The Meadows Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Panorama City, California.
- Location
- 14857 Roscoe Boulevard, Panorama City, California 91402
- CMS Provider Number
- 056137
- Inspections on file
- 47
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at The Meadows Post Acute during CMS and state inspections, most recent first.
A cognitively intact resident with COPD, heart failure, and type 2 DM was seated on a patio interacting with other residents when another cognitively intact resident in a wheelchair suddenly stood up and struck the resident in the right eye area with a closed hand, causing a laceration, bruising, and mild pain. Documentation on SBAR and skin assessments described the wound characteristics and discoloration, and interviews with the resident and staff confirmed that the contact was willful and non-consensual. The facility’s abuse policy defined such resident-to-resident contact as abuse and affirmed residents’ right to be free from abuse, neglect, misappropriation, and exploitation.
A resident with osteoarthritis and immunodeficiency reported unclean shower rooms, including mold odor and visible black discoloration in a shower booth. Facility staff confirmed the presence of black spots in multiple areas of the shower, and the janitor responsible for cleaning lacked a set schedule or checklist for deep cleaning. Facility policy required regular cleaning and a homelike environment, but these standards were not met.
A resident with impaired cognition and multiple chronic conditions attended an IDT care conference without the responsible party being notified or invited, despite facility policy and regulatory requirements. Interviews and record reviews confirmed the lack of notification and documentation, resulting in the responsible party not being able to participate in care planning and treatment decisions.
A resident with rheumatoid arthritis and other chronic conditions did not receive a scheduled Remicade IV infusion after an RN failed to promptly communicate an outpatient clinic's notification to the DON. The RN only notified the physician and assumed the resident would receive the infusion after discharge, resulting in a delay of treatment and not meeting the facility's policy for timely care.
A resident with multiple respiratory diagnoses was not provided with continuous oxygen therapy as ordered by the physician. During an observation, the resident was found without oxygen or related supplies, and both an LVN and the DON confirmed that the resident should have been receiving continuous oxygen at the prescribed rate.
A LTC facility failed to administer a prescribed medication for itchiness to a resident with prurigo nodularis, missing doses on two occasions. Additionally, the facility did not obtain physician orders before administering the COVID-19 vaccine to two residents with severe cognitive impairments, using an outside pharmacy without securing necessary documentation. These actions violated the facility's medication administration policy.
A facility failed to provide coordinated hospice services to a resident admitted to hospice care. There was no documented evidence of hospice staff presence, and the facility lacked a designated coordinator to manage hospice care. The resident, with severe cognitive impairment and multiple diagnoses, did not receive well-coordinated hospice services due to these deficiencies.
The facility failed to implement its infection control program by not ensuring a resident's oxygen tubing was labeled and off the floor, and by transporting clean laundry uncovered. The oxygen tubing for a resident with respiratory issues was found touching the floor and undated, contrary to facility policy. Additionally, laundry staff transported clean clothes uncovered, risking contamination, which was against the facility's guidelines.
A facility failed to complete a resident's Quarterly MDS assessment on time, as required by CMS guidelines. The resident, with neuropathy and difficulty walking, was admitted in 2021 and readmitted in 2022. The assessment, due 14 days after the ARD, was completed late, contrary to the facility's policy.
The facility failed to document non-pharmacological interventions before administering PRN opioid pain medication to two residents. Despite care plans outlining non-pharmacological strategies, hydrocodone-acetaminophen was frequently given without prior attempts at these interventions. Interviews confirmed the lack of documentation, contrary to the facility's policy emphasizing non-pharmacological approaches to pain management.
The facility failed to maintain safe food storage and preparation practices, as observed during a survey. Unlabeled wheat bread and English muffins were found in the kitchen, and a resident's food from home lacked a label and received date in the resident's refrigerator. The Dietary Manager and a Registered Nurse confirmed the importance of labeling to prevent foodborne illnesses, as per the facility's policies.
A facility failed to conduct a required quarterly rehabilitation screen for a resident with severe cognitive and physical impairments, as confirmed by the DOR. The resident, admitted with vascular dementia and cerebral palsy, was supposed to have a rehab screen quarterly, but no screen was conducted in August 2024. This oversight was against the facility's policy, which mandates timely and complete documentation in the EMR.
A facility failed to establish a policy for the POLST form, resulting in an incomplete form for a resident with decision-making incapacity. The resident's POLST form lacked the necessary signature from the resident or their legal decision maker, as confirmed by a registered nurse. The administrator acknowledged the absence of a specific policy, which could lead to confusion and delays in care.
The facility failed to document COVID-19 vaccine eligibility screening for two residents before administering the vaccine. Both residents had severely impaired cognition and required assistance with daily activities. The Infection Preventionist did not complete the eligibility screening section on the consent forms, contrary to the facility's policy.
A facility failed to implement proper infection control when an LVN did not wear an isolation gown and face shield before entering a resident's room under novel respiratory precautions for suspected COVID-19. Despite signage indicating the need for full PPE, the LVN entered with only an N-95 mask and gloves, potentially risking the spread of infection. The DON confirmed the requirement to follow posted precautions, as outlined in the facility's infection control plan.
A resident's call light was found out of reach, potentially delaying care. The resident, who required maximum assistance, was unable to call for help. Staff confirmed the call light's improper placement and acknowledged the oversight.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The facility failed to protect a resident from physical abuse when one cognitively intact resident struck another in the face while on the facility patio. Resident 3, who had COPD, heart failure, and type 2 diabetes and was assessed as cognitively intact with the capacity to make decisions, was seated on a patio chair interacting with other residents, including Resident 4. At approximately 10:55 a.m., while Resident 3 was conversing with the group, Resident 4, who was seated in a wheelchair in front of Resident 3, suddenly stood up and used a closed fist/hand to hit Resident 3 in the right upper eye area without warning. Resident 3’s assessments indicated that cognition was intact and that the resident required supervision or touching assistance for most ADLs. Following the incident, documentation on an SBAR form and a skin assessment described a linear cut above the right eye, initially measured at 0.5 cm in length by 0.1 cm in width and depth, with small bleeding and reddish discoloration. Subsequent observation by the ADON noted purplish discoloration around the right eye and a laceration approximately 1.0 cm in length by 0.1 cm in width and depth, covered with steri-strips. Resident 3 reported aching pain in the right eye area, rating it 2 out of 10, and expressed being shocked that the incident occurred. Resident 4’s records showed that this resident was also cognitively intact, had decision-making capacity, and required setup or clean-up assistance for most ADLs. On the date of the incident, Resident 4 was on the patio interacting with other residents, including Resident 3, in the presence of an activity staff member (ACS 1). The SBAR for Resident 4 and ACS 1’s interview indicated that Resident 4 suddenly stood up, raised a hand toward Resident 3, and, despite ACS 1’s attempt to intervene, struck Resident 3 in the right eye area. In a subsequent report to the state agency, Resident 4 stated that he felt his hand make contact with Resident 3’s face. The facility’s abuse policy stated that residents have the right to be free from abuse and that willful non-consensual contact between residents is considered abuse and is never to be deemed unavoidable.
Failure to Maintain Clean and Homelike Shower Facilities
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident by not maintaining cleanliness in the shower rooms. The resident, who had diagnoses including osteoarthritis of the left hip and immunodeficiency, reported that the shower rooms were not always clean and described smelling mold and observing black spots in the shower area during use. The resident expressed discomfort with the condition of the shower facilities, specifically noting black discoloration on the corners of the floors and around the soap rest in one of the shower booths. Multiple observations by facility staff, including maintenance assistants, the maintenance supervisor, the administrator, and the DON, confirmed the presence of black discolorations in the shower booth. These areas included around the soap rest, the cracks where the mosaic tile floors met the tile walls, and the corner edge of the tiled wall near the grab bar. Staff acknowledged that these areas were dirty and required cleaning, and the DON stated that the shower rooms should have been in better condition. Further interviews revealed that the janitor responsible for cleaning the shower rooms did not have a set schedule or checklist for deep cleaning and performed deep cleaning based on perceived need. The janitor was unable to remove the black spots and had not reported the issue to supervisors due to their absence. Facility policies reviewed indicated that residents should be provided with a clean, sanitary, and orderly environment, and that environmental surfaces should be disinfected regularly and when visibly soiled.
Failure to Notify Responsible Party of Care Conference
Penalty
Summary
The facility failed to inform the responsible party (RP) of a resident with moderately impaired cognition and multiple chronic conditions, including Parkinson's disease, rheumatoid arthritis, and type 2 diabetes, about an Interdisciplinary Team (IDT) Care Conference. The resident, who was dependent on staff for most activities of daily living and unable to make medical decisions, attended the care conference without the RP being notified or invited to participate. Review of the resident's records confirmed the absence of documentation showing that the RP was informed of the meeting. Interviews with the RP, Social Services Director (SSD), and Director of Nursing (DON) confirmed that the RP was not notified prior to the care conference, despite facility policy and federal and state regulations requiring such notification and involvement. The facility's policies emphasized the importance of including residents' families or legal representatives in care planning, but this was not followed in this instance, resulting in the RP not being able to participate in decisions regarding the resident's care, treatment, and services.
Failure to Provide Timely Remicade IV Treatment Due to Communication Breakdown
Penalty
Summary
The facility failed to provide timely intervention after being notified by an outpatient infusion clinic that a resident could not receive their scheduled Remicade (infliximab) IV treatment due to their admission to the facility. The resident, who had diagnoses including Parkinson's Disease, rheumatoid arthritis, and type 2 diabetes mellitus, was dependent on staff for multiple activities of daily living and had moderately impaired cognition. On 5/5/2025, RN 1 received a call from the outpatient clinic indicating they could not administer the Remicade IV. RN 1 notified the resident's physician but did not inform the Director of Nursing (DON) or take further steps to ensure the resident received the necessary treatment while admitted. The resident expressed concern to RN 1 on multiple occasions about the timing of the Remicade IV therapy, stating that the treatment improved mobility and ease of movement. RN 1 did not inform the DON of the situation until nearly a month later, after the resident inquired again about the therapy. The DON confirmed that timely notification would have allowed the facility to coordinate and provide the treatment. The facility's policy required timely, integrated, and efficient care, but the lack of communication and follow-up resulted in a delay of the resident's Remicade IV treatment.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
Facility staff failed to ensure that a resident received continuous oxygen therapy as ordered by the physician. The resident, who had diagnoses including cerebral palsy, chronic pulmonary edema, and bronchopneumonia, was admitted with a physician's order for oxygen at two liters per minute via nasal cannula to be administered continuously. The resident's care plan also specified the need for continuous oxygen therapy and outlined interventions to maintain the prescribed oxygen setting. During an observation in the activities room, the resident was found sitting without oxygen in place and no oxygen administration supplies nearby. The resident was unsure why the oxygen was not being used. A Licensed Vocational Nurse confirmed that the resident was not receiving oxygen at that time, despite being aware of the physician's order. The Director of Nursing also confirmed that the resident should have been receiving continuous oxygen according to the order and facility policy.
Medication Administration and Physician Order Deficiencies
Penalty
Summary
The facility failed to administer a physician-prescribed medication for itchiness to a resident diagnosed with prurigo nodularis, a chronic skin condition causing itchy bumps. The resident, who was moderately impaired cognitively and dependent on staff for personal care, did not receive the prescribed Triamcinolone cream on two occasions during the evening shift. This oversight was confirmed by a registered nurse who acknowledged the potential for discomfort and skin breakdown due to the missed medication. Additionally, the facility did not adhere to its medication administration policy by failing to obtain a physician's order before administering the COVID-19 vaccine to two residents. Both residents had severe cognitive impairments and were dependent on staff for daily activities. The facility used an outside pharmacy to administer the vaccine but did not secure the necessary physician's orders, as confirmed by the Infection Preventionist and the Director of Nursing. This lapse was attributed to a misunderstanding that the vaccine administration by an outside entity did not require a physician's order. The facility's policy on administering medications, which mandates adherence to prescribers' orders, was not followed in these instances. The lack of physician orders for the COVID-19 vaccine and the missed administration of the prescribed cream highlight deficiencies in the facility's medication management practices.
Failure to Provide Coordinated Hospice Services
Penalty
Summary
The facility failed to provide appropriate hospice services to a resident, identified as Resident 30, who was admitted to hospice care. The deficiency was identified through interviews and record reviews, which revealed that there was no documented evidence of hospice staff being physically present in the facility to provide hospice-related services to the resident. The resident, who had been admitted to the facility with diagnoses including dementia, psychotic disturbance, mood disturbance, Parkinson's disease, and heart failure, was severely impaired in cognition and dependent on assistance for daily activities. Despite an order to admit the resident to hospice on 10/23/2024, there was no record of hospice staff signing in to confirm their presence in the facility. Additionally, the facility lacked a designated staff member to coordinate care and services between the hospice provider and the facility. Interviews with the MDS Nurse and the Social Services Director revealed that there was no specific hospice coordinator, and any nursing staff or the Social Services Director would contact the hospice agency directly if needed. This lack of coordination was contrary to the facility's policy, which required a designated Social Service or Nursing Designee to coordinate care and communication between the facility and hospice staff. The facility's policy and procedure for the Hospice Program outlined the responsibilities of the designated coordinator, including collaborating with hospice representatives, coordinating facility staff participation in hospice care planning, and ensuring communication with hospice representatives and other healthcare providers. However, the absence of a designated coordinator led to a failure in ensuring well-coordinated and comprehensive hospice services for Resident 30.
Infection Control Deficiencies in Oxygen Tubing and Laundry Transport
Penalty
Summary
The facility failed to implement its infection control and prevention program in two key areas. Firstly, the facility did not ensure that a resident's nasal cannula oxygen tubing was properly labeled and kept off the floor. During an observation, it was noted that the oxygen tubing for a resident with chronic pulmonary disease and respiratory failure was touching the floor and was not dated. The Director of Nursing confirmed that the tubing should be changed weekly and labeled with the date of change to prevent contamination and infection. The facility's policy requires oxygen cannula and tubing to be changed every seven days, and the CDC guidelines highlight the risk of contamination from floors. Secondly, the facility did not adhere to its policy regarding the transportation of clean laundry. An observation revealed that laundry staff transported a cart of clean clothes uncovered, contrary to the facility's policy that mandates clean laundry to be covered during transport to prevent contamination. The Infection Preventionist confirmed that clean laundry should always be covered to maintain cleanliness and prevent infection. The facility's policy specifies that clean linen must be protected from dust and soiling during transport and storage.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of a Quarterly Minimum Data Set (MDS) assessment for a resident, which is a standardized assessment and care screening tool. This deficiency was identified during a review of the resident's records and interviews with the facility's MDS Nurse. The resident in question was originally admitted to the facility in May 2021 and readmitted in May 2022, with diagnoses including neuropathy and difficulty in walking. The resident was noted to have intact cognition and required supervision for most activities of daily living. The deficiency was discovered when reviewing the Centers for Medicare and Medicaid Services (CMS) Submission Report, which indicated that the assessment was completed more than 14 days after the assessment reference date (ARD). The ARD was set for October 18, 2024, and the assessment should have been completed by November 1, 2024. However, it was not completed until November 20, 2024. The facility's policy, last reviewed and revised in November 2024, requires that the resident assessment coordinator ensures timely assessments, with Quarterly Assessments not conducted less frequently than three months following the most recent OBRA assessment.
Failure to Document Non-Pharmacological Interventions Before Opioid Administration
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering PRN opioid pain medication to two residents, leading to a deficiency in pain management. Resident 7, who was admitted with chronic obstructive pulmonary disease and a history of falling, had a care plan that included assisting with positions of comfort. However, the facility's records showed that hydrocodone-acetaminophen was administered multiple times without documentation of non-pharmacological interventions being attempted first. Similarly, Resident 8, who was admitted with bilateral osteoarthritis of the knees, had a care plan that included non-pharmacological interventions such as repositioning and relaxation techniques. Despite this, the facility's records indicated that hydrocodone-acetaminophen was administered on several occasions without any documented evidence of non-pharmacological interventions being attempted first. Interviews with the Director of Nursing and Registered Nurse 1 confirmed the lack of documentation for non-pharmacological interventions prior to administering opioid medications. The facility's policy, which was last reviewed and revised on 11/6/2024, emphasized the importance of attempting non-pharmacological interventions to alleviate pain without medication due to potential side effects. However, this policy was not adhered to, resulting in the deficiency.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. A bag of wheat bread and a bag of English muffins were found without an open date label, which is required to inform kitchen staff when to discard the bread. The Dietary Manager (DM 1) acknowledged that labeling is necessary to ensure food items remain safe for consumption and prevent potential foodborne illnesses. Additionally, a resident's food from home stored in the resident's refrigerator was found without a label or received date, which is against the facility's policy. Registered Nurse 1 (RN 1) confirmed that leftover food brought by visitors is stored in the resident's refrigerator and should be labeled with the resident's name and the date received to ensure it is discarded after 72 hours. The facility's policy, titled 'Food Receiving and Storage,' mandates that foods be received and stored in compliance with safe food handling practices. Another policy, 'Food Brought by Family/Visitors, Receiving and Storage,' requires that food brought by family or visitors be labeled and stored in a manner that distinguishes it from facility-prepared food, with perishable items stored in resealable containers labeled with the resident's name and use-by date.
Failure to Conduct Quarterly Rehabilitation Screen
Penalty
Summary
The facility failed to implement its policy on rehabilitation screening by not conducting a quarterly rehabilitation screen for one of the sampled residents, identified as Resident 68. The resident was originally admitted with diagnoses including vascular dementia, psychotic disturbance, and cerebral palsy, which significantly impaired their cognitive and physical abilities. According to the facility's order summary report, Resident 68 was supposed to have a rehabilitation screen upon admission and quarterly thereafter. However, a review of the Rehabilitation Screening Forms revealed that no quarterly screen was conducted for Resident 68 in August 2024, as required. During interviews, the Director of Rehabilitation (DOR) confirmed the absence of the required quarterly rehabilitation screen for Resident 68 and acknowledged the importance of these screens in assessing the need for rehabilitation services. The facility's policy on rehabilitation screening and the PCC-UDA Schedule Guide emphasized the necessity of accurate, complete, and timely entries in the electronic medical record, including the completion of quarterly Rehab Screening Forms. The failure to conduct the quarterly screen placed Resident 68 at risk of not maintaining, improving, or restoring their functional abilities.
Lack of POLST Policy Leads to Incomplete Resident Form
Penalty
Summary
The facility failed to develop a specific policy and procedure for the Physician Orders for Life-Sustaining Treatment (POLST) form, which is crucial for outlining a resident's end-of-life care preferences. This deficiency was identified during a review of Resident 101's records, who was admitted with diagnoses including hyponatremia, lung disease, and metabolic encephalopathy. The review revealed that Resident 101 lacked the capacity to make decisions, and their POLST form was incomplete, missing the signature of either the resident or their legally recognized health care decision maker. This oversight was confirmed during an interview with a registered nurse, who acknowledged the importance of having a completed POLST form to ensure the resident's safety and adherence to their care preferences. Further investigation revealed that the facility's administrator admitted to the absence of a specific policy for the POLST form. The facility's governing board is responsible for establishing and reviewing policies, as indicated in their administrative management policy. However, the lack of a POLST-specific policy could lead to confusion among staff and potential delays in care. The administrator's job description emphasizes the need to direct operations in compliance with regulations and to establish policies that reflect the facility's goals, yet this critical policy was not in place, contributing to the deficiency.
Failure to Document COVID-19 Vaccine Eligibility Screening
Penalty
Summary
The facility failed to implement its COVID-19 vaccine policy by not ensuring that residents were screened for eligibility before administering the vaccine. This deficiency was identified for two residents, Resident 30 and Resident 68, who were both administered the COVID-19 vaccine without documented evidence of eligibility screening. The facility's policy requires screening for contraindications, medical precautions, and prior vaccinations before offering the vaccine. Resident 30, who has diagnoses including dementia, psychotic disturbance, and Parkinson's disease, was admitted to the facility in 2014. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and dependence on assistance for daily activities. Similarly, Resident 68, with diagnoses of vascular dementia and cerebral palsy, was admitted in 2022 and also had severely impaired cognition and dependence on assistance. In both cases, the Infection Preventionist (IP) failed to document the screening for vaccine eligibility, leaving the relevant section of the COVID-19 Vaccine Consent & Declination form blank.
Infection Control Breach by LVN
Penalty
Summary
The facility failed to implement proper infection control practices when a Licensed Vocational Nurse (LVN 1) did not wear an isolation gown and face shield before entering the room of a resident who was under novel respiratory precautions due to suspected COVID-19 infection. The resident, admitted with conditions including hemiplegia and atrial fibrillation, was placed on contact and droplet isolation as per physician's orders and care plan due to respiratory symptoms. Despite the presence of signage indicating the need for an isolation gown, N-95 mask, and face shield, LVN 1 entered the resident's room wearing only an N-95 mask and gloves. The Director of Nursing confirmed that staff should adhere to the posted novel respiratory precautions signage, which serves as a communication tool for the necessary isolation precautions. The facility's Infection Prevention Quality Control Plan, last reviewed in February 2024, outlines the requirement for personal protective equipment to prevent the spread of infection. The failure of LVN 1 to comply with these guidelines had the potential to result in the spread of infection, placing residents, staff, and visitors at risk of COVID-19.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach, which could delay resident care and assistance with activities of daily living. On 5/23/2024, Resident 2's call light was observed hanging behind the headboard frame, out of reach. Resident 2, who was admitted with a diagnosis of cerebral infarction and required maximum assistance with various activities, was unable to find or use the call light to call for help. This was confirmed during an interview with Resident 2, who stated he could not call staff for assistance. Certified Nursing Assistant 1 (CNA 1) confirmed that the call light was stuck behind the headboard and admitted she had not checked its placement since starting her shift. The Director of Nursing (DON) also stated that call lights should be within reach to promptly provide residents with needed assistance. The facility's policy, last reviewed on 2/1/2024, indicated that residents should have a means to call staff for assistance from their bed, toileting, and bathing facilities, and that the call system should remain functional at all times.
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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