Tulare Healthcare & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulare, California.
- Location
- 680 East Merritt Avenue, Tulare, California 93274
- CMS Provider Number
- 055649
- Inspections on file
- 38
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Tulare Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A dessert item on the written winter menu was changed from apple crisp to apple cake without required RD review and approval. A resident’s lunch tray was observed with cake instead of the planned dessert, and the substitution list documented the change due to the original item being out of stock but lacked RD initials. The CDM acknowledged making the substitution without notifying the RD, and the RD confirmed she had not been informed, contrary to facility P&P requiring dietitian review of all menu substitutions.
A resident with a fractured leg and chronic pain was left in bed while maintenance installed side rails using a power drill, causing the bed to shake and resulting in severe pain despite the resident's request to be moved. The procedure continued for about 15 minutes, and the DON later stated that maintenance should have stopped if pain was reported.
A resident with a left tibia fracture missed a scheduled orthopedic follow-up appointment because the facility did not arrange transportation as required. Documentation showed the need for the appointment and transportation, but the resident was not picked up, and the Social Service Designee confirmed that no alternative arrangements were made.
A resident with dementia and a history of elopement was found outside the facility without a required wander guard, despite care plan interventions and facility protocols mandating its use and monitoring. Staff observed the missing device but did not replace it, leading to the resident leaving unsupervised.
A resident reported that a CNA was rough during a wheelchair transfer, causing pain. Although the incident was documented and reported to the DON, the required SOC 341 abuse report was not sent to the Ombudsman as per facility policy, as confirmed by review of fax records and staff interviews.
A facility's generator failed during a planned power outage, leaving 13 residents who required oxygen concentrators without power for approximately 15 minutes. The generator malfunctioned due to a faulty oil pressure sensor, which was not detected during annual maintenance. This failure put residents at risk of respiratory distress.
The facility failed to follow infection control policies, including maintaining cleanliness in the laundry room, proper storage of cleaning tools, and adherence to PPE protocols. Nursing staff did not remove N95 masks after leaving precaution rooms, and some staff entered isolation rooms without full PPE. Hand hygiene was neglected, with CNAs wearing long false nails and not sanitizing hands between resident rooms. The facility also mixed clean and dirty items in utility areas and did not conduct required water testing for Legionella.
The facility failed to schedule regular resident council meetings, denying residents their right to organize and participate in such groups. The last meeting was recorded in July, and interviews revealed that one resident had only met once, while two others were unaware of the council's existence. The facility's policy required monthly meetings, but the administrator confirmed the last available notes were from July.
A resident's leg became red and swollen due to the facility's failure to follow physician orders to wrap the leg daily. Additionally, two residents did not receive required weekly nursing assessments, and three residents lacked assessments for self-administering medications, as observed by the DON and an LVN.
The facility did not complete activity assessments for five residents within the required timeframe, as per their policy. Additionally, an activity care plan was not developed for one resident, despite the policy requiring it after the initial assessment and MDS completion. These oversights meant the facility was unaware of the residents' activity preferences.
The facility did not complete Social Service Assessments (SSA) within the required seven days for three residents, potentially affecting their psychosocial needs. One resident's SSA was started late, while two others had their assessments completed six and nine days overdue, respectively. This was contrary to the facility's policy mandating timely completion of SSAs.
The facility failed to serve meals at safe and palatable temperatures for two residents, who reported consistently cold breakfasts. Observations showed uncovered meal carts and inadequate temperature checks, with food served below required temperatures. This non-compliance with facility policy potentially impacted residents' nutritional needs.
A Dietary Aide in the facility's kitchen failed to wash his hands after changing a sanitizer solution and before handling food, contrary to the facility's infection control policy. The aide acknowledged the oversight, which was observed during an interview. The policy requires hand washing during food preparation to remove contamination when changing tasks.
The facility failed to ensure that call lights were within reach for four residents, potentially preventing them from calling for assistance and delaying care. Observations showed call lights on the floor or behind beds, contrary to the facility's policy requiring them to be accessible. Staff confirmed the call lights should have been within reach.
A resident requested more information on advance directives, as noted in their AHCD. Despite the facility's policy requiring the Social Services Director or Designee to provide such information, the request was not fulfilled. The resident, who was cognitively intact, did not receive the requested information, resulting in a deficiency.
A former DON disclosed a resident's medical diagnosis to the resident's roommate, violating the facility's PHI policy. The incident was confirmed through interviews and a review of the resident's medical record, despite the DON having completed HIPAA education.
A resident with a Stage 3 pressure ulcer did not receive necessary preventative interventions as per the facility's policy. Despite recommendations for a Low Air Loss Mattress, the resident was observed on a regular mattress, and the Plan of Care lacked specific measures to prevent wound worsening. This led to a surgical procedure to remove non-living tissue, indicating a lapse in protocol adherence.
A PTA failed to use a facility-provided gait belt while assisting a resident with ambulation, instead holding onto the resident's pants waistband. The resident's care plan indicated a risk for falls due to balance issues, and the facility's policies required the use of gait belts for safety. The PTA used a personal, fraying gait belt, contrary to facility procedures.
A resident with chronic pain did not receive prescribed pain medications and non-pharmacological interventions as ordered, resulting in unmanaged pain and refusal to eat. The facility failed to administer Tylenol between scheduled Norco doses and did not consistently apply non-pharmacological interventions, despite the resident's high pain levels.
A resident did not receive their prescribed Brinzolamide for glaucoma due to the facility's failure to reorder the medication in a timely manner. The medication was unavailable for administration at scheduled times, as confirmed by an LVN and documented in the resident's records. The facility's policy required medications to be reordered three to four days in advance, which was not followed.
The facility failed to follow its medication storage policy, resulting in medications being found at residents' bedsides, improper storage of Aplisol, and mixing of topical and oral medications in carts. LVNs confirmed these practices were against policy, risking unauthorized access and cross-contamination.
A resident's need for a follow-up dental appointment was overlooked, resulting in her not wearing her loose lower denture. The resident's dental notes indicated that her dentures were 5-6 years old, and no follow-up appointment had been scheduled since her last dental visit. The MDSC confirmed the lack of follow-up dental notes and acknowledged the necessity for a denture realignment appointment.
The facility failed to honor meal preferences for two residents, leading to potential nutritional issues. One resident did not receive the requested juice, and another was served cheese despite a documented dislike. The Dietary Manager confirmed these discrepancies against the Meal Tray Tickets.
The facility failed to obtain a therapeutic diet order for a resident with no teeth and no dentures, who expressed difficulty eating due to their condition. The resident's care plan noted oral health problems and recommended consulting a dietitian if chewing issues were observed. However, the Registered Dietician did not recognize any chewing issues, maintaining a regular texture diet order. This oversight did not align with the facility's policy to ensure diets meet nutritional guidelines and physician orders.
The facility failed to maintain accurate medical records for two residents. One resident's MDS assessment inaccurately reported dental status, and their OSR included a discontinued medication order. Another resident's hospital transfer lacked a physician order, and their H&P and Discharge Summary were inaccessible. These issues contradict the facility's policy on accurate documentation.
The facility did not complete previous employment and personal reference checks for two RNs before hiring them. This was confirmed during a review of their employment records and an interview with the Administrator, who acknowledged the oversight. The facility's policy requires screening potential employees for any history of abuse, neglect, or mistreatment, which was not followed in these cases.
A resident who eloped from the facility was not monitored every 30 minutes as required. The resident was found outside and returned, but subsequent monitoring was inconsistent, with checks ranging from one to three times a day. The DON confirmed the monitoring did not meet the facility's policy for preventing further elopement.
A resident was discharged with another resident's medications due to a failure in the facility's medication verification process. The RN did not perform the required checks, leading to the potential risk of the resident taking incorrect medications. The error was identified when the medications were returned by the resident's family.
A resident with dementia and anxiety was disrespected by a CNA during a dinner service. The resident, known for swinging his arms, nearly hit the CNA, who responded by blocking his arm and telling him he "hits like a girl." The CNA admitted to raising her voice, which violated the facility's policy on treating residents with respect and dignity.
A resident experienced a significant change in condition requiring hospitalization, but the facility failed to notify the physician. The resident's responsible party confirmed the transfer to an acute hospital, and a review of the medical record showed no documentation of physician notification. The facility's administrator and DON acknowledged the lack of documentation, despite the facility's policy requiring such notification.
A resident was transferred to an acute hospital without an assessment or documentation of a significant change in condition by the nurse on duty. The facility's policy requires such documentation, but it was not followed, leading to a deficiency in meeting professional standards of quality.
A resident did not receive wound care as ordered, with missing documentation in the TAR for multiple dates. The resident had a Stage 2 pressure ulcer and abdominal wounds requiring specific treatments. Interviews with an LVN and the DON confirmed the absence of documentation, indicating treatments were not administered. Facility policy requires immediate documentation of treatments.
A resident under respite care fell while attempting to stand from her wheelchair, resulting in a black eye and a cut to the lip. The LVN notified the hospice agency but failed to inform the resident's responsible party, contrary to the facility's policy requiring notification of any change in condition, including falls.
Unapproved Menu Substitution Without RD Notification
Penalty
Summary
The facility failed to follow its menu and substitution policy when a planned dessert item was changed without required approval from the Registered Dietician (RD). On the winter menu for a specific lunch date, the written menu indicated that chicken jambalaya, seasoned zucchini with parsley garnish, garlic bread, apple crisp, and milk were to be served. During observation of a resident’s lunch tray in the hallway, the tray instead contained macaroni and cheese, zucchini, and a large piece of cake. Review of the facility’s substitution list for that date showed that apple crisp had been replaced with apple cake due to the apple crisp being out of stock, and the section for RD initials was left blank. In an interview, the Certified Dietary Manager (CDM) stated that apple cake was substituted for apple crisp because not all ingredients for the apple crisp were available and acknowledged that the RD should have been called to approve the substitution but was not. In a separate interview, the RD confirmed she had not been made aware of the substitution and stated she should have been notified prior to the change. Review of the facility’s “Menus” policy and procedure indicated that foods served should adhere to the written menu and that any substitutions must be reviewed by both the dietary manager and the dietitian for appropriateness per the diet order and recorded on the substitution list. The failure to obtain RD review and approval for the dessert substitution was identified as having the potential to place residents at risk of inadequate nutrition.
Failure to Accommodate Resident Needs During Bed Rail Installation
Penalty
Summary
A deficiency occurred when a resident with a left tibia fracture and chronic pain syndrome was left lying in bed while maintenance staff installed metal side rails using a power drill. Despite the resident's request to be removed from bed and placed in a wheelchair due to pain, maintenance continued drilling for approximately 15 minutes, causing the bed to shake and resulting in severe pain for the resident. The resident reported crying and experiencing significant discomfort during the incident. The resident was cognitively intact, as indicated by a BIMS score of 14, and had a full support brace on the affected leg. The maintenance staff stated that the installation was ordered by the DON and confirmed that the procedure was performed while the resident remained in bed. The DON acknowledged that maintenance should have stopped if the resident complained of pain. Facility policy states that residents have freedom of choice regarding their care, but this was not accommodated during the event.
Failure to Provide Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident with a left tibia fracture to attend a scheduled follow-up appointment with an orthopedic doctor. The resident's admission record and order summary indicated the need for a follow-up appointment and transportation arrangements. Progress notes documented the scheduled appointment, but the resident was not picked up by transportation and missed the appointment. During an interview and record review, the Social Service Designee confirmed that transportation was not arranged and acknowledged that the facility should have notified transportation and attempted to find an alternative provider. The facility's policy stated that the Social Service Department could coordinate transportation to outside services as necessary.
Failure to Implement Elopement Prevention Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with a known history of elopement attempts. The resident, who had dementia and a moderate cognitive impairment as indicated by a BIMS score of 9, was identified as being at risk for wandering and elopement. The care plan required that a wander guard be placed on the resident every shift and that its placement and function be monitored. However, on the day of the incident, staff observed the resident without a wander guard, and multiple staff interviews confirmed that the device was not replaced when missing, despite facility protocol requiring immediate replacement. The resident was last seen in the facility hallway and was later found unsupervised outside the facility, approximately 0.2 miles away. Staff interviews revealed that the LVN noticed the missing wander guard but did not replace it, believing it was not her responsibility. The DON confirmed that the resident was not wearing the required wander guard when found outside. Facility policies required comprehensive assessment and implementation of resident-centered care plans to mitigate safety risks, but these were not followed in this instance, resulting in the resident eloping from the facility.
Failure to Report Alleged Abuse to Proper Authorities
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely reporting of an allegation of abuse. Specifically, a resident reported to the DON that a male CNA was rough on purpose during a wheelchair transfer, which caused the resident pain. Progress notes documented the resident's statement, and the DON confirmed the report was made. However, during a review of records and interviews, it was determined that the required SOC 341 form, which is used to report suspected abuse, was not sent to the Ombudsman as mandated by facility policy. The fax transmittal record showed the form was not sent to the correct fax number for the Ombudsman, and the Administrator confirmed the omission. The facility's policy required that the SOC 341 be sent to the Ombudsman, Law Enforcement, and CDPH Licensing Certification within two hours of the allegation.
Generator Failure During Power Outage
Penalty
Summary
The facility failed to provide a working generator for 13 residents who required oxygen concentrators during a planned power outage. The generator, which was supposed to supply power during the outage, malfunctioned due to a faulty oil pressure sensor. This malfunction was not detected during the annual maintenance of the generator, leading to a power loss for approximately 15 minutes. During this time, the residents who depended on oxygen concentrators were at risk of being without oxygen, potentially leading to respiratory distress. The issue was identified during an interview with the Administrator, who confirmed the generator's failure during the planned outage. The Maintenance Environmental Services staff also confirmed the generator's malfunction and attributed it to the oil pressure sensor failure. The Director of Nurses acknowledged that all 13 residents required oxygen concentrators, highlighting the critical nature of the generator's failure. The facility's policy on emergency generator testing, dated 9/2017, indicated that generators should be maintained in an operational state, but this was not adhered to, resulting in the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures across multiple areas, leading to potential risks of spreading infectious diseases. In the laundry room, the Environmental Services Director (ESD) and housekeepers observed unclean conditions, including dusty debris, cobwebs, and personal items in the clean area, which violated the facility's policy for maintaining a clean and sanitary environment. Additionally, a used toilet brush was improperly stored on a clean housekeeping cart, contrary to the facility's housekeeping policy. Nursing staff also failed to follow personal protective equipment (PPE) protocols. Two staff members, an LVN and a CNA, did not remove their N95 masks before leaving a transmission-based precaution room, as required by the facility's PPE policy. Furthermore, a speech therapist and a housekeeper entered a droplet precaution isolation room without wearing the full required PPE, despite clear signage indicating the necessity for gowns, gloves, and face shields. Hand hygiene practices were not consistently followed, with CNAs providing resident care while wearing long false nails and failing to perform hand hygiene before entering and after exiting residents' rooms. The facility also did not maintain separate clean and dirty utility areas, as required by CDC guidelines, leading to the mixing of clean and dirty items. Additionally, the facility did not conduct water testing for Legionella, as mandated by CMS guidelines, which could lead to the growth and spread of the bacteria in the water system.
Failure to Schedule Regular Resident Council Meetings
Penalty
Summary
The facility failed to arrange regularly scheduled resident council meetings for three sampled residents, resulting in the denial of their right to organize and participate in resident/family groups. The last recorded resident council meeting was held on July 29, 2024, as indicated by the Resident Council Minutes. Interviews conducted on October 22, 2024, revealed that one resident stated they had only met once, while two other residents were not aware of the existence of a resident council. The facility's policy and procedure, dated November 1, 2013, stated that resident council meetings should be scheduled monthly or more frequently if requested. However, the administrator confirmed that the last meeting notes available were from July 29, 2024.
Failure to Follow Physician Orders and Conduct Assessments
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in the resident's left leg becoming red and swollen. The resident, who was alert and oriented, reported that her leg should have been wrapped daily as per physician orders, but staff had not done so for several days. A family member confirmed that the leg had not been wrapped since the resident's admission to the facility. A Licensed Vocational Nurse (LVN) acknowledged the physician's order to wrap the leg daily and confirmed that the leg was not wrapped during observations. The facility administrator admitted that there was no policy in place for following physician orders. Additionally, the facility did not complete weekly nursing assessments for two residents, which are crucial for monitoring changes and progress in resident status. The Director of Nursing (DON) and an LVN confirmed that these assessments were not conducted as required. Furthermore, the facility failed to follow its policy on medication self-administration for three residents, as assessments to determine their capability to self-administer medications were not completed. This oversight was observed through the presence of eye drops in residents' rooms without proper assessments documented in their medical records.
Failure to Complete Activity Assessments and Care Plans
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Activity Program' by not completing activity assessments for five sampled residents. Specifically, the Minimum Data Set Coordinator (MDSC) confirmed that activity assessments were missing for residents admitted or readmitted on various dates, including Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41. The facility's policy required that these assessments be completed within seven days of admission, but this was not done for any of the mentioned residents. The absence of these assessments meant the facility was not aware of the residents' activity preferences. Additionally, the facility did not complete an activity care plan for Resident 438, as required by their policy. The policy stipulated that after the initial activity assessment and the Minimum Data Set (MDS) are completed, an individualized care plan should be developed and implemented for each resident. However, the MDSC confirmed that no care plan was in place for Resident 438, indicating a failure to follow through with the necessary steps to ensure the resident's activity needs were met.
Failure to Timely Complete Social Service Assessments
Penalty
Summary
The facility failed to complete Social Service Assessments (SSA) within seven days of admission for three residents, potentially impacting their psychosocial needs. Resident 337 was admitted on an unspecified date, but their SSA was not started until 10/21/24. Resident 388 was admitted on 10/8/24, and their SSA was completed on 10/21/24, six days overdue. Resident 438 was admitted on 10/12/24, and their SSA was completed on 10/21/24, also late. The facility's policy requires SSAs to be completed within seven days of admission, which was not adhered to in these cases.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a safe and palatable temperature for two residents. Resident 41 reported that their breakfast was cold and bland, while Resident 42 stated that breakfast was consistently cold, particularly the sausage and eggs. Both residents were cognitively intact, with BIMS scores of 13 and 15, respectively. Observations revealed that meal carts in the B-wing hallway were not covered, and it took approximately 10 minutes to distribute meal trays, contributing to the food cooling down. A CNA confirmed that residents had complained about cold food and that the open food cart contributed to the issue. The facility's policy required meat and eggs to be served at temperatures above 140 degrees, with instructions to reheat if temperatures were not met. In another instance, a dietary aide failed to take the temperature of bread pudding before serving it on a lunch tray. The dietary manager confirmed that all food should have its temperature checked before serving. A random lunch tray was tested, revealing that the pork was at 117.8 degrees, carrots at 121.1 degrees, and rice at 134.9 degrees, all below the required serving temperatures. The facility's policy indicated that meat entrees and other hot foods should be served at temperatures higher than 140 degrees, with a preferred range of 160 to 175 degrees. The failure to adhere to these temperature guidelines resulted in meals being served at unsafe and unappetizing temperatures, potentially affecting residents' nutritional intake.
Failure to Follow Hand Hygiene Protocol in Dietary Department
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Dietary Department-Infection Control' when a Dietary Aide (DA) did not wash his contaminated hands before returning to food service. During an observation and interview, the DA was seen changing the red bucket sanitizer solution and placing the bucket back on the counter. Immediately after, the DA resumed handling food without performing hand hygiene. The DA acknowledged that he should have washed his hands before returning to handle food. The facility's policy indicated that proper hand washing should occur during food preparation as often as necessary to remove soil and contamination when changing tasks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights for four residents were within their reach, which could potentially prevent them from calling for assistance and delay care provision. During observations and interviews, it was noted that Resident 337's call light was found on the floor on the right side of her bed, making it inaccessible. Certified Nursing Assistant (CNA) 6 confirmed that the call light should have been within the resident's reach. Similarly, Resident 70's call light was observed on top of the bed frame behind the head of the bed, out of reach, as confirmed by the Director of Nursing (DON), who stated that the call light should be clipped to the sheet. Further observations revealed that Resident 10's call light was hanging on the wall behind the bed, and CNA 7 acknowledged that it should have been within reach. Additionally, Resident 41's call light was found on the floor, out of reach, as confirmed by Licensed Vocational Nurse (LVN) 1. The facility's policy and procedure on the communication-call system, dated 10/09/24, clearly indicated that the call alert device should be placed within the resident's reach. This failure to adhere to the policy resulted in the deficiency noted in the report.
Failure to Provide Requested Information on Advance Directives
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives, resulting in a deficiency. A resident, identified as Resident 41, requested more information on advance directives, as indicated in their Advance Health Care Directive (AHCD) dated June 7, 2024. However, during an interview and record review with the Administrator on October 24, 2024, it was found that no information was provided by social services, and there were no progress notes documenting the provision of additional information. The facility's policy, dated July 31, 2024, states that if a resident requests more information on advance directives, the Social Services Director or Designee should provide a copy of the Advance Directive form for review. Despite this policy, the resident's request was not fulfilled, leading to the identified deficiency. Resident 41 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 on May 31, 2024, and 14 on September 12, 2024, indicating their capability to make informed decisions.
Breach of Resident's PHI by Former DON
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information (PHI) as per their policy and procedure titled 'Disclosure of PHI'. This breach occurred when the former Director of Nursing (FDON) disclosed one of Resident 61's medical diagnoses to Resident 61's roommate, Resident 15. The incident came to light when Resident 61's family member was questioned by Resident 15 about the medical condition, which Resident 15 had learned from the FDON. The FDON had previously completed the facility's Health Information Portability and Accountability Act (HIPAA) education, which emphasizes the importance of protecting PHI. The facility's policy, dated December 1, 2012, aims to limit the access, use, and disclosure of PHI to the minimum necessary to accomplish the intended purpose. Despite this, the FDON, who was employed at the facility from October 16, 2023, to July 12, 2024, disclosed sensitive health information without authorization. This disclosure was confirmed through interviews with Resident 15, the Administrator, and the Payroll Clerk, as well as a review of Resident 61's medical record, which included the diagnosis in question.
Failure to Implement Pressure Injury Prevention Measures
Penalty
Summary
The facility failed to adhere to its policies and procedures for pressure injury prevention for a resident with a Stage 3 pressure ulcer. The resident, who was admitted with a pressure injury to the sacrum, did not receive the necessary preventative interventions as outlined in the facility's policy. Despite the presence of a Stage 3 pressure wound for over 19 days, the resident was observed lying on a regular mattress instead of a Low Air Loss Mattress, which was recommended to off-load pressure and prevent further skin breakdown. Interviews with staff confirmed that the resident was not provided with the appropriate pressure-relieving mattress. The resident's Plan of Care did not include specific measures to prevent the worsening of the pressure wound, despite the resident being at moderate risk for skin breakdown according to the Braden scale. The facility's policy on pressure injury prevention included the use of pressure redistributing devices and positioning aids, but these were not implemented for the resident. This oversight resulted in the need for a surgical excisional procedure to remove non-living tissue from the resident's pressure wound, highlighting a significant lapse in the facility's adherence to its own protocols for pressure injury prevention.
Failure to Use Gait Belt During Resident Ambulation
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the use of gait belts during resident ambulation, as observed with Resident 438. A Physical Therapy Assistant (PTA) was seen assisting Resident 438 to walk by holding onto the resident's pants waistband instead of using a facility-provided gait belt. The gait belt on Resident 438 was noted to be fraying, indicating wear and tear. The PTA admitted to not using a gait belt, despite acknowledging its role in reducing falls and maintaining resident safety. The PTA used his own gait belt, which was not in optimal condition, rather than a facility-provided one. Resident 438's care plan highlighted a tendency to lose balance during transfers and ambulation due to decreased motor planning, safety awareness, increased loss of balance, leg weakness, and pain, placing the resident at risk for falls. The care plan included interventions such as gait training and safety measures. The facility's policies, dated 9/16 and 1/1/12, emphasized the use of gait belts to assist clinical staff in moving residents safely and to prevent falls, specifying the use of an underhand grasp for greater safety. The Director of Rehabilitation Services confirmed that holding residents by their pants during ambulation was not appropriate.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility failed to adhere to physician orders for pain management for a resident, resulting in unmanaged pain and refusal to eat. The resident, who experienced chronic pain in the knees, feet, and back, reported a pain level of 8 out of 10. Despite having physician orders for Norco and Tylenol to manage pain, the resident did not receive Tylenol as needed between scheduled doses of Norco. An LVN was unable to administer pain medication during a lunch break due to not having access to the narcotic drawer, further contributing to the resident's unmanaged pain. Additionally, the facility did not implement non-pharmacological interventions as ordered for the resident. The resident's Medication Administration Record indicated that non-pharmacological interventions were not consistently applied on several occasions when the resident reported pain. The resident's plan of care emphasized the need for timely pain relief and evaluation of pain interventions, but these measures were not followed, leading to the resident experiencing significant pain and refusing meals.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to reorder medication in a timely manner for one of the residents, identified as Resident 28, which resulted in the resident not receiving his physician-ordered medication. Resident 28 was prescribed Brinzolamide Ophthalmic Suspension 1% to be instilled as one drop in both eyes three times a day for glaucoma. On the date of the survey, it was observed and confirmed through an interview with LVN 6 that the 12 p.m. dose of Brinzolamide was not available for administration. A review of Resident 28's Medication Administration Record indicated that the doses scheduled for 12 p.m. and 5 p.m. were missed. Additionally, the facility's progress notes documented that the eye medication was missed earlier that day. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply, which was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Medication Storage in the Facility' for three residents when medications were found at their bedsides. During observations, single-use vials of eye drops were found on the bedside tables of three residents. A Licensed Vocational Nurse (LVN) confirmed that medications should not be at the bedside as it allows unauthorized access. The facility's policy indicates that medications should be stored safely and securely, accessible only to authorized personnel. Additionally, the facility did not follow the manufacturer's instructions for storing Aplisol, a tuberculosis testing medication, which was found in a medication cart instead of being refrigerated as required. This could lead to a loss of potency and inaccurate test results. Furthermore, the facility's policy was not followed when topical and oral medications were stored together in medication carts, risking cross-contamination. LVNs acknowledged that medications should be stored separately, as per the facility's policy.
Failure to Schedule Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure that a resident received a follow-up dental appointment, which was necessary for the adjustment of her dentures. During an observation and interview, the resident indicated that her lower denture was loose, leading her to not wear it. A review of the resident's dental notes revealed that her dentures were 5-6 years old, and there was no record of a follow-up appointment with the dentist since her last visit several months prior. The Minimum Data Set Coordinator confirmed the absence of follow-up dental notes and acknowledged that a follow-up appointment should have been scheduled for denture realignment.
Failure to Honor Meal Preferences for Residents
Penalty
Summary
The facility failed to honor meal preferences for two residents, which could potentially impact their nutritional needs. In the first instance, a Certified Nursing Assistant (CNA) delivered a lunch tray to a resident that was missing the requested juice. The Meal Tray Ticket (MTT) for this resident indicated that 4 ounces of juice should have been included, but it was not present. The resident confirmed that he did not receive the juice he had requested. In the second instance, another resident was served a meal that included cheese, despite her documented dislike for it. The resident expressed dissatisfaction with being served cheese quesadillas, which she did not like. The Dietary Manager confirmed that the MTT for this resident indicated a dislike for cheese, and acknowledged that the resident should not have been served cheese. The facility's policy requires that meals be consistent with residents' preferences, and if a preferred item is unavailable, a substitute should be provided.
Failure to Obtain Therapeutic Diet Order for Edentulous Resident
Penalty
Summary
The facility failed to obtain a therapeutic diet order for Resident 388, who was observed to have no teeth and no dentures. During an observation and interview, Resident 388 expressed difficulty eating an uncut zucchini due to their edentulous condition. The resident's care plan, dated 10/14/24, indicated a nutritional problem with interventions including a No Added Salt diet and regular texture. However, the care plan dated 10/22/24 noted oral/dental health problems related to being edentulous, with an intervention to consult with a dietitian if chewing or swallowing problems were noted. Despite this, the Registered Dietician stated that Resident 388's diet order was regular texture and did not acknowledge any chewing issues, even though the resident had no teeth. The facility's policy on therapeutic diets, dated 6/1/14, aims to ensure diets meet nutritional guidelines and physician orders, which was not adhered to in this case.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, which could potentially impact their care. For one resident, the Minimum Data Set (MDS) assessment inaccurately indicated that the resident had no natural teeth, despite being edentulous. Additionally, the Order Summary Report (OSR) incorrectly included a physician order to monitor for adverse reactions to Zoloft, an antidepressant medication that had been discontinued earlier in the month. The Minimum Data Set Coordinator (MDSC) confirmed these inaccuracies during a review. For another resident, the Director of Nursing (DON) was unable to locate a physician order for a hospital transfer that occurred the previous year. Furthermore, the facility could not obtain the resident's History and Physical (H&P) or Discharge Summary from the hospital due to issues accessing the hospital's electronic health record system. The facility's policy and procedure on medical record completion and correction emphasize the need for complete and accurate documentation, which was not adhered to in these instances.
Failure to Conduct Employment and Reference Checks for RNs
Penalty
Summary
The facility failed to ensure that previous employment and personal reference checks were completed for two registered nurses (RN 1 and RN 2) before they were hired. This oversight was identified during a review of the Employee Information Sheets and Previous/Current Employment Verification forms for both RNs, which showed that these checks were not conducted prior to their hire dates. During an interview and record review with the Administrator, it was confirmed that the necessary checks were not performed, despite the facility's policy requiring screening of potential employees for any history of abuse, neglect, or mistreatment of residents. The policy mandates obtaining information from previous or current employers and checking with appropriate boards and registries.
Inadequate Monitoring After Resident Elopement
Penalty
Summary
The facility failed to adequately monitor a resident who had previously eloped from the facility, as required by their policy. The resident was found outside the facility on Prosperity Ave in Tulare, CA, in their wheelchair, and was redirected back by a staff member. Despite the recommendation for monitoring every 30 minutes, the resident was only checked once on the day of the incident and inconsistently monitored in the following days, with checks ranging from one to three times a day. The Director of Nursing acknowledged that the documentation showed insufficient monitoring, which did not align with the facility's policy for preventing further elopement.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was sent home with another resident's prescribed medications. During an interview, the resident expressed concern about the potential risk of taking the wrong medication. The incident occurred when a Licensed Vocational Nurse handed the resident a bag filled with medications without verifying that they were the correct prescriptions. The Registered Nurse admitted to not performing the necessary double or triple checks to confirm the medications were intended for the discharged resident. The Director of Nurses confirmed that the resident was mistakenly sent home with another resident's medications, which were later returned by the resident's family. The facility's policy and procedure for the discharge and transfer of residents, dated February 2018, requires a triple check of all prescribed medications before they are given to a resident upon discharge. This policy was not followed, leading to the potential for the resident to take incorrect medications.
Violation of Resident's Rights Due to Disrespectful Treatment
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, resulting in a violation of the resident's rights. The incident involved a resident with unspecified dementia and anxiety, who was admitted to the facility with cognitive impairments that made communication challenging. During a dinner service, the resident exhibited a behavior of swinging his arms at staff, which was a known behavior pattern. A Certified Nursing Assistant (CNA) was assisting the resident when he began to hit the table and nearly struck her arm. In response, the CNA blocked the resident's arm and verbally admonished him by saying, "We don't hit," and further remarked that he "hits like a girl," which she later acknowledged was disrespectful. The CNA admitted to raising her voice during the incident, which was confirmed by the facility's administrator. The administrator stated that the CNA should not have raised her voice and should have sought assistance instead. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this situation. The incident was documented in a Facility Reported Event, and the CNA's actions were found to be in violation of the resident's rights to a dignified existence and respectful treatment.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident, which required hospitalization. During an interview, the resident's responsible party stated that the resident was transferred to an acute hospital. A review of the resident's medical record showed no documented evidence that the physician was notified of this significant change in condition and subsequent transfer. The facility's administrator confirmed the lack of documentation and was unaware of the specific change in condition that necessitated the transfer. The Director of Nurses stated that it was the facility's practice to notify the physician of significant changes in a resident's condition, as outlined in the facility's policy and procedure for alert charting documentation.
Failure to Document Change in Condition
Penalty
Summary
The facility failed to assess and document a significant change in condition for one of the sampled residents, leading to a deficiency in meeting professional standards of quality. The incident involved a resident who was transferred to an acute hospital without an assessment being completed by the nurse on duty. The resident's Responsible Party reported the transfer, and upon review, there was no documented evidence of an assessment or a completed Change of Condition form in the resident's medical records. Interviews with the facility's Administrator and Director of Nurses (DON) confirmed that the nurse on duty did not perform the required assessment or documentation. The facility's policy, titled 'Alert Charting Documentation,' mandates that licensed nurses must note and document any change in a resident's medical condition. However, this procedure was not followed, resulting in a lack of awareness about the specific change in condition that necessitated the resident's transfer to the hospital.
Failure to Document and Administer Wound Care
Penalty
Summary
The facility failed to provide wound care for a resident according to the physician's orders, as evidenced by missing documentation in the Treatment Administration Record (TAR). The resident had multiple wounds requiring specific treatments, including a Stage 2 pressure ulcer on the coccyx, surgical sutures and scarring on the abdomen, and a dehisced surgical wound on the abdomen. The prescribed treatments involved cleansing with wound cleanser, applying topical ointments, and covering with dressings as needed. However, the TAR lacked signatures on several dates, indicating that the treatments were not documented as completed. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) confirmed the absence of documentation for the specified dates, which suggested that the treatments were not administered. The facility's policy and procedure for medication administration emphasized the importance of documenting the time and dose of treatments in the patient's medication record. The LVN acknowledged that the facility's practice was to document treatments immediately after completion, and the DON confirmed that the treatments were not provided on the specified dates.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party of a resident after a fall incident, which resulted in the resident sustaining a black eye and a cut to the left lower lip. The incident occurred when the resident, who was under respite care, attempted to stand from her wheelchair in the front lobby and fell. The Licensed Vocational Nurse (LVN) on duty notified the hospice agency but did not inform the resident's responsible party, despite the facility's policy requiring notification of any change in condition, including falls. The resident's medical records indicated that her son was the responsible party and had given consent for treatment. The facility's Fall Management Program policy, dated March 13, 2021, mandates that the licensed nurse notify both the resident's attending physician and responsible party of all incidents.
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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