Watsonville Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Watsonville, California.
- Location
- 535 Auto Center Drive, Watsonville, California 95076
- CMS Provider Number
- 055240
- Inspections on file
- 22
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Watsonville Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in food storage and preparation, with black stains on steel trays and buildup in the ice machine. Dietary staff did not wear proper hairnets and beard restraints. Additionally, the facility did not follow its policy on labeling foods brought in by family, using the date received instead of a 'use by' date. These deficiencies could expose residents to contaminants.
The facility failed to implement proper infection control practices, with CNAs not performing hand hygiene while serving lunch trays, and improper management of medical equipment such as nebulizers and glucometers. Additionally, a humidifier bottle was found on the floor, and a NA did not perform hand hygiene between assisting residents. These actions were confirmed through observations and staff interviews, indicating non-compliance with infection control policies.
The facility failed to ensure food was prepared to conserve nutritive value and appearance, as evidenced by resident complaints and a test tray evaluation. Residents reported food being cold, bland, and improperly textured. A test tray evaluation confirmed these issues, with food temperatures below recommended safe levels, contrary to facility guidelines. This deficiency had the potential to negatively impact residents' nutritional status.
The facility failed to develop and implement comprehensive care plans for five residents, neglecting to address specific medical and personal care needs. This included omissions in care plans for ADLs, anticoagulant therapy, UTIs, and prescribed medications such as Zoloft, Aripiprazole, and Alendronate Sodium. The lack of individualized care plans highlights a pattern of neglect in meeting residents' physical, psychosocial, and functional needs.
The facility failed to manage medications properly, with expired and unlabeled medications found in storage, and medications requiring refrigeration left unrefrigerated. Labeling issues were noted, with medications labeled only with room numbers, risking errors due to room changes. A medication order discrepancy was also identified, highlighting potential for medication errors.
The facility failed to ensure dietary staff had the necessary skills for food safety. A pair of tongs with residues was found in a drawer, and a dietary cook couldn't explain the cool down process. A dietary aide incorrectly tested the dish machine's chemical concentration. In-service meetings were attended, but documentation lacked specific steps.
The facility failed to follow the recipe for a pureed diet, potentially compromising residents' nutritional needs. A Dietary Aide was observed preparing pureed bread without measuring the water added, contrary to the facility's menu instructions, which specify adding one cup of warm milk or water for every five portions. This oversight was noted during an observation with a Registered Dietician.
A resident's dignity was compromised when their suprapubic catheter drainage bag was left uncovered, displaying urine. The resident, who has End Stage Renal Disease and obstructive uropathy, was found in this state after returning from dialysis. Staff, including a CNA and LVN, acknowledged the oversight, confirming that the bag should have been covered with a privacy bag, as per facility policy.
The facility failed to obtain informed consent for lorazepam for a resident with Major Depressive Disorder and Catatonic Schizophrenia. The consent form lacked the name of the person who gave consent, contrary to the facility's policy requiring documentation of consent by the resident or their representative.
A facility failed to develop a baseline care plan for a resident's oxygen use within 48 hours of admission, as required by CMS. The resident, admitted with multiple health issues, had a physician's order for oxygen at specific levels, but was observed receiving a higher amount. Interviews confirmed the absence of a care plan, leading to improper oxygen administration.
The facility failed to follow physician's orders for oxygen administration for three residents, leading to potential complications. One resident received a higher oxygen flow than prescribed, and the 'Oxygen in Use' sign was not properly displayed. Another resident was administered oxygen at a higher rate than ordered, and a third resident received oxygen at a higher rate than needed for shortness of breath. These deviations from prescribed oxygen levels were confirmed by staff and did not align with the facility's policy on oxygen administration.
The facility failed to ensure proper use of bed rails for two residents, lacking physician orders, assessments, and care plans. One resident used 1/4 bilateral side rails without documentation, while another used 1/4 mid bilateral side rails for assistance without necessary orders or assessments. These omissions violated the facility's policy requiring informed consent and assessments before bed rail use.
A resident with Major Depressive Disorder and catatonic schizophrenia did not receive necessary follow-up psychological evaluations due to the Social Services Director's failure to schedule appointments. Despite an initial attempt to arrange an evaluation, no further action was taken after the assigned clinician was on leave, leading to unmet psychosocial care needs.
A resident was prescribed Seroquel for dementia with psychotic disturbance without sufficient documentation to support the diagnosis. The facility's policy requires that psychotropic medications are only prescribed for diagnosed and documented conditions, but there were no psychiatrist notes or active diagnosis to justify the medication. Interviews with staff confirmed the need for clarification with the prescribing doctor.
A medication error rate of 5.88% was identified in an LTC facility when a resident did not receive medications as ordered. An LVN administered Zaditor eye drops without an open date and gave an incorrect dose of Levetiracetam, contrary to the physician's orders. The facility's policy requires medications to be administered as prescribed, including recording open dates and verifying dosages.
The facility failed to report suspected abuse and theft allegations in a timely manner for two residents. One resident's missing money was not reported to the appropriate authorities when initially reported, and another resident's incident of striking another resident was reported late. Both incidents were not reported according to the facility's policy, which requires immediate reporting of such allegations.
A deficiency was identified in the facility's compliance with room size requirements, as multiple multi-resident rooms provided less than the required 80 square feet per resident. Despite this, observations indicated that the room sizes did not inhibit care, and both staff and residents reported no concerns about the room sizes.
Sanitation and Labeling Deficiencies in Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, as evidenced by several observations during a survey. Steel trays with black stains were found inside the kitchen freezer, indicating a lack of proper cleaning and maintenance. Additionally, the ice machine had a black substance buildup and a yellow stain on the baffle, suggesting inadequate cleaning practices. The facility's policy on sanitization, which requires all utensils, counters, shelves, and equipment to be kept clean and in good repair, was not adhered to. Furthermore, dietary staff were observed not wearing appropriate hairnets and beard restraints, contrary to the facility's policy on employee hygiene and sanitary practices. The facility also failed to follow its policy regarding the labeling of foods brought in by family or visitors. During an inspection of the refrigerator storing these foods, it was found that the items were labeled with the date they were received rather than the date they should be discarded, as required by the facility's policy. This oversight was confirmed by the Director of Nursing, who acknowledged that the policy mandates labeling with a 'use by' date. These deficiencies had the potential to expose residents to contaminants that could cause foodborne illness.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during various instances involving staff and residents. Certified Nursing Assistants (CNAs) N and O did not perform hand hygiene while serving lunch trays to residents, despite handling potentially contaminated surfaces such as food carts. This was confirmed through interviews with the CNAs and the infection preventionist, who emphasized the importance of hand hygiene in preventing the spread of infections. Additionally, the facility did not properly manage medical equipment, as seen with Resident 187's nebulizer mask, which was undated and improperly stored, and Resident 238's outdated nebulizer tubing left on a bedside table. The Licensed Vocational Nurse (LVN) C also failed to disinfect a blood pressure apparatus between residents, and a Registered Nurse (RN) I did not follow the manufacturer's instructions for disinfecting a glucometer, using an incorrect disinfectant wipe. These lapses were confirmed through observations and interviews with staff, including the infection preventionist and the Director of Nursing. Further deficiencies were noted with Resident 50's humidifier bottle, which was found on the floor, and Nursing Assistant (NA) P's failure to perform hand hygiene between assisting residents during lunch. These actions were observed and confirmed through interviews with the involved staff, highlighting a pattern of non-compliance with the facility's infection control policies, which are designed to prevent healthcare-associated infections.
Deficiency in Food Preparation and Temperature Control
Penalty
Summary
The facility failed to ensure that food was prepared in a manner that conserved its nutritive value and appearance, as evidenced by multiple resident complaints and a test tray evaluation. Eight out of 18 residents reported that the food was served cold, lacked flavor, and was not at the appropriate texture. Specific complaints included food being inedible, meat being tough, and chicken being too dry. During interviews, residents expressed dissatisfaction with the taste and temperature of the meals, with some describing the food as bland and hard to chew. A test tray evaluation conducted with a Registered Dietician and Dietary Supervisor confirmed the residents' complaints. The evaluation revealed that both regular and pureed meals were bland, with the pureed chicken being particularly dry. The food temperatures were below the recommended safe levels, with hot food items measuring between 112.9 F and 118 F, and cold milk at 50.8 F. This was contrary to the facility's in-service training, which emphasized that hot food should be at 135 F or above and cold food at 41 F or below. These deficiencies had the potential to decrease residents' food intake and negatively impact their nutritional status.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for five residents, leading to deficiencies in addressing their specific medical and personal care needs. For Resident 19, the facility did not create a care plan for activities of daily living (ADLs) related to hygiene, despite the resident's need for assistance with personal hygiene and upper body dressing. Additionally, the facility did not implement the care plan for anticoagulant therapy, as there was no documentation of monitoring for signs and symptoms of bleeding, which was a critical aspect of the resident's care. Resident 66 was admitted with a urinary tract infection (UTI) and a physician's order for Ciprofloxacin Hydrochloride, but the facility failed to develop a care plan addressing the UTI and the prescribed medication. Similarly, Resident 78, who was also diagnosed with a UTI and prescribed Cephalexin, did not have a care plan developed for the infection or the medication. These omissions indicate a lack of proper assessment and planning for the residents' medical conditions and treatments. For Resident 238, the facility did not develop care plans for the use of Zoloft and Aripiprazole, medications prescribed for anxiety, depression, and dementia. Resident 59 also lacked care plans for osteoporosis treatment with Alendronate Sodium and the use of a concave mattress as a fall intervention. These failures demonstrate a pattern of neglect in creating individualized, person-centered care plans that address the residents' physical, psychosocial, and functional needs, as required by the facility's policies and procedures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper medication management in two out of three medication rooms and two out of three medication carts. An outdated vial of Tuberculin was found in the medication refrigerator, with an open date exceeding the 30-day discard period. Additionally, an open Ozempic injection pen was found unlabeled, posing a risk of medication error if the box label was lost. These observations were confirmed by the Licensed Vocational Nurse (LVN) present during the inspection. Further deficiencies were noted in the storage of medications requiring refrigeration. Two unopened bottles of latanoprost ophthalmic solution and an unopened Insulin Glargine U 100 pen were found unrefrigerated in medication cart BB, contrary to the manufacturer's instructions. Similarly, an unopened Insulin Humalog 100-unit pen was found unrefrigerated in med cart EE. The Interim Director of Nursing (IDON) confirmed that new medications should be refrigerated until used. Additionally, expired items such as antiperspirants and a biohazard spill kit were found in med storage CC. Labeling issues were also identified, with two over-the-counter eye medication bottles labeled only with room numbers, lacking resident names, which could lead to medication errors due to room changes. A discrepancy was found in the medication order for Eplerenone, where the blister pack label did not match the physician's order. The IDON emphasized the importance of following the 5 Rights of medication administration to prevent errors. These practices had the potential to result in medication errors and reduced potency of medications.
Deficiencies in Dietary Staff Competency and Food Safety Procedures
Penalty
Summary
The facility failed to ensure that the dietary staff possessed the necessary competencies and skills to effectively carry out the functions of the food and nutrition services. During an initial kitchen tour, a pair of tongs with visible residues was found in a kitchen drawer, which the Dietary Supervisor acknowledged should not have been stored there if unclean. Additionally, during an interview, Dietary Cook E was unable to articulate the cool down process for food, despite having attended an in-service meeting on food safety that covered this topic. Furthermore, Dietary Aide G demonstrated an incorrect method for checking the chemical sanitation concentration of the dish machine. Instead of testing the strip on a plate, as stated by the Dietary Supervisor, DA G tested it on the running water from the dish machine's drain. Although DA G attended an in-service meeting on the dishwasher, the document did not include specific steps on how to check the chemical concentration, and the manufacturer's recommendation document was not provided.
Failure to Follow Pureed Diet Recipe
Penalty
Summary
The facility failed to ensure that the recipe for a pureed diet was followed, which could potentially lead to inadequate nutritional value and nutritional requirements for the residents. During an observation and interview in the facility kitchen, a Dietary Aide (DA) was seen preparing pureed bread by placing a whole loaf of bread into a food processor and then transferring the processed bread into a steel container. The DA then added water from a hot water machine without measuring the amount. When questioned, the DA admitted to not measuring the water, while the Registered Dietician (RD) mentioned that typically a recipe is followed, but they also watch for consistency. A review of the facility's menu for Pureed Bread indicated that the recipe requires placing portions of bread and margarine into a food processor to create fine crumbs, and for every five portions needed, one cup of warm milk or water should be added. The failure to follow this recipe as specified could result in the residents not receiving the appropriate nutritional content in their meals.
Failure to Cover Urinary Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident 12, by leaving their suprapubic catheter drainage bag uncovered. This deficiency was observed during a survey when Resident 12 was found lying in bed with the urine bag visibly hanging on the right side of the bed, displaying yellow-colored urine. The resident had recently returned from dialysis, and the drainage bag was not covered, which was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) during interviews. Both staff members acknowledged that the urinary drainage bag should have been covered with a privacy or dignity bag at all times. Resident 12's medical history includes a diagnosis of End Stage Renal Disease and obstructive uropathy, necessitating the use of a suprapubic catheter. The facility's Director of Nursing (DON) also confirmed that the urinary drainage bag should always be covered, both inside and outside the facility, in accordance with the facility's policy and procedure on dignity, revised in February 2023. This policy mandates that residents are treated with dignity and respect at all times, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of lorazepam to Resident 44, who was diagnosed with Major Depressive Disorder and Catatonic Schizophrenia. The physician's order for lorazepam was dated 7/4/2023, and the informed consent form was signed by the physician on 7/10/2023. However, the form indicated that consent was obtained by phone on 7/4/2023, but it did not specify whether the consent was given by Resident 44 or a surrogate decision maker. During an interview and record review on 8/14/2024, the Director of Nursing confirmed that the informed consent form lacked the name of the person from whom consent was obtained. The facility's policy and procedure on psychotropic medication use and informed consent, dated March 2004, requires that the prescriber personally examine the resident and obtain written consent signed by the resident or their representative. If the resident or representative cannot sign, a licensed nurse must document the name of the person who gave consent and the date, which was not done in this case.
Failure to Develop Baseline Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a baseline care plan for a resident's oxygen use within the required 48 hours of admission, as mandated by CMS guidelines. Resident 190, who was admitted with a supracondylar fracture of the left femur, morbid obesity, and obstructive sleep apnea, had a physician's order for oxygen administration at 0.5 liters per minute via nasal cannula at bedtime, which was later adjusted to 1 liter per minute. However, during an observation, it was noted that the oxygen was being administered at 1.5 liters per minute, indicating a deviation from the prescribed order. Interviews with the registered nurse and the minimum data set nurse revealed that there was no baseline care plan in place for the resident's oxygen use, despite the order being present since admission. The director of nursing acknowledged that the baseline care plan should have been developed within 72 hours, but CMS guidelines require it within 48 hours. This oversight resulted in improper oxygen administration, which could potentially lead to adverse effects such as oxygen toxicity.
Oxygen Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen administration for three residents, leading to potential complications. Resident 190, who was admitted with conditions including a displaced supracondylar fracture, morbid obesity, and obstructive sleep apnea, had a physician's order for oxygen at 1 liter/min at bedtime. However, during an observation, the resident was found to be receiving oxygen at 1.5 liter/min. Additionally, the 'Oxygen in Use' sign was not properly displayed, as it was obscured by another sign, making it not visible to all passersby. Resident 18, diagnosed with congestive heart failure, acute and chronic respiratory failure, and obstructive sleep apnea, had a physician's order for continuous oxygen at 4 liter/min. During an observation, the resident was found to be receiving oxygen at 4.5 liter/min, which was confirmed by a registered nurse upon review of the records. This deviation from the prescribed oxygen level was not in accordance with the physician's order. Resident 36, with diagnoses including cerebrovascular disease, chronic congestive heart failure, and COPD, had an order for oxygen at 3 liter/min as needed for shortness of breath. However, observations revealed that the resident was receiving oxygen at 3.5 liter/min, both while asleep and when seated at the edge of the bed. The registered nurse confirmed that the oxygen administration did not align with the physician's order. The facility's policy on oxygen administration emphasizes the importance of following physician's orders and ensuring proper signage, which was not adhered to in these cases.
Failure to Ensure Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed rails for two residents, leading to potential safety risks. For both residents, there were no physician orders obtained prior to the use of bed rails, and no side rail assessments were completed. Additionally, there were no care plans in place regarding the use of side rails for these residents. These omissions were observed during facility visits and confirmed through interviews with staff, including the Interim Director of Nursing (IDON) and the Minimum Data Set Nurse (MDSN). Resident 78 was observed with 1/4 bilateral side rails on her bed, but her Side Rails Utilization Assessment was blank, and there was no physician's order or care plan documented. Similarly, Resident 39 was using 1/4 mid bilateral side rails for assistance with repositioning and activities of daily living, yet there was no physician order, care plan, or side rail assessment indicating their use. The facility's policy requires informed consent, physician orders, and assessments before the installation of bed rails, which were not adhered to in these cases.
Failure to Schedule Follow-Up Psychological Evaluation
Penalty
Summary
The facility failed to provide adequate social services for a resident diagnosed with Major Depressive Disorder and catatonic schizophrenia. The resident was admitted with these diagnoses, which require regular psychological evaluations to address their mental health needs. However, since admission, only one psychological evaluation was conducted, dated several months prior to the survey. This lack of follow-up was confirmed during interviews with the Interim Director of Nursing and the Social Services Director, who acknowledged the oversight. The Social Services Director was responsible for scheduling follow-up appointments but failed to arrange a subsequent psychological evaluation after the initial one. Although an attempt was made to schedule an appointment, the assigned clinician was on leave, and no further action was taken to reschedule. The Director of Nursing confirmed that residents with psychological diagnoses should be seen regularly, either monthly or bi-weekly, and that the Social Services Director should have ensured the follow-up appointment was scheduled. This inaction resulted in the resident's psychosocial care needs potentially being unmet.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication. Specifically, the facility did not provide sufficient documentation to support a diagnosis of dementia with psychotic disturbance manifested by paranoia for one resident. The resident was prescribed Quetiapine fumarate (Seroquel), an antipsychotic medication, for dementia with psychotic disturbance, but there was no active diagnosis or psychiatrist notes to justify this prescription. The facility's policy requires that psychotropic medications are only prescribed when necessary to treat a specific, diagnosed, and documented condition. The resident in question was admitted with diagnoses including hemiplegia, hemiparesis, unspecified depression, and severe vascular dementia with other behavioral disturbances. Despite the continuation of Seroquel for agitation as noted in the facility physician's notes, there was no documentation from a psychiatrist to support the use of this medication for the stated condition. Interviews with the Medical Records Director and the Director of Nursing confirmed the lack of psychiatric evaluation and the need for clarification with the prescribing doctor regarding the medication's indication.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 5.88% during a medication administration observation involving one resident. The first error occurred when a Licensed Vocational Nurse (LVN) administered Zaditor Ophthalmic Solution to a resident without an open date on the bottle, which is against the facility's policy. The LVN acknowledged the oversight and stated she would inform the physician to obtain a new order for the medication. The facility's policy requires that medications be administered safely, timely, and as prescribed, including recording the open date on multi-dose containers. The second error involved the administration of Levetiracetam (Keppra) to the same resident. The LVN administered 1500 mg of Levetiracetam, while the physician's order required 2000 mg every 12 hours for the treatment of generalized idiopathic epilepsy. This discrepancy was confirmed during a review of the resident's clinical record and a concurrent interview with another LVN. The facility's policy mandates that any concerns about medication dosage be discussed with the prescriber or attending physician, which was not adhered to in this instance.
Delayed Reporting of Abuse and Theft Allegations
Penalty
Summary
The facility failed to report a suspected allegation of resident abuse in a timely manner for two residents. For Resident 196, the alleged missing money was not reported to the California Department of Public Health (CDPH), Adult Protective Services (APS), and the Office of the Long Term Care Ombudsman (LTCO) when it was first reported to the Social Services Director (SSD) on November 18, 2022. The resident, who had a BIMS score indicating moderate cognitive impairment, reported missing money that was brought to her by a friend. Despite the resident's request to file a police report, the SSD only educated her about financial responsibility. It was not until December 13, 2022, after a follow-up by the LTCO, that a report was filed. Interviews with the SSD, Director of Nursing (DON), and Administrator confirmed the delay in reporting. For Resident 24, an incident of resident-to-resident abuse occurred when the resident, who had severe cognitive impairment, randomly struck another resident in the face. This incident, which took place on December 31, 2022, was not reported to CDPH, the Ombudsman, and law enforcement until January 3, 2023. The DON acknowledged the late reporting and stated that such incidents should be reported immediately or within two hours. The facility's policy on abuse prevention requires prompt reporting of all alleged violations of abuse, neglect, exploitation, or mistreatment. The facility's policies and procedures, as reviewed, clearly outline the requirement for immediate reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment. However, in both cases, there was a failure to adhere to these policies, resulting in delayed reporting of the incidents. This delay had the potential to hinder the identification and implementation of appropriate corrective actions, thereby putting residents at risk for abuse.
Room Size Deficiency in Multi-Resident Rooms
Penalty
Summary
The report identifies a deficiency in the facility's compliance with room size requirements for residents. Specifically, multiple multi-resident rooms were found to provide less than the required 80 square feet per resident. The rooms in question varied in size, with some providing as little as 70 square feet per resident. Despite this, during observations conducted over a week, it was noted that the room sizes did not inhibit staff from providing care, and both staff and residents reported that the room sizes were not a concern. The deficiency was observed through a combination of observation, interviews, and record reviews. The surveyors noted that the rooms, although smaller than the required size, did not impede the movement of staff or residents. The report suggests that the facility may continue with a room waiver, indicating that the current room sizes have not been problematic in terms of care delivery or resident satisfaction.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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