Vineyards At Fowler
Inspection history, citations, penalties and survey trends for this long-term care facility in Fowler, California.
- Location
- 1306 East Sumner Avenue, Fowler, California 93625
- CMS Provider Number
- 055454
- Inspections on file
- 20
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Vineyards At Fowler during CMS and state inspections, most recent first.
A resident with multiple chronic conditions but no cognitive impairment reported that a CNA showed her a nude video of another CNA, describing the content as the CNA naked in a bathroom with only a small towel or his nude behind visible. An LVN received the allegation, notified the IP and the Administrator (the abuse coordinator), and acknowledged that such conduct could constitute abuse and should be reported immediately. The IP, DSD, and DON all recognized that staff are mandated reporters and that facility policies require reporting all abuse allegations to the Administrator, SA, ombudsman, APS, and law enforcement within strict timeframes, including completion of an SOC 341. Despite these policies and job description requirements for the Administrator, DON, charge nurse, CNA, and IP to report abuse allegations, the facility did not complete the SOC 341 or report the allegation to the ombudsman, SA, or local law enforcement, and the ombudsman confirmed no report was received, resulting in a deficiency for failure to timely report suspected abuse.
Two CNAs spoke loudly and disrespectfully to a resident, accusing her of taking a roommate's remote control and calling her a liar, which was witnessed by an LVN. The resident, who had no cognitive impairment and multiple medical conditions, reported feeling hurt by the staff's behavior. Facility staff and policy confirmed that such conduct violated the requirement to treat residents with dignity and respect.
A nurse diverted controlled medications intended for two residents, failing to document and properly discard discontinued drugs as required by facility policy. This resulted in the residents not receiving their prescribed pain medications, with discrepancies discovered during medication audits. The facility did not consistently follow its own protocols for controlled substance management and documentation.
Licensed nurses failed to accurately document and reconcile controlled substances for two residents, resulting in discrepancies between medication removals and the Medication Administration Record (MAR), with no documentation of refusals, wastage, or returns. The facility's inventory logs contained calculation errors, and required audits were not performed as per policy, leading to delayed detection of potential diversion and risk of medication errors.
Licensed nurses administered PRN pain medications intended for severe pain to residents experiencing only mild or moderate pain, contrary to physician orders and facility policy. This included giving higher doses of narcotics for lower pain scores, as documented in medication administration records and confirmed by staff interviews.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
A resident with multiple medical conditions and a history of non-compliance left the facility without staff knowledge and did not return. Despite being aware of the resident's behavior, staff did not follow the facility's elopement policy, failed to notify administration or authorities promptly, and did not initiate a search, resulting in the resident being missing overnight.
A resident with multiple medical conditions left the facility without signing out and was not accounted for during shift changes. LVNs on duty failed to notify the ADM, DON, or authorities as required by policy, and staff did not initiate a search or follow elopement procedures, resulting in a delayed response and the resident's whereabouts being unknown overnight.
The facility did not update and review its facility-wide assessment annually as required by policy. The last documented review was in August 2023, and although an assessment was completed in September 2024, it had not been reviewed or revised. This oversight could potentially affect all residents.
The facility failed to maintain an effective infection control program due to the lack of a surveillance plan to track and monitor infections. The new Infection Preventionist (IP) had not been shown how to manage infection data and was awaiting guidance. The Director of Nursing (DON) and Administrator expected the IP to track infections daily and identify trends monthly, but the IP had not been performing these duties.
A resident with mobility issues was unable to get out of bed due to the facility's failure to provide a necessary specialized wheelchair. Despite expressing a desire to participate in activities, the resident had to rely on a borrowed wheelchair from another resident. Staff interviews revealed that the facility had not ordered the required equipment, and the administrator was unaware of the need.
A resident with quadriplegia and intact cognition did not receive proper nail care as required by their care plan. Despite the facility's policy for routine nail trimming, staff interviews revealed that the resident's nails were not regularly trimmed, and there were no refusals of care documented. The DON acknowledged the oversight, but the resident's nails remained untrimmed upon follow-up observation.
A resident with COPD and a history of respiratory issues was receiving supplemental oxygen without a physician's order, contrary to facility policy. Observations showed varying oxygen flow rates, and staff confirmed the absence of a documented order, highlighting a deficiency in respiratory care management.
The facility did not ensure RN coverage for eight consecutive hours daily, as required by policy. On two occasions, RNs worked fewer or nonconsecutive hours, failing to meet the regulation. The DON and RN were unaware of the consecutive hour requirement, and the administrator expected compliance with this regulation.
A facility failed to ensure a PRN psychotropic medication for a resident had a 14-day stop date, as required by policy. The resident, diagnosed with schizoaffective disorder, was prescribed aripiprazole for agitation without an end date. Interviews with the DON, Administrator, and Pharmacist confirmed the requirement for a 14-day stop date, highlighting a lapse in policy adherence.
A resident with schizoaffective disorder was readmitted to an LTC facility with hospital discharge instructions for daily aripiprazole. The facility incorrectly transcribed the medication as a PRN order for agitation. Staff, including an LVN and the DON, confirmed the error, and the pharmacist identified it as a medication error.
The facility was found to have exceeded the resident capacity in two rooms, with one room housing seven residents and another eight, contrary to the policy limiting occupancy to four residents per room. Despite the rooms being comfortable, the Administrator confirmed the policy breach.
A facility failed to provide the required 80 sq ft of living space per resident in six multiple occupancy rooms, as identified through observations and interviews. Despite having privacy and storage, the rooms did not meet the space requirement, with measurements ranging from 64.9 to 78.9 sq ft per resident. The DON and Administrator were aware of the issue and had requested a waiver.
A resident's MDS assessment contained six errors, including misreporting cognitive status, wandering behavior, UTI history, fall incidents, weight gain, and the use of a wander alarm. The resident, diagnosed with psychosis, exhibited disorganized thinking and attempted to leave the facility, yet these behaviors were not accurately recorded. Additionally, the resident had a UTI and experienced a fall, both of which were not reflected in the MDS. The resident's weight gain and use of a wander guard were also inaccurately documented.
A facility failed to develop a comprehensive care plan for a resident with new confusion and hallucinations. Despite documented episodes and family reports of new confusion after admission, no care plan addressed the altered level of consciousness. Staff interviews confirmed the resident's confusion, and the facility's policy on comprehensive care planning was not followed.
A resident in a long-term care facility experienced new confusion and hallucinations, which were linked to an untreated urinary tract infection (UTI). Despite abnormal urinalysis results indicating a UTI, a culture and sensitivity test was not performed due to a lack of a separate physician's order required by the facility's contracted lab. This oversight resulted in the resident's UTI remaining untreated, exacerbating her symptoms.
A resident with a history of psychological issues and elopement risk left the facility unsupervised, despite being identified as needing constant supervision. The resident was found wandering on a nearby street after staff failed to maintain line-of-sight supervision. The facility's policy emphasized the need for adequate supervision, which was not followed, leading to the resident's unsupervised departure.
A facility failed to conduct a Trauma Informed Care Evaluation for a resident, as required within 48 hours of admission. The Social Services Director admitted to not completing the evaluation due to being overwhelmed with work. The resident's family member confirmed that no inquiry about trauma history was made during a care plan meeting, contrary to facility policy.
A facility failed to conduct a Social Services Evaluation for a newly admitted resident, which is crucial for assessing mood, behaviors, and support systems. The Social Services Director, who was new to the role, did not complete the evaluation due to a lack of training on required assessments, despite facility policies mandating comprehensive information gathering upon admission.
Failure to Timely Report Alleged Sexual Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a cognitively intact resident to required external agencies, as mandated by federal and state regulations and the facility’s own abuse policies. A resident with diagnoses including COPD, DM2 with neuropathy, asthma, epilepsy, bipolar disorder, major depressive disorder, PTSD, and age-related cognitive decline, but with an MDS BIMS score of 15 indicating no cognitive impairment, reported that a CNA showed her a nude video of another CNA. The resident described the video as showing the CNA naked in a bathroom with only a small towel over his privates or his nude behind as he was getting into or out of the shower. The resident stated she was shocked that an employee would show her such a video and reported the incident to staff, after which she was interviewed by the Administrator and identified the CNA who allegedly showed her the video. Multiple staff interviews and policy reviews confirmed that the conduct described by the resident met the facility’s definition of potential abuse, specifically sexual abuse, which includes forced observation of pornography. The LVN who first received the allegation from the resident stated that staff are required to protect residents from abuse, ensure dignity and respect, and report abuse allegations right away. The LVN reported the allegation to the Infection Preventionist and then to the Administrator, who served as the abuse coordinator, but did not complete the SOC 341 form herself. The LVN acknowledged that showing a resident a video of a naked person was not acceptable, could be considered a form of abuse, and that the alleged sexual incident should have been reported to the required government agencies. The Infection Preventionist, Director of Staff Development, and DON each confirmed that all facility staff are mandated reporters and that the facility’s Abuse, Neglect and Exploitation and Abuse Prevention and Prohibition Program policies require reporting all alleged violations involving abuse to the Administrator, state agency, adult protective services, ombudsman, and law enforcement within specified timeframes, including within two hours for abuse allegations. The IP stated that the SOC 341 should have been completed and the allegation reported within two hours. The DSD stated that the SOC 341 should have been completed and that the abuse coordinator was responsible for reporting to law enforcement and the ombudsman. The DON acknowledged that the facility did not report the allegation because the resident did not report distress after seeing the video, despite recognizing that it was inappropriate for staff to show a nude video to a resident and that failure to report abuse allegations could jeopardize the facility’s license. A subsequent interview with the ombudsman confirmed that he was not aware of the allegation and had no SOC 341 on file. The facility’s job descriptions for the Administrator, CNA, charge nurse, DON, and IP all required reporting allegations of abuse and compliance with abuse reporting policies, yet the allegation involving this resident was not reported to the required government agencies as mandated. The report also documents that the CNA accused of showing the video denied the allegation but acknowledged that it would be considered abuse to show a resident a naked video and that SOC 341 should be completed and submitted immediately to ensure prompt facility response. The CNA noted that delayed reporting of alleged abuse could result in continued occurrences. Despite this, and despite the facility’s written policies outlining mandated reporting duties, timeframes, and penalties for failure to report, the allegation involving the resident and the nude video was not reported to the ombudsman, state survey agency, or local law enforcement. The DON explicitly stated that the facility did not maintain mandated reporting for this incident because they did not report the allegation, confirming the core deficiency of failure to timely report suspected abuse as required. The facility’s policies and job descriptions further emphasized that facility staff are mandated reporters under the Elder Justice Act and state regulations, that the facility will not impede reporting, and that failure to report within mandated timeframes may result in civil money penalties, exclusion from federal health care programs, and disciplinary action up to and including termination. The policies also defined sexual abuse to include forced observation of pornography and required telephone and written reports to the ombudsman or local law enforcement within specified timeframes for incidents including emotional or psychological abuse. Despite these clear written requirements and staff awareness that the alleged conduct could constitute abuse, the facility did not complete the SOC 341 or submit required reports for the resident’s allegation, and the ombudsman confirmed no report was received. This sequence of inaction by facility leadership and staff in response to a reported potential sexual abuse incident constitutes the documented deficiency.
Failure to Treat Resident with Dignity and Respect During Staff Interaction
Penalty
Summary
Two Certified Nurse Assistants (CNAs) spoke loudly and disrespectfully to a resident, accusing her of taking her roommate's remote control and adjusting the television to face herself. The CNAs called the resident a liar and engaged in an argument with her, raising their voices in a manner that was described as unprofessional and hurtful by the resident. This interaction was witnessed by a Licensed Vocational Nurse (LVN), who confirmed that the CNAs were yelling at the resident and making inappropriate statements, including calling the resident a liar and referencing the possibility of losing their jobs. The resident involved had no cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 13, and had a medical history including type 2 diabetes mellitus, protein-calorie malnutrition, stimulant abuse, bipolar disorder, major depressive disorder, post-traumatic stress disorder, and chronic pain syndrome. The incident was corroborated by interviews with staff, including another CNA, the LVN, the Registered Nurse (RN), the Director of Nursing (DON), and the Infection Preventionist (IP), all of whom stated that staff should not yell at residents and must treat them with dignity and respect. The facility's policies on promoting and maintaining resident dignity and resident rights were reviewed and indicated that all staff must speak respectfully to residents and avoid yelling or scolding. The deficiency was identified through interviews and record reviews, which established that the CNAs' actions failed to honor the resident's right to a dignified existence, self-determination, and respectful communication. The staff's behavior was found to be inconsistent with facility policy and placed the resident at potential risk for emotional distress, as directly stated in the report.
Controlled Substance Diversion and Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect residents' rights and ensure proper management of controlled substances, resulting in the misappropriation of medications intended for two residents. Specifically, a Licensed Vocational Nurse (LVN) diverted controlled medications prescribed for two residents for personal use and failed to document and discard discontinued medications according to facility policy. The LVN removed two bubble packs of oxycodone, each containing 30 pills, from the controlled substance drawer after a resident's discharge, documented a zero count in the inventory log, and removed the corresponding record sheet, making the medication untraceable. This action was discovered during a shift change audit when the missing medications were identified, and the LVN later admitted to taking the medications. The facility's procedures required that discontinued controlled substances be handed off to the Director of Nursing (DON) for proper destruction, but this protocol was not followed. In another instance, the same LVN signed out multiple doses of hydrocodone-acetaminophen for a second resident on the controlled drug record, but these administrations were not documented on the Medication Administration Record (MAR). The resident had moderate cognitive impairment and was prescribed pain medication as needed. The discrepancies were identified after the initial drug diversion incident, revealing that the medications were not administered as ordered and were unaccounted for. The facility's policy required daily visual audits of controlled substances, but the DON only conducted these audits Monday through Friday, leaving weekends unmonitored until the following Monday. Both residents involved had significant medical histories, including chronic pain, recent surgery, and cognitive impairment, making the proper administration and accountability of their medications critical. The failures in following established protocols for controlled substance management, documentation, and destruction led to residents not receiving their prescribed medications as ordered and placed them at risk for inadequate pain management and anxiety. The facility's lack of adherence to its own policies and procedures directly contributed to the deficiency.
Failure to Accurately Document and Reconcile Controlled Substances
Penalty
Summary
The facility failed to maintain accurate controlled substance records, documentation, and reconciliation in accordance with its own policies and procedures for two of three sampled residents. Licensed nurses did not accurately document or account for controlled substances on the Controlled Drug Records and Medication Administration Records (MAR), resulting in discrepancies between medication removals and documentation. Specifically, for one resident with a history of muscle weakness, liver failure, diabetes, and recent spinal surgery, multiple removals of oxycodone were recorded on the Controlled Drug Record but not reflected on the MAR, with no documentation of refusal, wastage, or return. For another resident with multiple fractures, chronic pain, and osteoporosis, hydrocodone removals were similarly not documented on the MAR, and there was no record of refusal, wastage, or return. Interviews with nursing and pharmacy staff revealed that the facility's process required licensed nurses to verify controlled substances upon delivery, document receipt, and update inventory logs. Each shift change required two nurses to count and reconcile controlled substances, and any discrepancies were to be resolved before the end of the shift or reported to the DON and Administrator. However, review of the Shift Change Controlled Substance Inventory Log showed multiple calculation inaccuracies, with incorrect counts recorded on several dates. The DON acknowledged that required audits were not performed as stipulated by facility policy. The facility's policy mandated that all controlled substances be accounted for and that documentation on the Controlled Drug Record must match the MAR. The policy also required that any discrepancies be resolved or reported immediately, and that staff not leave until discrepancies were addressed. Despite these requirements, the facility did not ensure accurate documentation or reconciliation of controlled substances, leading to delayed detection of potential diversion and placing residents at risk for medication errors.
Failure to Administer PRN Pain Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medication administration, specifically regarding the use of PRN pain medications. Licensed nurses administered pain medications prescribed for severe pain to three residents, even when their assessed pain levels were only mild to moderate. This was not in accordance with the physician's orders, which specified different medications and dosages based on the severity of pain as measured by a standardized pain scale. For example, one resident with chronic pain syndrome and diabetes received Hydrocodone-Acetaminophen and Tramadol for pain levels reported as 3 out of 10, despite these medications being ordered for moderate to severe pain. Another resident with a history of muscle weakness, liver failure, and recent spinal surgery was administered two tablets of Oxycodone for pain levels of 3 or 4 out of 10, even though the physician's order specified this dosage only for severe pain. A third resident with multiple fractures and chronic pain was also given Hydrocodone-Acetaminophen for pain scores below the threshold indicated in the physician's order. Interviews with nursing staff confirmed that PRN pain medications were to be administered according to the pain scale and physician's orders, and that deviations from this practice could result in medication errors. Facility policies and procedures reviewed during the survey also required adherence to the pain scale and physician's orders when administering PRN medications. Despite these policies, the records showed repeated instances where higher doses or stronger medications were given for lower pain scores than prescribed.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Non-Compliance
Penalty
Summary
A deficiency occurred when a resident left the facility without staff knowledge and did not return, despite being known for non-compliance with sign-out procedures. The resident, who had diagnoses including a left femur fracture, alcoholic cirrhosis, bipolar disorder, and pancreatic pseudocyst, was cognitively intact according to a recent BIMS assessment. Staff interviews revealed that the resident frequently left the facility without signing the Leave of Absence (LOA) binder or notifying staff, and this behavior was known to multiple staff members. On the day of the incident, staff failed to notice the resident's absence in a timely manner. Several staff members, including LVNs and CNAs, acknowledged that the resident did not sign out and was not accounted for during shift changes. Although staff were aware of the facility's policy to notify administration and authorities when a resident was missing, this protocol was not followed. Communication lapses occurred between staff and administration, with delayed or missed notifications and no immediate search or alert initiated. The facility's policy and procedure for elopement and wandering residents required prompt action to locate missing residents and notify authorities if the resident could not be found. However, staff did not implement these procedures, resulting in the resident being unaccounted for overnight. The failure to provide adequate supervision and follow established protocols directly led to the deficiency cited in the report.
Failure to Notify Administration and Authorities of Missing Resident
Penalty
Summary
Licensed Vocational Nurses (LVN) 3 and 4 failed to follow facility policy and procedure when a resident left the facility and did not return. The resident, who had diagnoses including a non-displaced intertrochanteric fracture of the left femur, alcoholic cirrhosis, bipolar disorder, and pancreatic pseudocyst, was cognitively intact according to a recent BIMS assessment. Staff interviews revealed that the resident did not sign out in the leave of absence binder and was not accounted for during shift changes. LVN 3 observed the resident in the facility earlier in the day but did not see him leave and failed to notify the Administrator, Director of Nursing, or authorities when the resident was discovered missing at the end of the shift. LVN 4, who received the report from LVN 3, became concerned about the resident's absence but only sent a text message to the Administrator and DON, without receiving a response. LVN 4 did not make further attempts to contact facility leadership or authorities until the following day. Certified Nursing Assistant (CNA) 1, who worked the night shift, also noted the resident's absence but did not initiate a search or notify the appropriate personnel as required by facility policy. The Director of Nursing confirmed that the required notifications and search procedures were not followed, and the facility's policy on elopement and missing residents was not implemented. The facility's policies clearly state that staff must alert personnel and notify the Administrator and authorities if a resident is missing and cannot be located on the premises. Despite these protocols, staff failed to act promptly, resulting in a delayed emergency response and a period during which the resident's location and medical status were unknown.
Failure to Update Facility-Wide Assessment Annually
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was updated and reviewed annually, as required by their policy. The policy, implemented in June 2024, stated that the assessment should be reviewed and updated as necessary and at least annually. However, the Facility Assessment Tool showed that the last documented review and update occurred on August 31, 2023. During interviews, the Administrator admitted that the assessment had not been reviewed prior to this date and that it was his responsibility to ensure it was done. Although the assessment was reportedly completed on September 10, 2024, it had not been reviewed or revised by the time of the survey. This oversight had the potential to affect all residents residing in the facility.
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to maintain an effective infection control program by not establishing and implementing a surveillance plan to identify, track, and monitor infections. The Infection Preventionist (IP), who had been in the position for two months, was unable to provide evidence of tracking and trending infections monthly. The IP stated she had not been shown how to handle infection information and was waiting for guidance from a corporate infection control consultant. Despite having access to the previous IP, who still worked at the facility, the new IP had not received instruction on tracking, monitoring, or trending infections for surveillance purposes. The Director of Nursing (DON) and the Administrator both expressed expectations that the IP should track infections daily and identify trends monthly. The DON was unaware that the IP had not been performing these duties and expected the IP to look for infection trends, such as clusters of urinary tract infections (UTIs). The Administrator expected the IP to implement a surveillance system that included mapping infections by room and unit at the end of each month. This system was intended to facilitate the identification of infections and provide necessary in-services to decrease the spread of infection.
Failure to Provide Necessary Wheelchair for Resident
Penalty
Summary
The facility failed to support a resident's choice to be out of bed by not providing the necessary specialized wheelchair needed for the resident. Resident #26, who was admitted to the facility with a medical history of abnormalities of gait and mobility, lack of coordination, and weakness, expressed a desire to get out of bed more frequently to participate in activities. Despite this, the resident did not have a wheelchair and was dependent on staff for chair/bed-to-chair transfers. The facility's policy on resident rights emphasized the importance of promoting and facilitating resident self-determination, including the right to choose activities and schedules. Interviews with staff and the resident's responsible party revealed that Resident #26 required a special wheelchair with a high back due to slumping over when tired. However, the facility had not provided this equipment, and staff had to borrow a wheelchair from another resident. The Director of Rehabilitation acknowledged the need for a reclining wheelchair but stated that one had not been ordered due to cost. The Director of Nursing confirmed that residents should not have to borrow equipment and that necessary equipment should be ordered promptly. The facility administrator was unaware of the resident's need for a wheelchair, indicating a lack of communication and coordination among staff.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #4, who was unable to perform activities of daily living (ADLs) independently due to quadriplegia and other physical impairments. Despite having a care plan that required staff assistance for personal hygiene, including nail care, Resident #4's fingernails were observed to be long and untrimmed. The facility's policy mandated routine nail care, but interviews with staff revealed that the resident's fingernails were not regularly trimmed, and there were no documented refusals of care by the resident. Resident #4, who had intact cognition and required moderate assistance with personal hygiene, reported that staff occasionally offered to trim their nails but failed to follow through when asked to return later. Interviews with CNAs and an LVN confirmed that nail trimming was part of the bathing routine, yet none had trimmed Resident #4's nails. The Director of Nursing acknowledged the oversight and stated that staff were expected to offer nail trimming on shower days and as needed. Despite this acknowledgment, an observation the following day showed that Resident #4's nails remained untrimmed.
Lack of Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident with a history of acute respiratory failure with hypoxia, acute pulmonary edema, and chronic obstructive pulmonary disease (COPD). The resident, who was readmitted to the facility, was observed receiving supplemental oxygen at varying levels without a corresponding physician's order in their electronic health record. The facility's policy requires oxygen to be administered under a physician's order, except in emergencies, which was not adhered to in this case. Observations and interviews revealed that the resident was receiving oxygen therapy at different flow rates, yet there was no documented order for this treatment. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the absence of a physician's order for the supplemental oxygen. The resident's care plan indicated the need for oxygen therapy, but the lack of a formal order constituted a deficiency in following the facility's policy and ensuring proper respiratory care management.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on duty for eight consecutive hours daily, as required by their policy and regulations. The facility's policy, implemented in October 2022, mandates the utilization of RN services for at least eight consecutive hours per day, seven days a week. However, the nursing schedule for September 2024 showed no RNs were scheduled to work on September 5, 2024, and RN #5's time card indicated she only worked 1.40 hours that day. Additionally, on September 8, 2024, RN #7 worked nonconsecutively for seven hours, failing to meet the eight-hour consecutive requirement. Interviews conducted on September 20, 2024, revealed that the Director of Nursing (DON) was unaware of the requirement for RNs to work eight consecutive hours. The DON was out sick from September 1 to September 5, 2024, and believed she had scheduled adequate RN coverage during her absence. RN #7 also stated she was unaware of the need to work eight consecutive hours. The facility administrator expressed an expectation for the facility to have an RN on duty for at least eight consecutive hours daily.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication for a resident had a 14-day stop date, as required by their policy. The policy, implemented in October 2022, mandates that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days. If the attending physician deems it appropriate to extend the PRN order beyond 14 days, they must document their rationale in the resident's medical record. However, for Resident #12, who was diagnosed with schizoaffective disorder and had a BIMS score indicating intact cognition, the facility did not include an end date for the PRN order of aripiprazole, an antipsychotic medication prescribed for agitation. The deficiency was identified through interviews and record reviews. The Director of Nursing and the Administrator both acknowledged that PRN psychotropic medications should have a 14-day stop date and must be reviewed and updated every 14 days. The Pharmacist also confirmed that PRN psychotropic medications should have a 14-day stop date unless otherwise addressed by the physician. Despite these acknowledgments, the order for Resident #12's medication lacked the required stop date, indicating a lapse in adherence to the facility's policy and regulatory requirements.
Medication Transcription Error for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to accurately transcribe hospital discharge medication orders for a resident, leading to a deficiency in medication administration. The resident, who had a medical history of schizoaffective disorder, was initially admitted to the facility and later readmitted. Upon readmission, the hospital discharge summary indicated that the resident was to receive aripiprazole, an atypical antipsychotic, as a daily oral tablet. However, the facility's order summary incorrectly transcribed this medication as an as-needed order for agitation, which was not in accordance with the hospital's discharge instructions. Interviews with facility staff, including an LVN and the DON, confirmed that the transcription error occurred when the resident returned to the facility. The DON acknowledged that the medication should not have been entered as a PRN order unless specified by the hospital. The pharmacist also noted that the admission nurse should have verified the accuracy of the orders, identifying the transcription as a medication error. This error was recognized by the facility's administration, who stated that the order would be reviewed and corrected to align with the hospital's physician orders.
Exceeding Resident Capacity in Rooms
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as observed in two specific rooms. The facility's policy, implemented in October 2022, stated that resident bedrooms should not accommodate more than four residents. However, a Client Accommodations Analysis dated September 19, 2024, indicated that two rooms were approved for eight residents each, despite the policy. Observations on September 20, 2024, revealed that one room housed seven residents and another housed eight residents. Although the rooms were described as comfortable with adequate space and amenities, the number of residents exceeded the facility's stated policy and regulatory requirements. The Administrator acknowledged that a maximum of four residents should reside in a room, yet the facility had two rooms with eight beds each.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet of living space per resident in six of its multiple occupancy rooms. This deficiency was identified through observation, interviews, and a review of facility documents and policies. The facility's policy, implemented in October 2022, mandates that resident bedrooms must measure at least 80 square feet per resident in multiple occupancy rooms. However, a Client Accommodation Analysis conducted in September 2024 revealed that the living space per resident in Rooms 1, 6, 8, 10, 11, and 16 was below the required standard, with measurements ranging from 64.9 to 78.9 square feet per resident. During a concurrent observation and interview, the Department Head of Maintenance confirmed that these rooms did not meet the 80 square feet requirement. Despite this, the observation noted that residents had privacy, adequate storage space, and unobstructed bathrooms, and there were no resident complaints about the space. Interviews with the Director of Nursing and the Administrator confirmed their awareness of the requirement and the deficiency. The Director of Nursing acknowledged the issue and mentioned that a waiver had been requested for the affected rooms, while the Administrator confirmed the submission of a waiver request, anticipating a citation for the deficiency.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, resulting in six incorrect entries. These errors included misreporting the resident's cognitive status, wandering behavior, urinary tract infection (UTI) history, fall incidents, weight gain, and the use of a wander/elopement alarm. The inaccuracies in the MDS assessment did not reflect the resident's actual status and had the potential to lead to unmet care needs. The resident was admitted with diagnoses including psychosis and exhibited disorganized thinking, as evidenced by an incident where the resident attempted to leave the facility. Despite this, the MDS inaccurately indicated that disorganized thinking and wandering behavior were not present. Additionally, the resident had a documented UTI within the last 30 days, but the MDS incorrectly reported no UTI. The resident also experienced an intercepted fall, which was not recorded in the MDS. Further errors included the resident's weight gain, which was significant enough to be noted as a change in condition, yet was not accurately reflected in the MDS. The resident was also equipped with a wander guard, an electronic monitoring device, which was not acknowledged in the MDS. These discrepancies were identified through interviews and record reviews with facility staff, including the Director of Social Services, the Director of Nursing, and the MDS Coordinator.
Failure to Implement Comprehensive Care Plan for Resident with New Confusion
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a new onset of confusion and hallucinations. The resident, a female admitted to the facility, was noted to have moderate cognitive impairment according to her Minimum Data Set (MDS) assessment. Progress notes documented episodes of yelling, confusion, and hallucinations, which were discussed in a care conference with the resident's family. Despite these documented behaviors, there was no care plan addressing the resident's altered level of consciousness, which was confirmed during a review with the Clinical Resource Registered Nurse. Interviews with facility staff, including the Social Services Director and a Certified Nursing Assistant, confirmed the resident's episodes of confusion. The resident's family also reported that the confusion was new and had started after admission to the facility. The facility's policy on the admission of residents emphasizes the importance of developing comprehensive care plans based on gathered information, but this was not adhered to in the case of this resident, leading to unmet needs for monitoring and safety.
Failure to Conduct Urine Culture Leads to Untreated UTI
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident who was assessed with a new onset of confusion and hallucination. The resident, an elderly female, was admitted to the facility and later exhibited symptoms such as yelling, talking about a fire, and slight confusion. A physician ordered a urinalysis and a culture and sensitivity test to determine if a urinary tract infection (UTI) was present, which could explain the confusion. However, the culture and sensitivity test was not performed, leaving the UTI untreated. The resident's urinalysis showed several abnormal results indicative of a UTI, including positive white blood cells, high levels of leukocyte esterase, positive nitrates, positive protein, positive red blood cells, and many bacteria. Despite these findings, the culture and sensitivity test was not conducted due to a lack of a separate physician's order, which was required by the facility's contracted laboratory for residents with a urinary catheter. This oversight was not recognized by the facility's staff, including the Infection Preventionist Nurse and Licensed Vocational Nurse, who were unaware of the laboratory's policy and procedures. Interviews with facility staff and the resident's family confirmed the resident's episodes of confusion and hallucinations, which were new since her admission to the facility. The staff acknowledged that confusion is a common sign of UTI in the elderly, yet there was no follow-up on the urinalysis results to ensure the culture and sensitivity test was completed. This lack of follow-up and awareness of the laboratory's requirements led to the resident's UTI going untreated, contributing to her ongoing confusion and hallucinations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of psychological problems and previous elopement attempts. On the morning of 5/12/24, the resident, who was identified as an elopement risk, managed to leave the facility unsupervised. The resident was found 20 minutes later wandering on a nearby street, which posed a potential risk for injury. The resident's care plan had previously identified her as an elopement risk, and staff were instructed to keep her in their line of sight and use a call phone to request assistance rather than leaving her unattended. On the day of the incident, a Licensed Vocational Nurse (LVN) heard the wander guard alarm and saw the resident outside the facility. The LVN attempted to convince the resident to return but, fearing aggression, left the resident to seek additional help. During this time, the resident left the premises. The Activities Director noticed the resident's empty wheelchair in the parking area and alerted the staff. Multiple staff members, including a Registered Nurse (RN), searched for the resident, who was eventually found by the RN and two Certified Nursing Assistants (CNAs) following her on the street. The facility's policy on elopements and wandering residents emphasized the need for adequate supervision and stated that alarms should not replace necessary supervision. Despite this policy, the staff's actions on 5/12/24 did not align with the required supervision protocols, leading to the resident's unsupervised departure from the facility. Interviews with staff revealed that the resident was known to be quick and had previously eloped, highlighting the need for constant supervision, which was not provided on this occasion.
Failure to Conduct Trauma Informed Care Evaluation
Penalty
Summary
The facility failed to ensure that a Trauma Informed Care Evaluation was conducted for one of the residents, identified as Resident 1. This evaluation is crucial for understanding a resident's life experiences to deliver effective care and treatment. The Social Services Director (SSD) admitted that she did not complete the evaluation for Resident 1 within the required 48 hours after admission, as per her responsibilities. The SSD acknowledged her oversight, attributing it to being overwhelmed with work since she started at the facility on March 7, 2024. The deficiency was identified during a review of Resident 1's records and an interview with the resident's family member, who confirmed that they were not asked about any history of trauma or mental illness during a care plan meeting. The facility's policy mandates that such evaluations be conducted upon admission to gather comprehensive information for care planning. The SSD's job description also emphasizes the importance of providing medically related social services in compliance with state and federal regulations, which includes conducting trauma-informed evaluations.
Failure to Complete Social Services Evaluation for New Resident
Penalty
Summary
The facility failed to complete a Social Services Evaluation for a recently admitted resident, which is a requirement to help residents achieve the highest possible quality of life. The resident, a female, was admitted to the facility without this evaluation being conducted, which is essential for assessing mood and behaviors, adjustment to the new environment, mental health history, support systems, and behavioral interventions. This oversight was identified during a review of the resident's admission record and confirmed in an interview with the Social Services Director (SSD). The SSD, who started working at the facility shortly before the resident's admission, acknowledged the absence of the evaluation and attributed it to a lack of training on the necessary assessments. The facility's policy mandates that upon admission, designated staff must gather comprehensive information to develop care plans and assist residents in adjusting to the facility. The SSD's job description also emphasizes the responsibility to provide medically related social services in compliance with state and federal regulations, which was not fulfilled in this instance.
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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