Thousand Oaks Post Acute, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Thousand Oaks, California.
- Location
- 93 West Avenida De Los Arboles, Thousand Oaks, California 91360
- CMS Provider Number
- 055342
- Inspections on file
- 29
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Thousand Oaks Post Acute, Llc during CMS and state inspections, most recent first.
A resident with foot and buttocks wounds had active physician orders and posted signage requiring Enhanced Barrier Precautions (EBP), including gown and glove use, during high-contact care such as hygiene and brief changes. Facility policy, state AFL guidance, and CDC recommendations all supported the need for EBP for residents with wounds. Despite these requirements, an IP and a CNA were observed changing the resident’s brief without wearing gowns, and both later acknowledged they should have been using this PPE. The ADM reported being aware of the infection control issue after being informed by staff.
A resident with diabetes and multiple comorbidities did not receive prescribed Glargine (insulin) for several days due to medication unavailability and lack of staff action to obtain or clarify orders. Staff failed to notify the physician about missed doses, did not use the emergency medication kit, and administered insulin from another resident's supply. Blood glucose monitoring was not performed as ordered, and the need for monitoring was not recognized. The resident developed severe hyperglycemia and was transferred to the hospital, where they died.
A resident with severe neurological and physical impairments was provided bed rails without documented attempts at alternatives, a complete safety assessment, or proper installation by trained staff. The decision was made based on a family request, with incomplete documentation and no evaluation of bed, mattress, or device compatibility, contrary to facility policy and FDA guidance.
Nurses failed to administer insulin as ordered, did not notify the physician or charge nurse about missed doses, and did not clarify conflicting medication administration routes for a resident with diabetes. Blood glucose monitoring orders were not correctly entered or followed, and medications were given by mouth despite enteral feeding orders. These failures led to unsafe care and hospital admission for diabetes management.
A resident's medical record lacked complete and accurate documentation, including missing records of physician communication, incorrect skilled nursing service entries, inaccurate risk assessment reporting, and repeated blood pressure values in the MAR. Nursing staff and the DON confirmed these inaccuracies, which were not in accordance with the facility's documentation policy.
A resident with a history of stroke, diabetes, dysphagia, and a gastrostomy tube was admitted without a baseline care plan addressing diabetes management, abdominal binder use, or appropriate interventions for NPO status. Staff confirmed that required care plans were missing or contained incorrect interventions, leading to the resident's transfer to the hospital for elevated blood sugar and further management.
A resident with diabetes, dysphagia, and psychiatric needs did not receive care according to professional standards. The facility failed to develop a baseline care plan for diabetes, used non-specific interventions, did not clarify medication administration routes, and did not follow physician orders for blood pressure monitoring or PRN Seroquel duration. Care plans were developed by LVNs instead of RNs, and psychiatric assessments were not incorporated into care planning. These failures led to the resident's hospitalization for severe hyperglycemia and subsequent death.
A resident's Minimum Data Set (MDS) assessment was incorrectly coded to indicate an active diagnosis of benign prostatic hyperplasia (BPH), even though the resident did not have this condition. The MDS Coordinator acknowledged the error during a review, resulting in inaccurate data being reported to CMS.
A resident with a recent hip fracture and joint replacement had an x-ray showing a dislocated hip, but the nurse supervisor did not promptly notify the physician, resulting in a delay in treatment. The facility's policy required prompt reporting and escalation if the physician could not be reached, but these steps were not followed.
The facility failed to accurately code the MDS assessments for three residents, resulting in omissions of supplemental oxygen use for two residents with COPD and incorrect discharge status for another resident. Despite documentation and staff confirmation of oxygen therapy and discharge to home, the MDS assessments did not reflect the residents' actual care needs and status during the assessment periods.
A resident was admitted with a negative Level I PASRR, but after admission developed new mental health diagnoses and was prescribed antipsychotic and antianxiety medications. Despite these changes, facility staff did not resubmit the PASRR as required by policy, and interviews confirmed that the process for reassessment was not followed when the resident's condition and medication regimen changed.
A CNA removed her bra behind a curtain in a resident's room and stored it in the resident's closet, while the resident—who was cognitively intact and had multiple medical conditions—was present. The resident reported the incident as abuse and harassment. The CNA admitted to the act, and facility policy review confirmed this behavior violated standards for resident dignity and professional conduct.
A resident with moderate cognitive impairment and dependency for toileting was not treated with respect and dignity when a CNA repeatedly instructed them to wait for a brief change. The resident activated the call light twice, but the responding CNA did not provide the necessary assistance, citing the absence of the assigned CNA. The facility's policy on dignity and respect was not upheld, as all CNAs are responsible for answering call lights and providing care.
A resident with a colostomy in an LTC facility received improper care when an unlicensed CNA removed, emptied, and replaced the colostomy bag, contrary to facility policy that only allows licensed nurses to perform such tasks. The resident, who had a BIMS score indicating intact cognition, expressed concerns about the reuse of the colostomy bag. Interviews confirmed the CNA acted beyond their scope, as instructed by a licensed nurse to only empty the bag.
A facility failed to follow hand hygiene protocols during colostomy care for a resident. An LPN was observed changing gloves without washing hands between glove changes while providing care. The LPN acknowledged not washing hands, stating it made her hands sticky. The facility's policy required handwashing between glove changes.
Failure to Use Required Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) for a resident with wounds. Physician orders dated 3/5/26 directed that the resident be on EBP due to foot and right buttocks wounds, and the facility’s policy on EBP, dated January 2025, required staff to implement EBP, including gown and glove use, for residents with wounds during high-contact care activities such as providing hygiene and changing briefs. The California Department of Public Health AFL 24-15 and CDC guidance also indicated that EBP, including targeted gown and glove use, should be implemented for residents with wounds regardless of MDRO colonization status. The resident’s Order Summary Report confirmed an active order for EBP due to the identified wounds. During an observation on 3/4/26 at 3 p.m., a sign posted outside the resident’s room indicated that EBP were required. Despite this signage and the active orders, the Infection Preventionist (IP) and a CNA were observed inside the room changing the resident’s brief without wearing the required PPE gowns. In a subsequent interview, both the IP and the CNA acknowledged they should have been wearing gowns and were not. In a separate interview, the Administrator stated he was aware of the infection control issue because staff had informed him about it.
Failure to Administer Insulin and Monitor Blood Glucose Leads to Resident Harm
Penalty
Summary
A 65-year-old resident with multiple complex medical conditions, including diabetes mellitus, cerebral infarction, hypertension, hemiplegia, chronic myelogenous leukemia, anemia, drug-induced polyneuropathy, atrial fibrillation, dysphagia, and a gastrostomy tube, was admitted to the facility. The resident had a physician's order for Glargine (insulin) to be administered every 12 hours for diabetes management. However, Glargine was not administered for three consecutive days at several scheduled times. Documentation indicated that the medication was not given due to new admission and unavailability, but there was no evidence that the physician or pharmacist was notified about the missed doses. Additionally, the facility failed to use the emergency medication kit to obtain the insulin, and staff did not seek assistance when unsure how to proceed. The facility also failed to ensure proper medication administration practices. When the resident's prescribed Glargine was not available, a nurse administered insulin from another resident's supply, which was not properly labeled for the intended resident. This action was contrary to facility policy, which prohibits borrowing medications between residents. Furthermore, the order for finger stick blood sugar (FSBS) monitoring was not clarified with the physician, and the correct monitoring frequency was not established. As a result, no blood glucose monitoring was performed during the resident's stay, and the need for such monitoring was not recognized by the nursing staff. Due to these failures, the resident experienced a critically high blood glucose level (593 mg/dL), which was identified through abnormal lab results. The physician was notified only after this result, and the resident was subsequently transferred to an acute care hospital for evaluation and treatment of uncontrolled diabetes. The resident ultimately died following the transfer. The facility's policies and procedures for medication administration, medication procurement, and diabetes management were not followed, and staff interviews revealed a lack of knowledge and experience in handling new admissions, medication errors, and diabetes care.
Failure to Assess, Document, and Safely Install Bed Rails
Penalty
Summary
The facility failed to ensure that appropriate alternatives to bed rails were identified and attempted before installing bed rails for a resident with significant neurological and physical impairments. Documentation showed that no less restrictive measures or alternatives were tried, despite facility policy requiring such steps. The decision to use bed rails was based on a family request, and staff complied without conducting a thorough evaluation or identifying a medical symptom that necessitated the use of bed rails. The resident was dependent on staff for all bed mobility and transfers, was non-verbal, unable to follow commands, and not oriented, which placed them at higher risk for entrapment and injury according to FDA guidance. The assessment process for bed rail use was incomplete and lacked critical information. Key assessment forms had unanswered questions regarding the resident's bed mobility, balance, trunk control, and the specific reason for device use. The interdisciplinary team documentation indicated that the bed rail was considered solely due to a patient or family request, without evidence of a comprehensive risk-benefit analysis or informed consent process as required by facility policy. Additionally, there was no documented assessment of the compatibility between the bed, mattress, and bed rail prior to installation. Installation of the bed rails was performed by a licensed nurse who was not trained for this task, rather than by the maintenance department as per facility protocol. The maintenance director confirmed that no request for bed rail installation was made, and the nurse admitted to installing the rails after hours to accommodate the family's wishes. The bed was not measured or assessed for safety prior to installation, further deviating from established procedures and increasing the risk of resident harm.
Failure to Ensure Nursing Competency in Medication Administration and Monitoring
Penalty
Summary
Nurses and nurse aides at the facility failed to demonstrate the necessary competencies to provide safe care for a resident with diabetes mellitus type 2. The licensed nurses did not administer Glargine insulin as ordered over several days, failed to notify the physician about the missed doses, and did not communicate these omissions to the charge nurse. Additionally, the nurses did not clarify conflicting medication administration orders, resulting in medications being given by mouth despite an order for enteral administration via feeding tube. The Director of Nursing confirmed that the insulin was not given for multiple days and that the physician was not notified, attributing these failures to the inexperience of the nursing staff. The facility also failed to ensure that blood glucose monitoring orders were correctly entered and followed. The order for finger stick blood sugar (FSBS) monitoring did not appear on the Medication Administration Record (MAR), and as a result, no blood sugar monitoring was performed. The Director of Nursing acknowledged that the FSBS order was entered incorrectly and that the new nurses did not recognize the need to clarify or implement the order. One nurse admitted that inexperience was the reason for not clarifying the missing FSBS order with the physician. Documentation review revealed that the resident received multiple medications by mouth, despite orders indicating the need for enteral administration due to NPO status and enteral feeding. The Director of Nursing and a licensed nurse both confirmed that medications were administered orally without clarification from the physician. The resident ultimately required hospital admission for fluids and diabetes control following these failures in care.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, resulting in care being planned and delivered based on incorrect assessments. Specifically, a licensed nurse reported texting a physician to clarify the resident's medication administration route, but there was no documentation of this communication in the resident's medical record. Additionally, the resident's Medicare Skilled Charting did not reflect the skilled nursing services provided, such as diabetic care and enteral feeding care, as required. The Bed/Side Rail Entrapment Risk Assessment inaccurately indicated that alternatives to bed/side rails had been attempted, when in fact, no such alternatives were tried. Further review of the Medication Administration Record revealed that the same blood pressure readings were recorded for both lying and sitting positions over several days, which a nurse confirmed was inaccurate. The Director of Nursing also acknowledged that the charting was inaccurate upon review of the relevant records. The facility's own documentation policy requires that relevant findings be accurately documented in the clinical record, which was not followed in these instances.
Failure to Develop Baseline Care Plan for Complex Medical Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for a resident with multiple complex medical needs. Specifically, there was no BCP created for diabetes management, despite physician orders for regular blood sugar monitoring and insulin administration. Additionally, the BCP did not address the use of an abdominal binder, which was being used to prevent the resident from pulling on a gastrostomy tube. The absence of these care plans was confirmed during interviews and record reviews with facility staff, who acknowledged that the required BCPs were missing. Furthermore, the BCP interventions for the resident's NPO (nothing by mouth) status were not appropriate. The care plan included instructions to monitor meal intake and to offer warm beverages, which were not suitable for a resident who was NPO and receiving nutrition via a G-tube. Staff interviews confirmed that these interventions were incorrect and should have been individualized to the resident's needs. As a result of these deficiencies, the resident was transferred to the hospital for elevated blood sugar and required admission for fluids and diabetes control.
Failure to Provide Care According to Professional Standards Results in Resident Harm
Penalty
Summary
The facility failed to provide care according to accepted professional nursing standards for a resident with multiple complex medical needs, including diabetes, dysphagia, and psychiatric concerns. Upon admission, the facility did not develop a baseline care plan for diabetes management, despite the resident's diagnosis and risk for abnormal blood sugar levels. Both the Licensed Nurse and the Director of Nursing confirmed during interviews and record reviews that a baseline care plan for diabetes was missing. Additionally, care plans that were developed contained non-specific interventions, such as monitoring meal intake and offering warm beverages, even though the resident was NPO (nothing by mouth) and receiving nutrition via G-tube. These interventions were not tailored to the resident's actual needs, and staff acknowledged that they should have been updated to reflect the resident's status. There were also failures in medication management and adherence to physician orders. The facility did not clarify conflicting orders regarding the route of medication administration, resulting in medications being given by mouth instead of via feeding tube, contrary to the resident's NPO status and physician orders. Blood pressure monitoring orders related to Seroquel administration were not followed as directed; staff documented identical lying and sitting blood pressures without actually performing the required assessments or notifying the physician of their inability to obtain accurate readings. Furthermore, a PRN Seroquel order was continued for an excessive duration without an end date, and there were conflicting indications for its use in the clinical documentation. The psychiatric assessment and its results were not incorporated into the care plan, and staff were unclear about who was responsible for reviewing and communicating consultant notes to the physician. The report also identified that Licensed Vocational Nurses (LVNs) were performing tasks outside their scope of practice, such as developing and revising care plans, which is the responsibility of Registered Nurses (RNs) and physicians. Multiple care plans for the resident were initiated and revised by LVNs, contrary to regulatory requirements. As a result of these failures, the resident experienced abnormally high blood sugar, required transfer to an acute care hospital, and ultimately died.
Inaccurate Diagnosis Recorded on MDS Assessment
Penalty
Summary
The facility failed to ensure that an accurate diagnosis was recorded on the Minimum Data Set (MDS) assessment for one of two sampled residents. During an interview and record review with the MDS Coordinator, it was found that the MDS 3.0 Section I - Active Diagnoses incorrectly indicated that the resident had benign prostatic hyperplasia (BPH), despite the resident not having this diagnosis. The MDS Coordinator acknowledged that this section was incorrectly coded. Review of the facility's MDS manual confirmed that the MDS assessment is intended to provide an updated and accurate picture of the resident's current health status, and the incorrect coding resulted in the facility reporting inaccurate data to CMS.
Delay in Physician Notification of Abnormal X-ray Results
Penalty
Summary
The facility failed to promptly notify the physician of x-ray results for one of two sampled residents. The resident was admitted with a midcervical fracture of the right femur and aftercare following joint replacement surgery. On 5/19/2025, a radiology report indicated a superior dislocation of the femoral component of the hip implant. The nurse supervisor received the radiology results around 7 p.m. and communicated the findings to the physician via text message at 10:44 p.m. However, the physician did not respond or contact the facility until the following afternoon. The delay in communication resulted in a delay in treatment for the resident's dislocated hip. The facility's policy required that abnormal test results be promptly reported to the ordering provider, and if there was no response after three call attempts, the staff should escalate the report to the medical director. The director of nursing confirmed that staff should have continued attempts to contact the physician and escalated the issue to avoid delays in care.
Inaccurate MDS Coding for Oxygen Use and Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for three residents, as required by facility policy and federal regulations. For one resident with chronic obstructive pulmonary disease (COPD) and a physician's order for supplemental oxygen, the MDS did not reflect the use of oxygen therapy, despite documentation in care plans, progress notes, and vital records indicating the resident received oxygen as needed during the assessment period. The MDS Coordinator confirmed the omission, stating that only the physician order and electronic medication administration record were referenced during the assessment, and acknowledged the MDS was coded incorrectly. Another resident, who had diagnoses including speech and language deficits, dysphagia, aphasia, apraxia, dementia, seizures, and heart failure, was discharged to home with home health services. However, the discharge MDS incorrectly indicated the resident was discharged to a hospital setting. The MDS Coordinator admitted to the error, explaining that she had attended the care plan meeting and was aware the resident returned home, but the MDS was not coded accordingly. The Director of Nursing and Administrator both confirmed the importance of accurate MDS coding and attributed the error to human mistake. A third resident with a history of COPD, idiopathic interstitial pneumonia, and dependence on supplemental oxygen was also affected by inaccurate MDS coding. Although the resident's care plan, physician orders, and progress notes documented regular use of supplemental oxygen, the MDS did not indicate oxygen use during the lookback period. The MDS Coordinator and DON both confirmed, after reviewing the records, that the resident was using oxygen intermittently and that the MDS should have reflected this. Interviews with nursing staff further confirmed the resident wore supplemental oxygen continuously at their request.
Failure to Resubmit PASRR After Change in Mental Health Status
Penalty
Summary
The facility failed to resubmit a Level I Preadmission Screening and Resident Review (PASRR) as required for a resident who developed or was identified with mental health diagnoses and was prescribed psychotropic medications after admission. The facility's policy states that a negative Level I PASRR screen permits admission unless a possible serious mental disorder or intellectual disability arises later, in which case a new screening and referral for Level II evaluation must occur. The resident in question was admitted with a negative Level I PASRR obtained from the hospital, which indicated no serious mental disorder or psychotropic medication use at the time of admission. After admission, the resident was diagnosed with psychotic disorder, dementia with behavioral disturbance, and anxiety disorder, and was prescribed antipsychotic and antianxiety medications. The resident's Minimum Data Set (MDS) assessment showed severe cognitive impairment and ongoing use of psychotropic medications. The care plan and physician orders reflected the presence of psychosis, the use of olanzapine, and monitoring for side effects and behavioral symptoms. Despite these changes in the resident's condition and treatment, the facility did not resubmit the PASRR as required by policy and regulation. Interviews with facility staff, including the Admissions Co-Director, Business Development Director, DON, and MDS Coordinator, confirmed that the PASRR process was not followed when the resident's diagnoses and medication regimen changed. Staff acknowledged that a new PASRR should have been completed when the resident was started on routine psychotropic medication and developed new mental health diagnoses. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with PASRR requirements for residents whose mental health status changes after admission.
CNA Removed Undergarment in Resident's Room, Violating Dignity Policy
Penalty
Summary
A Certified Nursing Assistant (CNA) removed her bra while in a resident's room, behind a curtain, and stored the bra in the resident's closet. The resident, who was cognitively intact and had diagnoses including muscle weakness, aphasia, type 2 diabetes mellitus, and cerebral infarction, reported the incident via email to the facility administrator, describing it as verbal, emotional, and physical abuse, and also alleged sexual harassment by the CNA. The CNA admitted to removing her bra behind the curtain, stating it was due to feeling hot, and claimed the resident could not see her during the act. The facility's investigation confirmed that the CNA violated company policy regarding professional conduct and resident dignity. Facility policies reviewed emphasized the importance of treating residents with dignity, respect, and privacy, and outlined that inappropriate behavior, including suggestive gestures or unprofessional conduct, is not tolerated. The facility's work rules require employees to maintain acceptable standards of respect and professional conduct towards residents. The incident was determined to be a violation of these policies, as the CNA's actions did not uphold the resident's right to dignity and privacy.
Failure to Provide Timely Assistance with Brief Change
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity when a Certified Nursing Assistant (CNA) repeatedly instructed the resident to wait for a brief change. The resident, who had been admitted with diagnoses including encephalopathy, arthritis, and muscle weakness, had a BIMS score indicating moderate cognitive impairment and was dependent on assistance for toileting. On the night in question, the resident activated the call light for assistance with a brief change, and a tall female staff member responded but instructed the resident to wait for the assigned CNA, turning off the call light without providing the requested assistance. The resident had to activate the call light a second time, and the same staff member again instructed the resident to wait for the assigned CNA. The resident's CNA was late for the shift, arriving approximately an hour after the shift began, and the resident's brief was not changed until 20 minutes after the CNA's arrival. Interviews with the CNA and the Director of Staff Development confirmed that all CNAs are responsible for answering call lights and providing necessary care, and the CNA who responded should have changed the resident's brief. The facility's policy on dignity and respect emphasizes assisting residents in exercising their rights and ensuring they are treated with respect, kindness, and dignity, which was not upheld in this instance.
Improper Colostomy Care by Unlicensed Staff
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a colostomy. The deficiency involved an unlicensed staff member, a Certified Nurse Assistant (CNA), who removed, emptied, and replaced a colostomy bag for a resident. This action was contrary to the facility's policy, which states that only licensed nurses are permitted to remove colostomy bags. The CNA was instructed by a licensed nurse to only empty the bag, but instead, the CNA removed and rinsed it before placing it back on the resident. The resident, who was admitted with a colostomy, artificial opening of the urinary tract, hypertension, and hyperlipidemia, expressed concerns about the reuse of the colostomy bag. The resident's cognitive status was intact, as indicated by a BIMS score of 15. Interviews with the CNA, the licensed nurse, and the Director of Nursing confirmed the inappropriate handling of the colostomy bag by the unlicensed staff, which was not in line with the facility's policy and procedure for colostomy care.
Failure to Perform Hand Hygiene During Colostomy Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during colostomy care for one of the sampled residents, identified as Resident 3. During an observation, a licensed nurse (LN 1) was seen removing a soiled colostomy bag and disposing of it, then changing gloves without washing hands in between. LN 1 continued to clean the stoma and again changed gloves without performing handwashing. In an interview, LN 1 admitted to not washing hands between glove changes, citing that it made her hands sticky and made it difficult to put on new gloves. The facility's policy and procedure for colostomy care, dated November 2017, clearly stated that handwashing should occur between glove changes.
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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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