Vacaville Ranch Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Vacaville, California.
- Location
- 101 S Orchard Ave, Vacaville, California 95688
- CMS Provider Number
- 055412
- Inspections on file
- 33
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Vacaville Ranch Post Acute during CMS and state inspections, most recent first.
The facility failed to ensure proper labeling and dating of food items in the kitchen refrigerator, leading to potential foodborne illness. Observations revealed unlabeled sliced tomatoes, meats, and hash browns, as well as soy milk without open and use-by dates. Additionally, utensil storage was unsanitary, with food crumbs present, and contaminated brown rice was improperly returned to its container. The Registered Dietician confirmed these actions violated facility policy and posed risks of cross-contamination and allergies.
The facility failed to remove two expired multi-dose vials of Tuberculin skin test solution from use. During an observation, two vials with expired dates were found in the Medication Storage Room Refrigerator. Licensed Staff A confirmed the vials were expired and should have been discarded. The facility's policy requires that outdated drugs be returned to the pharmacy or destroyed.
The facility failed to provide appetizing and palatable meals, as evidenced by three residents who reported the fish served was dry and tasteless. The Dietary Assistant confirmed the issue, and the Registered Dietician noted the difficulty in keeping the thinly sliced fish moist. This failure to adhere to the facility's food preparation policy could impact residents' food intake and nutritional status.
A LTC facility failed to provide prescribed medications for two residents, leading to significant care deficiencies. One resident did not receive her Spiriva inhaler for four days, causing shortness of breath and anxiety. Another resident received nine scheduled medications nearly two hours late. The facility's policies on timely medication administration were not followed, and there was a lack of communication and follow-up with the pharmacy.
The attending Physician failed to document responses to the Pharmacist's recommendations over five months, leaving 26 recommendations unacknowledged. Licensed Staff A confirmed that the process involved verbal discussions without written documentation, contrary to facility policy. This oversight posed potential risks for 49 residents.
The facility failed to follow hand hygiene protocols during medication administration and meal service. A licensed staff member did not perform hand hygiene before or after administering medications to two residents, and an unlicensed staff member did not ensure hand hygiene before assisting a resident with their meal. These actions were contrary to the facility's policy, which requires hand hygiene in these situations.
A resident expressed a preference to get out of bed for meals, but the facility failed to assist her on multiple occasions, resulting in her eating meals in bed. Staff interviews revealed inconsistencies in care, with some unable to explain why the resident's preferences were not honored.
The facility failed to remove expired medications from stock, as six bottles of Docusate Sodium 50 MG/5 ML were found in the medication storage room two months past their expiration date. Licensed Staff A confirmed the oversight, noting that the medications were stored on a higher shelf and missed during monthly checks by the AM Unit Manager.
The facility failed to follow its antibiotic stewardship policies, leading to inappropriate antibiotic prescriptions for two residents with suspected UTIs. One resident was given Macrobid before culture results showed no infection, and another received Keflex despite having a bacteria resistant to it. Staff confirmed that neither resident met the criteria for antibiotic use, highlighting a breach in protocol.
A resident developed sheared skin on the coccyx, but the responsible party was not notified, despite a physician's order indicating the resident lacked decision-making capacity. The facility's policy requiring notification of significant changes was not followed, leading to a deficiency.
A resident with severe cognitive impairment experienced a loss of personal belongings during their stay at the facility. Despite family reports of missing clothes, the facility failed to properly document and verify the return of items upon discharge. The inventory sheet was incomplete, and the Social Service Director was not informed of the loss, indicating a lapse in following the facility's policy.
The facility failed to provide adequate supervision and fall prevention for two high-risk residents, resulting in multiple falls and injuries. One resident fell and fractured her hip due to lack of supervision and absence of a call light, while another experienced three falls within two weeks due to inadequate interventions.
A resident experienced severe pain that was not adequately managed by the facility. Despite continuous complaints of an 8/10 pain level, the staff administered only acetaminophen, ignoring the physician's order for a higher dose of morphine. The facility also prioritized the family's preferences over the resident's comfort, leading to prolonged pain and distress.
The facility failed to submit required staffing information to CMS for several months due to operating under the previous owner's provider number. The pending Change of Ownership (CHOW) process prevented the Office Manager from accessing the system needed for the electronic submission of Payroll-Based Journal (PBJ) data.
The facility failed to ensure hot water in the sink of bathrooms used by seven residents. Residents reported waiting up to 15 minutes for hot water, and the Director of Maintenance confirmed that it took up to ten minutes for the water to get hot. Observations showed that water temperatures started cold or lukewarm and took several minutes to reach 100 F.
The facility failed to ensure staff were aware of what a Basic Care Plan (BCP) was and its completion time frame, resulting in no BCPs being completed for four sampled residents. Interviews with various staff members revealed a lack of awareness and understanding of the BCP and its importance. The facility was using an Interim Care Plan (ICP) instead, which did not include essential information, putting residents' safety at risk and potentially leading to inadequate and inappropriate care.
The facility failed to ensure that food meant for residents was not stored in the staff refrigerator, that residents' food items were properly labeled with names and dates, and that expired food items were discarded. The removal of the residents' refrigerator in the Activity Room left staff uncertain about where to store residents' perishable food brought in by family or visitors, leading to potential safety risks.
The facility failed to ensure proper hand hygiene for residents before and after meals, improperly stored residents' valuables with medications, did not require laundry staff to use protective clothing, and lacked a detailed water system diagram to prevent Legionella growth.
The facility failed to maintain an updated surveillance log for residents receiving antibiotics, as confirmed by the Infection Preventionist. Despite eight residents currently on antibiotics, the log for February 2024 contained data for only one resident, contrary to the facility's policy on Antibiotic Stewardship.
The facility failed to ensure that three residents were offered and provided COVID-19 vaccines, and did not maintain documentation that staff were educated about and offered the COVID-19 vaccine. Additionally, the facility's COVID-19 policies and procedures had not been updated since June 2020.
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to a resident who no longer qualified for Medicare Part A skilled services but had not exhausted all her Medicare benefit days. Interviews with staff revealed a lack of knowledge and understanding regarding the correct notice to issue, and the facility did not provide a policy for Medicare Beneficiary Notice when requested.
The facility failed to follow the care plan for a Spanish-speaking resident, resulting in a lack of daily visits, Spanish music, TV channels, and religious services. Additionally, the facility did not have an effective communication system for non-English speaking residents, relying on untrained staff and family members for interpretation, leading to potential miscommunication and unmet care needs.
A resident did not receive physician visits every 60 days, resulting in over 8 months without a documented visit. The DON confirmed the lapse and noted that the hospice provider was responsible for the resident's care but failed to provide the necessary documentation.
The Consulting Pharmacist failed to accurately review and provide recommendations on antibiotic usage for two residents. One resident was prescribed Doxycycline Hyclate indefinitely without an end date, and the PharmD did not review the medical record for the duration of treatment. Another resident was prescribed Keflex for six months without an initial indication of the reason for use, which was only added later. The facility's policies require clear indications and periodic re-evaluations for antibiotic use.
The facility failed to ensure proper antibiotic usage for two residents, with one resident lacking an end date for Doxycycline and another resident's Keflex usage not being properly documented or re-evaluated. This led to potential antibiotic resistance.
The facility failed to ensure the medical record of a resident admitted to hospice care was complete and readily accessible. The DON acknowledged the absence of documented physician visits and initially lacked hospice records, which were later received by fax.
The facility failed to ensure that binding arbitration agreements were explained in a language and form residents understood, leading to a deficiency for one resident. The resident's Responsible Party signed the agreement without understanding its implications, as confirmed through interviews and record reviews.
The facility failed to post the daily direct care staffing schedule in a visible and accessible location for all residents, staff, and visitors. The schedule was kept inside a binder and taped inside the Nurses' Station counter, making it only visible to staff. Additionally, the schedule lacked essential information such as the resident census, the number of nursing personnel, and the actual time worked during the shift.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen refrigerator, which could lead to misidentification and potential foodborne illness. During observations, it was noted that sliced tomatoes, sliced meat, cut-up meat, and opened hash browns were not labeled with open and use-by dates. Additionally, a carton of soy milk was found without an open and use-by date. The facility's policy requires all food items to be labeled and dated to ensure freshness and safety for residents' consumption. The Registered Dietician confirmed the importance of labeling to prevent food poisoning and acknowledged that the facility policy was not followed. The facility also failed to maintain sanitary conditions for utensil storage and proper disposal of contaminated food items. Observations revealed that a drawer containing utensils was dirty with food crumbs, including a cooked macaroni noodle, which could attract pests and lead to cross-contamination. Furthermore, an incident was observed where brown rice was poured back into its container after being placed in a greased pan, which was acknowledged as a mistake by the staff member involved. The Registered Dietician highlighted the risk of cross-contamination and allergy concerns due to this action. The facility lacked specific policies for cleaning utensil storage and discarding contaminated food items.
Expired Tuberculin Vials Not Removed from Use
Penalty
Summary
The facility failed to remove two expired multi-dose vials of Tuberculin skin test solution from use, which are used to test for tuberculosis (TB). During an observation and interview, two vials were found in the Medication Storage Room Refrigerator, both labeled with expired dates. Licensed Staff A acknowledged that the vials were expired and should have been discarded. According to the drug information on Tubersol, a vial that has been opened and in use for 30 days should be discarded and not used after its expiration date. The facility's policy on the storage of medications also states that discontinued, outdated, or deteriorated drugs or biologicals should not be used and must be returned to the dispensing pharmacy or destroyed.
Facility Fails to Ensure Palatable and Appetizing Meals
Penalty
Summary
The facility failed to ensure that food served to residents was appetizing and palatable, as evidenced by the experiences of three sampled residents. Resident 42, who has Type II Diabetes Mellitus, Chronic Pain Syndrome, and Anemia, reported that the fish served for lunch was dry and tasteless. Similarly, Resident 208, diagnosed with Depression, Anxiety Disorder, and Cellulitis, stated that the fish was dry and unpalatable. Resident 33, who has Dysphagia, Essential Hypertension, and Hyperlipidemia, also found the fish to be too dry, chewy, and lacking in taste. These observations were corroborated by the Dietary Assistant, who agreed that the fish was dry and not flavorful. The Registered Dietician acknowledged the issue with the fish being dry, attributing it to the thin slicing of the fish, which made it difficult to keep moist. The facility's policy and procedure on food preparation emphasize that food should be prepared to conserve nutritive value, flavor, and appearance, and that prepared food should be sampled to ensure satisfactory flavor and consistency. However, the failure to adhere to these guidelines resulted in the residents' dissatisfaction with the meal, potentially impacting their food intake and nutritional status.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide prescribed medications as ordered for two residents, leading to significant deficiencies in care. Resident 153, who was admitted with chronic heart failure and Chronic Obstructive Pulmonary Disease (COPD), did not receive her prescribed Spiriva inhaler for four days due to its unavailability in the facility. Despite notifying the nursing staff about her medication needs, the resident was informed that the medication was not yet available. This oversight resulted in the resident experiencing shortness of breath and anxiety, as she was unable to receive her necessary treatment for COPD. Additionally, the facility failed to administer nine scheduled medications to Resident 208 at the prescribed times. These medications, which included treatments for heart failure, hypertension, and anemia, were administered one hour and forty-five minutes past the scheduled time. The facility's policy required medications to be administered within 60 minutes of the scheduled time, but this was not adhered to, as confirmed by the Medication Administration Audit Report and staff interviews. The deficiencies were further highlighted by the lack of communication and follow-up actions by the nursing staff and the pharmacy. Licensed staff did not notify the physician of the missed doses for Resident 153, nor did they follow up with the pharmacy or check if the resident could bring medications from home. The pharmacist consultant expressed concerns about the lack of urgency and communication regarding the delayed delivery of medications. These failures in medication management and administration compromised the health and safety of the residents involved.
Physician's Failure to Document Pharmacist Recommendations
Penalty
Summary
The attending Physician at the facility failed to document the review of the Pharmacist's findings and the actions taken or not taken in response to these recommendations over a five-month period from February 2024 to June 2024. This oversight was identified during a record review of the Medication Regimen Review (MRR) Binder, which revealed that the Physician/Prescriber Response sections for 26 Pharmacist recommendations were left blank. The recommendations included various suggestions for medication adjustments, but there was no written acknowledgment or rationale provided by the Physician for agreeing or disagreeing with these recommendations. Interviews with Licensed Staff A and Pharmacist Consultant J highlighted a lack of clarity in the process for documenting the Physician's responses to the Pharmacist's recommendations. Licensed Staff A indicated that the current practice involved verbal discussions with the Physician, and any changes to medication were made if the Physician agreed with the recommendations. However, if the Physician disagreed, there was no documentation of the rationale for this decision. The facility's policy required that recommendations be acted upon and documented, with explanations provided for any disagreements, but this was not adhered to, leading to potential risks for the 49 vulnerable residents.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to standard precautions for infection prevention and control, specifically in the area of hand hygiene. During medication administration, a licensed staff member did not perform hand hygiene before preparing medications, before entering the room, or after leaving the room for two residents. Interviews with other licensed staff revealed inconsistencies in the understanding and application of hand hygiene protocols, with some staff indicating that hand hygiene was only performed if hands were visibly soiled, contrary to the facility's policy. Additionally, during meal service, an unlicensed staff member did not perform hand hygiene while assisting a resident with their meal tray. The staff member was unable to confirm if hand hygiene was provided to the resident before the meal, despite the facility's policy requiring hand hygiene before and after assisting residents with meals. The facility's policy, dated August 2015, clearly outlines the need for alcohol-based hand rub or soap and water in these situations, yet these guidelines were not followed, potentially exposing residents to infectious agents.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to accommodate the preferences of a resident, identified as Resident 6, who expressed a desire to get out of bed to have meals either in her wheelchair in her room or in the dining room. Despite her preference, the facility did not assist her in getting out of bed for meals on multiple occasions. This was confirmed through interviews and observations conducted over several days. On 7/8/24, Resident 6 mentioned she liked to get out of bed for meals, but the facility did not assist her. Observations on subsequent days showed Resident 6 eating meals in bed, and staff were unable to provide a reason for this deviation from her usual routine. Interviews with staff revealed inconsistencies in the care provided to Resident 6. Unlicensed Staff F and Licensed Staff A acknowledged that Resident 6 typically got up for meals but could not explain why she remained in bed on certain days. Unlicensed Staff H noted that Resident 6 did not get up on 7/8/24 because they were not working that day. These observations and interviews indicate a lack of consistent adherence to Resident 6's preferences, resulting in her remaining in bed for meals on several occasions, contrary to her expressed wishes.
Expired Medications Not Removed from Stock
Penalty
Summary
The facility failed to ensure expired medications were promptly removed from stock and disposed of, as evidenced by the presence of six bottles of Docusate Sodium 50 MG/5 ML in the medication storage room that had expired two months prior. During an observation and interview, Licensed Staff A confirmed the expiration of these medications. Licensed Staff A stated that the expiration dates of medications were checked monthly by the AM Unit Manager, but the expired bottles were overlooked because they were stored on a higher shelf. The facility's policy, dated March 2018, requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures.
Failure to Implement Antibiotic Stewardship Policies
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship policies and procedures, resulting in the inappropriate prescription of antibiotics to two residents with suspected urinary tract infections (UTIs). Resident 34 was prescribed Macrobid for three days before the results of a urine culture sensitivity test were available, which later showed no growth, indicating no infection. Similarly, Resident 31 was given Keflex for seven days after reporting abdominal pain and purulent discharge from a catheter, but the urine culture revealed the presence of Pseudomonas aeruginosa, a bacteria resistant to the prescribed antibiotic. Licensed Staff B confirmed that neither resident met the criteria for antibiotic use according to the McGreer Criteria for UTIs, which requires at least one sign or symptom and culture sensitivity test results before starting antibiotics. The Medical Director emphasized the importance of waiting for culture sensitivity results to avoid the risk of residents developing multi-drug-resistant organisms (MDROs) due to inappropriate antibiotic use. The facility's policy on antibiotic stewardship, dated December 2016, mandates that antibiotics be prescribed based on pathogen susceptibility and clinical definitions of active infection, which was not followed in these cases.
Failure to Notify Responsible Party of Resident's Skin Condition
Penalty
Summary
The facility failed to implement its policy on change of condition/notification for a resident when the responsible party was not informed of a new skin issue. The resident, who was admitted with no skin issues, developed sheared skin on the coccyx, a condition that can occur during transfers or repositioning. Despite a physician's order indicating the resident lacked the capacity to make healthcare decisions, the responsible party was not notified of the new wound. This oversight did not allow the responsible party to be informed or participate in the resident's care and treatment. Interviews and document reviews revealed that the facility's staff did not follow the policy requiring immediate notification of the resident, physician, and responsible party in the event of a significant change. The DON acknowledged that the responsible party should have been informed, as the resident was not capable of making healthcare decisions. The facility's policy, effective since 2016, mandates such notifications, but it was not adhered to in this case, leading to the deficiency.
Failure to Safeguard Resident's Belongings
Penalty
Summary
The facility failed to safeguard a resident's personal belongings, resulting in missing clothes upon discharge. The resident, who had a severe cognitive impairment with a BIMS score of 7, was admitted with a diagnosis of cerebral infarction and dementia. During the resident's stay, family members reported missing items, including gray pants, compression socks, underwear, and a black shirt. Despite notifying the facility staff, the family was only informed that a search would be conducted, and clothes from other residents were mistakenly sent home with the resident. The facility's policy required that all personal belongings be recorded upon admission and verified upon discharge, with signatures from the resident or their representative. However, the inventory sheet for the resident was incomplete, with no checkmarks indicating the return of items, and the resident, despite cognitive impairment, signed the document. Interviews with staff revealed inconsistencies in following the policy, as the Social Service Director was not informed of the missing items, and there was no record of a search or a report of the loss being processed.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and fall prevention interventions for two residents at high risk for falls. Resident 20, who had diagnoses including generalized muscle weakness, abnormalities of gait and mobility, and senile degeneration of the brain, fell and fractured her hip due to the lack of supervision and the absence of a call light within her reach. Despite being at high risk for falls, as indicated by her care plan and Morse Fall Scale, Resident 20 was left unsupervised in the hallway, leading to her attempting to pick up an object from the floor and subsequently falling out of her wheelchair. The incident occurred during a shift change, and no staff were present in the hallway to monitor her at the time of the fall. The DON confirmed that the fall prevention interventions in place were insufficient to prevent the fall, as Resident 20 did not have access to a call light and was not being actively supervised when the fall occurred. The fall resulted in a right hip fracture, and Resident 20 was taken to the hospital for evaluation and treatment of her injuries. Resident 14, who had diagnoses including generalized muscle weakness, difficulty walking, and dementia, experienced three falls within a two-week period due to inadequate supervision and fall prevention measures. Despite being identified as high risk for falls, as indicated by her care plan and Morse Fall Scale, the facility failed to implement effective interventions after each fall. The first fall occurred when Resident 14 was seen standing unassisted with a walker in front of the nurse's station and lost her balance. No new fall interventions were implemented after this incident. The second fall happened when Resident 14 attempted to get up from her bed to use the bathroom and tripped on a blanket, with the bed alarm being disconnected at the time. The third fall occurred in the activities room when Resident 14 attempted to get up from a table using her walker, which rolled out from under her, causing her to fall. The facility's response to these falls was inadequate, with only minimal new interventions being implemented after each incident. The facility's policies on fall risk management and dementia care were not effectively followed, leading to repeated falls and injuries for both residents. The staff failed to provide the necessary supervision and timely interventions to prevent these falls, despite the residents' high-risk status and documented care plans. The lack of adequate monitoring, failure to ensure call lights were within reach, and insufficient implementation of fall prevention measures directly contributed to the residents' falls and subsequent injuries.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to ensure adequate pain relief for Resident 34, who was experiencing severe pain. Despite Resident 34's continuous complaints of an 8 out of 10 pain level, the nurse administered only acetaminophen (APAP) 650 mg, which was insufficient for such severe pain. The resident had received a dose of morphine at 6:30 a.m., but when the pain persisted, the staff did not follow the physician's order to administer a higher dose of morphine for severe pain. Instead, they opted for APAP, which did not alleviate the resident's pain, leading to continued discomfort and distress. The facility also failed to prioritize Resident 34's comfort over the family's preferences. The Director of Nursing (DON) acknowledged that the family was heavily involved in the resident's care and often interfered with pain management decisions. Despite the resident being capable of making his own decisions, the staff felt intimidated by the family's wishes and did not administer the appropriate pain medication as per the physician's order. This resulted in the resident experiencing prolonged severe pain without adequate relief. Additionally, the facility did not adhere to its pain management policy, which required staff to notify the physician if the prescribed pain medication was ineffective. The staff did not reassess the resident's pain or seek further medical advice when the initial dose of morphine did not provide relief. The Medical Director confirmed that the nurse should have contacted him for an additional dose of morphine. The failure to follow the pain management protocol and the physician's orders led to Resident 34 enduring significant pain and discomfort unnecessarily.
Failure to Submit PBJ Data Due to Pending CHOW
Penalty
Summary
The facility failed to electronically submit the required staffing information to CMS for the months of September, October, November, December 2023, and January 2024. This failure was due to the facility operating under the previous owner's provider number, which prevented the Office Manager from accessing the system to submit the Payroll-Based Journal (PBJ) data. The Change of Ownership (CHOW) process was still pending, and as a result, the facility did not have its own provider number to facilitate the electronic submission of staffing data. During an interview on February 8, 2024, the Office Manager and Administrator confirmed the inability to submit the PBJ data electronically. The Office Manager stated that he had no access to the computer system required for the submission due to the pending CHOW. The Administrator corroborated this, explaining that the lack of an approved provider number was the reason for the submission failure. This non-compliance with the Health & Safety code S483.70(q) had the potential to result in inaccuracies in the reported numbers of licensed and unlicensed nurses available to provide care to residents, thereby impacting their health and safety.
Failure to Ensure Hot Water in Resident Bathrooms
Penalty
Summary
The facility failed to ensure hot water in the sink of bathrooms used by seven of ten residents. During a resident group interview, two residents reported that there was no hot water in their bathroom sinks, and they had to wait up to 15 minutes for the water to get hot. This issue was confirmed by the Director of Maintenance (DM), who stated that the water in some resident bathrooms took up to ten minutes to get hot. Observations and measurements of water temperature in the bathrooms used by Residents 29, 30, 33, 92, 95, 192, and 243 showed that the water temperature started at a cold or lukewarm level and took several minutes to reach a hot temperature of 100 F. During the observations, the DM measured the water temperature in the bathrooms and found that it took between three to ten minutes for the water to reach a hot temperature. For example, in the bathroom used by Resident 192, the water temperature was 68 F initially and took ten minutes to reach 100 F. Similarly, in the bathroom used by Residents 30 and 33, the water temperature started at 63 F and took seven and one-half minutes to reach 99 F. The facility's policy on maintenance service, revised in December 2009, indicated that the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
Failure to Complete Basic Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure staff were aware of what a Basic Care Plan (BCP) was and its completion time frame, resulting in no BCPs being completed for four sampled residents. Resident 34, who was dependent on staff for Activities of Daily Living (ADLs) and a recipient of hospice care, did not have a BCP completed within 48 hours of admission. Similarly, Resident 13, who had severe cognitive impairment and needed assistance with ADLs, also did not have a BCP completed within the required timeframe. Resident 242, with moderately impaired cognition and requiring assistance with ADLs, and Resident 41, who needed supervision for ADLs, were also without a BCP within 48 hours of admission. Interviews with various staff members, including the Minimum Data Set (MDS) Coordinator, Activity Director (AD), Director of Rehabilitation (DOR), Registered Dietician (RD), and Assistant Director of Nursing (ADON), revealed a lack of awareness and understanding of the BCP and its importance. The MDS Coordinator and other staff members were not familiar with the BCP process and its completion time frame, and the facility was using an Interim Care Plan (ICP) instead, which did not include essential information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, or PASARR recommendations. The facility's policy and procedure indicated that a BCP should be developed within 48 hours of admission to meet residents' immediate care needs. However, the ADON confirmed that BCPs for late Friday admissions were completed the following Monday, making them late. The ICP used by the facility was completed by the Admission Nurse only, without input from the interdisciplinary team, the resident, or the Responsible Party (RP). This lack of a timely and comprehensive BCP put residents' safety at risk and could lead to inadequate and inappropriate care.
Failure to Properly Store and Label Residents' Food
Penalty
Summary
The facility failed to ensure that food meant for residents was not stored in the staff refrigerator, that residents' food items were properly labeled with names and dates, and that expired food items were discarded. During observations, it was found that dough and a box of tater tots were stored in the staff refrigerator/freezer, which posed a risk for cross-contamination. The Dietary Manager and other staff confirmed that these items should not have been there due to the risk of residents getting sick from cross-contamination and infection. Additionally, the residents' refrigerator in the Activity Room contained various food items such as sorbets, popsicles, and yogurt that were not labeled with resident identifiers or expiration dates. Some of these items were expired, and staff acknowledged that keeping expired food items in the refrigerator put residents at risk for food poisoning and gastrointestinal illnesses. Multiple staff members, including the Activity Director and Licensed Staff, confirmed that the facility's policy required food to be labeled with the resident's name and discard date, and that expired food should be discarded. The facility had recently removed the residents' refrigerator in the Activity Room, leaving staff uncertain about where to store residents' perishable food brought in by family or visitors. Several staff members, including the Director of Nursing and the Assistant Director of Nursing, were unaware of the removal and acknowledged that the facility did not have a plan in place to safely store residents' food. This lack of a dedicated refrigerator for residents' food led to confusion and potential safety risks, as staff did not know where to keep perishable food items until the residents were ready to consume them.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene (HH) practices for six sampled residents before and after meals. Observations revealed that staff did not offer or perform HH for residents before they started eating. Interviews with residents and staff confirmed that HH was not consistently provided, which is against the facility's hand-washing policy. The policy emphasizes the importance of HH in preventing the spread of infections, including gastrointestinal infections and food-borne illnesses like norovirus. The Director of Nursing (DON) and other staff acknowledged that the lack of HH was an infection control issue and could lead to sickness or disease among residents. The facility also failed to properly manage residents' valuables, which were found mixed with medications in the medication carts. Observations and interviews with staff revealed that residents' personal items, such as reading glasses and bracelets, were stored in the narcotic drawers of medication carts. Staff admitted that this practice posed a risk of cross-contamination and infection. The facility did not provide a specific policy for the safekeeping of residents' valuables, but the DON and other staff recognized that mixing personal items with medications was an infection control issue. Additionally, the facility did not ensure that laundry staff used aprons or gowns while handling clean resident laundry. An observation showed a laundry staff member folding clean linen without any protective clothing, allowing the linen to touch his clothing. The Infection Preventionist (IP) confirmed that protective clothing should be worn to prevent contamination. Furthermore, the facility lacked a detailed description and diagram of the water system, which is necessary for identifying areas that could encourage the growth and spread of Legionella bacteria. The Administrator admitted that the facility did not have this documentation, which is required by their Legionella Water Management Program policy.
Failure to Maintain Updated Antibiotic Surveillance Log
Penalty
Summary
The facility failed to maintain a system to monitor and track antibiotic use, as evidenced by an incomplete and outdated surveillance log of residents receiving antibiotics. During an interview and record review, the Infection Preventionist (IP) confirmed that the facility's Infection Prevention and Control Surveillance Log for February 2024 contained data for only one resident, despite there being eight residents currently receiving antibiotics. The IP acknowledged that the log was not updated with the necessary information and data for all residents on antibiotics. A review of the facility's policy on Antibiotic Stewardship indicated that all resident antibiotic regimens should be documented on a facility-approved antibiotic surveillance tracking form, including detailed information such as resident name, medical record number, unit and room number, date symptoms appeared, name of antibiotic, start date, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. The failure to maintain an updated surveillance log placed residents at risk of receiving antibiotics for longer than needed and developing antibiotic-resistant organisms.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to ensure that three of five sampled residents were offered and provided COVID-19 vaccines. Specifically, Resident 13 had not received the latest COVID-19 booster, and there was no documentation in his clinical record indicating he was offered or declined the booster. Resident 34 had consented to the latest COVID-19 booster but had not received it because the facility had not ordered the booster. Resident 30 had not received the latest COVID-19 booster, and there was no documentation in his clinical record that he was offered or refused the booster. Additionally, the facility failed to maintain documentation that staff were provided education regarding the benefits and risks of COVID-19 vaccines and were offered the COVID-19 vaccine. The Infection Preventionist (IP) stated that all staff were offered education and COVID-19 vaccines, but there was no documentation of it. Furthermore, the facility's COVID-19 policies and procedures had not been updated or revised since June 2020, as evidenced by the outdated COVID-19 Mitigation Plan provided by the IP.
Failure to Issue SNF ABN for Resident with Remaining Medicare Days
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to a resident (Resident 13) who no longer qualified for Medicare Part A skilled services but had not exhausted all her Medicare benefit days. Resident 13, who had severe cognitive impairment and required assistance with activities of daily living, was discharged from Medicare Part A but elected to stay at the facility. The Social Services Director (SSD) confirmed that the SNF ABN was not issued, and other staff members, including the MDS coordinator, Director of Nursing (DON), and Business Office Manager (BOM), were unsure of the correct notice to issue in such situations. Interviews with the SSD, MDS coordinator, DON, and BOM revealed a lack of knowledge and understanding regarding the issuance of the SNF ABN when a resident still had Medicare days but chose to remain at the facility. The SSD acknowledged the potential for miscommunication and resident frustration due to the failure to issue the SNF ABN. The facility did not provide a policy for Medicare Beneficiary Notice when requested, indicating a possible gap in their procedures and staff training related to Medicare coverage notifications.
Failure to Follow Care Plan and Provide Adequate Communication for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure that Resident 34 received the necessary care and services to maintain his highest practicable physical, mental, and psychosocial well-being. The activity care plan for Resident 34 was not followed, as evidenced by the lack of daily visits from activity staff, the absence of Spanish music or TV channels, and the failure to provide Spanish newspapers or religious services. Despite the care plan indicating daily visits and specific activities, the activity staff did not engage with Resident 34 as required, leading to potential risks of depression, frustration, and isolation for the resident. Additionally, the facility did not have an effective system for communicating with Spanish-speaking residents like Resident 34. Staff relied on Spanish-speaking employees or the resident's daughter to interpret, which is against the facility's policy. This lack of a proper communication system led to difficulties in understanding and addressing Resident 34's needs, as most of the staff, including nurses and hospice care providers, spoke only English. The reliance on untrained staff and family members for interpretation posed significant risks of miscommunication and unmet care needs. Interviews with various staff members, including the Activity Director, unlicensed staff, licensed staff, and the Director of Nursing, confirmed the absence of a structured communication system for non-English speaking residents. The facility's policy required the use of trained and competent interpreters, but this was not implemented. The failure to follow the care plan and the lack of proper communication methods compromised Resident 34's care and well-being, highlighting significant deficiencies in the facility's operations.
Failure to Ensure Regular Physician Visits for Hospice Resident
Penalty
Summary
The facility failed to ensure that Resident 2 received physician visits every 60 days, resulting in a lapse of over 8 months without a documented physician visit. Resident 2 was admitted to the facility and later to hospice care. The Director of Nursing (DON) confirmed that there were no documented physician visits for Resident 2 since the admission to hospice care. The DON initially stated that the hospice provider was responsible for the resident's care and physician visits but later admitted that the facility did not have the hospice records. Upon receiving the hospice records, it was confirmed that there were no physician visits documented after the resident's admission to hospice care.
Pharmacist Fails to Review and Recommend Antibiotic Usage
Penalty
Summary
The Consulting Pharmacist (PharmD) failed to perform the Medication Regimen Review (MRR) accurately and safely provide recommendations on antibiotic usage for two residents, Resident 5 and Resident 25. For Resident 5, the PharmD did not review the medical record to check the duration of antibiotic treatment for Doxycycline Hyclate, which was prescribed indefinitely without an end date. Additionally, the PharmD reviewed the MRR but did not provide any recommendations on the antibiotic usage for Resident 5, despite the order lacking an end date and reason for treatment. This oversight was confirmed during a telephone interview where the PharmD admitted to not reviewing the medical record for the duration of treatment and not providing recommendations in the MRR dated 1/31/24. For Resident 25, the PharmD also failed to provide recommendations on the antibiotic usage of Keflex, which was prescribed for prophylactic use for six months without an indication of the reason for the antibiotic usage. The initial physician order did not specify the reason for the antibiotic, which was only added later on 2/8/24. The facility's policies and procedures require that the medication order must have a reason for the antibiotic usage and that the physician and staff periodically re-evaluate the conditions and symptoms for which each resident is receiving medications. The PharmD acknowledged that the use of terms like 'Indefinitely' or 'STOP DATE PENDING' should not be used in antibiotic orders and emphasized the need for monthly evaluations and clear indications for antibiotic use.
Failure to Ensure Proper Antibiotic Usage
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications, specifically antibiotics. For Resident 5, the doctor's order for Doxycycline did not include an end date, and the care plan did not specify when to re-evaluate the effectiveness of the antibiotic. The medication label also indicated 'STOP DATE PENDING,' which was not acceptable. The Assistant Director of Nursing (ADON) acknowledged that the Infection Preventionist should have addressed this issue immediately, and the Licensed Nurse should have clarified the order with the doctor and notified the pharmacy of the discrepancy. For Resident 25, the doctor's order for Keflex did not initially indicate the reason for the antibiotic usage, and the urine culture and sensitivity test did not test for the effectiveness of Keflex. The care plan noted the antibiotic therapy but did not document the indication for its use until a later date. The ADON stated that the urine analysis and culture sensitivity were not repeated for re-evaluation since the resident was already on antibiotics. The Medical Director confirmed that antibiotic orders should have an end date and be re-evaluated for effectiveness after one month. These deficiencies were identified through interviews and record reviews, revealing that the facility did not follow proper protocols for antibiotic usage, potentially leading to antibiotic resistance. The ADON and Medical Director both acknowledged the lapses in procedure, emphasizing the need for clear documentation and regular re-evaluation of antibiotic treatments.
Incomplete Medical Record for Hospice Resident
Penalty
Summary
The facility failed to ensure the medical record of one resident was complete and readily accessible. Resident 2 was admitted to the facility and later to hospice care. During an interview and record review, the Director of Nursing (DON) acknowledged that there were no documented physician visits for Resident 2 since the admission to hospice care. The DON stated that the hospice provider was responsible for the resident's care and physician visits. Upon request, the DON admitted that the facility did not have the hospice records for Resident 2 but later received them by fax from the hospice provider, which included 34 pages of hospice records.
Failure to Explain Arbitration Agreements Properly
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were explained to residents in a language and form they understood, resulting in a deficiency for one of three residents (Resident 94). During an interview, the Administrator stated that arbitration agreements were offered to all residents upon admission, and the Director of Admissions was responsible for these agreements. However, it was found that Resident 94's Responsible Party (RP) signed the arbitration agreement without understanding its implications. The RP admitted to signing many forms during the admission process but did not recall signing an arbitration agreement or understanding what it entailed. When the concept of arbitration was explained, the RP stated she would not have signed the agreement if she had known its meaning. The deficiency was identified through interviews and record reviews. The Director of Admissions confirmed her responsibility for the arbitration agreements and provided copies of the agreements signed by three sampled residents, including Resident 94. The RP of Resident 94, who signed the arbitration agreement, was unaware of its significance and stated she did not understand that signing the agreement meant giving up the right to sue in court. This lack of understanding and proper explanation led to the deficiency noted in the report.
Failure to Post Daily Direct Care Staffing Schedule
Penalty
Summary
The facility failed to post the daily direct care staffing schedule in a location that was visible and accessible to all residents, staff, and visitors. The daily staffing schedule was found to be inserted in a binder inside the Nurses' Station and taped inside the Nurses' Station counter, making it only visible to CNAs and other staff. This deficiency was confirmed through observations and interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing. The daily staffing schedule lacked essential information such as the resident census at the beginning of the shift, the number of nursing personnel responsible for providing direct care, the actual time worked during the shift for each category and type of nursing staff, and the total number of licensed and non-licensed staff working for the posted shift. A review of the facility's policy and procedure titled
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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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