The Pines At Placerville Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Placerville, California.
- Location
- 1040 Marshall Way, Placerville, California 95667
- CMS Provider Number
- 055497
- Inspections on file
- 40
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Pines At Placerville Healthcare Center during CMS and state inspections, most recent first.
The facility did not designate a physician to serve as medical director, resulting in a lack of oversight and coordination for the implementation of resident care policies and medical care.
The facility failed to maintain safe room temperatures for several residents due to a broken HVAC system, resulting in discomfort. Despite being aware of the issue, the maintenance department delayed ordering floor heaters, and residents were left with inadequate heating solutions. Staff acknowledged the problem, but the facility's actions were insufficient to address the residents' needs.
The facility failed to meet food safety standards, with uncovered facial hair on dietary staff, an unclean juice machine, improperly stored wet utensils, and the use of unpasteurized eggs. Additionally, a dietary aide lacked knowledge of proper dishwashing procedures, highlighting training deficiencies.
A facility failed to accurately document controlled medications for four residents, leading to discrepancies between the MAR and CDR. Residents with chronic pain, osteoarthritis, peripheral vascular disease, and cancer had inconsistencies in the administration records of hydrocodone-acetaminophen and lorazepam. The DON acknowledged the importance of consistent documentation for accountability and proper medication timing.
A long-term care facility experienced a medication error rate of 17.95% due to improper administration of medications to four residents. Errors included late administration, incorrect dosages, and failure to follow prescribed methods. These issues were confirmed through observations and interviews with nursing staff and the DON.
The facility failed to follow prescribed dietary menus for residents on therapeutic diets during lunch meals. Residents on CCHO, DM texture, and FF diets received incorrect food items, such as full slices of garlic bread, regular rice and beans, and inappropriate desserts. These discrepancies were confirmed by the Dietary Supervisor and Registered Dietitian, potentially compromising the residents' medical and nutritional status.
The facility failed to accommodate the food preferences of five residents during meal service, as meal tickets were not followed. Residents did not receive specific food items as indicated, such as cottage cheese, side salad with blue cheese dressing, and ice cream. Interviews with the Dietary Supervisor and RD confirmed these findings, acknowledging the kitchen staff's failure to provide the food items as indicated. The facility's policy stated that residents' food preferences should be adhered to.
The facility failed to implement proper infection control practices, including sanitizing medical equipment between uses and providing nail care for residents. Additionally, a CNA did not adhere to neutropenic precautions for a resident with multiple myeloma, failing to wear protective equipment. The facility lacked a specific policy for neutropenic precautions.
The facility did not meet the required space standards for 10 resident rooms, with several rooms providing less than the mandated 80 square feet per resident. Despite the space being sufficient for assistive devices and care provision, the Administrator confirmed the shortfall. Residents reported the space as adequate for their needs, and a waiver continuation was recommended.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in care. One resident's narcotic pain medication was not coded, and another's pressure ulcers were omitted from their assessments. These oversights were confirmed by the DON and MDSC during record reviews.
A resident's anticoagulant care plan was not updated in a timely manner after a medication change from rivaroxaban to apixaban. The facility's policy requires care plans to be reviewed and revised quarterly or upon receiving new orders, but this was not done, impacting the facility's ability to provide effective, resident-centered care.
The facility failed to provide proper respiratory care for two residents with COPD. One resident did not receive continuous oxygen therapy as prescribed, using it only at night with a CPAP machine. Another resident missed nebulizer treatments on two occasions, leading to shortness of breath and distress. The MAR lacked documentation for these treatments, and staff confirmed the absence of records. The DON and DSD highlighted the need for adherence to physician orders and accurate documentation.
A facility failed to follow a physician's order for fluid restriction for a resident with stage four chronic kidney disease who was dependent on dialysis. Despite an order limiting fluid intake to 1000 ml per day, three water pitchers were found on the resident's bedside table. This oversight was confirmed by a nurse and the ADON, who emphasized the importance of adhering to fluid restrictions to prevent complications. The facility's policy also stated that water pitchers should not be placed in rooms of residents with fluid restrictions.
A facility failed to adequately monitor a resident's behaviors while on quetiapine for dementia with agitation. The MAR required behavior monitoring every shift, but the night shift only had yes or no options, lacking quantification. Interviews with staff confirmed this was ineffective for assessing medication effectiveness and planning for GDR.
A facility failed to label two respiratory medications with open dates, as observed during a survey. A nurse confirmed the medications were unsealed and undated, and the DON stated that staff were expected to label medications to track expiration. This oversight increased the risk of administering expired medications.
A resident with impaired vision and dysphagia was not assisted during meals as required by her care plan, despite having an order for feeding assistance. Observations and interviews revealed that staff failed to provide necessary help, which was confirmed by the DON and the Director of Rehabilitation. This oversight contravened the facility's policy on meal assistance.
A resident with severe cognitive decline and a history of aggressive behavior physically assaulted another resident in an LTC facility. The incident, witnessed by a CNA, involved the resident punching another in the stomach. Despite having a care plan to manage aggressive behavior, the facility failed to prevent this altercation, which was confirmed by the DON and Administrator.
The facility failed to ensure that two residents were treated with dignity and respect. One resident had to wait three hours on a bedpan for assistance, while another resident's call light was not accessible, leading to delays in receiving help. The facility's policies on answering call lights and promoting dignity were not followed.
A resident with cognitive impairment and at risk for elopement left the facility unnoticed due to non-functional or semi-functional wanderer monitoring systems on exit doors. The resident's care plan and physician's order for a wander guard were not followed, leading to the resident's fall and injuries. Staff interviews revealed that door alarms were either not functioning or had low sound levels, and there was a lack of adherence to facility policies for monitoring and maintaining the wanderer monitoring system.
Failure to Designate Medical Director for Resident Care Policies
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a physician to serve as the medical director. This physician is responsible for the implementation of resident care policies and the coordination of medical care within the facility. The absence of a designated medical director resulted in a lack of oversight and coordination for resident care policies and medical services, as required.
Failure to Maintain Safe Room Temperatures
Penalty
Summary
The facility failed to maintain a safe and comfortable room temperature for four residents, as observed during a survey. The room temperatures in the facility's back hallway were recorded below the acceptable range, with temperatures ranging from 67.1 to 70.2 degrees Fahrenheit. The Maintenance Director confirmed these low temperatures and acknowledged that the HVAC system was broken, affecting rooms 33-38. Despite being aware of the issue since early December, the maintenance department did not provide alternative heat sources until much later, leaving residents in discomfort. Residents expressed their discomfort and dissatisfaction with the cold temperatures. One resident, wearing a hospital robe and covered with multiple blankets, reported feeling cold since Thanksgiving and stated that requests for a floor heater were ignored. Another resident, also diagnosed with heart failure, mentioned having a cold nose and ears despite being given extra blankets. A third resident, wearing a winter robe, expressed frustration over the ongoing cold conditions and the lack of effective solutions. The fourth resident, who had multiple diagnoses including heart failure and cirrhosis, reported closing a window to prevent cold air from entering and using an oxygen compressor for warmth. Interviews with staff revealed that the issue was known to the Director of Nursing and the Administrator, who acknowledged the need for room temperatures to be between 71 and 81 degrees Fahrenheit. The facility's policy required maintaining a comfortable temperature and ensuring the building was in good repair. However, the maintenance department failed to order floor heaters promptly, and the facility did not provide adequate alternative heating solutions, leading to prolonged discomfort for the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during a survey. Two dietary staff members were found with uncovered facial hair, which is against the facility's policy and the FDA Food Code 2022, which requires hair restraints to prevent contamination of food and clean equipment. The Dietary Supervisor confirmed the lack of beard guards and acknowledged the oversight. Additionally, the juice machine in the kitchen was found to be unclean, with sticky residue and dust accumulation, contrary to the facility's policy that mandates daily cleaning and maintenance. The Dietary Supervisor admitted the machine was not cleaned as required, highlighting a lapse in adherence to sanitation protocols. Furthermore, several kitchen utensils were improperly stored while still wet, which could foster microbial growth, violating both the facility's policy and FDA guidelines that require air-drying before storage. The facility also failed to ensure the use of pasteurized eggs, as raw shelled eggs were found in the refrigerator and served to residents, including those who consumed over-easy eggs with running yolks. This practice poses a risk of foodborne illness, especially in a vulnerable elderly population. The Dietary Supervisor was unaware of the unpasteurized eggs being delivered and acknowledged the error. Moreover, a dietary aide demonstrated a lack of knowledge in the correct manual dishwashing process, with expired food handler certification and failure to attend relevant in-service training, further indicating gaps in staff training and compliance with established procedures.
Inconsistent Documentation of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substance medications for four residents, leading to discrepancies between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR). Resident 33, diagnosed with chronic pain syndrome, had inconsistencies in the documentation of hydrocodone-acetaminophen administration on specific dates, with doses recorded in the CDR but not in the MAR, and vice versa. Similarly, Resident 51, with primary osteoarthritis and chronic pain, had hydrocodone-acetaminophen doses documented in the MAR but missing from the CDR, and vice versa, on various dates. Resident 37, suffering from peripheral vascular disease and abnormal posture, also had discrepancies in the documentation of hydrocodone-acetaminophen doses between the CDR and MAR over several months. Additionally, Resident 73, with primary osteoarthritis of the hip and a malignant neoplasm of the bladder, had lorazepam doses inconsistently recorded between the CDR and MAR across multiple months. During an interview, the Director of Nursing acknowledged the importance of consistent documentation for accountability and proper medication administration timing, as outlined in the facility's policy on controlled medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 17.95% during a medication pass observation. This deficiency involved four residents and included seven medication errors out of 39 opportunities. The errors were observed during the administration of medications by licensed nurses, who did not adhere to prescribed medication schedules and dosages. Resident 3, diagnosed with gastro-esophageal reflux disease and glaucoma, received medications incorrectly. The nurse administered omeprazole later than the prescribed time and failed to instill eye drops correctly. Additionally, the nurse administered a lower dose of vitamin D3 than ordered. Resident 38, with atherosclerosis and peripheral vascular disease, received cilostazol within a meal timeframe, contrary to the order to administer it 30 minutes before or two hours after a meal. Resident 55, diagnosed with cerebral infarction, was given enteric-coated aspirin in a crushed form, which was against the order for chewable aspirin. Resident 67, with kidney atrophy and hydronephrosis, did not receive omeprazole before a meal as prescribed and missed a dose of phenazopyridine due to its unavailability. These errors were confirmed through interviews with the nurses involved and the Director of Nursing, who acknowledged the deviations from prescribed medication administration times and methods.
Failure to Follow Prescribed Dietary Menus
Penalty
Summary
The facility failed to adhere to the prescribed dietary menus for residents on therapeutic diets during lunch meals on 10/21/23 and 10/22/23. On 10/21/23, two residents on a consistent or controlled carbohydrate (CCHO) diet received a full slice of garlic bread instead of the prescribed half slice. Another resident on a dysphagia mechanical (DM) texture diet with thin liquids was served pudding instead of the prescribed ice cream. Additionally, a resident on a finger food (FF) diet received spaghetti instead of the specified bowtie or twister pasta and did not receive a dessert. On 10/22/23, three residents on a DM texture diet were served regular rice and beans instead of the prescribed puree version, and puree apple bread pudding instead of soaked chopped bread pudding. Two residents on a renal and CCHO diet received white rice and regular dessert instead of brown rice and diet dessert. Furthermore, two residents on an FF diet were served pork cut in slices, penne pasta, and diced pear dessert instead of the prescribed bite-sized pork, diced potato with margarine, and apple bread pudding cut in four pieces. These discrepancies were confirmed by the Dietary Supervisor and Registered Dietitian, who acknowledged the failure to follow the menu, potentially compromising the medical and nutritional status of the affected residents.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of five residents during meal service, as observed during a lunch meal distribution. The meal tickets, which included residents' diets, allergies, and specific food preferences, were not followed. For instance, a resident on a regular diet did not receive cottage cheese, while another on a sodium-restricted diet did not receive a side salad with blue cheese dressing. Additionally, a resident on a mechanical soft texture diet did not receive several items, including cottage cheese and chicken noodle soup, and a resident on a dysphagia mechanical texture diet did not receive ice cream. Another resident on a no added salt fortified diet also did not receive cottage cheese. Interviews with the Dietary Supervisor and Registered Dietitian confirmed these findings, acknowledging that the kitchen staff failed to provide the food items as indicated on the meal tickets. The facility's policy on food preferences, dated 2023, stated that residents' food preferences should be adhered to, and the Dietary Supervisor's job description included assessing resident food preferences and checking trays for accuracy before delivery. These deficiencies had the potential to result in meal dissatisfaction and decreased meal intake, which could further compromise the residents' medical and nutritional status.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a medication pass. Licensed Nurse 1 (LN 1) used a blood pressure cuff and stethoscope on a resident in a room with Enhanced Barrier Precautions and did not sanitize the equipment before using it on another resident. LN 2 also failed to change gloves after resident care before sanitizing medical equipment. The Director of Nursing confirmed that equipment should be sanitized between uses and gloves should be changed, as per facility policy. Nail care was neglected for several residents, including those with dementia, muscle weakness, and hemiplegia. Observations revealed long, jagged fingernails with black substances underneath, which residents expressed a desire to have trimmed. The Director of Nursing stated that nail care should be provided weekly, and untrimmed nails could pose an infection risk. The facility's policy indicated that residents unable to perform daily activities independently should receive assistance with grooming and hygiene. Certified Nurse Assistant 5 (CNA 5) did not adhere to neutropenic precautions for a resident with multiple myeloma, failing to wear a gown and mask upon entering the resident's room. The Infection Preventionist confirmed that all staff and visitors should wear protective equipment to prevent infection. The facility lacked a specific policy for neutropenic precautions, relying instead on general isolation guidelines.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 10 resident rooms met the required space standards, with rooms 3, 4, 5, 6, 7, 8, 9, 15, and 16 measuring 228.55 square feet for three residents, equating to 76.2 square feet per resident, and room 14 measuring 159.38 square feet for two residents, equating to 79.7 square feet per resident. This deficiency was identified through observation, interviews, and record reviews, confirming that the rooms did not meet the minimum requirement of 80 square feet per resident. Despite the space being adequate for storing assistive devices and facilitating care, the Administrator acknowledged the shortfall in space per resident. Interviews with residents indicated that they felt the space was adequate for their care needs. The Department recommended the continuation of a waiver for these rooms.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care. Resident 18, who was admitted with a compression fracture of the vertebra, had an order for tramadol hydrochloride, a narcotic pain medication, which was not coded in her MDS admission assessment. This oversight was confirmed during a review with the Director of Nursing (DON), who acknowledged the omission of the opioid medication order in the MDS assessment. Similarly, Resident 48, admitted with an intertrochanteric left femur fracture, had pressure ulcers on the left heel and coccyx that were not accurately coded in her MDS admission assessment. The MDS coordinator (MDSC) was unaware of these pressure ulcers and confirmed the omission during a review of the resident's records. The DON expressed that the expectation was for the nurse responsible for the assessments to complete them accurately to ensure appropriate care and interventions for the residents.
Failure to Update Anticoagulant Care Plan
Penalty
Summary
The facility failed to revise and update the care plan for a resident in a timely manner, specifically concerning the resident's anticoagulant medication. The resident, who was admitted in November 2022 with a diagnosis of hemiplegia, had an anticoagulant care plan dated March 2024. This care plan indicated the resident was receiving rivaroxaban. However, a physician's order showed that rivaroxaban was discontinued and replaced with apixaban on September 9, 2024. During an interview and record review, the Assistant Director of Nursing confirmed that the care plan had not been updated to reflect the change in medication. The facility's policy requires care plans to be reviewed and revised at least quarterly or as soon as a new order is received. The failure to update the care plan decreased the facility's ability to provide resident-centered care and evaluate its effectiveness.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards for two residents. Resident 19, who was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), was observed not using her prescribed continuous oxygen therapy. Despite the physician's order for continuous oxygen via nasal cannula at two liters per minute, Resident 19 only used oxygen at night with her CPAP machine. This inconsistency was confirmed by both the Licensed Nurse and the Infection Preventionist, who noted that the resident was not on oxygen during their observations. The Director of Nursing acknowledged that the nursing staff should have followed the physician's orders and revised them if necessary. Resident 40, also diagnosed with COPD, missed scheduled nebulizer treatments on two occasions, as documented in the medication administration record (MAR). The resident reported experiencing shortness of breath and distress due to the missed treatments. The MAR lacked documentation for the administration of ipratropium bromide inhalation on the specified dates, which was confirmed by the Licensed Nurse. The Director of Nursing and the Director of Staff Development emphasized the importance of accurate and timely documentation, stating that if it was not documented, it was not done. The facility's policy requires compliance with professional standards and proper documentation of care provided.
Failure to Adhere to Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide dialysis care and services consistent with professional standards for a resident with stage four chronic kidney disease. The resident, admitted in January 2017, had a physician's order for fluid restriction of 1000 milliliters per day, divided into 700 ml for dietary and 300 ml for nursing. Despite this order, three water pitchers were observed on the resident's bedside table, indicating a failure to adhere to the fluid restriction. This oversight was confirmed by a licensed nurse during an observation and interview. Further review of the resident's records and input/output logs by the Assistant Director of Nursing (ADON) confirmed the fluid restriction order due to the resident's dependence on dialysis, which was scheduled three times a week. The ADON stated that it was expected for nurses to follow the physician's orders to prevent complications such as fluid overload. The facility's policy on fluid restriction, reviewed in 2024, also indicated that residents with such orders should not have water pitchers placed in their rooms, highlighting a clear deviation from established protocols.
Inadequate Monitoring of Resident's Behaviors on Quetiapine
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident prescribed quetiapine for dementia with agitation and combativeness. The resident was admitted with a diagnosis of dementia with behavioral disturbance and was prescribed quetiapine 25 mg at bedtime. The facility's Medication Administration Record (MAR) required behavior monitoring for agitation and combativeness every shift, but the night shift only had yes or no options to indicate whether behaviors occurred, lacking a section to quantify the behaviors. Interviews with Licensed Nurse 4 and the Director of Nursing revealed that the night shift's yes or no options were ineffective for quantifying behaviors, which was necessary to assess the medication's effectiveness and plan for gradual dose reduction (GDR). The facility's policy on antipsychotic medication use required staff to observe, document, and report pertinent information regarding the effectiveness of interventions, including antipsychotic medications, to the attending physician. The lack of quantification during the night shift hindered the ability to make informed decisions about the resident's medication management.
Failure to Label Medications with Open Dates
Penalty
Summary
The facility failed to ensure that two medications in a medication cart were properly labeled with open dates, which is a requirement for maintaining medication safety. During an observation and interview, a Licensed Nurse confirmed that two respiratory treatment medications were found unsealed and without open dates in a medication cart. Specifically, an opened and undated foil pouch of budesonide nebulization suspension and a box with an Advair Diskus inhaler were identified. The Licensed Nurse acknowledged that nursing staff were expected to write open dates on pouches containing respiratory medications and that the dates on the medication and box were confusing. The Director of Nursing stated that the expectation was for nursing staff to label medications with open dates to ensure proper tracking and disposal of medications. The facility's policy on medication labeling indicated that medications should be labeled appropriately, following the manufacturer's expiration date for inhalers. The failure to label these medications with open dates increased the potential for administering expired medications to residents, as there was no way to determine when the medications should be discarded.
Failure to Assist Visually Impaired Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance to a resident with impaired vision, identified as Resident 48, during meal times. Resident 48, who was admitted with a diagnosis of dysphagia and significant visual impairment, was observed not eating during lunch because she could not see her food. Despite having an order for feeding assistance and a care plan indicating the need for help due to her visual deficits, staff did not assist her during meals. This lack of assistance was confirmed through interviews with Resident 48, who reported that she was not helped during meals, and with the Director of Rehabilitation, who acknowledged the resident's need for assistance. Further review of Resident 48's records, including her Baseline Care Plan and Minimum Data Set, confirmed her impaired vision and the requirement for feeding assistance. The Director of Nursing also acknowledged that Resident 48 should always be assisted when eating to ensure she receives proper nutrition. The facility's policy on meal assistance, which mandates assistance for residents who cannot feed themselves, was not adhered to in this case, leading to a failure in meeting the resident's nutritional needs.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when an incident occurred where one resident physically assaulted another. Resident 1, who has a history of aggressive behavior and severe cognitive decline due to paranoid schizophrenia and bipolar disorder, was observed punching Resident 2. This incident was witnessed by a Certified Nurse Assistant (CNA 2) who reported seeing Resident 1 punch Resident 2 in the stomach. The altercation was confirmed by the Director of Nursing and the Administrator during interviews. Resident 1's care plan indicated a history of aggressive and combative behavior, with interventions such as providing distractions to calm the resident. Despite these measures, the incident occurred, suggesting a failure in effectively managing Resident 1's behavior. Resident 2, who has mild cognitive decline and a history of verbal aggression, may have triggered Resident 1's reaction. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse, yet this incident highlights a lapse in ensuring this protection.
Failure to Ensure Dignity and Timely Assistance for Residents
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect. Resident 1 had to wait three hours on a bedpan for assistance. Despite pressing the call light multiple times, the resident was not attended to promptly. The resident's daughter had to be called for help, and the resident expressed feelings of neglect and being less important. Interviews with CNAs and the Director of Nursing confirmed the incident and highlighted a failure to meet the facility's expectation of answering call lights within five minutes. Resident 2's call light was not accessible when she was in her wheelchair, making it difficult for her to request assistance. During observations, the call light in Resident 2 and another resident's room was on for an extended period without being answered. Multiple staff members were observed walking past the call light without responding. Resident 2 expressed frustration about not being able to find her call light and not receiving timely assistance to go to the bathroom. The facility's policies on answering call lights, activities of daily living, and promoting dignity were not followed, leading to these deficiencies. The failure to respond to call lights and provide timely assistance compromised the residents' dignity and ability to receive necessary care.
Resident Elopement Due to Non-Functional Monitoring Systems
Penalty
Summary
The facility failed to prevent an avoidable accident involving a resident who eloped from the facility, resulting in a fall and subsequent injuries. The resident, who had a history of cognitive impairment and was at risk for elopement, was able to leave the facility unnoticed due to non-functional or semi-functional wanderer monitoring systems on three out of four main entrance/exit doors. The resident's elopement care plan and physician's order for a wander guard were not followed, contributing to the incident. The resident had been admitted with multiple diagnoses, including traumatic subdural hemorrhage, cerebral infarction, and cognitive communication deficit, and was assessed as being at risk for elopement. Despite this, the facility's staff failed to adequately monitor the resident's whereabouts and ensure the proper functioning of the wander guard and door alarms. Interviews with staff revealed that the door alarms were either not functioning or had low sound levels, making it difficult for staff to hear and respond to potential elopements. Additionally, the facility's policy and procedures for monitoring and maintaining the wanderer monitoring system were not adhered to. Staff were unaware of the resident's wander guard status, and there was a lack of communication and responsibility regarding the checking and maintenance of the wander guard and door alarms. This lack of adherence to established protocols and failure to ensure the safety of a resident at risk for elopement resulted in the resident's unauthorized departure and subsequent injuries.
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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