Veterans Home Of California - Fresno
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 2811 W Cesar Chavez Blvd, Fresno, California 93706
- CMS Provider Number
- 555900
- Inspections on file
- 30
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Veterans Home Of California - Fresno during CMS and state inspections, most recent first.
A resident with left hemiplegia and severe mobility limitations was transferred using a Sara lift by a CNA without the required second staff member, despite facility policy and training mandating a two-person assist for such transfers. The resident reported feeling unsafe, and both therapy staff and care documentation confirmed the necessity of two-person assistance for all transfers.
A resident with severe cognitive impairment and a history of falls was not provided with a new intervention after a fall, despite being assessed as high risk. The IDT continued the existing care plan without changes, contrary to the facility's policy requiring new interventions for high-risk residents.
The facility failed to maintain proper sanitation and maintenance in the kitchen, leading to a build-up of grease and grime on equipment and floors. The fryer had significant grease accumulation, and the tile floor was missing grout with a build-up of food and grease. The Dietary Director acknowledged the need for more frequent cleaning, and the Director of Plant Operations was unaware of the grout issue. The facility's cleaning practices and adherence to sanitation policies were inadequate.
A facility failed to meet professional standards for three residents due to improper medication administration. A resident received heart and blood pressure medications without vital sign checks, another was given prostate medication without food, and a third received insulin without proper priming. These actions were contrary to physician orders and facility policies.
A facility exceeded the acceptable medication error rate during a medication pass observation. A resident received heart medications without vital sign checks, another was given prostate medication without food, and a third received insulin without proper priming of the device. These actions were contrary to physician orders and facility policies.
A resident with Parkinson's disease experienced difficulty moving around in a manual wheelchair and requested an assessment for a power wheelchair, which was not provided. The Restorative Nursing Assistant communicated the request to the Physical Therapy department, but no referral was made, and the Occupational Therapy department did not conduct the assessment. The Director of Nursing Services noted that the request should have been communicated to a licensed nurse for follow-up.
A resident with Parkinson's disease requested an assessment for a power wheelchair due to difficulties with a manual wheelchair. Despite the resident's ability to make healthcare decisions and communicate effectively, the request was not fulfilled. The RNA mentioned the request to a staff member, but the OT confirmed no referral was received, and the DON indicated the RNA should have communicated the request to a licensed nurse.
The facility failed to maintain accurate medical records for two residents. One resident's Restorative Nurses Aide-Weekly Notes had incorrect session dates, while another resident's chart contained a Physician Progress Note for a different resident. These errors were confirmed by staff and violated the facility's documentation principles.
A facility failed to follow its infection control policy for a resident with an indwelling Foley catheter under Enhanced Barrier Precaution (EBP). Two CNAs transferred the resident without wearing gowns, contrary to the facility's policy and CDC guidelines, which require gowns and gloves for high-contact activities. The CNAs were unaware of the EBP status and did not check the door sign before entering the room.
A resident, fully dependent on assistance for all ADLs, sustained a head injury when their head hit the bed's headboard during repositioning by a CNA. The resident's MDS assessment and care plan indicated a need for extensive assistance, highlighting a failure in maintaining a safe environment and providing adequate supervision.
The facility failed to store and prepare food in accordance with professional standards for food service safety. Ice machines in two satellite kitchens had discoloration and residue, kitchen appliances and countertops had dirt and grime buildup, bulk sugar was contaminated, and toolboxes used for clean utensils were dirty. These failures posed risks of contamination, microorganism growth, and pest attraction.
The facility failed to ensure that residents' disposable care equipment (DCE) such as basins, urinals, and bedpans were stored in a clean and sanitary manner. Observations revealed multiple instances of undated and unlabeled DCE in various rooms, with items improperly stored. Interviews with staff indicated inconsistencies in the facility's practices and a lack of adherence to the policy requiring labeling and dating of DCE.
The facility failed to follow the menu for lunch when pureed cheesecake was served with a #16 scoop (1/4 cup) instead of the indicated #12 scoop (1/3 cup), potentially affecting the nutritional status of 10 residents. Interviews revealed that staff were trained to use the correct scoop size as per the menu and Portion Control Menu Planner.
The facility failed to ensure that two residents were treated with dignity during meal times, as a CNA was observed standing while feeding them, contrary to the facility's policy requiring CNAs to sit at eye level with residents. Both residents required maximum assistance when eating and have conditions such as Alzheimer's Disease and Dementia.
The facility failed to update a resident's ADL care plan based on his needs, despite a significant decline in ADLs and a history of falls. The care plan lacked interventions to maintain or improve his ADLs after discontinuation of rehabilitation therapy, potentially not meeting the resident's needs.
The facility failed to re-evaluate a resident for the Restorative Nursing Program after discontinuation of physical and occupational therapy, despite the resident's significant decline in ADL functions and multiple falls. The nursing staff did not communicate the need for the resident to be placed on the program, contrary to the facility's policy.
A resident experienced inadequate pain management due to the facility's failure to update the care plan and follow up on physician's progress notes. Despite the resident's complaints of severe pain, the current pain management was ineffective, and necessary diagnostic imaging was not ordered. The facility's policy required care plans to be updated based on ongoing assessments, but this was not done for the resident.
An opened Acidophilus Probiotic bottle requiring refrigeration was found stored at room temperature in a medication cart. The RN confirmed it was not in use and the Pharmacist stated it was unusable once stored at room temperature. Facility policy mandates proper storage according to manufacturer's recommendations.
The facility failed to maintain kitchen equipment in safe operating condition when a water hose connection site under a food preparation table was found leaking. Despite a work order indicating the need for a new part, a miscommunication led to the part not being ordered, violating the facility's policies for equipment maintenance and sanitation.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a Sara lift without the required second staff member. The resident, who had left hemiplegia and contracture of the left hand due to a stroke, was assessed as having very limited functional ability and required a two-person assist for all transfers. Despite this, the CNA performed the transfer alone, which was confirmed during interviews with the resident and the CNA. The resident reported feeling unsafe during the transfer and noted that only one person often assisted, even though two were required. Further review of the resident's clinical records, assessments, and care plan confirmed the need for a two-person assist due to the resident's physical limitations, including being tall, heavy, and non-ambulatory with no functionality on the left side. Both the physical and occupational therapists stated that a two-person assist was necessary for safety. Facility training records showed that the CNA had attended training on the proper use of mechanical lifts, and facility policy required adherence to manufacturer recommendations and assessment of the resident's condition to determine the appropriate level of assistance.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident (R3) after a fall occurred on 3/14/25. The interdisciplinary team (IDT) did not create a new intervention following the incident, despite the resident being assessed as a high risk for falls with a score of 21 on the fall risk assessment. The IDT decided to continue with the existing plan of care without adding new interventions, which was contrary to the facility's policy that requires new approaches to be implemented based on IDT findings. The resident, who was severely cognitively impaired and had a history of two falls with injuries, was found on the floor in their room on 3/14/25. Despite this, the IDT note and care plan review indicated no new interventions were added to address the fall risk. The facility's policy on Fall Prevention and Intervention Program mandates that new interventions should be developed for residents assessed as high risk, but this was not adhered to in R3's case.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain food storage and preparation areas in accordance with professional standards for food service safety. During an observation in the main kitchen, it was noted that the fryer had a significant build-up of yellow grease on its wheels and in the compartment underneath. Additionally, the compartment housing the gas lines contained a black grease build-up. The tile floor in front of the cooking line was missing grout, and there was a black build-up of food and grease between the tiles. The floor under the center island of the cooking line also had a build-up of black grime and old food. The Dietary Director acknowledged these issues, stating that the fryer should be cleaned more frequently and that the cabinet next to the stove should be included in the cleaning schedule. The facility's cleaning practices were found to be inadequate, as the main kitchen floor was only deep cleaned once a quarter, which the Dietary Director admitted should occur more often. The Director of Plant Operations was unaware of the grout issue and stated that a contract request for a complete rehaul of the tile flooring had been filed, but it was a lengthy process. The facility's policy and procedure for sanitation required that kitchen and serving areas be kept clean and maintained in good repair, which was not adhered to. The U.S. Food and Drug Administration's Food Code also mandates that nonfood-contact surfaces be kept free of dust, dirt, food residue, and other debris to prevent the accumulation of pathogenic microorganisms, which was not followed in this case.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of quality for three residents due to improper medication administration. For Resident 77, medications including Diltiazem, Lisinopril, and Metoprolol were administered without checking the resident's blood pressure and heart rate as required by the physician's orders. The Licensed Vocational Nurse (LVN) did not take the necessary vital signs before administering these medications, which was confirmed during a medication pass observation and subsequent interviews with the Director of Nursing Services (DON). Resident 51 was administered Alfuzosin, a medication for benign prostate hypertrophy, without food, contrary to the physician's orders that specified it should be taken with food. This was observed during a medication pass with a Registered Nurse (RN), and the facility's policy indicated that medications ordered in relation to meals should be administered during or up to 30 minutes after meal time. For Resident 47, Novolog insulin was administered using an ASPART insulin flexpen without priming the device as per the manufacturer's instructions. The LVN did not ensure a drop of insulin appeared at the needle tip before administration, which is necessary to avoid injecting air and ensure proper dosing. The DON confirmed that the insulin flexpen should be primed with two units before administration, as outlined in the manufacturer's instructions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass observation, resulting in a cumulative error rate of 15.15%. This was observed in the cases of three residents. For Resident 77, medications including Diltiazem, Lisinopril, and Metoprolol were administered without checking the resident's blood pressure and heart rate, despite physician orders requiring these checks before administration. The facility's policy also mandates that vital signs be taken when medication administration is conditioned upon them. Resident 51 was administered Alfuzosin, a prostate medication, without food, contrary to the physician's order that specified it should be taken with food. The facility's policy states that medications ordered in relation to meals should be administered during or up to 30 minutes after meal time. This oversight was noted during a medication pass observation with a registered nurse. For Resident 47, Novolog insulin was administered using an ASPART insulin flexpen without priming the device, as required by the manufacturer's instructions. The insulin pen should be primed to ensure proper dosing and avoid injecting air. The Director of Nursing confirmed that the insulin flexpen needs to be primed before administration, aligning with the manufacturer's guidelines.
Failure to Provide Power Wheelchair Assessment for Resident
Penalty
Summary
The facility failed to enhance the quality of life for Resident 68 by not providing a qualification assessment for a power wheelchair, which was requested by the resident. Resident 68, who was admitted with a diagnosis of Parkinson's disease, expressed difficulty in maneuvering around the puzzle table in the common area using a manual wheelchair. Despite requesting an assessment for a power wheelchair, the resident did not receive one, as confirmed by the absence of a referral form and assessment documentation in the clinical record. Interviews with facility staff revealed that the Restorative Nursing Assistant (RNA) was aware of the resident's request and communicated it to a staff member in the Physical Therapy department, but the request was not followed through. The Occupational Therapist (OT) confirmed that the Occupational Therapy department was responsible for conducting such assessments upon receiving a referral from the nursing department, but no referral was made for Resident 68. The Director of Nursing Services (DON) indicated that the RNA should have communicated the request to a licensed nurse for follow-up, which did not occur, leading to the deficiency.
Failure to Conduct Power Wheelchair Assessment for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain the highest practicable physical and psychosocial well-being for a resident diagnosed with Parkinson's disease. The resident, who was capable of making healthcare decisions and communicating effectively, requested an assessment for a power wheelchair due to difficulties maneuvering a manual wheelchair. Despite the resident's repeated requests, no assessment was conducted, and there was no referral form for the assessment found in the resident's clinical record. Interviews with staff revealed that the resident had requested the assessment approximately one month prior, but the request was not properly communicated to the appropriate department. The Restorative Nursing Assistant (RNA) mentioned discussing the request with a staff member in the Physical Therapy department, but the Occupational Therapist (OT) confirmed that no referral was received. The Director of Nursing Services (DON) indicated that the RNA should have communicated the request to a licensed nurse for follow-up, highlighting a breakdown in communication and procedure within the facility.
Inaccurate and Disorganized Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and systematically organized medical records for two residents. For one resident, the Restorative Nurses Aide-Weekly Notes contained incorrect session dates, with dates from January and November 2025 mistakenly recorded for February 2025. This error was confirmed by the Restorative Nursing Assistant during an interview and record review. The facility's policy on documentation principles, which requires records to be complete, accurately documented, and systematically organized, was not adhered to in this instance. For another resident, a Physician Progress Note belonging to a different resident was found in their medical chart. This was confirmed by a Quality Registered Nurse during a concurrent interview and record review. The facility's policy on documentation principles was again not followed, as the records were not accurately documented or systematically organized. These deficiencies had the potential to result in inaccurate clinical records for the residents involved.
Infection Control Policy Violation for Resident with Foley Catheter
Penalty
Summary
The facility failed to adhere to its infection control policy for a resident with an indwelling Foley catheter who was under Enhanced Barrier Precaution (EBP). During an observation, two Certified Nursing Assistants (CNAs) were seen transferring the resident from a wheelchair to a bed without wearing gowns, which is required for high-contact care activities under EBP. The CNAs admitted to not being aware of the resident's EBP status and not checking the door sign before entering the room. The resident, who was admitted with diagnoses including Alzheimer's Disease, pneumonitis, chronic kidney disease, and urinary retention, was confirmed to have an indwelling Foley catheter. The facility's policy and the CDC guidelines both indicate that gowns and gloves should be worn during high-contact activities, such as transferring residents with urinary catheters, to prevent the spread of infections. The Director of Nursing confirmed that staff are expected to wear gowns in such situations to break the chain of infection.
Resident Injury Due to Inadequate Supervision During Repositioning
Penalty
Summary
The facility failed to maintain a safe environment free from accidents and hazards for a resident who was fully dependent on assistance for all Activities of Daily Living (ADLs). The resident, diagnosed with vascular dementia, unspecified osteoarthritis, and a history of repeated falls, sustained a head injury while being repositioned by a Certified Nursing Assistant (CNA). The incident occurred when the resident's head hit the headboard of the bed, resulting in a 3 x 4 cm abrasion on the posterior head, accompanied by a bump and bleeding. The Minimum Data Set (MDS) assessment indicated that the resident was completely dependent on assistance for repositioning, requiring the support of one or more helpers. The care plan also highlighted the resident's decreased functional mobility and need for extensive to total assistance with ADLs. Despite these assessments, the incident occurred, suggesting inadequate supervision or improper handling during repositioning. The facility's policy on accident prevention emphasized maintaining an environment free of hazards and providing adequate supervision, which was not adhered to in this case.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. The ice machines in the satellite kitchens of buildings one and five had a buildup of yellow and purple discoloration on their water tubes, which had the potential to contaminate the water and ice used for residents' beverages and ice baths. The Director of Dietetics (DD) and the Chief of Plant Operations (CPO) acknowledged that the ice machine tubing should be replaced if discolored and that food-contact surfaces should not have any buildup or discoloration. The facility's policy indicated that ice machines should be cleaned according to the manufacturer's guidelines, which were not followed in this case. Additionally, the Food and Drug Administration's Food Code requires routine cleaning of ice makers to prevent microorganism accumulation, which was not adhered to by the facility. The facility's failure to maintain clean ice machines posed a risk of contamination to the residents' food and beverages. The facility's policy and procedure for cleaning and sanitizing ice machines were not followed, leading to the potential contamination of the ice used for residents' beverages and ice baths. The facility's policy and procedure for food storage and sanitation were also not followed, as evidenced by the buildup of dirt and grime under kitchen appliances and countertops, crumbs found behind an ice machine and on the bottom shelf of a reach-in freezer, and the contamination of bulk sugar with a black substance. The Director of Dietetics (DD) acknowledged that the area under kitchen equipment was hard to clean and that the freezer shelves were supposed to be wiped out daily. The facility's policy indicated that all utensils, counters, shelves, and equipment should be kept clean and maintained in good repair, which was not adhered to in this case. The Food and Drug Administration's Food Code requires nonfood contact surfaces to be kept free of an accumulation of dust, dirt, food residue, and other debris, which was not followed by the facility. The facility's failure to maintain clean kitchen appliances and countertops posed a risk of microorganism growth and pest attraction. The facility's policy and procedure for food storage were not followed, as evidenced by the contamination of bulk sugar with a black substance. The Director of Dietetics (DD) acknowledged that contaminated food items should be discarded immediately upon discovery and that the bulk food bin should be washed and sanitized before refilling. The facility's policy indicated that food should be protected from contamination by storing it in a clean, dry location, which was not adhered to in this case. The Food and Drug Administration's Food Code requires food to be protected from contamination, which was not followed by the facility. The facility's failure to maintain clean food storage areas posed a risk of food contamination. The facility's policy and procedure for sanitation were not followed, as evidenced by the buildup of dust, grime, and food residue in toolboxes used to store clean utensils. The Director of Dietetics (DD) acknowledged that the tool cabinet drawers should have been kept clean with daily cleanings and that the tool cabinets may not have been food-safe equipment. The facility's policy indicated that all utensils, counters, shelves, and equipment should be kept clean and maintained in good repair, which was not adhered to in this case. The Food and Drug Administration's Food Code requires nonfood contact surfaces to be free of unnecessary ledges, projections, and crevices and designed and constructed to allow easy cleaning and facilitate maintenance, which was not followed by the facility. The facility's failure to maintain clean toolboxes for storing clean utensils posed a risk of microorganism growth and pest attraction.
Failure to Maintain Clean and Sanitary Disposable Care Equipment
Penalty
Summary
The facility failed to ensure that residents' disposable care equipment (DCE) such as basins, urinals, and bedpans were stored in a clean and sanitary manner, as observed in multiple bathrooms in building five. During an observation, multiple instances of undated and unlabeled DCE were found, including basins stacked together with unknown residue inside, urinals placed on top of linen hampers, and bedpans stored improperly. Specific rooms were noted to have these deficiencies, with items found on the floor, on shower chairs, and on top of hampers, all undated and unlabeled. Interviews with various staff members, including registered nurses (RNs) and certified nursing assistants (CNAs), revealed inconsistencies in the facility's practices regarding the care and disposal of DCE. Staff members provided conflicting information about the frequency of DCE replacement and the requirement for labeling and dating. The Infection Control Registered Nurse (ICRN) and other staff members indicated that the facility did not have a consistent policy for labeling and dating DCE, and there was no clear procedure for ensuring the cleanliness and proper storage of these items. A review of the facility's policy and procedure indicated that disposable items should be labeled with the projected discard date and the resident's name, which was not being followed.
Failure to Follow Menu Portion Sizes for Pureed Dessert
Penalty
Summary
The facility failed to follow the menu for lunch on March 18, 2024, when pureed cheesecake was served with a #16 scoop (1/4 cup) instead of the indicated #12 scoop (1/3 cup). This discrepancy was observed in Building Five Satellite Kitchen, where a Food Service Tech I prepared the dessert for residents in Skilled Nursing Building 5A. The facility's lunch menu and Portion Control Menu Planner (PCMP) both specified that the #12 scoop should be used, but the staff used the #16 scoop instead. This resulted in residents receiving less dessert than prescribed, potentially affecting the nutritional status of the 10 residents assigned to receive pureed dessert from the kitchen. Interviews with the Director of Dietetics (DD) on March 19 and March 20, 2024, revealed that staff were trained to use the PCMP as their color guide for selecting scoop utensils and were expected to use the scoop size indicated on the menu. The facility's policy and procedure titled 'Food & Nutrition Services - Diet Manual & Menu Guidelines,' dated October 31, 2023, also stated that menus must meet nutritional needs and be followed as prepared in advance. Despite these guidelines, the staff's failure to use the correct scoop size led to the deficiency observed by the surveyors.
Failure to Ensure Residents' Dignity During Meal Times
Penalty
Summary
The facility failed to ensure that two residents, Resident 34 and Resident 49, were treated with dignity during meal times. Certified Nursing Assistant (CNA) 1 was observed standing while feeding both residents, which is against the facility's policy that requires CNAs to sit at eye level with residents to ensure their dignity. This was observed during dining meal observations in the residents' rooms. CNA 1 admitted that she typically sits while feeding residents to maintain their dignity, and both Registered Nurse (RN) 1 and Supervising Registered Nurse (SRN) 2 confirmed that CNAs should be sitting while assisting residents with meals to prevent them from feeling rushed or hovered over. The facility had previously conducted in-services about this requirement. Resident 49, who has Alzheimer's Disease and requires maximum assistance when eating, and Resident 34, who has Dementia and also requires maximum assistance when eating, were both affected by this failure. The facility's policies on the RNA - CNA Dining Program and Residents Rights emphasize the importance of providing a conducive environment for meeting residents' nutritional needs and respecting their personal rights. However, these policies were not followed, leading to a potential violation of the residents' dignity during meal times.
Failure to Update ADL Care Plan for Resident
Penalty
Summary
The facility failed to ensure that Resident 10's activities of daily living (ADL) care plan was revised and updated based on his needs. Resident 10, who has a history of falls and was admitted with diagnoses including Atherosclerosis Heart Disease and Chronic Kidney Disease, experienced a significant change of condition (SCOC) due to a decline in ADLs. Despite documented fall incidents and a decline in ADL functions, the care plan did not include interventions to maintain or improve his ADLs after the discontinuation of rehabilitation therapy. This was observed during interviews and record reviews, where it was noted that Resident 10 required extensive assistance for transfers and was unable to ambulate at the time. The Minimum Data Set (MDS) Registered Nurse and other staff confirmed that Resident 10 had a significant decline in ADLs and required more assistance than previously documented. Despite being placed on physical and occupational therapy, Resident 10 was unable to tolerate these therapies and expressed a desire to walk again. The care plan, reviewed on multiple occasions, lacked documentation of interventions to prevent further decline in range of motion and mobility. This failure had the potential to not meet Resident 10's ADL needs, as the care plan did not reflect his current condition and needs.
Failure to Re-evaluate Resident for Restorative Nursing Program
Penalty
Summary
The facility failed to ensure that Resident 10 was re-evaluated to maintain or improve his activities of daily living (ADL). Resident 10, who has a history of falls and was admitted with diagnoses including Atherosclerosis Heart Disease and Chronic Kidney Disease, experienced a significant decline in ADL functions. Despite being alert and able to make decisions, as indicated by a BIMS score of 30, Resident 10 required extensive assistance for transfers and maximum assistance for bed mobility following a significant change of condition due to weakness and falls. The resident had multiple fall incidents and was placed on physical and occupational therapy, which was later discontinued without a subsequent re-evaluation for the facility's Restorative Nursing Program to maintain his functional levels of independence gained through therapy. During interviews, it was revealed that the nursing staff did not communicate the need for Resident 10 to be placed on the Restorative Nursing Program after his therapy was discontinued. The Chief Restorative Care and the MDS Registered Nurse confirmed that Resident 10 was not re-evaluated and was not placed on the restorative nursing program, despite the facility's policy indicating that residents who no longer require specialized rehabilitation therapy services should be referred to the Restorative Nursing Program. This oversight had the potential to prevent Resident 10 from receiving appropriate treatment and services to prevent further decline in range of motion and mobility.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to ensure adequate pain management for Resident 88, who was observed lying in bed and complaining of severe pain in his right arm and hernia pain. Despite the resident's complaints, the physician's progress notes were not followed up on, and the comprehensive care plan was not updated to reflect the new pain sites. The resident had been receiving Diclofenac gel and Acetaminophen, which were not effectively managing his pain, and there was no evidence of a physician's order for further diagnostic imaging as noted in the progress notes. Licensed Vocational Nurse (LVN) 1 was unaware of the resident's hernia pain and stated that the current pain management was ineffective. The physician confirmed the resident's complaints and diagnosed lateral epicondylitis, ordering Diclofenac gel but no imaging. The Supervising Registered Nurse (SRN) and Director of Nursing (DON) acknowledged that the care plan should have been updated based on the physician's notes and that licensed nurses should review progress notes daily to make necessary updates. The Treatment Administration Record (TAR) indicated that staff assessed the resident's pain as zero every shift, which contradicted the resident's reported pain level of 5/10. The facility's policy required comprehensive care plans to be updated based on ongoing assessments, but this was not done for Resident 88. The failure to update the care plan and follow up on the physician's recommendations resulted in inadequate pain management for the resident.
Improper Storage of Probiotic Medication
Penalty
Summary
The facility failed to ensure an opened probiotic medication bottle was stored at an appropriate temperature in one of eight medication carts. During a medication storage inspection, an opened Acidophilus Probiotic bottle, which required refrigeration after opening, was found inside the medication cart. The Registered Nurse (RN) stated that the medication was never used and there were no residents with an order for it. The RN was unable to determine when the medication was last administered, and the bottle still contained 30 capsules out of 100. The Pharmacist confirmed that the medication should have been refrigerated and was unusable once stored at room temperature. The facility's policy indicated that medications should be stored according to the manufacturer's recommendations to maintain their integrity and shelf life.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition when a water hose connection site under a food preparation table was found leaking. During an observation in the Main Kitchen, water was seen leaking from the hose connection under the stainless-steel countertop in the food preparation area. A work order dated 8/17/23 indicated that the water spigot under the prep sink was leaking and required a new part to fix the issue. However, the Director of Dietetics stated that there was a miscommunication, and the necessary part was not ordered. The facility's policies and procedures for maintaining equipment in good working order and keeping equipment clean and in good repair were not followed.
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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