Stanford Court Skilled Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santee, California.
- Location
- 8778 Cuyamaca Street, Santee, California 92071
- CMS Provider Number
- 555290
- Inspections on file
- 27
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Stanford Court Skilled Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide dedicated vital signs equipment for two residents with C. diff infections, as required by their care plans and facility policy. Observations revealed the absence of such equipment in the residents' rooms, despite signs indicating the need for contact precautions. Interviews with staff confirmed the expectation for dedicated equipment to prevent infection spread.
The facility failed to follow proper infection control practices for two COVID-19 positive residents. Staff were observed wearing an N-95 mask over a surgical mask, compromising its effectiveness, and entering rooms without required face shields. Interviews confirmed these practices were against facility policy, which mandates proper PPE, including an N-95 mask, gown, gloves, and eye protection.
A facility failed to create a resident-centered care plan for a resident at high risk for falls. Despite a Fall Risk Evaluation indicating the high risk, the care plan did not reflect this. The Clinical Care Coordinator acknowledged the oversight, highlighting the importance of individualized care plans. The facility's policy requires care plans to be based on assessments and developed by an interdisciplinary team.
A facility failed to update a resident's care plan to reflect their high fall risk, despite assessments indicating increased risk. The resident, with hemiplegia and hemiparesis, was assessed as high risk for falls on multiple occasions, but the care plan still showed a moderate risk. The Clinical Care Coordinator acknowledged the discrepancy, noting the importance of accurate care plans for staff to prevent falls. The facility's policy lacked guidance on care plan revisions.
A resident, identified as high risk for falls due to conditions like morbid obesity and mobility issues, experienced a fall. The facility failed to conduct a thorough investigation to determine the cause of the fall and implement specific interventions. The Clinical Care Coordinator admitted the investigation was insufficient, not exploring the resident's actions leading to the fall, contrary to the facility's policy requiring cause identification within 24 hours.
The facility failed to provide palatable and flavorful meals, leading to resident dissatisfaction and potential nutritional issues. Residents reported repetitive menus, particularly with chicken, and meals often being cold and bland. The Dietary Supervisor and Registered Dietician acknowledged these issues, noting the potential for weight loss due to unappetizing food options.
The facility failed to maintain sanitary practices by using a low-temperature dishwasher that did not reach the required 120 F for proper sanitation. Despite knowing the temperature was insufficient, a Dietary Assistant continued to use the machine without notifying a supervisor. Another Dietary Assistant was aware of the issue but unsure of alternative cleaning methods. The Dietary Supervisor confirmed that staff should have reported the issue and used a three-compartment sink instead.
A resident's dignity was compromised when a staff member instructed them to urinate in a diaper instead of assisting with a bedpan or toilet. The resident, who was continent and typically used a bedpan, reported feeling terrible about the incident. The Director of Nurses confirmed that such instructions are demeaning and against the facility's rehabilitation goals. The facility's policy emphasizes care that promotes dignity and respect.
The facility failed to maintain a homelike environment for three residents due to damaged walls behind their beds. Observations showed scraped and peeling paint and drywall, and residents reported that maintenance had not assessed the damage. Staff were unaware of the issue, and the Environmental Service Director noted that mechanical beds caused the damage. The Director of Nursing acknowledged the importance of timely repairs to support a homelike setting.
A resident with schizoaffective disorder was not re-evaluated for PASARR after admission, despite being on antipsychotic medication. The case manager and DON acknowledged the oversight, noting the resident was not included in the PASARR review calendar, contrary to facility policy requiring such evaluations to ensure appropriate care and placement.
A resident was using a left-hand splint and had triamcinolone ointment without MD orders. The splint was applied by an RNA without documentation, and the ointment was left uncapped on the nightstand, posing risks of misuse. Facility policies require MD orders for such treatments, which were not followed, compromising the resident's care.
A resident with a history of hemiplegia and hemiparesis was found with long, dirty fingernails, indicating a failure in personal hygiene care. Despite being dependent on staff for hygiene, the resident's nail care was neglected, and hand splints were not consistently applied as per orders. Interviews with staff confirmed the lack of sufficient nail care, contrary to the facility's policy.
A resident with hemiplegia did not receive appropriate care as per professional standards. The resident's fingernails were neglected, remaining long and dirty, and the hand splint was not managed according to physician orders. Staff failed to remove the splint within the prescribed timeframe and did not provide necessary nail care, as confirmed by facility staff and policy reviews.
A resident with a peritoneal abscess and sepsis did not receive proper care for their drainage tube, as staff failed to consistently squeeze the accordion bulb to create necessary suction. Observations and interviews revealed a lack of understanding among staff about the correct procedure, leading to a deficiency in care.
The facility failed to securely store medications for two residents, leading to potential misuse and allergic reactions. A discontinued triamcinolone ointment was left uncapped on a resident's nightstand, and a prescribed Salonpas patch was stored at another resident's bedside without a self-administration safety screen. Facility policy requires medications to be stored in locked compartments, which was not followed in these cases.
Two residents in a LTC facility had food brought by family improperly stored, leading to potential health risks. One resident had fruits left at the bedside for over a week, while another had a sandwich, pastries, and a banana improperly stored. Facility policies requiring labeling and refrigeration were not followed, posing risks of spoilage and foodborne illness. Staff interviews confirmed the failure to adhere to these policies.
A facility failed to enforce neutropenic precautions for a resident with a low white blood cell count, allowing raw fruits in the resident's room despite policy prohibiting them. Staff interviews revealed inconsistencies in understanding and enforcing the precautions, with some staff allowing washed fruits and vegetables. The Director of Nursing acknowledged the oversight and emphasized the importance of following the protocol to protect the resident from infection.
A resident with severe cognitive impairment reported being physically abused by staff, but the incidents were not reported immediately as required by facility policy. A CNA witnessed the abuse but delayed reporting due to fear of gossip, leading to a failure in protecting the resident from further harm.
Failure to Provide Dedicated Equipment for Residents with C. diff
Penalty
Summary
The facility failed to ensure proper infection control practices by not designating dedicated vital signs (VS) equipment for two residents with Clostridium difficile (C. diff) infections. During observations, it was noted that the rooms of both residents had signs indicating the need for contact precautions and the use of dedicated or disposable equipment. However, the Certified Nurse Assistant (CNA) was unable to find any VS equipment in the rooms or on the carts outside the rooms. The care plans for both residents indicated the requirement for dedicated equipment due to their C. diff infections, but this was not adhered to. Interviews with facility staff, including a Licensed Nurse (LN), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed that dedicated VS equipment should have been available in the isolation rooms to prevent the spread of infection. The facility's policy on Clostridium Difficile, dated October 2018, also emphasized the importance of using dedicated medical equipment to prevent transmission. The lack of dedicated VS equipment for these residents posed a risk of spreading the infection throughout the facility.
Inadequate Infection Control Practices for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to current infection control practices for two residents who tested positive for COVID-19. Staff members were observed wearing an N-95 mask over a surgical mask, which was against the facility's policy and compromised the effectiveness of the N-95 mask. Certified Nurse Assistants (CNAs) and Licensed Nurses (LNs) were seen entering rooms of COVID-19 positive residents with improper personal protective equipment (PPE). Specifically, CNAs were observed wearing an N-95 mask over a surgical mask, and one LN entered a COVID-19 positive resident's room without a face shield, despite the precaution sign indicating the need for eye protection. Interviews with staff, including the Infection Prevention Nurse (IPN) and the Director of Nurses (DON), confirmed that the practice of double masking with an N-95 over a surgical mask was incorrect and compromised the seal of the N-95 mask. The IPN also stated that prescription glasses were not a substitute for a face shield, which was required for additional protection. The facility's policy, dated November 2024, clearly outlined the need for proper PPE, including an N-95 mask, gown, gloves, and eye protection, when entering the room of a resident with suspected or confirmed COVID-19 infection.
Failure to Develop Resident-Centered Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident identified as being at high risk for falls. This deficiency was identified during a review of the care plan for a resident who was readmitted to the facility with diagnoses including abnormalities of gait and mobility. Despite a Fall Risk Evaluation indicating the resident was at high risk for falls, the care plan did not reflect this risk. During an interview and joint record review, the Clinical Care Coordinator acknowledged that the care plan did not address the resident's individual concerns and needs, emphasizing the importance of developing a care plan tailored to each resident's specific requirements. The facility's policy on care planning, revised in March 2022, mandates that comprehensive, person-centered care plans be based on resident assessments and developed by an interdisciplinary team.
Failure to Revise Resident's Fall Risk Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident concerning their fall risk, which was identified during an interview and record review. The resident, who was readmitted with diagnoses of hemiplegia and hemiparesis, had a fall risk assessment indicating a moderate risk on 12/26/23, which later assessments on 2/20/24, 3/20/24, and 6/17/24 showed as high risk. However, the care plan dated 8/11/23 still reflected a moderate risk for falls. During an interview on 8/16/24, the Clinical Care Coordinator acknowledged that the care plan did not reflect the resident's current fall risk, which was necessary for staff to implement appropriate interventions to prevent falls. The facility's policy on care planning did not provide guidance on revising care plans.
Inadequate Fall Investigation for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident was free from future falls by not conducting a thorough investigation of the resident's fall. The resident, who was admitted with diagnoses including diverticulitis, morbid obesity, and gait and mobility abnormalities, was identified as high risk for falls. The resident experienced a fall and reported attempting to brace herself before falling. During an interview, the Clinical Care Coordinator acknowledged that the investigation into the fall was not thorough, as it did not explore what the resident was attempting to do when she tried to stand. The facility's policy requires identifying possible causes of falls within 24 hours, which was not adequately followed in this case.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, flavorful, and maintained its nutritional value, as observed during dining observations and interviews. Residents expressed dissatisfaction with the repetitive menu, particularly the frequent serving of chicken, and noted that meals were often cold and lacked flavor. Some residents reported relying on food brought by family members due to the unappetizing meals provided by the facility. The facility's menu on a specific date included pot roast and pureed options, which were found to be bland and salty during a test tray observation with the Dietary Supervisor. The facility's policy on taste testing, dated 2017, was not adhered to, as food that did not pass the taste test due to seasoning or other negative factors was still served. The Dietary Supervisor and Registered Dietician acknowledged the issues with the menu and the potential for weight loss among residents due to the lack of palatable food options. The Registered Dietician noted the need for a better nutritional menu equivalency for different meal textures, as residents were not receiving the planned menu items.
Improper Use of Low-Temperature Dishwasher
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, specifically in the use of a low-temperature dishwasher. During an observation, it was noted that the dishwasher's temperature gauge read 111 F, below the required 120 F necessary for proper sanitation. Despite this, the Dietary Assistant (DA) 1 continued to use the machine without notifying a supervisor, contrary to the facility's policy. DA 1 acknowledged that the temperature was insufficient to kill germs and bacteria, yet proceeded to wash and store dishes as if they were sanitized. Further interviews revealed that another Dietary Assistant (DA 2) was also aware of the inadequate temperature but was unsure of alternative methods to clean the dishes if the dishwasher was not functioning properly. The Dietary Supervisor confirmed that staff should have reported the issue and used a three-compartment sink as an alternative. The failure to adhere to these procedures posed a risk of foodborne illness to the 90 residents served by the kitchen.
Resident Dignity Compromised by Inappropriate Care Instructions
Penalty
Summary
The facility failed to ensure that a resident's dignity was maintained when a staff member instructed the resident to urinate in a diaper instead of providing assistance to use a bedpan or toilet. Resident 178, who was admitted with a need for assistance with personal care, reported feeling terrible after being told to urinate in the diaper. The resident was continent and typically used a bedpan, as confirmed by CNA 11. This incident was observed and reported during interviews with the resident and staff. The Director of Nurses acknowledged that residents should not be instructed to urinate in diapers, as it is demeaning and contrary to the facility's rehabilitation goals. The facility's policy on dignity, dated June 16, 2016, emphasizes that residents should be cared for in a manner that promotes dignity, respect, and individuality. The care plan for Resident 178 indicated a need for assistance with toileting, highlighting the importance of providing appropriate support during activities of daily living.
Failure to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to provide a homelike environment for three residents due to damaged walls in their rooms. Observations revealed that the walls behind the beds of these residents were in disrepair, with paint and drywall scraped and peeling. Interviews with the residents indicated that maintenance had not assessed or repaired the damage, despite the residents' awareness of the issue. Staff members, including a CNA and an LN, were unaware of the disrepair and stated that the process for requesting maintenance involved filling out a repair slip at the nurse's station. The Environmental Service Director (ESD) was also unaware of the damage and explained that the mechanical beds were causing the scraping. The ESD mentioned that plastic protection sheets were being used to prevent further damage but acknowledged that complete repairs would require moving residents out of their rooms. The Director of Nursing (DON) confirmed that the damaged walls did not provide a homelike environment and emphasized the importance of timely communication with maintenance for repairs. The facility's policy on maintaining a homelike environment highlighted the need for a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Re-evaluate PASARR for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to re-evaluate a resident for the Pre-Admission Screening and Resident Review (PASARR), which is a federal requirement to ensure individuals with mental illness, developmental disability, or intellectual disability are appropriately placed in nursing homes. The resident in question was admitted with a diagnosis of schizoaffective disorder and was on antipsychotic medication. Despite these indicators, the resident was not included in the facility's PASARR review calendar for the month following their admission. The case manager acknowledged that a PASARR Level I review should have been conducted at the facility, given the resident's diagnosis and medication. The Director of Nurses also confirmed that the PASARR should have been re-evaluated to ensure the resident received proper care and to determine if a different placement was necessary. The facility's policy and procedure on PASARR indicated that such screenings are essential to determine the appropriateness of nursing facility care and the need for specialized services, but this was not adhered to in this case.
Failure to Obtain MD Orders for Splint and Medication Use
Penalty
Summary
The facility failed to provide services meeting professional standards of practice for Resident 47, who was using a left-hand splint without a Medical Doctor's (MD) order. Resident 47, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed using the splint without proper documentation or orders. The Restorative Nursing Assistant (RNA) applied the splint but did not chart its use due to the absence of an MD order, which is required for such devices. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that all splints need MD orders to ensure proper monitoring and prevent complications. Additionally, Resident 47 was found to have triamcinolone ointment on their nightstand without an MD order. The ointment, used to treat skin irritation, was left uncapped and accessible, posing a risk of misuse or allergic reactions. The licensed nurse (LN) and DSD confirmed that all treatments, including ointments, require MD orders and should be stored securely. The ointment was not prescribed, and there was no evaluation for self-administration, leading to its improper storage and potential for cross-contamination. The facility's policies require MD orders for both splint use and medication administration, which were not followed in these instances. The lack of proper orders and documentation for the splint and ointment use highlights a failure in adhering to professional standards, potentially compromising Resident 47's safety and care.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary care to maintain good grooming and personal hygiene for a resident who required dependent assistance. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was observed with long, thick, yellowish-brown fingernails with dirt-like debris underneath and old chipped nail polish. Despite having no cognitive deficits, the resident was dependent on staff for personal hygiene. Observations and interviews revealed that the resident's hand splint was not consistently applied as per the physician's orders, and nail care was neglected. Interviews with the restorative nursing assistant and the Director of Staff Development confirmed that the resident's nail care was insufficient, as the nails were long and dirty. The Director of Nursing also acknowledged that the resident was not receiving appropriate nail care. The facility's policy on nail care, which includes daily cleaning and regular trimming to prevent infections, was not followed, leading to the deficiency in maintaining the resident's personal hygiene.
Deficiency in Care for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide necessary care and services in accordance with professional standards for Resident 15, who required dependent assistance. Resident 15 was readmitted with a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side. Despite having no cognitive deficits, Resident 15 was dependent on staff for personal hygiene. Observations revealed that Resident 15's fingernails were long, thick, yellowish brown, with debris underneath, and old chipped nail polish, indicating a lack of nail care. Additionally, Resident 15's left hand, which required a splint due to contracture, was not consistently managed according to physician orders. On multiple occasions, Resident 15 reported that the staff only applied the hand splint sporadically and could not recall the last time nail care was provided. Observations confirmed that the splint was not removed within the prescribed four to six hours, and hand hygiene was neglected. The restorative nursing assistant acknowledged the oversight, noting that the splint was applied at 10:15 A.M. on one day and was not removed until the following day, contrary to the physician's orders. The assistant also admitted that Resident 15's nails were dirty and should have been cleaned and clipped. Interviews with the Director of Staff Development and the Director of Nursing corroborated the findings. They confirmed that the splint should have been removed within the specified timeframe and that nail care should have been provided. The facility's policy required that dependent residents receive necessary services to maintain grooming and hygiene, which was not adhered to in this case. The Director of Nursing emphasized the importance of following physician orders to prevent risks such as skin breakdown and infection, which were not adequately addressed for Resident 15.
Inadequate Care of Resident's Drainage Tube
Penalty
Summary
The facility failed to appropriately care for a resident's drainage tube, which was necessary for managing a peritoneal abscess and sepsis. The resident, who was admitted with these conditions, reported that the staff did not properly maintain the drainage tube, specifically noting that the accordion bulb had not been squeezed for two days. Observations confirmed that the bulb was not squeezed, which is essential for creating suction to drain fluid effectively. The physician's orders and hospital records indicated that the bulb should be squeezed to prevent infection and promote healing. Interviews with nursing staff revealed inconsistencies in understanding and executing the care required for the drainage tube. The treatment nurse stated that the bulb must be squeezed to create suction, while another nurse incorrectly believed the drain worked by gravity and did not require squeezing. The Director of Nurses confirmed that the bulb should be squeezed to remove fluids, aligning with the facility's policy on maintaining negative pressure for drainage. This lack of consistent and correct practice among staff members led to the deficiency in care for the resident's drainage tube.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications securely for two residents, leading to potential risks of medication misuse and allergic reactions. For one resident, a discontinued order for triamcinolone ointment was found uncapped and unsecured on the nightstand table. Despite the resident having no cognitive deficits, the ointment was left unattended, and there were no current orders for its use in the resident's clinical chart. Interviews with the Licensed Nurse and Director of Staff Development confirmed that the ointment should have been discarded or stored securely in a treatment cart. Another resident had a prescribed Salonpas pain patch stored on the bedside table without a self-administration safety screen. The resident had mild cognitive deficits, and the presence of the medication at the bedside was inappropriate as it required safe application and proper storage to maintain its effectiveness. The Licensed Nurse and Director of Staff Development acknowledged that the Salonpas should have been stored in the medication cart due to the lack of a self-administration evaluation. The facility's policy on medication labeling and storage, revised in February 2023, mandates that all medications and biologicals be stored in locked compartments with access limited to authorized personnel. The Director of Nursing reiterated the importance of storing medications securely to prevent misuse and preserve their effectiveness, highlighting the potential for severe allergic reactions if not properly monitored and administered.
Improper Storage of Outside Food in LTC Facility
Penalty
Summary
The facility failed to store foods brought by family and visitors in a safe and sanitary manner according to their policies and procedures, affecting two residents. Resident 59 had a bag of unlabeled apples and oranges placed at the bedside for over a week. Despite the resident's cognitive ability to understand the situation, the fruits were not stored properly, posing a risk of spoilage and foodborne illness. The facility's policy required such items to be labeled and stored in a refrigerator, but this was not followed. Additionally, the presence of fresh fruits and flowers in the room was inappropriate due to the roommate's neutropenic precautions, which require a sterile environment to prevent infection. Resident 47 also had unlabeled and improperly stored food items at the bedside, including a sandwich, chocolate pastries, and a banana. These items were not stored in a refrigerator or labeled as required by the facility's policy. The resident expressed dissatisfaction with the facility's food, leading to the family bringing outside food. However, the lack of proper storage and labeling increased the risk of spoilage and foodborne illness. The facility's policy mandates that perishable foods be stored in resealable containers with tightly fitting lids and labeled with the resident's name and use-by date. Interviews with staff, including a licensed nurse, the Director of Staff Development, and the Director of Nursing, confirmed the failure to adhere to the facility's policies. The staff acknowledged that the food items should have been stored in the designated refrigerator and labeled appropriately. The failure to follow these procedures not only posed health risks to the residents but also highlighted a lack of communication and enforcement of the facility's food storage policies.
Failure to Enforce Neutropenic Precautions
Penalty
Summary
The facility failed to maintain appropriate neutropenic precautions for Resident 58, who was admitted with a diagnosis of malignant neoplasm of the endometrium and had a low white blood cell count, making her prone to infections. Despite signage indicating neutropenic precautions, raw fruits were found in the room shared by Resident 58 and her roommate, Resident 59. Resident 59's daughter had brought the fruits weeks prior, and they were only removed after being noticed by state surveyors. Interviews with staff revealed inconsistencies in understanding and enforcing the neutropenic precautions, with some staff allowing washed fruits and vegetables, contrary to the facility's policy. The facility's policy, dated April 2018, clearly prohibited raw and partially cooked fruits and vegetables, as well as plants and flowers, in rooms of residents on neutropenic precautions. However, there was a lack of adherence to these guidelines, as evidenced by the presence of raw fruits in the room. Staff interviews indicated a lack of consistent enforcement of PPE use and visitor protocols, with some visitors not following gowning procedures. The Director of Nursing acknowledged the oversight and emphasized the importance of following the neutropenic protocol to protect Resident 58 from potential infection.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation involving a resident with severe cognitive impairment. The resident, who was admitted with metabolic encephalopathy, reported being physically abused by staff members. The Director of Nurses (DON) was informed of the abuse by a licensed nurse (LN) two days after the incidents occurred. The abuse was witnessed by a certified nurse assistant (CNA) who did not report the incidents immediately due to fear of gossip, contrary to the facility's policy requiring immediate reporting within two hours. The incidents involved a CNA witnessing another CNA physically assaulting the resident on two separate occasions. The first incident involved the resident being slapped and sustaining a cut on the hand, while the second involved the resident being pushed and choked. Despite witnessing these events, the CNA delayed reporting them to the charge nurse until the following day. The facility's policy mandates immediate reporting of abuse allegations to prevent further harm to residents, 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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