The Terraces At San Joaquin Gardens Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 5551 N. Fresno St, Fresno, California 93710
- CMS Provider Number
- 055846
- Inspections on file
- 19
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Terraces At San Joaquin Gardens Village during CMS and state inspections, most recent first.
A deficiency was identified when a licensed nurse did not perform or document a complete skin assessment using the SBAR tool after a resident's family member reported an abuse allegation. The resident, who had severe cognitive impairment and multiple medical conditions, was unable to provide details about the incident. Despite facility policy requiring assessment and documentation after such reports, no evidence of a thorough assessment or SBAR note was found in the EMR.
The facility failed to maintain a safe and sanitary environment in the laundry room, as the tumble dryers were not maintained per the manufacturer's recommendations, leading to debris accumulation on the dryer's vent and pipes. This posed a potential fire hazard, risking the safety of all residents. The Director of Buildings and Grounds and the Administrator acknowledged the issue, noting that the facility's maintenance schedule did not align with the manufacturer's guidelines.
A facility failed to develop timely baseline care plans for three residents, leading to potential health risks. One resident with severe cognitive impairment and dental issues did not have a care plan addressing their dental needs. Additionally, two residents requiring oxygen therapy did not have this included in their care plans, risking hypoxia and respiratory failure. The facility's policy required care plans within 48 hours of admission, but this was not met, leaving staff without guidance for immediate health needs.
The facility failed to develop comprehensive care plans for two residents. One resident, admitted with a sling and splint, did not have a care plan for these orthopedic needs, leading to a lack of guidance for CNAs. Another resident on antibiotics for C. diff also lacked a care plan, risking continuity of care. The facility's policy requires immediate care planning upon admission, but this was not followed, resulting in deficiencies.
Two residents in a facility experienced deficiencies related to oxygen administration and repositioning orders. One resident received less oxygen than prescribed, while another had an incorrect oxygen flow rate set. Additionally, there was a failure to obtain an order for repositioning every two hours, as indicated in the provider's notes. These issues were confirmed by nursing staff and highlighted the importance of following physician orders to prevent respiratory distress and pressure ulcer worsening.
The facility failed to properly label and store medications, leading to potential errors. Discontinued medications were not separated from active ones, and a partially used insulin vial lacked an open or discard date. Staff acknowledged these oversights, which could lead to medication errors.
The facility failed to maintain a sanitary environment, as nasal cannulas for three residents were found on the floor, posing infection risks. Additionally, Enhanced Barrier Precautions were not implemented for two residents with medical conditions requiring such measures. Staff interviews revealed a lack of adherence to infection control protocols, increasing the risk of infection transmission.
A facility failed to accurately code a resident's surgical wound on the MDS assessment, despite the resident having undergone open heart surgery. The MDS Coordinator confirmed the error, acknowledging that the assessment should have indicated the presence of a surgical wound. The facility's policy requires accuracy in MDS assessments, and the Administrator emphasized the importance of this expectation.
The facility failed to ensure residents were free from unnecessary drugs, as one resident received ondansetron exceeding the maximum daily dose, and another was given apixaban without proper side effect monitoring. The ondansetron orders were not clarified, leading to a potential overdose, while the apixaban monitoring was not documented, risking unmonitored bleeding. Interviews confirmed these deficiencies, highlighting a lack of adherence to medication management policies.
A resident with severe cognitive impairment and poor dentition was not provided timely dental care upon admission, despite visible signs of decay and broken teeth. Facility staff acknowledged the oversight, noting the resident had not been evaluated by a dental hygienist or seen by a dentist. The facility's policy for dental services was not followed, resulting in the resident experiencing embarrassment and dietary changes due to her dental condition.
A resident on a mechanical soft-chopped diet was served inappropriate food, including roasted red potatoes, instead of the prescribed mashed potatoes, placing them at risk for choking. Interviews with staff revealed a breakdown in the meal preparation and delivery process, with CNAs responsible for plating food and ensuring diet orders are followed. The facility's policies for mechanical soft-chopped diets were not adhered to, as confirmed by the DON and RD.
The facility failed to document food allergies in the care plans of three residents, leading to a risk of severe allergic reactions. One resident had an allergic reaction to shrimp, requiring emergency care. Interviews with staff confirmed that the facility's policy on documenting food allergies was not followed.
A resident with a documented shrimp allergy was mistakenly served shrimp due to a failure to list the allergy on their meal ticket. This led to an allergic reaction requiring emergency treatment. The error occurred because the CDM did not enter the allergy into the meal ticket system, which is separate from the EHR.
A resident was discharged with medications belonging to another resident, resulting in the resident not receiving her prescribed medications for four days. The error was due to the LVN's failure to verify medications with current orders and review them with the resident or family member.
Failure to Assess and Document After Abuse Allegation
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow professional standards of practice after a resident's family member reported an allegation of abuse. The family member informed the nurse that the resident had stated someone was hitting her at night. The resident, who had a history of severe cognitive impairment as indicated by a low BIMS score, was unable to provide further details about the alleged incident during an interview. Despite the report, there was no documentation that a complete skin assessment was performed or that the findings were recorded using the facility's SBAR communication tool, as required by policy. The resident involved had multiple medical conditions, including a recent fracture, aphasia following a cerebral infarction, hypertensive heart disease, chronic kidney disease, and a history of falls. The resident's cognitive status was severely impaired, making it difficult for her to communicate details about the alleged abuse. Staff interviews confirmed that the resident was often confused, emotional, and frequently cried, but no prior signs or symptoms of abuse had been observed by the staff. Interviews with the DON and Administrator revealed that their expectations were for the nurse to ensure the resident's safety, perform a thorough skin assessment to check for signs of abuse, and document the assessment in the EMR using the SBAR format. However, both the DON and Administrator were unable to locate any documentation of such an assessment or SBAR note in the resident's record. The facility's policy required detailed observation and documentation in the event of a significant change in a resident's condition, which was not followed in this case.
Failure to Maintain Safe and Sanitary Laundry Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry room, as observed during a survey. The three tumble dryers in the laundry room were not maintained according to the manufacturer's recommendations, resulting in a layer of gray and white debris accumulating on the back of the dryer's vent and pipes. This accumulation of debris had the potential to create a fire hazard, putting all 50 residents at risk for displacement. During an interview, the Director of Buildings and Grounds (MAIN) and the laundry staff (LAU) acknowledged the presence of dust and debris, although LAU initially stated that the dust did not appear to be problematic. MAIN later confirmed that the facility was not following the manufacturer's guidelines for monthly maintenance of the dryer exhaust system. Further investigation revealed that the facility's maintenance schedule for the dryer exhaust ductwork was semi-annual, contrary to the manufacturer's recommendation for monthly cleaning. The Administrator (ADM) also acknowledged that the laundry room should not have dust due to the risk of contamination and fire hazards. A review of the facility's policies indicated that laundry equipment should be maintained according to the manufacturer's instructions to prevent microbial contamination. The failure to adhere to these guidelines and policies resulted in the deficiency noted in the report.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents within 48 hours of their admission, leading to potential health risks. Resident 17, who had severe cognitive impairment and a history of cancer treatments, was admitted with broken teeth and visible signs of tooth decay. Despite the evident dental issues, no specific care plan interventions were put in place to address these needs. Interviews with staff revealed that they relied on care plans to guide resident care, and without a care plan addressing Resident 17's dental needs, staff were unsure of the appropriate actions to take. Additionally, the facility did not include physician-prescribed oxygen therapy in the baseline care plans for Residents 197 and 247. Both residents required oxygen therapy due to their medical conditions, which included acute respiratory failure and dependence on supplemental oxygen. Observations and interviews indicated that the absence of oxygen therapy in the care plans could lead to the residents not receiving the necessary treatment, posing a risk of hypoxia and respiratory failure. Staff interviews highlighted the importance of care plans in ensuring that residents receive the correct treatments and monitoring. The facility's policy required baseline care plans to be completed within 48 hours of admission, including instructions for effective, person-centered care. However, the care plans for the residents in question were not completed within this timeframe, resulting in a lack of guidance for staff on how to address the residents' immediate health needs. The failure to include critical interventions in the care plans demonstrated a lapse in adhering to professional standards of quality care, as outlined in the facility's policies and procedures.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident 347, who was admitted with a sling on the left arm and a splint on the left foot. Despite being admitted with these orthopedic precautions, there was no care plan initiated for these needs until several days after admission. Interviews with CNAs revealed a lack of communication and guidance from licensed nurses regarding the care of the sling and splint, which were crucial for Resident 347's recovery from a dislocated shoulder and foot drop. The Infection Preventionist and Minimum Data Set Coordinator acknowledged the oversight and confirmed that care plans should have been initiated immediately upon admission. Similarly, the facility did not create a care plan for Resident 24, who was on an antibiotic treatment for Clostridium difficile. The resident was readmitted with a diagnosis that included malnutrition, muscle weakness, and a pressure ulcer, yet there was no care plan for the antibiotic use. The Infection Preventionist admitted that a care plan should have been developed when the antibiotic was initiated to ensure continuity of care and effective communication among the nursing staff. The Director of Nursing and the Administrator both stated that it was the responsibility of the licensed nurses to initiate care plans upon admission, with follow-up by the Director of Nursing and the Minimum Data Set Coordinator. The facility's policy requires comprehensive, person-centered care plans to be developed and implemented for each resident, reflecting recognized standards of practice. However, in these cases, the facility failed to adhere to its own policies, resulting in deficiencies in care planning for the residents involved.
Oxygen Administration and Repositioning Deficiencies
Penalty
Summary
The facility failed to meet professional standards of practice for two residents, resulting in deficiencies related to oxygen administration and repositioning orders. For Resident 98, the oxygen flow rate was not administered according to the physician's order. During an observation, it was noted that the oxygen concentrator was set to 1 liter per minute, while the physician had ordered 2 liters per minute. This discrepancy was confirmed by both a Registered Nurse and a Licensed Vocational Nurse, who acknowledged the responsibility of licensed nurses to ensure the correct oxygen flow rate is administered. The Director of Nursing also emphasized the importance of monitoring the flow rate to prevent respiratory distress. Resident 247 also experienced a deficiency in oxygen administration. The oxygen concentrator was set to 1.5 liters per minute instead of the prescribed 2 liters per minute. This was observed during an initial tour and confirmed by a Licensed Vocational Nurse, who noted the risk of inadequate oxygenation if the provider's orders were not followed. The Director of Nursing reiterated the importance of checking the oxygen flow rate to prevent desaturation and respiratory distress. Additionally, there was a failure to obtain an order to turn and reposition Resident 247 every two hours, as indicated in the provider's notes. Despite the presence of a low air loss mattress, the provider's notes specified the need for repositioning to prevent the worsening of a pressure ulcer. The Licensed Vocational Nurse and Minimum Data Set Coordinator acknowledged the lack of a written order and the expectation for nurses to follow up on provider instructions. The Director of Nursing confirmed that repositioning every two hours is a standard practice and emphasized the importance of documentation to ensure the task is implemented.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential medication errors. During an observation, it was found that a resident's discontinued ondansetron was not separated from active medications in the west wing medication cart. The Licensed Vocational Nurse (LVN) acknowledged that discontinued medications should be removed from active medications to prevent errors. Similarly, in the south wing medication cart, another resident's discontinued benzonatate was not separated from active medications, and a partially used insulin lispro vial was not labeled with an open or discard date. The LVN confirmed that the insulin vial should have been dated to avoid administering expired medication. Interviews with the Director of Nursing (DON) and the facility's Consultant Pharmacist (CRPH) highlighted the importance of removing discontinued medications and properly labeling multidose vials to prevent medication errors. The facility's policies and procedures indicated that expiration dates should be checked before administering medications and that opened multidose containers should be dated. However, these procedures were not followed, leading to the potential for incorrect medication administration.
Infection Control Deficiencies in Oxygen Management and Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to potential infection risks for several residents. Specifically, the nasal cannulas of Residents 98, 197, and 247 were found on the floor in their respective rooms, which could lead to respiratory infections. Observations and interviews revealed that the oxygen tubing was not properly managed, with staff acknowledging that the tubing should not be on the floor due to infection control concerns. The residents involved were cognitively intact and dependent on supplemental oxygen due to various medical conditions, including acute respiratory failure and pulmonary edema. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for Residents 197 and 247 upon admission, despite their medical conditions requiring such measures. Resident 197 had a colostomy, and Resident 247 had a sacral wound, both of which necessitate EBP to prevent the spread of multidrug-resistant organisms. The absence of EBP signage and procedures was confirmed through interviews with staff, who admitted that these precautions were not initiated as required. The facility's failure to follow proper infection control protocols extended to staff not adhering to EBP procedures when providing care to Resident 22. This oversight increased the risk of infection transmission among residents and staff. Interviews with various staff members, including CNAs, LVNs, and the Infection Preventionist, highlighted a lack of adherence to established infection control policies, which are crucial for preventing cross-contamination and ensuring resident safety.
Inaccurate MDS Assessment of Surgical Wound
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding a surgical wound. During an observation and interview, it was noted that the resident had a surgical wound on her midchest following open heart surgery. However, the MDS assessment did not code this surgical wound, which was confirmed by the MDS Coordinator during a review of the resident's admission assessment. The MDS Coordinator acknowledged that the assessment was incorrect and should have indicated the presence of a surgical wound. The facility's policy requires that each individual who completes a portion of the MDS assessment certifies the accuracy of their work. The Administrator expressed that the expectation was for MDS assessments to be accurate and timely. The failure to accurately code the surgical wound on the MDS assessment had the potential to result in unmet care needs for the resident. The professional reference manual used by the facility defines surgical wounds and outlines the steps for assessment, which includes examining the resident for any wounds or skin problems.
Failure to Monitor Medication Dosage and Side Effects
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs, as evidenced by two specific cases. In the first case, a resident was administered ondansetron for nausea, with active orders for both routine and as-needed doses. This resulted in a potential daily dosage that exceeded the manufacturer's recommended maximum of 24 mg per day. The resident's routine order was added after hospice care began, but the previous as-needed order was not discontinued, leading to a potential total of 28 mg per day if both orders were followed. Interviews with nursing staff and the Director of Nursing confirmed that the orders exceeded the maximum dose and that there was a lack of clarification on whether to continue or discontinue the old order. In the second case, another resident was administered apixaban, a blood thinner, without proper monitoring for side effects. The resident's care plan required monitoring for signs of bleeding and other side effects every shift, but there was no documentation in the Medication Administration Record to show that this monitoring was being conducted. Interviews with nursing staff and the Director of Nursing revealed that the monitoring was not documented, and it was acknowledged that monitoring for side effects was crucial due to the bleeding risk associated with apixaban. The facility's Consultant Pharmacist confirmed the risks associated with exceeding the maximum dose of ondansetron and the importance of monitoring for apixaban side effects. The manufacturer's package inserts for both medications highlighted the potential side effects and the need for careful monitoring. The facility's policy on medication management emphasized the need for appropriate dosing and minimizing adverse consequences, which was not adhered to in these cases.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident, identified as Resident 17, who was admitted with poor dentition characterized by visible signs of decay, missing, and broken teeth. Despite the resident's condition and her report of embarrassment due to her dental state, the facility did not ensure that she was referred to or assessed by a dental hygienist in a timely manner. This oversight was noted during a review of the resident's admission record and Minimum Data Set (MDS), which indicated severe cognitive impairment and obvious dental issues. Interviews with facility staff, including a Certified Nursing Assistant (CNA), Social Services Director (SSD), and the Director of Nurses (DON), revealed that the resident had not been evaluated by a dental hygienist or seen by a dentist since her admission. The SSD acknowledged that the resident might have been overlooked during the transition from short-term to long-term care, and there was no process in place for residents to sign a refusal of treatment for dental issues. The DON confirmed that the resident should have been offered dental services immediately upon admission. The facility's policy and procedure for dental services, dated 2016, indicated that routine and emergency dental services should be available to meet residents' oral health needs. However, the policy was not followed in this case, as evidenced by the lack of dental evaluation and services provided to Resident 17. The failure to address the resident's dental needs was further highlighted by documentation from speech therapy indicating pain with swallowing and dietary changes made to accommodate her broken teeth.
Failure to Follow Mechanical Soft-Chopped Diet
Penalty
Summary
The facility failed to ensure that menus were followed for a resident on a mechanical soft-chopped diet, which placed the resident at risk for choking. During an observation, the resident was served roasted red potatoes, which were not consistent with the mechanical soft-chopped diet order. The resident's meal ticket indicated a diet order of mechanical soft-chopped, but the meal served did not comply with this order, as it included red roasted potato wedges instead of mashed potatoes. Interviews with facility staff revealed a breakdown in the meal preparation and delivery process. The Executive Chef stated that the kitchen prepares the food and delivers it to the satellite kitchen for plating by the nurses, while the Certified Dietary Manager (CDM) indicated that Certified Nursing Assistants (CNAs) are responsible for plating the food. The CNAs receive training on therapeutic diets, but there was a failure in ensuring the correct diet was served to the resident. The Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN) confirmed that the tray line process involves checking the meal ticket for the correct diet order, but the oversight in this case led to the resident receiving an inappropriate meal. The Registered Dietician (RD) emphasized the importance of following therapeutic diets to minimize the risk of complications from diseases. The facility's policies and procedures outline the requirements for mechanical soft-chopped diets, which include ensuring that foods are fork-tender and meats are chopped. However, the facility did not adhere to these guidelines, as evidenced by the meal served to the resident. The Director of Nursing (DON) acknowledged that the failure to follow the menu could result in the resident not receiving the diet ordered by the physician, potentially leading to choking.
Failure to Document Food Allergies in Care Plans
Penalty
Summary
The facility failed to develop and implement a resident-centered comprehensive care plan for three residents, specifically regarding their food allergies. Residents 1, 2, and 3 did not have care plans addressing their food allergies, which included shrimp, peanut butter flavor, and shellfish, respectively. This oversight placed these residents at risk of being served foods they were allergic to, with the potential for severe allergic reactions. The deficiency was identified during interviews and record reviews, where it was noted that the facility's policy and procedure for documenting food allergies in care plans was not followed. Resident 1 experienced an allergic reaction to shrimp, requiring emergency department transfer, highlighting the critical nature of the oversight. Interviews with facility staff, including an LVN, the Certified Dietary Manager, the Infection Preventionist, the Director of Nursing, and the Administrator, confirmed that the facility's policy on food allergies was not adhered to. The facility's policy required that food allergies be documented in the care plan upon admission and as part of the comprehensive assessment, but this was not done for the affected residents.
Resident Served Allergen Due to Documentation Error
Penalty
Summary
The facility failed to ensure that a resident with a documented shrimp allergy was served food that accommodated their allergies. On a specific date, the resident was mistakenly served shrimp for lunch, which was not listed as an allergy on their meal ticket. This oversight led to the resident experiencing an allergic reaction, including nausea, vomiting, and abdominal pain, necessitating a transfer to the emergency department for treatment. The incident occurred because the Certified Dietary Manager (CDM) did not enter the resident's shrimp allergy into the meal ticket system, which is separate from the electronic health record (EHR). As a result, the allergy was not printed on the meal ticket, and the resident was served shrimp. The CDM acknowledged the mistake, stating that the facility's process was to list all food allergies on meal tickets to prevent such occurrences. The dietary aide, who was responsible for checking the meal ticket for allergies before plating the food, also confirmed that shrimp was not listed as an allergy on the ticket. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), revealed that the resident began coughing and showing signs of distress shortly after consuming the shrimp. The LVN checked the resident's EHR and confirmed the shrimp allergy, which was not reflected on the meal ticket. The facility's policy and procedure documents emphasize the importance of documenting and communicating food allergies to prevent exposure, but in this case, the failure to do so resulted in the resident's allergic reaction.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure that Resident 1 received treatment and care in accordance with professional standards of practice when an LVN discharged Resident 1 home with seven medications that belonged to another resident, Resident 2. This error resulted in Resident 1 not receiving her prescribed blood pressure medications for four days, placing her at risk for adverse effects of medication. The incident was discovered when Resident 1's family member (FM) noticed the error and reported it to the facility administrator (ADM). Resident 1 was admitted to the facility with multiple diagnoses, including Type 2 Diabetes Mellitus, hypertensive heart disease, hyperlipidemia, and osteoarthritis. The Minimum Data Set (MDS) assessment indicated that Resident 1 had a moderate cognitive impairment. During the discharge process, the LVN responsible for Resident 1's discharge failed to verify the medications with the current medical orders and did not review the medications with the resident or FM. As a result, Resident 1 was given medications intended for Resident 2, including blood thinners and high blood pressure medications, instead of her prescribed medications. Interviews with other LVNs and the Director of Nursing (DON) revealed that the facility had a triple-check process for discharging residents with medications, which was not followed in this case. The facility's policy and procedure for discharge medications required verification of medications with current physician orders and a review of medication instructions with the resident or FM before discharge. The failure to follow these procedures led to Resident 1 receiving incorrect medications, which could have resulted in serious health issues such as low blood pressure, unstable blood sugar, and bleeding.
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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