staff was not informed of the residents' presence in the dining room, leading to the delay. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for three residents, leading to potential risks and unmet medical needs. For Resident 31, there was no care plan for the use of clotrimazole medication, which was prescribed for a fungal infection on the toenails. This oversight was identified during a review of the resident's order summary and confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that a care plan should have been initiated immediately upon receiving the order. Resident 1's care plan was not properly implemented, as the padding on the left bedrail was not intact, exposing a metal bar. This was observed during room inspections and interviews with Certified Nursing Assistants (CNAs) and a Registered Nurse (RN). The care plan indicated the need for padded side rails due to the resident's history of seizures, but the nursing staff failed to ensure the padding was maintained, potentially putting the resident at risk of injury during a seizure. For Resident 53, there was no care plan developed for a change in condition related to diarrhea, which was documented in the SBAR communication form and progress notes. Despite the physician ordering tests to rule out C-Diff, the DON and other staff members confirmed that a care plan should have been created to address this change in condition. The absence of a care plan meant that the resident's medical needs might not have been adequately met.
Failure to Follow Fluid Restriction Order
Penalty
Summary
The facility failed to adhere to professional standards of quality care for a resident by not following the physician's fluid restriction order. The resident, who was admitted with diagnoses including psychosis and muscle weakness, was observed consuming more fluids than the prescribed limit during a meal. Specifically, the resident was allowed to consume 28 ounces of fluid in one meal, exceeding the allowed 10 ounces per meal as per the physician's order. This oversight was confirmed by multiple staff members, including a CNA, the Assistant Dietary Service Manager, and the Dietary Service Manager, who acknowledged that the resident received more fluid than ordered. Interviews with staff revealed a lack of compliance with the fluid restriction order, which was crucial to prevent potential health issues such as fluid overload. The Director of Nursing noted that the resident was confused and frequently requested more coffee, indicating a need for staff to consistently explain the fluid restriction to the resident. The facility's policy required the Food Service Manager or designee to check trays for correct diets before distribution, but this protocol was not effectively followed, leading to the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.54%. This deficiency was observed in two separate incidents involving medication administration. In the first incident, an LVN administered glucophage and methenamine to a resident without food, contrary to the medication instructions that specified administration with food. The LVN acknowledged the error, noting that the resident had eaten breakfast earlier, but did not provide food at the time of medication administration. The Assistant Director of Nursing and the Director of Staff Development confirmed that the medication orders should have been followed to prevent gastrointestinal distress. In the second incident, another LVN did not adhere to the medication instructions for administering Polyethylene Glycol to a different resident. The LVN mixed the medication with only four ounces of water instead of the prescribed eight ounces, resulting in a more concentrated solution. This deviation from the prescribed method was acknowledged by the LVN and confirmed by the Director of Staff Development, who noted that the error could lead to gastrointestinal discomfort and inefficient absorption. The facility's policy on medication errors emphasizes the importance of following physician orders and manufacturer instructions to prevent adverse consequences.
Failure to Ensure Competency in Food Temperature Checks
Penalty
Summary
The facility failed to ensure that a dietary staff member was competent in carrying out the functions of the food and nutrition services safely and effectively. During an observation, the dietary staff member was seen removing a baking tray containing three pork loins from the oven without checking their internal temperature. The staff member then proceeded to the prep area to slice the pork loins for service without verifying if they were cooked to the required temperature. In an interview, the staff member admitted to not checking the internal temperature and was unsure of what it should have been, acknowledging that he should have checked it upon removal from the oven. Further interviews with the Dietary Service Manager and the Dietitian confirmed that the staff member should have checked the temperature to ensure the pork loins were properly reheated, as per the facility's policy. The Dietary Service Manager stated that the pork loins were precooked but emphasized the importance of verifying the temperature to prevent foodborne illness. The Dietitian reiterated the necessity of following the recipe's temperature requirements and indicated that the Dietary Service Manager was responsible for training the staff member. The facility's policy and professional references reviewed highlighted the importance of using a food thermometer to ensure food safety.
Sanitation Deficiencies in Food Preparation and Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, affecting 87 of 91 residents. During an observation, a serving cart was found with a white powdered substance scattered across its surface, alongside items such as serving trays, gloves, aprons, garbage bags, and a utensil holder. The Dietary Manager Supervisor (DMS) acknowledged that the cart should be cleaned daily to prevent contamination and infection, and that it was the responsibility of the dietary aide to maintain its cleanliness. Additionally, a storage room in the kitchen was observed to have dirt and debris on the floor, with a missing baseboard on one wall. The DMS stated that maintenance was responsible for fixing the floors and baseboards, and acknowledged that the area was not clean. The Registered Dietitian (RD) and the Administrator (ADM) both confirmed the importance of maintaining cleanliness to prevent cross-contamination and pest attraction. The facility's policy and the USFDA Food Code emphasize the need for cleanliness in food-contact and non-food-contact surfaces, as well as proper storage of maintenance tools.
Failure to Timely Complete POLST Form
Penalty
Summary
The facility failed to ensure that a resident's code status was documented upon admission on the Physician Order for Life Sustaining Treatment (POLST) form. The POLST form for the resident was not completed and signed by the physician for more than eleven days after admission, which was not in accordance with the facility's policy and procedure. This oversight had the potential to result in the resident's wishes not being honored and unnecessary medical interventions being administered. Interviews with staff revealed that the POLST form should have been completed upon admission, with the physician or nurse practitioner required to sign it within 72 hours. The admission nurse was responsible for completing the POLST form and communicating the resident's wishes to the physician. However, the form was not signed by the physician until much later, and the resident was automatically considered a full code due to the incomplete POLST form. The resident involved was admitted with diagnoses including COVID-19, polyneuropathy, depression, hypertension, and constipation. The resident was moderately cognitively impaired but was her own responsible party. The facility's policy stated that the POLST form is not valid until signed by both the resident and a physician, and the failure to complete this process in a timely manner was a clear deficiency in the facility's adherence to its own procedures.
Privacy Breach Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect the privacy of a resident's personal information when a Licensed Vocational Nurse (LVN) left her workstation computer open and unattended, exposing the resident's information to public view. This incident involved Resident 34, whose personal and medical information was left visible on the computer screen outside their room. The LVN acknowledged that leaving the computer screen open was inappropriate and that it allowed any passing residents, staff, or visitors to potentially view the resident's private information. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed that the facility's practice and expectation were to always close computer screens when not in use to protect residents' information. The DSD identified this incident as a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of sensitive health information. The facility's policy and procedure document also emphasized the residents' rights to privacy and confidentiality, which were not upheld in this instance.
Failure to Maintain a Clean and Homelike Environment Due to Food Hoarding
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, Resident 16 and Resident 39, due to the improper storage of personal food items. Resident 16 had a collection of fresh produce, canned goods, and various food items stored in their room, including on the floor and shelves, which created clutter and an unclean environment. This situation was observed during multiple visits, and Resident 39, who shared the room, expressed that the clutter made it impossible to use the shared sink. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), Resident 16 continued to hoard food despite repeated discussions and education from facility staff, including the Infection Preventionist, Director of Staff Development, and Registered Dietitian. The staff explained the risks of food hoarding, such as pest infestation and foodborne illness, but Resident 16 and their family persisted in bringing food into the facility. The facility staff attempted to manage the situation by checking expiration dates and offering to store food in a refrigerator, but Resident 16 often refused these measures. Housekeeping staff were observed cleaning the room but stated that their responsibilities did not include managing the food clutter. The Director of Nursing and other staff members acknowledged the ongoing issue and the potential risks it posed to the facility. Despite efforts to educate and offer alternative solutions, Resident 16's preference to remain in the facility with friends and continue their habits contributed to the deficiency in maintaining a clean and homelike environment.
Inaccurate PASRR Completion for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Level I Preadmission Screening and Resident Review (PASRR) for a resident upon admission. The resident, who was admitted with diagnoses of unspecified psychosis and depression, was also on psychotropic medications. However, the PASRR completed at the general acute care hospital inaccurately indicated that the resident did not require a Level II screening and did not have a diagnosis of mental illness or prescriptions for psychotropic medications. This discrepancy was not identified or corrected by the facility upon the resident's admission. During a review, the Director of Nursing (DON) acknowledged that the PASRR assessment was not accurate and should have been reviewed and updated to reflect the resident's mental health diagnoses and medication needs. The facility's policy required confirmation and review of PASRR documentation from the hospital, which was not adequately followed in this case. This oversight had the potential to impact the resident's receipt of necessary psychiatric treatment and evaluation.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 3, whose toenails were observed to be long, thick, and crooked. This condition was noted during an observation and interview with a registered nurse, who acknowledged that the toenails were not in an acceptable condition and should have been reported by certified nursing assistants (CNAs). Despite being aware of the condition, CNA 1 stated that Resident 3 had refused nail care, and no report was made to the nurse. The resident's refusal of podiatry visits was documented in the podiatry notes, and the Social Services Director indicated that if staff had alerted her, alternative arrangements could have been made. Interviews with various staff members, including a licensed vocational nurse, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, revealed a consensus that the resident's refusal of nail care should have prompted further action. The staff acknowledged the potential risks associated with the resident's diabetic condition, which could lead to complications such as skin breakdown or infection. The facility's policy on foot care emphasized the importance of maintaining foot health, particularly for residents with medical conditions like diabetes, but the policy was not effectively implemented in this case.
Failure to Document and Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to document and accommodate a resident's meal preferences, resulting in the resident not eating his lunch. The resident, who had no cognitive impairment, expressed a dislike for Italian food, which was not documented on his meal ticket. On the day of the incident, the resident was served a meal consisting of spaghetti and zucchini, which he refused to eat due to his dislike for Italian food. Despite the availability of meal alternatives, the resident's appetite was ruined, and he did not request a different meal. Interviews with facility staff revealed a lack of communication and responsibility in ensuring meal preferences were documented and respected. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) acknowledged their roles in checking meal tray accuracy and addressing resident meal preferences. The Dietary Services Manager and Assistant Dietary Services Manager stated that it was the dietary department's responsibility to document food preferences, and the Registered Dietitian emphasized the importance of providing alternate meals if a resident's meal was untouched. The facility's policy indicated that residents should receive meals according to their preferences, but this was not adhered to in this case.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, identified as Resident 68, who required built-up utensils to feed herself independently and safely. During an observation in the dining room, it was noted that Resident 68's meal tray contained regular utensils instead of the prescribed built-up utensils. The resident's admission record and order summary report indicated the need for adaptive equipment, including a divided plate and built-up utensils, due to her diagnoses of psychosis and muscle weakness. Interviews with various staff members, including a Certified Nurse Assistant, Assistant Dietary Service Manager, Dietary Aide, Dietary Service Manager, and Registered Dietitian, revealed that the dietary aides were responsible for ensuring the correct utensils were placed on meal trays. However, the dietary aides failed to perform a final check before sending out the tray cart, resulting in the omission of the necessary adaptive utensils. The facility's policy and procedure on self-feeding devices stated that such devices should be provided with each meal, but this was not adhered to in the case of Resident 68.
Resident with Dementia Sustains Burns Due to Lack of Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accident hazards for a resident with dementia, who was known to independently move around the facility in a wheelchair. The resident, who had severe cognitive impairment and was a fall risk, managed to exit the facility unsupervised and was found in the rose garden exposed to extreme heat. The temperature on that day reached up to 108 degrees Fahrenheit, and the resident was outside for an unknown amount of time. As a result of this lack of supervision, the resident sustained second-degree burns on multiple parts of the body, including the scalp, right ear, neck, left shoulder, and both knees. Additionally, the resident suffered an acute kidney injury, likely due to dehydration from prolonged sun exposure. The resident required treatment at an acute care hospital for these injuries. Interviews with facility staff revealed that the resident had a history of wandering and required constant supervision. Staff members acknowledged that the resident should not have been left unattended outside, especially given the high temperatures. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision based on individual resident needs, which was not adhered to in this case.
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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