The Grove Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodland, California.
- Location
- 124 Walnut Street, Woodland, California 95695
- CMS Provider Number
- 055438
- Inspections on file
- 33
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Grove Post-acute during CMS and state inspections, most recent first.
A resident with dementia shoved a walker into another resident's legs during an argument, causing a skin tear and bruising to the left knee. The incident was witnessed by a CNA and confirmed by nursing assessment, with documentation showing the injury required dressing changes. The facility's abuse prevention policy prohibits such abuse between residents.
The facility failed to maintain sanitary conditions in the kitchen, with a used cookie wrapper and an open thickener container found in the dry storage area. Additionally, expired diced apples and boiled eggs were discovered in the walk-in refrigerator. The Dietary Manager confirmed these unsanitary conditions and expired items, which were not in compliance with the facility's policy and the US FDA 2022 Food Code.
The facility failed to ensure call lights were accessible and functional for three residents, posing a safety risk. A resident with moderate cognitive impairment had a call light out of reach and without a button, while another severely impaired resident's call light was similarly inaccessible. A third resident's call light was obscured and unreachable. Staff confirmed these issues, but they were not reported for maintenance as required by facility policy.
A facility failed to notify the responsible party of a resident's transfer to an acute care hospital, as required by policy. The resident, with severe cognitive impairment due to memory deficit and dementia, was sent to the ER for disturbing behaviors. The Director of Nursing confirmed the lack of notification, which is against the facility's policy requiring documentation of such notices.
A facility failed to submit a resident's MDS within the required timeframe. The resident's discharge assessment was completed and transmitted more than 14 days after discharge, contrary to the facility's policy and federal requirements. The MDS Coordinator confirmed the delay, and the DON expected adherence to submission timeframes.
A facility failed to complete a required PASARR for a resident admitted with Major Depressive Disorder. The resident's medical record indicated the need for a new Level 1 Screening if the stay exceeded 30 days, which was not done. The DON and Administrator confirmed the oversight during an interview, and no additional PASARR documentation or policy was provided upon request.
A LTC facility failed to adhere to professional standards of care for several residents. A nurse administered the wrong dosage of psyllium powder to a resident, while another resident's feeding tube became blocked due to improper medication administration. Additionally, a resident received another's insulin, and the order for compression socks was not followed. Another resident's catheter was not flushed as ordered, leading to sediment buildup. These actions indicate a failure to follow physician orders and facility policies.
A resident with vascular dementia, at risk for wandering, was not wearing a prescribed wander guard during multiple observations, despite an active order. The ADON confirmed the oversight, and the DON acknowledged the necessity of the device for the resident's safety. The facility's policy requires strategies for residents at risk of unsafe wandering.
A facility failed to communicate pharmacy recommendations to a physician for a resident with insomnia, who had multiple PRN orders for Melatonin. The Consultant Pharmacist recommended discontinuing one PRN order, but there was no documented evidence that the physician was informed. The DON confirmed the issue, but the MRD could not find documentation of communication, leading to a deficiency.
A facility experienced a medication error rate of 23.08% due to multiple administration errors. A nurse gave a resident the wrong dosage of psyllium powder, another resident received insulin from a different resident's supply, and a third resident's feeding tube was blocked after medications were improperly administered together. These incidents highlight failures in following prescribed orders and facility policies.
A resident with Type 1 Diabetes Mellitus received insulin from another resident's supply due to a nurse's failure to check the label properly. The nurse, in a hurry, administered 22 units of insulin glargine without verifying the correct supply, despite having undergone training in proper medication administration. The facility's policy requires verification of the right resident, medication, dose, time, and method before administration.
A resident with Type 1 Diabetes Mellitus had their insulin glargine order changed to 22 units daily, but the vial label still indicated 27 units. During a medication administration, a nurse confirmed the discrepancy. The ADON noted the label should have been updated to prevent errors, as per facility policy.
The facility failed to have written agreements for dialysis services for two residents with end-stage renal disease. Despite policy requirements, the facility did not secure a contract with the dialysis provider, as confirmed by the Administrator. This oversight could lead to a lack of accountability in the care provided.
The facility failed to maintain effective infection control, with deficiencies in PPE disposal for a resident on Enhanced Barrier Precautions, improper insulin administration without disinfecting the vial top, and overdue nebulizer tubing changes and improper storage of an incentive spirometer for another resident. These lapses increased infection transmission risks.
A resident experienced discomfort due to a shattered glass patio door covered with plastic in their room, which was not repaired despite requests. The maintenance log showed the issue was reported, but only a temporary fix was applied. An invoice for repair was found without a signed acceptance, and the facility's maintenance policy was not followed.
A resident with severe cognitive impairment and multiple fractures experienced a delay in the reporting of an injury of unknown origin. Despite the X-ray results indicating a fracture on June 22, the facility's management was not informed until June 24, contrary to the facility's policy requiring immediate reporting. This delay hindered the investigation process and reduced the facility's ability to protect the resident from harm.
A resident with severe cognitive impairment and aggressive behaviors was not accurately documented in the MDS, despite evidence of frequent physical aggression. Staff interviews confirmed the behaviors, but the MDS was improperly coded, potentially affecting the resident's care plan.
The facility failed to protect two residents from physical abuse when they were involved in an altercation, resulting in one resident sustaining a skin tear and bruising. The incident occurred over a disagreement about a balcony door, leading to both residents swinging their arms at each other. The altercation and resulting injuries were confirmed by both residents and documented in their medical records.
The facility failed to report an alleged physical abuse incident between two residents within the required two-hour timeframe. Both residents confirmed a physical altercation, but the incident was not reported to the Department immediately as per facility policy.
The facility failed to provide a safe and homelike environment. A resident's low air loss mattress was not in good working condition for five months, and five rooms had peeling paint and damaged drywall. Despite complaints, no maintenance reports were made.
A resident identified as a good candidate for bladder retraining did not receive the necessary interventions, leading to a decline in continence. Despite being initially continent and aware of the need to toilet, the resident became frequently incontinent due to the lack of a scheduled toileting program. Staff interviews and record reviews confirmed the absence of a bladder retraining program, contrary to the facility's policy.
The facility failed to replace used E-Kit boxes and did not administer IV antibiotics per physician's order for a resident with sepsis. The E-Kits were not replaced within the required 72 hours, and the resident did not receive the full dose of antibiotics as prescribed.
A resident with dementia was administered Seroquel without adequate indication for over six months. Despite no documented episodes of physical aggression, the resident continued to receive the medication without attempts at dose reduction or non-pharmacological interventions. Staff interviews and record reviews confirmed the lack of justification for the medication use.
The facility failed to properly store medications for 120 residents. Expired ertapenem intravenous medication bags were found in the medication refrigerator, and three loose pills were found in a medication cart. Additionally, two prescription blister packs were found displaced and stuck in the back of the medication cart. The DON confirmed that medication storage areas should be checked every shift and cleaned to ensure proper medication accounting.
The facility failed to prepare foods that conserved nutritive value, flavor, and palatability when a cook did not follow recipes or measure ingredients for stir fry vegetables and pureed meals. The Registered Dietitian confirmed that this practice could alter nutrition, and the facility's policy emphasized the importance of following specific recipes.
The facility failed to store, prepare, and distribute food safely, affecting 117 residents. Issues included improper food labeling, expired foods, unsafe food temperatures, ice build-up in the freezer, dirty kitchen areas, and improper thermometer use. These deficiencies were confirmed by the AD and DM, posing potential health hazards.
A resident with a history of falls and a right femur fracture did not receive the ordered physical therapy (PT) evaluation and treatment. Despite physician orders to start PT, the facility failed to provide the necessary services, and the resident's physician was not notified of the non-compliance. The lack of communication and documentation contributed to the deficiency.
The facility failed to follow infection prevention and control practices when a blood pressure monitor was not disinfected between uses and an exhaust fan above the clean linen area in the laundry room was found to be coated with a thick, sticky substance. These lapses were confirmed by staff and violated the facility's policies.
The facility failed to complete and transmit the discharge MDS assessment for a resident with essential hypertension within the required time frame. The MDS Coordinator confirmed that the assessment was missed and not completed on time, resulting in the most recent MDS resident assessment not being reported to CMS as required.
A facility failed to ensure the MDS for a resident accurately reflected the resident's POLST, leading to a discrepancy where the MDS indicated 'Attempt resuscitation / CPR' while the POLST indicated 'Do Not Attempt Resuscitation (DNR)'. This was confirmed by the MDSC and DON, highlighting a failure to correct the information during the MDS admission assessment.
The facility failed to refer a resident for a PASRR assessment after the resident received a new mental illness diagnosis. Despite being diagnosed with Schizoaffective disorder and Major Depressive disorder, the resident's PASRR Level I assessment from 2011 was not updated, and no referral for a PASRR Level II assessment was made. Interviews with staff confirmed the oversight, and the facility's policy requiring adherence to CMS guidelines was not followed.
The facility failed to develop a comprehensive care plan for a resident refusing nail care. Despite being cognitively intact and having long, dirty fingernails, the resident's refusals were reported but not documented or addressed in a care plan, contrary to facility policy.
A resident with hemiplegia and hemiparesis was observed with extremely long and dirty fingernails, despite being dependent on staff for personal hygiene. The resident had been refusing care, and the staff failed to document the refusals or create a care plan addressing the issue, leading to a deficiency in nail care.
The facility failed to provide adequate supervision and assistive devices for two residents, leading to falls. One resident fell while being assisted by a CNA who turned her back, and another resident fell from bed due to the absence of side rails and fall mats, despite physician orders and care plan interventions. Facility policies on resident safety and supervision were not followed.
The facility failed to provide sufficient fluids to a resident at risk for dehydration, who had severe cognitive impairment and was dependent on staff for hydration. Despite the Registered Dietitian's assessment of a daily fluid need of 1625 ml, the resident's average intake was only 874 ml. Observations and staff interviews confirmed inadequate assistance and monitoring, with the resident's water pitcher consistently placed out of reach and no documented evidence of water being offered at night.
A resident with COPD and respiratory failure received more oxygen than prescribed, as the oxygen concentrator was set at 3 L/min instead of the ordered 2 L/min. The facility's policy requires reviewing physician's orders and care plans to ensure proper oxygen flow, which was not followed, potentially causing harm to the resident.
The facility failed to properly dispose of garbage and refuse when one of the four covers of the garbage dumpster was found open during an observation with the Assistant Dietary Manager. The AD confirmed the dumpster should have been shut to prevent bacteria contamination, as per facility policy and the US FDA 2022 Food Code.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and mental abuse when one resident shoved a walker into another resident's legs, resulting in a skin tear. The incident occurred after an argument between the two residents, one of whom had a diagnosis of dementia and was seated in a wheelchair, while the other was cognitively intact and standing. A certified nursing assistant witnessed the event, confirming that the walker was pushed into the standing resident, causing a skin tear to the left knee with bleeding that required dressing changes. Documentation and interviews confirmed the injury, with the affected resident displaying a circular scab and bruising on the left knee during observation. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents. The incident was recognized by staff as physical abuse, and the injury was directly linked to the altercation between the two residents.
Unsanitary Kitchen Conditions and Expired Food Items
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during a survey. In the dry storage area, a used cookie wrapper was found on a shelf next to condiment sauce bottles. Additionally, a thickener container was left open and exposed to air, containing a piece of yellow cereal and a silver foil piece. The Dietary Manager (DM) acknowledged these unsanitary conditions and confirmed that the area was not maintained according to sanitary standards. In the walk-in refrigeration area, expired food items were discovered. A plastic container of diced apples with an expiration date that had passed was found, as well as a container of boiled eggs that were also expired. The DM confirmed the expiration of these items. The facility's policy and procedure on food storage, which requires routine cleaning and proper storage of dry bulk food in containers with tight covers, was not followed. The US FDA 2022 Food Code also mandates that equipment and surfaces be clean and free of debris, which was not adhered to in this instance.
Inaccessible Call Lights Pose Safety Risk
Penalty
Summary
The facility failed to ensure that call lights were accessible and in good repair for three residents, which posed a safety risk by limiting their ability to call for help. Resident 16, who was moderately cognitively impaired and required substantial assistance for daily activities, had a call light that was not within reach and lacked a red button to press for help. This issue was observed multiple times over several days, and staff confirmed the call light's inaccessibility and the absence of a button. Resident 24, who was severely cognitively impaired and dependent on staff for assistance, also had a call light that was out of reach and missing a red button. Observations confirmed the call light's inaccessibility, and staff acknowledged the safety risk. Despite the facility's process for reporting equipment repairs, there was no record of the missing button being reported for Resident 24. Resident 1, who was severely cognitively impaired and required maximum assistance, had a call light that was out of reach and obscured by other items. Staff confirmed the call light's inaccessibility and the potential harm if the resident attempted to get out of bed without assistance. The facility's policy required call lights to be accessible and defective ones to be reported promptly, but this was not adhered to, as evidenced by the lack of maintenance reports for the missing buttons.
Failure to Notify Responsible Party of Resident Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's transfer to an acute care hospital, which is a requirement under the facility's policy. The resident, who was admitted in December 2024, had several diagnoses including memory deficit following cerebral vascular disease and dementia, indicating severely impaired cognition. On December 13, 2024, the resident was sent to the emergency room due to disturbing behaviors. However, there was no documentation that the RP was informed of this transfer. During an interview, the Director of Nursing confirmed the lack of notification and stated that the expectation was for the licensed nurse to notify the RP before a resident is transferred. The facility's policy, dated October 2022, requires that appropriate notice be documented in the medical records when a resident is transferred or discharged.
Delayed Submission of MDS for a Resident
Penalty
Summary
The facility failed to submit a Minimum Data Set (MDS) for a resident within the required regulatory timeframe. The resident was admitted and later discharged from the facility, but the discharge assessment was not completed and transmitted within 14 days of discharge as required. During an interview and record review, the MDS Coordinator confirmed that the discharge assessment was delayed. The Director of Nursing expected the MDS Coordinator to adhere to the submission timeframes. The facility's policy and a document titled 'Assessments for the RAI' both stipulated that the MDS completion date for discharge assessments must be completed no later than 14 calendar days after discharge.
Failure to Complete PASARR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to ensure that a PASARR (Pre-admission Screening and Resident Review) was completed for one of the sampled residents, who was admitted with a diagnosis of Major Depressive Disorder. The resident was admitted in December 2024, and the PASARR document indicated that if the individual remained in the nursing facility for more than 30 days, a new Level 1 Screening should be resubmitted on the 31st day. During a review of the resident's medical record, it was found that this additional PASARR was not completed. The Director of Nursing and the Administrator confirmed during an interview that the PASARR was missed and acknowledged that it should have been done. A request for additional PASARR documentation and the facility's PASARR policy was made, but no documentation was provided.
Medication and Care Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide services according to professional standards of quality for several residents. For Resident 13, a licensed nurse did not follow the physician's order when administering psyllium powder. Instead of giving the prescribed tablespoon mixed in 8 ounces of water, the nurse administered a teaspoon mixed in 5 ounces of water. This deviation from the prescribed dosage was confirmed by the nurse during a review of the resident's order summary report. Resident 83, who receives nutrition and medication through a feeding tube, experienced a medication administration error. The nurse combined multiple medications and administered them simultaneously through the feeding tube, which led to the tube becoming blocked. The Assistant Director of Nursing confirmed that the medications should have been administered separately with water flushes in between to prevent blockage. Resident 115 was given another resident's insulin supply, and the order for compression socks was not followed. The nurse admitted to using the wrong insulin vial due to being in a hurry. Additionally, there was no documentation of Resident 115's refusal to wear compression socks, and the care plan for their use was not initiated until much later. Resident 33's physician order to flush an indwelling Foley catheter was not followed, leading to the presence of thick yellow sediment and cloudy urine in the catheter tubing. The treatment nurse confirmed that the catheter should have been flushed as ordered.
Failure to Implement Wander Guard Order for Resident at Risk of Elopement
Penalty
Summary
The facility failed to adhere to safety measures for a resident diagnosed with vascular dementia, who was at risk for wandering and elopement. The resident, admitted in November 2024, had an active order for a wander guard to be applied to the left arm or wrist and checked every shift. However, during multiple observations on March 4th, 5th, and 6th, 2025, the resident was not wearing the wander guard as ordered. This oversight was confirmed by the Assistant Director of Nursing during a review of the resident's Order Summary Report and Medication Administration Record. The Director of Nursing acknowledged that the resident should have been wearing the wander guard to ensure safety and prevent wandering incidents. The facility's policy on Wandering and Elopements, revised in 2019, mandates the identification of residents at risk for unsafe wandering and the inclusion of strategies and interventions in their care plans to maintain safety. The failure to follow the order for the wander guard increased the resident's risk for elopement.
Failure to Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident during a Medication Regimen Review (MRR) were communicated to the physician. The resident, who was admitted with multiple diagnoses including insomnia, had multiple orders for Melatonin to treat insomnia and regulate circadian rhythm. The Consultant Pharmacist identified an irregularity in the resident's medication regimen, noting two PRN orders for Melatonin and recommended that one should be discontinued. Despite the facility's policy requiring the communication of pharmacy recommendations to the physician, there was no documented evidence that the physician was notified of the pharmacy's recommendation to discontinue one of the PRN Melatonin orders. The Director of Nursing confirmed the presence of multiple PRN orders and acknowledged that one should have been discontinued. However, the Medical Records Director could not find documentation that the physician was informed of the pharmacy's recommendations, leading to a deficiency in the facility's medication management process.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 23.08% for a census of 132 residents. Licensed Nurse 1 (LN 1) did not adhere to the physician's order for Resident 13, administering a teaspoon of psyllium powder in 5 ounces of water instead of the prescribed tablespoon in 8 ounces. This discrepancy was confirmed during a review of Resident 13's Order Summary Report. Additionally, Resident 115, who has Diabetes Mellitus, was administered another resident's insulin glargine due to LN 2's failure to properly check the label on the insulin vial. LN 2 admitted to being in a hurry and not verifying the medication before administration. Furthermore, Resident 83, who receives nutrition and medication through a feeding tube due to anoxic brain damage, experienced a blockage in the feeding tube. LN 2 combined and administered multiple medications simultaneously without flushing the tube between each medication, contrary to the facility's policy. This led to the tube becoming plugged, requiring intervention from the Assistant Director of Nursing. The Director of Nursing confirmed that all nurses had received training in medication administration, including through feeding tubes, and were expected to follow these protocols to prevent such errors.
Medication Error: Insulin Administered from Wrong Supply
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a licensed nurse administered insulin from another resident's supply. Resident 115, who was admitted with Type 1 Diabetes Mellitus, was supposed to receive 22 units of insulin glargine daily in the morning. However, during a medication administration, the nurse did not properly check the label on the insulin vial and used another resident's insulin supply. This error occurred because the nurse was in a hurry and neglected to verify the name on the insulin vial. The incident was observed when the nurse checked Resident 115's blood sugar level, which was 375, and then proceeded to administer the insulin without verifying the correct supply. The Director of Nursing later confirmed that all nurses had undergone skills training in proper medication administration and were expected to follow the seven rights of medication administration. The facility's policy on administering medications, revised in 2019, also emphasized the importance of verifying the right resident, medication, dose, time, and method before administration.
Failure to Update Insulin Label Leads to Potential Medication Error
Penalty
Summary
The facility failed to update the medication label for a resident when their insulin glargine order was changed. The resident, who was admitted with Type 1 Diabetes Mellitus, had an order for insulin glargine to be administered at 22 units daily in the morning. However, during a medication administration observation, it was noted that the label on the insulin vial still indicated a dosage of 27 units, which was incorrect. The Licensed Nurse confirmed the discrepancy between the order and the label on the vial. Further review with the Assistant Director of Nursing confirmed that the insulin vial label had not been updated to reflect the new order of 22 units. The ADON acknowledged that the nurse responsible for changing the order should have updated the label and attached an order sticker to alert other nurses of the change. The facility's policy on administering medications, revised in 2019, requires that medications be administered safely and as prescribed, with the individual administering the medication verifying the correct dose by checking the label.
Lack of Written Agreements for Dialysis Services
Penalty
Summary
The facility failed to ensure that services provided by outside resources had written agreements in place, specifically for dialysis services for two residents. Resident 56 and Resident 96, both diagnosed with end-stage renal disease and dependent on renal dialysis, were receiving dialysis treatments at a clinic without a formal contract between the facility and the dialysis provider. This lack of agreement was confirmed during interviews with the facility's Administrator, who acknowledged that the contract was not available for review. The facility's policies and procedures require written agreements with agencies providing services to residents, including dialysis services. These agreements are meant to outline how care will be managed and how information will be exchanged between the facility and the service provider. Despite these requirements, the facility did not have the necessary agreements in place, potentially leading to a lack of responsibility and accountability in the dialysis services received by the residents.
Infection Control Deficiencies in PPE Disposal, Insulin Administration, and Equipment Maintenance
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. For Resident 15, personal protective equipment (PPE) was not properly contained, with a used gown protruding from a trash bag tied to the closet handle. This was confirmed by a licensed nurse who acknowledged the lack of appropriate disposal containers due to a high number of residents on Enhanced Barrier Precautions (EBP). The infection preventionist also confirmed that improper containment of used gowns poses an infection control issue. For Resident 115, a licensed nurse failed to follow proper infection control practices during insulin administration. The nurse did not disinfect the top of the insulin vial before withdrawing the medication, which was acknowledged as an oversight. The facility's policy requires the disinfection of the vial top to prevent infection, a practice that was not adhered to during the observed medication administration. Resident 46's nebulizer tubing was not changed as scheduled, and the incentive spirometer was improperly stored. The nebulizer tubing was overdue for replacement, and the incentive spirometer was found below the bed, out of the resident's reach. The Director of Nursing confirmed that the nebulizer tubing should be changed every 14 days and stored properly, while the incentive spirometer should be accessible and replaced every 30 days. These lapses in infection control practices increased the risk of infection transmission among residents.
Failure to Maintain Homelike Environment Due to Unrepaired Patio Door
Penalty
Summary
The facility failed to maintain a homelike environment for a resident when a patio door in the resident's room was found to be in disrepair. The resident, who was admitted with multiple diagnoses including muscle weakness, difficulty walking, and depression, expressed discomfort due to the shattered glass patio door covered with plastic. Despite the resident's requests for repair over several weeks, the issue remained unresolved, impacting the resident's comfort and potentially their psychosocial well-being. The maintenance log indicated that the issue was reported on January 4, 2025, but the maintenance director confirmed that only a plastic film was applied and the door was not replaced. An invoice for window repair dated January 27, 2025, was found, but there was no signature of acceptance for the proposed estimate. The facility's policy and procedure for maintenance service, which requires maintaining the building in good repair and free from hazards, was not adhered to in this instance. The administrator was unable to provide documentation of a signed order for the window repair.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of an injury of unknown origin in a timely manner for a resident with severe cognitive impairment and multiple fractures. The resident was admitted with a pathological fracture of the right humerus and a displaced oblique fracture of the shaft of the humerus, along with dementia. On June 19, a CNA reported the resident's right arm pain, but no swelling was noted. By June 22, the resident's arm was swollen and dark purple, prompting a family member to request an X-ray, which revealed an acute transverse distal humerus supracondylar fracture. The facility's Director of Nursing and Administrator were not informed of the fracture until June 24, despite the X-ray results being available on June 22. The facility's policy requires immediate reporting of suspected abuse or injuries of unknown origin to management and relevant authorities, which was not adhered to in this case. The delay in reporting resulted in a delay in the investigation process and decreased the facility's potential to protect the resident from harm.
Inaccurate MDS Documentation of Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for a resident accurately reflected her behavioral symptoms. The resident, who was admitted with severe cognitive impairment and multiple fractures, had a care plan indicating non-compliance with care and aggressive behaviors. However, the MDS Section E did not document these behaviors, despite evidence from the Medication Administration Record (MAR) and staff interviews indicating frequent episodes of physical aggression and combative behavior. Interviews with the Director of Nursing, Restorative Nursing Assistant, and Certified Nursing Assistants confirmed the resident's aggressive behaviors, which were not reflected in the MDS. The MDS Coordinator acknowledged the improper coding of the MDS, which failed to capture the resident's behavioral symptoms. This discrepancy between the MDS and the care plan could lead to inadequate treatment of the resident's behaviors, as the MDS is used to complete the plan of care.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents, Resident 1 and Resident 2, were free from physical abuse when they were involved in a physical altercation. Resident 1, who has moderate cognitive impairment, sustained a skin tear on her right forearm and discoloration on her right upper arm. The incident occurred when Resident 1 attempted to open the balcony door, and Resident 2, who is cognitively intact, wanted to close it. This led to both residents swinging their arms at each other, resulting in Resident 1's injuries. The altercation was confirmed by both residents and documented in their medical records and grievance investigations. Resident 1's medical records indicated that she had a skin tear approximately 3 inches long and bruising on her right upper arm. The Nurse Practitioner noted that Resident 1 reported being hit with a hard object by her roommate, leading to the injuries. Resident 2 confirmed that Resident 1 was swinging her arms and hitting her, which led Resident 2 to push Resident 1. The facility's policy on abuse prevention states that residents have the right to be free from abuse, neglect, and exploitation, but this policy was not upheld in this instance, resulting in physical harm to Resident 1.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report immediately to officials an alleged violation involving physical abuse between two residents. Resident 1 reported on 5/1/24 around 8 p.m. that her roommate, Resident 2, struck the front of her right arm causing a skin tear and discoloration, as well as discoloration on her right upper arm. Both residents confirmed a physical altercation had occurred. However, the facility did not report the incident to the Department within the required two-hour timeframe as per their policy. The licensed nurse and certified nursing assistant were aware of the incident on 5/1/24 but did not notify the Administrator on the same day. During an interview and record review on 5/15/24, the Administrator confirmed that the alleged abuse happened on 5/1/24 and acknowledged that there was no proof the alleged abuse had been reported to the Department within two hours of becoming aware of the situation. The facility's policy, dated 12/2023, stipulates that any suspicion of resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately to the administrator and other officials according to state law. The policy defines 'immediately' as within two hours of an allegation involving abuse or resulting in serious bodily injury.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for its residents. One resident, admitted with diagnoses including difficulty in walking and low back pain, had a low air loss (LAL) mattress that was not in good working condition. The mattress had two rows of deflated support surfaces in the middle portion, which was confirmed by the Maintenance Supervisor (MS) and Central Supply (CS). Despite the resident's complaints and a Certified Nursing Assistant (CNA) being aware of the issue, no report was made in the maintenance log, and the problem persisted for five months. The Director of Nursing (DON) stated that the expectation was for CNAs to report such issues to either the nurse or maintenance and document it in the maintenance log, which did not happen in this case. Additionally, five of the twelve sampled rooms had holes and peeling paint on the walls. Observations confirmed that rooms 458, 459, 561, 565, and 566 had patches of paint peeling and damage to the drywall. Both the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed the disrepair in these rooms. The facility's policy indicated that maintenance service should be provided to all areas of the building and that the building should be maintained in good repair, which was not adhered to in these instances.
Failure to Provide Bladder Retraining Program
Penalty
Summary
The facility failed to administer appropriate treatment and services to maintain continence for a resident who was assessed as a candidate for bladder retraining. Despite being identified as a good candidate for bladder retraining upon admission, the resident did not receive any bladder retraining or scheduled toileting program. This lack of intervention led to the resident's decline in continence, as documented in subsequent assessments and interviews with staff and the resident herself. The resident, admitted with multiple diagnoses including muscle weakness and difficulty in walking, was initially continent and aware of the need to toilet. However, over time, the resident became frequently incontinent. The resident expressed that she could maintain continence if assisted promptly but often had to wait for staff assistance, leading to episodes of incontinence. Staff interviews confirmed that the resident was not placed on any bladder retraining program or scheduled toileting. The facility's policy on urinary continence and incontinence management was not followed, as there was no documented evidence of a toileting plan or bladder retraining being implemented for the resident. The Director of Nursing acknowledged the oversight and confirmed that the resident should have been provided with a toileting retraining program, which was not done, resulting in the resident's decline in bladder function.
Failure to Implement Pharmaceutical Policies and Administer IV Antibiotics
Penalty
Summary
The facility failed to implement its pharmaceutical policies and procedures, affecting a census of 120 residents. During an inspection of the medication room, two used and unsealed E-Kit boxes were found. E-Kit #3 was previously opened with one out of three medications missing, and E-Kit #16 was accessed with one out of four medications missing but not replaced by the pharmacy. The Infection Preventionist (IP) nurse and the Director of Nursing (DON) acknowledged the issue, and the facility's policy indicated that opened kits should be replaced within 72 hours, which was not followed in this case. Additionally, Resident 433's intravenous (IV) antibiotics were not administered per the physician's order. The resident, admitted with sepsis, had an IV antibiotic bag labeled Ampicillin 2 GM/100 ml NS hanging on the IV pole with approximately 30 ml of medication remaining and not attached to the resident. The IP nurse confirmed that the medication was started but not fully administered, and the Assistant Director of Nursing (ADON) verified that the entire medication was not given. The DON stated that staff should follow the doctor's orders and ensure all medication is infused, as per the facility's policy on administering medications.
Unnecessary Administration of Seroquel
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs when the resident was administered Seroquel without adequate indication. The resident, who was admitted with dementia without behavioral, psychotic, or mood disturbances, was prescribed Seroquel for dementia manifested by physical aggression. However, the resident's records showed no documented episodes of physical aggression in the months leading up to and following the prescription. Despite this, the resident continued to receive Seroquel for over six months without documented justification or attempts at dose reduction or non-pharmacological interventions. Interviews with staff, including CNAs and the DON, revealed that the resident did not exhibit aggressive behaviors and was not a danger to herself or others. The DON acknowledged that the clinical records did not support the use of Seroquel and that non-drug interventions were not attempted. The facility's policy on psychotropic medication use emphasized the need for clinical indications and non-pharmacological approaches, which were not followed in this case. The Consultant Pharmacist also confirmed that Seroquel was not FDA-approved for dementia treatment and should only be used short-term for aggression or psychosis, neither of which were documented for the resident. The failure to adhere to these guidelines resulted in the resident receiving unnecessary medication, placing her at risk for adverse effects and further decline in health.
Improper Medication Storage
Penalty
Summary
The facility failed to properly store medications for a census of 120 residents. During an observation of the medication storage room for units 2 and 3, two expired ertapenem intravenous medication bags were found in the medication refrigerator. The Licensed Nurse (LN) acknowledged the expired medications and stated they should have been removed. The Director of Nursing (DON) confirmed that storage rooms are to be checked for expired medications every shift, and the expired medications should have been removed. The facility's policy and procedure (P&P) indicated that nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and expired medications should be returned or destroyed as per the dispensing pharmacy's instructions. Additionally, three loose pills were found in the bottom drawer of a medication cart for unit 2, which were acknowledged by LN 2 and the DON. The DON stated that medication carts are expected to be cleaned after each shift to ensure medications are properly accounted for. Furthermore, two prescription blister packs were found displaced and stuck in the back of the medication cart. LN 2 and the DON acknowledged that the blister packs should not have been stuck there, and the medication carts are expected to be cleaned and prepared for the next shift. The facility's P&P indicated that medications should be stored in an orderly manner to prevent mixing medications of several residents.
Failure to Follow Recipes and Measure Ingredients in Food Preparation
Penalty
Summary
The facility failed to prepare foods that conserved nutritive value, flavor, and palatability when vegetables and pureed meals were prepared without following the recipe with measured ingredients. During an observation in the kitchen, Cook 1 (CK 1) was seen preparing stir fry vegetables and adding unmeasured garlic powder and salt by pouring into her gloved hand. The Registered Dietitian (RD) confirmed that recipes should be followed and ingredients measured to ensure proper taste and nutrition. The facility's recipe for stir fry vegetables specified exact measurements for ingredients, which were not followed by CK 1. Further observations revealed that CK 1 prepared pureed chicken, vegetables, and noodles without measuring ingredients or following recipes. CK 1 added unmeasured amounts of broth and thickener to the blender, resulting in inconsistent preparation. The RD stated that not following recipes for pureed diets could alter nutrition. The facility's policy and procedure on food preparation emphasized the importance of conserving nutritive value, flavor, and appearance by following specific recipes, which CK 1 did not adhere to during the preparation of meals.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety, affecting 117 residents. Observations revealed multiple issues, including improper food labeling, expired foods not being discarded, and food items not being kept at safe temperatures. Specifically, undated cereal bowls, incorrectly dated mayonnaise containers, and expired produce and condiments were found. The egg and tuna salads were stored at temperatures above the safe range, posing a potential health hazard. The Assistant Dietary Manager (AD) and Dietary Manager (DM) confirmed these observations and acknowledged the potential risks involved. Further inspection of the kitchen revealed significant maintenance and cleanliness issues. Ice build-up was observed around the freezer door frame, and ice crystals and freezer burns were found on food items stored in the reach-in freezer. The can opener had missing metal from the cutting blade, and various kitchen areas, including dry food storage and the refrigerator, were found to be dirty with dust, dirt, and food debris. Additionally, a box of lentils was left open to air, and wet pans and a stained blender container were improperly stored. These conditions were confirmed by the AD and DM, who acknowledged the need for maintenance and cleaning. Improper use of a thermometer during food temperature checks was also noted. A cook was observed inserting the full length of the thermometer probe into cooked chicken, with the thermometer head touching the food. The DM confirmed that this was not the correct procedure and that it posed a potential contamination risk. The facility's policies and procedures were reviewed, and it was found that they were not being followed correctly, leading to these deficiencies in food safety and sanitation practices.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitation services for Resident 4, who did not receive a physical therapy (PT) evaluation and treatment as ordered by the resident's physician. Resident 4 was admitted with multiple diagnoses, including high blood pressure and heart disease, and had a history of multiple falls, with the last fall resulting in a right femur fracture. Despite a physician's order dated 1/16/24 to start PT and progress to weight-bearing as tolerated, there was no documented evidence that Resident 4 received the required PT evaluation and treatment. Additionally, another physician order dated 3/19/24 to start PT was also not followed, and the resident's physician was not notified of the failure to implement the orders. During an interview, Resident 4 expressed concerns about not receiving therapy and stated that she had been waiting for therapy since January. The Restorative Nursing Assistant (RNA) confirmed that no exercises had been provided to Resident 4 since her leg fracture and that she had informed the rehabilitation director about the resident's desire to walk. The Physical Therapist (PT) acknowledged that Resident 4 had not received PT following her fracture and was unaware of the physician's order dated 3/18/24 due to a lack of communication and the order not being entered into the electronic charting system. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that the physician orders for PT were not followed and that Resident 4 did not receive the prescribed therapy. The facility's policy on scheduling therapy services indicated that therapy should be scheduled in accordance with the resident's treatment plan and documented in the resident's medical records, which was not adhered to in this case.
Infection Control and Laundry Room Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in two instances. First, during a medication pass observation, a Licensed Nurse (LN) used a blood pressure monitor to measure a resident's blood pressure and then parked the device in the hallway without cleaning and disinfecting it according to the manufacturer's instructions. The LN admitted to forgetting to clean the equipment between patients. The facility's policy and procedure, as well as the manufacturer's instructions, clearly state that such equipment must be disinfected between uses to prevent infection spread. Interviews with the Infection Prevention (IP) nurse and the Director of Nursing (DON) confirmed that the equipment should have been sanitized before and after use. Second, during an observation of the laundry room, an exhaust fan located above the clean linen area was found to be coated with a thick, sticky substance. The Laundry and Housekeeping Supervisor (LHS) confirmed that the fan had not been cleaned for a while and acknowledged that the substance could contaminate the clean linen when the fan was turned on. The Administrator (ADM) was aware of the issue but indicated that no one had been assigned to clean the fan. The facility's policy on laundry and linen handling emphasizes the importance of maintaining a clean environment to prevent contamination, but this policy was not followed in this instance.
Failure to Complete and Transmit Discharge MDS Assessment on Time
Penalty
Summary
The facility failed to ensure the discharge MDS (Minimum Data Set) assessment was completed and transmitted to the CMS (Centers for Medicare and Medicaid Services) System within the required time frame for one resident, who was part of a census of 120. Resident 112, who had multiple diagnoses including essential hypertension, was discharged from the facility on December 6, 2023. During an interview and record review on April 12, 2024, the MDS Coordinator confirmed that the discharge assessment for Resident 112 was missed and not completed on time. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the discharge assessment should have been completed within 14 days of discharge and transmitted within 7 days after completion. This failure resulted in the most recent MDS resident assessment not being reported to CMS as required.
Inaccurate MDS Documentation of POLST
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for one resident accurately reflected the resident's Physician's Order for Life Sustaining Treatment (POLST). Specifically, the MDS Section S for the resident was inaccurately documented as indicating 'Attempt resuscitation / CPR' when the resident's POLST indicated 'Do Not Attempt Resuscitation (DNR)'. This discrepancy was identified during a review of the resident's clinical record and confirmed by the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON). The MDSC acknowledged that the information should have been corrected during the MDS admission assessment. The resident involved had multiple diagnoses, including acute paralytic syndrome following a cerebral infarction. The inaccurate documentation in the MDS Section S occurred on multiple dates and was not aligned with the resident's expressed wishes as documented in the POLST. The DON confirmed that the MDS assessment should match the POLST to ensure the resident receives appropriate care. This failure had the potential to result in the resident receiving interventions contrary to their choices.
Failure to Refer Resident for PASRR Assessment After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer one of its residents, who had received a new mental illness diagnosis, for a Pre-Admission Screening and Resident Review (PASRR) as required by federal regulations. Resident 22, who had been admitted to the facility in late 2011, was diagnosed with Schizoaffective disorder in November 2021 and Major Depressive disorder in August 2017. Despite these diagnoses, the resident's PASRR Level I assessment, conducted in October 2011, indicated that no referral for a PASRR Level II assessment was needed, and no subsequent referral was made following the new diagnoses. Interviews with the Medical Records Director (MRD) and the Minimum Data Set Coordinator (MDSC) confirmed that Resident 22 was not referred for a PASRR Level II assessment after the new mental illness diagnosis. The Director of Nursing (DON) acknowledged that PASRR assessments should be updated if there is a change in the resident's condition. The facility's policy, effective January 2016, mandates the use of CMS guidelines to ensure that residents with mental illness receive necessary services, but this policy was not followed in the case of Resident 22.
Failure to Develop Comprehensive Care Plan for Resident Refusing Nail Care
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident who was refusing nail care. Resident 20, who was admitted with hemiplegia and hemiparesis following cerebrovascular disease, was observed with extremely long fingernails on the left hand and dirty fingernails on the right hand. Despite being cognitively intact, as indicated by a BIMS score of 14, Resident 20 had been refusing nail care and showers. This refusal was reported by CNA 7 to the nursing staff, but no care plan was developed to address these refusals. During an interview, the DON confirmed that Resident 20's left hand fingernails were extremely long and curling, while the right hand fingernails were dirty, possibly from bowel movement. The DON acknowledged that Resident 20 did not want his nails to be touched and that staff had informed her of his refusals. However, there was no documentation or care plan in place to address this issue, which was against the facility's policy that requires care plans to include measurable objectives and timeframes, and to document any refusals of care by residents.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received necessary nail care. Resident 20, who was admitted with hemiplegia and hemiparesis affecting the right side, was observed with extremely long fingernails on the left hand and dirty fingernails on the right hand. Despite being cognitively intact and dependent on staff for personal hygiene, the resident's nails were not trimmed or cleaned, posing a risk of infection and self-inflicted injury. The resident had been refusing care, including showers, and this refusal was reported to the nurse by the Certified Nursing Assistant (CNA). However, there was no care plan addressing the resident's refusals for nail care, and the staff did not document the risks associated with the refusal or take appropriate interventions as per the facility's policy. The Director of Nursing (DON) confirmed the observations and acknowledged that the resident's refusal to have his nails trimmed was not documented or care planned. The facility's policies on nail care and activities of daily living require staff to document refusals and notify supervisors, but these steps were not followed. The DON stated that her expectation was for staff to document and care plan any new problem or situation, which was not done in this case. The lack of documentation and care planning for the resident's refusal to receive nail care led to the deficiency identified in the report.
Failure to Ensure Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices for two residents, leading to falls. Resident 87, who had a history of falls and required assistance from two staff members, fell while being assisted by a CNA. The CNA turned her back to open a bathroom door, causing the resident to fall backward. The Director of Nursing confirmed that the resident typically required two-person assistance and that the fall could have been prevented with proper supervision. Resident 90, who was in a vegetative state and required two staff members for bed mobility, fell from his bed due to the absence of side rails and fall mats. Despite physician orders and care plan interventions requiring side rails and fall mats, these were not in place at the time of the fall. The Director of Nursing and other staff confirmed the resident's condition and the lack of required safety measures. The facility's policies on resident safety and supervision were not followed, leading to these incidents. The policies required frequent visual checks, proper positioning, and the use of assistive devices like side rails and fall mats, which were not consistently implemented. The deficiencies highlight a failure to adhere to established safety protocols, resulting in preventable falls for both residents.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide sufficient fluids to Resident 97, who was identified at risk for dehydration. Despite the Registered Dietitian's assessment indicating a daily fluid need of 1625 ml, Resident 97's average daily intake was only 874 ml, significantly below the required amount. Observations revealed that the resident's water pitcher was consistently placed out of reach, and the resident, who was dependent on staff for feeding and drinking, was not assisted adequately. Interviews with staff confirmed that the resident was unable to drink independently and relied entirely on staff for hydration, yet there was no documented evidence that water was offered at night or that fluid intake was monitored and addressed appropriately in nursing summaries. Resident 97, who had severe cognitive impairment and multiple diagnoses including dementia, was observed multiple times with dry lips and an open mouth, indicating potential dehydration. The Director of Nursing acknowledged that the resident's fluid intake was not meeting the estimated needs and that there was a lack of documentation and monitoring regarding the resident's hydration status. The failure to provide adequate fluids and monitor the resident's hydration placed Resident 97 at further risk for dehydration.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with the physician's order and the resident's care plan for one of the sampled residents, resulting in the resident receiving more oxygen than prescribed. Resident 80, who was admitted in 2021 with multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure, had a physician's order for oxygen at 2 liters per minute (L/min) via nasal cannula. However, during observations on two separate occasions, the oxygen concentrator was set at 3 L/min, exceeding the prescribed amount. Licensed Nurse 5, who was familiar with Resident 80's care, confirmed that the oxygen was being delivered at 3 L/min instead of the ordered 2 L/min and acknowledged that the oxygen delivery should be checked every shift. The facility's policy on oxygen administration, dated October 2010, requires reviewing the physician's orders and the resident's care plan to ensure the proper flow of oxygen is administered. The Director of Nursing (DON) validated that administering supplemental oxygen at a higher rate could be harmful to Resident 80's health and emphasized that nurses are expected to follow the physician's orders. This failure to adhere to the prescribed oxygen therapy had the potential to cause serious health complications for Resident 80.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly when one of the four covers of the garbage dumpster was found open during an observation and interview with the Assistant Dietary Manager (AD) in the parking lot. The AD confirmed the observation and acknowledged that the dumpster should have been shut to prevent bacteria contamination. The facility's policy and procedure (P&P) indicated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that the lids are closed. Additionally, the US FDA 2022 Food Code requires outside receptacles for refuse containing food residue to have tight-fitting lids, doors, or covers. This deficiency was observed during a kitchen tour for a facility with a census of 120 residents, highlighting a failure to adhere to proper waste disposal protocols.
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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