Willow Pass Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, California.
- Location
- 3318 Willow Pass Road, Concord, California 94519
- CMS Provider Number
- 055241
- Inspections on file
- 23
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Willow Pass Healthcare Center during CMS and state inspections, most recent first.
A cognitively intact resident with a BIMS score of 15/15 was verbally abused by a CNA in the TV dining area after the resident asked the CNA to help another resident who was crying out. The CNA, who had a known history of a loud voice and prior counseling about professionalism, responded in a rude, loud, and angry tone, used profanity, and engaged in a shouting exchange with the resident, requiring staff to intervene. Witnesses, including another CNA and the SSD, reported hearing loud yelling and profanities, and observed the resident crying, visibly upset, and trembling from anger afterward. Documentation by nursing and social services reflected the resident’s report that the CNA’s tone was rude and loud and not an acceptable way to speak to him, in violation of the facility’s abuse prevention policy that guarantees residents freedom from verbal and mental abuse by staff.
A CNA engaged in a loud verbal altercation with a cognitively intact resident in a TV dining area after the resident requested help for another resident who was crying out. The CNA and the resident yelled and exchanged profanities, and the resident was later noted to be trembling from anger. Despite the incident and prior counseling of the CNA about professionalism and voice volume, staffing records showed the CNA continued providing direct care to nine residents for the remainder of his shift. The ADM, acting as Abuse Coordinator, acknowledged that facility policy required immediate removal of an employee suspected of abuse from the care or vicinity of residents, but this did not occur in this case.
A cognitively intact resident with right knee pain purchased a new pair of shoes for a CNA after noticing the CNA’s swollen feet and being told the CNA had arthritis. The CNA accepted the shoes for personal use and later gave the resident twenty dollars, stating she did not see anything wrong with accepting the gift. The Administrator and DON were unaware of this transaction, and facility policy stated that abuse and financial abuse would not be tolerated, indicating a failure to prevent financial exploitation of the resident’s resources.
A resident with intact cognition and a history of skin cancer had not received a shower for over a month despite being scheduled for twice-weekly showers, and the ADL care plan did not address the resident’s repeated refusals to shower or include interventions as required by facility policy. The DON confirmed the resident refused showers and that the care plan had not been updated to reflect this ongoing issue. In addition, although IDT care plan conferences documented that the resident had discharge potential, no discharge care plan was developed upon admission, and the DON could not produce one, stating discharge planning was only discussed during conferences. The resident’s family member was not consistently invited to these conferences, contrary to the facility’s Care Planning and IDT policies requiring identification and care planning of all needs with measurable objectives and adequate interventions, and inclusion of the resident’s representative whenever possible.
A cognitively impaired resident, dependent on staff for hygiene and bathing, was repeatedly observed with facial hair despite having requested shaving and having it documented on multiple Shower Day Skin Inspection forms. A CNA stated that shaving should occur during scheduled showers but could not explain why it was not done for this resident. The DON reported that CNAs were expected to offer shaving with showers, obtain consent, and notify charge nurses of refusals, consistent with facility policy requiring regular showers and documentation, but the resident’s facial hair remained unaddressed over several shower days.
Two residents, one male and one female, were assigned to rooms sharing a single bathroom without a lock, leading both to feel uncomfortable and lacking privacy. Both residents were able to express their concerns, and the DON acknowledged the privacy risk and the need for a lock to prevent abuse. The facility's policy required person-centered care, but this was not maintained in the shared bathroom arrangement.
The facility did not maintain required records for quarterly fire sprinkler system inspections and testing, as only one quarter's documentation was available and the Maintenance Director confirmed inspections were done in-house without a vendor. This deficiency affected all residents in the facility.
Fire extinguishers in two areas were found obstructed by carts, including a metal cart in the kitchen and a medical cart near a resident room. The Maintenance Director indicated these obstructions were due to ongoing activities, and the facility handles extinguisher inspections internally without vendor support. These issues affected a significant portion of residents and did not meet NFPA 10 requirements for accessibility and visibility.
The facility did not maintain complete fire drill records for the AM shift in the fourth quarter, and was unable to provide the missing documentation when requested. Additionally, surveyors observed improper use of extension cords and daisy-chained power strips in multiple areas, with staff confirming these were used due to a lack of available outlets and to power specific equipment.
Surveyors identified that the facility did not maintain required inspection and maintenance records for kitchen equipment, including missing annual inspection records, and incomplete semiannual maintenance and cleaning records for the kitchen suppression system and hood-exhaust. The Maintenance Director confirmed the absence of an annual inspection plan and was unable to provide all required documentation.
The facility did not maintain complete fire drill records, specifically missing documentation for the AM shift during a quarter, and was unable to provide the required records when requested by surveyors. This deficiency affected all residents in the facility.
The facility failed to maintain a safe and comfortable room temperature for two residents during a heat wave, with temperatures reaching 84°F. Despite ongoing repairs, the air conditioning system remained faulty, causing discomfort for a resident with COPD and another with dementia. The facility lacked documentation of air filter replacements and preventative maintenance, contrary to its policy.
A resident with dementia and mobility issues fell and fractured their hip due to inadequate supervision in an LTC facility. The resident attempted to use an out-of-order bathroom and was found in the hallway without a walker. Despite being at high risk for falls, the resident was not properly monitored, resulting in a fall and subsequent surgery for a hip fracture.
A resident with dementia and mobility issues fell while searching for a bathroom because her room's toilet was out of order. The CNA found the bathroom out of order and no bedside commode available. The Maintenance Supervisor confirmed the issue was not logged, and the DON stated a commode should have been provided.
The facility failed to protect a resident from verbal and physical abuse by another resident, resulting in a skin tear. The incident occurred in the courtyard without staff presence, and the injured resident's care plan was not updated to address the incident or injury. The aggressor had a history of behavioral problems, and the facility's abuse prevention policy was not effectively implemented.
Verbal Abuse of Cognitively Intact Resident by CNA in Common Area
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a CNA used profanity, raised his voice, and yelled at the resident in the TV dining area after the resident requested help for another resident who was crying out. The involved resident had an admission date of 2/10/26 and an MDS dated 3/6/26 showing intact cognition, clear communication, and full understanding, with a BIMS score of 15/15. On Super Bowl Sunday, while in the TV dining room, the resident observed another resident crying out for help and called out to a CNA for assistance. The resident reported that the CNA responded in a rude tone, saying, “We got a problem?” in a loud and angry manner, and that other staff had to remove the CNA from the room. The resident stated that the CNA’s tone was “pissed and loud,” that people should not talk to residents that way, and that the CNA should have been fired. In interviews, the CNA acknowledged that he had previously been counseled about professionalism and his loud voice, and admitted that during the 2/8/26 incident he raised his voice at the resident instead of “swallowing his pride.” The DSD confirmed that the CNA had a loud voice that some residents did not like and that loud talking by direct care staff could make residents feel hurt or scared, and stated the CNA had been spoken to before about his loud voice. Another resident described the CNA as sometimes “obnoxious.” The Social Services Director reported hearing a commotion, then observing the CNA and the resident yelling and shouting at each other and exchanging profanities, with the CNA appearing “hot headed,” and documented the verbal altercation in the progress notes. A witness statement and interview from another CNA indicated she heard loud screaming, was told the CNA was “fighting with a resident,” and then saw both the CNA and the resident arguing, with the resident crying and visibly upset afterward. A nurse’s progress note documented that the resident perceived the CNA’s tone as rude and loud and stated, “That’s not the way they can talk to me.” The facility’s abuse prevention policy stated that each resident has the right to be free from verbal, sexual, physical, and mental abuse and must not be subjected to abuse by anyone, including facility staff.
Failure to Remove CNA From Resident Care After Verbal Altercation
Penalty
Summary
The deficiency involves the facility’s failure to remove a CNA from resident care areas after he engaged in a verbal altercation with a resident. On the date of the incident, Resident 1, who had an intact mental status with a BIMS score of 15 and was able to clearly express ideas and understand others, was in the TV dining room when another resident (Resident 2) began crying out for help. Resident 1 asked CNA 1, who was sitting in the room, to help Resident 2. According to Resident 1, CNA 1 responded in a rude tone, asking, “We got a problem?” and used a loud, angry tone. Social Services Director 1 reported hearing a commotion and, upon entering the TV room, observed Resident 1 and CNA 1 yelling and shouting at each other and exchanging profanities, with CNA 1 described as hot headed. SSD 1 documented in the progress notes that Resident 1 had a verbal altercation with CNA 1, and she noted that Resident 1 was trembling from anger after the incident. CNA 1 acknowledged that he raised his voice at Resident 1 during the incident and stated he had previously been counseled about being professional and lowering his voice with residents. The DON confirmed that CNA 1 had a generally loud voice and had been told in the past to treat residents with respect. Despite the altercation occurring around midday, staffing records and the CNA’s timecard showed that CNA 1 continued working his full shift from approximately 7:00 a.m. to 3:30 p.m., providing direct care to nine assigned residents for more than three hours after the incident. The Administrator, who served as the Abuse Coordinator, stated that if the incident occurred around noon, CNA 1 should have been sent home immediately and suspended during the investigation, and that the facility’s abuse prevention policy required immediate removal of an employee suspected of abuse from the care or vicinity of the resident. The failure to remove CNA 1 from resident care areas after the altercation constituted the cited deficiency.
Failure to Prevent Financial Exploitation by CNA
Penalty
Summary
The facility failed to prevent financial exploitation of a resident when a CNA accepted a new pair of shoes that the resident purchased for the CNA’s personal use. The resident had been admitted with a diagnosis that included right knee pain, and the MDS assessment showed a BIMS score of 15, indicating intact cognitive status with the ability to recall the correct year, month, and day of the week. According to the CNA, the resident noticed the CNA’s swollen feet, inquired about the condition, and was told the CNA had arthritis. The resident then bought a new pair of shoes and gave them to the CNA, who accepted them and later gave the resident twenty dollars for the shoes. During an interview, the CNA stated she did not see anything wrong with accepting the shoes from the resident. The Administrator and DON reported they were not aware that the CNA had received shoes purchased by the resident and stated the facility did not expect the CNA to receive shoes from the resident for personal use. Review of the facility’s Abuse Prevention policy, dated 9/1/2008, indicated that abuse, neglect, abandonment, isolation, and financial abuse would not be tolerated at any time. Despite this policy, the CNA’s acceptance of the shoes constituted exploitation, as the resident’s belongings or money were used for the CNA’s personal gain.
Failure to Care Plan for Shower Refusals and Discharge Needs
Penalty
Summary
Surveyors identified a deficiency in care planning related to a cognitively intact resident admitted with malignant neoplasm of the skin. The resident’s Minimum Data Set (MDS) showed a BIMS score of 15, indicating intact mental status, with clear speech and ability to understand and be understood. The resident reported during interview that he had not showered for some time and that he sometimes refused showers. Review of the shower record from 2/10/26 to 3/11/26 showed the resident had not received a shower for more than a month, despite being scheduled for showers twice weekly. The ADL care plan did not address the resident’s ongoing refusal to shower, and the DON acknowledged that the facility’s expectation was that the care plan be updated with the refusal and appropriate interventions. This was inconsistent with the facility’s “Shower for Residents” policy, which required that continual refusal to shower/bathe trigger social services involvement and care plan interventions to remedy the situation. Surveyors also found that the Interdisciplinary Team (IDT) did not develop a care plan addressing the resident’s discharge plan upon admission. Although the MDS indicated no discharge plan, care plan conference documentation on multiple dates reflected that the resident had discharge potential. The DON was unable to provide a discharge care plan for the resident and stated that discharge planning was addressed during care conferences rather than through a written care plan initiated on admission. Additionally, care plan conference records showed that the resident’s family member was not invited to participate, and the DON confirmed that the family member was not consistently invited. These findings were not in accordance with the facility’s Care Planning policy, which required that all resident care needs be identified through continuous assessments and care planned with measurable objectives and adequate interventions, and with the facility’s Care Planning-IDT process that included the resident and family/representative whenever possible.
Failure to Provide Assisted Grooming and Shaving With Scheduled Showers
Penalty
Summary
Surveyors identified that a resident who was cognitively impaired and dependent on staff for toileting, hygiene, and bathing was not provided grooming services to maintain personal hygiene. The resident had been admitted with a hip fracture and had a BIMS score of 03, indicating impaired mental status and inability to recall the correct year, month, and day of the week. The resident’s MDS documented that she required maximal assistance with showering/bathing and assistance of two or more helpers with toileting and hygiene. During observation, the resident was seen sitting in a wheelchair next to her bed with visible facial hair around her chin. The resident stated she had previously asked staff for a shave and that she wanted to be shaved. CNA 1 reported that residents’ facial hair was supposed to be shaved during scheduled showers but could not explain why this resident had not been shaved. Review of the resident’s Shower Day Skin Inspection forms on multiple dates showed that the resident had facial hair documented on each occasion, indicating the condition was ongoing. The DON stated that the facility’s expectation was that CNAs offer shaving with scheduled showers after obtaining consent, and that refusals should be reported to the charge nurse and documented. The facility’s shower policy required showers at least twice weekly, documentation of showers on the ADL flow sheet, and involvement of nursing and social services if residents continually refused bathing, with care plan interventions to address the situation. Despite these expectations and policies, the resident’s facial hair remained unshaven over multiple shower days.
Failure to Provide Privacy and Safety in Shared Resident Bathroom
Penalty
Summary
The facility failed to provide a safe, private, and homelike environment for two residents by assigning them to rooms that shared a single bathroom without a lock, resulting in both male and female residents having to share the same bathroom. During observation and interviews, a female resident expressed feeling unsafe due to sharing the bathroom with a male resident and noted the absence of a lock on the bathroom door. The male resident also reported discomfort with the arrangement and stated that there should be a lock for privacy. Both residents were cognitively able to express their needs and concerns, and their Minimum Data Set (MDS) assessments indicated they required only minimal assistance with toileting and ambulation. The shared bathroom was located between the two residents' rooms, and the lack of a lock required the male resident to signal when the bathroom was in use to avoid accidental entry. The Director of Nursing acknowledged that female and male residents should not be sharing bathrooms and recognized the lack of privacy as a risk, further stating that a bathroom lock was necessary to prevent abuse. The facility's policy emphasized providing person-centered care that respects residents' comfort, independence, and personal preferences, which was not upheld in this situation.
Failure to Maintain and Document Quarterly Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25 requirements. During a record review and interview with the Maintenance Director, it was found that the facility could not provide records of quarterly sprinkler inspections and testing for the first, second, and fourth quarters of the year. Only the third quarter inspection record was available. The Maintenance Director stated that the inspections and testing are performed in-house and that no external vendor had been used for these services. This deficiency affected all 77 residents across three smoke compartments. The lack of required documentation for quarterly inspections and testing was identified during the survey, and the absence of these records could result in a malfunctioning fire sprinkler system in the event of a fire. The findings were based solely on the review of records and staff interview, with no mention of any specific incidents involving residents at the time of the deficiency.
Plan Of Correction
Corrective Action Facility renewed the contract with the sprinkler company. Moving forward, the facility will make sure that sprinkler inspections are done by a professional company on a quarterly basis. Maintenance director will make sure that there will be no quarterly missing inspections. He will make sure that it is done by a contracted professional vendor. Identify other residents. All other residents have the potential to be affected by this deficient practice, so the facility will ensure that fire sprinklers are inspected on a quarterly basis by a professional vendor. Maintenance director and administrator made a walk-through and made sure that this deficiency is not affecting any other areas of the facility. Systemic Changes As a systemic change, the facility will add a quarterly sprinkler inspection into the safety committee action list. Team members will monitor and also check the maintenance records for compliance. Any discrepancy will be brought to the maintenance director and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction was completed on 04/18/2025.
Obstructed Fire Extinguishers Compromise Safety Compliance
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by observations during a facility tour. Specifically, fire extinguishers were found to be obstructed in two separate locations. In the kitchen, a K fire extinguisher was blocked by a metal cart approximately three feet high and one inch away from the extinguisher. The Maintenance Director stated that the cart was placed there temporarily during dishwashing activities. In another instance, a fire extinguisher next to Room 133 was obstructed by a four-foot-high medical cart, which was about three inches away from the extinguisher. The Maintenance Director explained that the cart was being used to charge a computer. These obstructions affected 54 of 77 residents in two of three smoke compartments. The facility conducts fire extinguisher inspections in-house and has not had a vendor perform inspections or testing. The observed obstructions could result in a delay in accessing a fire extinguisher in the event of a fire, as the extinguishers were not readily accessible or visible as required by NFPA 10.
Plan Of Correction
Corrective Action Maintenance director immediately removed the obstruction (metal cart) in front of the fire extinguisher. The Dietary manager will do an in-service to the kitchen team regarding the importance of keeping the fire extinguister area clean and easily accessible. Maintenance director pulled the med cart away from the fire extinguisher immediately. DSD will in-service the nursing team regarding the importance of keeping the fire extinguishers area clear and accessible all the time. Identify Other Residents Facility will ensure that no other residents are affected by this deficient practice by ensuring that fire extinguishers in the facility are not obstructed by anything. K 353 Maintenance director in conjunction with dietary manager periodically checks the fire extinguisher in the kitchen to ensure that it is not obstructed by any equipment. Maintenance director will make sure that this deficiency is not affected in any other area by checking all other fire extinguishers at the facility. Systemic changes As a systemic change, safety committee members check the fire extinguishers at the facility randomly to ensure that there are no impediments in front of any fire extinguishers. Monitoring Process Administrator and maintenance supervisor will monitor for compliance on a quarterly basis. QA Process This plan of correction is integrated into the facility's monthly QA process. POC will review for the completeness and effectiveness. Completion Date This plan of correction will be completed on 04/18/2025.
Incomplete Fire Drill Records and Improper Use of Electrical Equipment
Penalty
Summary
The facility failed to maintain complete fire drill records, as evidenced by the absence of documentation for fire drills conducted during the AM shift in the fourth quarter of 2024. During a record review and interview, the Administrator was unable to provide the required fire drill records and could not locate them in the designated binders. The facility was given an opportunity to submit the missing records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. Additionally, the facility did not maintain electrical equipment in accordance with regulatory requirements. Observations revealed the use of extension cords and daisy-chained power strips in several areas, including the Main Entrance, Kaiser Room, and Dietary Supervisor's Office. Specifically, extension cords were used to power a wander guard detector and a portable air conditioning unit, while a power strip was found powering another power strip for computers and monitors. The Maintenance Director confirmed these setups were due to insufficient outlets and the need to power specific equipment.
Plan Of Correction
Systemic Changes As a new system, the safety committee monthly meeting will review the documentation to ensure the plan of correction is sustained and completed. Any discrepancy will be addressed to the maintenance supervisor and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025. Corrective Action Maintenance director removed the yellow extension cord at the main entrance. Wander guard system is directly connected to the main power. Facility immediately removed the power strip from the kaiser room. The maintenance director will make sure that all electrical equipment is connected directly to the power outlet in the wall. Maintenance director and dietary manager removed the extension cord from the dietary manager's office and the portable air conditioner connected directly to the wall outlet. Identify other residents Maintenance director will do walk through the facility to make sure that this deficiency is not repeating in any other rooms. Any similar violations will be corrected immediately. Safety committee members will assist the maintenance director to identify any similar violations at the facility. Systemic Changes As a systemic change, the DSD and maintenance director will conduct an in-service to housekeeping and maintenance staff to re-educate them about the importance of not having any extension cords in the rooms & hallway. Housekeeping will assist and report to the maintenance director if they see any similar violations anywhere in the facility, and maintenance will correct it immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025.
Failure to Maintain Kitchen Equipment Inspection and Maintenance Records
Penalty
Summary
Surveyors found that the facility failed to maintain required inspection and maintenance records for its kitchen cooking equipment. During a tour and record review, it was observed that the facility could not provide annual inspection records for the kitchen equipment, and the Maintenance Director confirmed that there was no annual inspection plan in place. The Maintenance Director stated that equipment was only checked by a vendor when it broke down, rather than being inspected regularly as required. Additionally, the facility was unable to provide one of two required semiannual maintenance records for the kitchen suppression system and one of two required semiannual kitchen hood-exhaust cleaning records. Although one record for each was provided, the other records were not located, and the facility did not submit the missing documentation by the deadline given by surveyors. These deficiencies affected 17 of 77 residents in one of three smoke compartments.
Plan Of Correction
Corrective Actions Facility will make sure that all cooking equipment is maintained as required. Facility contacted the company to come for the semi-annual kitchen suppression system service and semi-annual kitchen hood cleaning system. Facility will contact a qualified company to inspect the kitchen equipment annually. Maintenance director will make sure that he is organized and keeping all maintenance records for kitchen equipment regularly and ready for an inspection. Identify other residents. Other residents may have the potential to be affected by this deficient practice, so maintenance supervisor along with dietary supervisor will make sure that all kitchen equipment is serviced, and preventive maintenance is done regularly. Administrator and maintenance director will walk through in the building to ensure that this deficient practice is not affecting any other areas. Systemic Changes As a result of systemic change, the maintenance director, dietary manager, and administrator will meet monthly to ensure that there is no kitchen equipment inspection due at that time. Facility will keep a special binder to keep all the maintenance records for the kitchen equipment. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction completed on 04/18/2025.
Incomplete Fire Drill Records
Penalty
Summary
The facility failed to maintain complete fire drill records as required by NFPA 101. During a record review and interview with the Administrator, it was found that fire drill documentation for the AM shift during the fourth quarter of 2024 (October, November, December) was missing. The Administrator was unable to provide these records when requested and stated that it was unusual for them not to be in the binders. The facility was given an opportunity to submit the missing fire drill records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. No additional information about the medical history or condition of the residents at the time of the deficiency was provided in the report.
Plan Of Correction
Corrective Action Facility will ensure that fire drills are conducted each quarter each shift. The Director of Staff Development and Maintenance Supervisor is on board with the new plans. Facility already contacted the vendor and explained to them the importance of fire drills in each quarter. Facility got the copies of the missing fire drills conducted from the vendor. Please see attached. Facility will make sure that disaster drill is not mingled with the quarterly fire drills. Identify Other Residents Facility will ensure that other residents in the facility are not affected by this deficiency. As a new plan, there will be a new schedule for the fire drills for the whole year to make sure each quarter, each shift are covered, and with the new documentation sheet, it will be clearly documented. Disaster drills will be separated from the fire drill.
Failure to Maintain Safe Room Temperature During Heat Wave
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature level in the rooms of two residents during a heat wave, with room temperatures recorded at 84 degrees Fahrenheit. Resident 1, who has chronic obstructive pulmonary disease and intact mental status, reported discomfort due to the heat despite using a fan. Similarly, Resident 3, who has dementia and impaired mental status, also expressed discomfort with the room temperature. Both residents experienced fluctuating room temperatures, with no cool air flow from the vents, indicating a malfunctioning air conditioning system. The Maintenance Supervisor (MS) and Administrator acknowledged the issue, noting that the air conditioning unit had been faulty for weeks and repairs were ongoing. However, they were unable to provide records of air filter replacements or preventative maintenance for the air conditioning units. The facility's policy requires maintenance services to ensure all equipment is operable and safe, but the lack of documentation and unresolved air conditioning issues suggest a failure to adhere to these standards.
Failure to Supervise Resident Leads to Hip Fracture
Penalty
Summary
The facility failed to adequately supervise a resident with a history of falls, resulting in the resident sustaining a left hip fracture. The resident, who was admitted with dementia, muscle weakness, and mobility issues, required supervision during activities of daily living. Despite these needs, the resident was left unsupervised and attempted to use a bathroom that was out of order, leading to a fall in the hallway. The resident's care plan indicated a high risk for falls, and staff were instructed to anticipate and meet the resident's needs promptly, which was not adhered to in this instance. On the day of the incident, a Certified Nursing Assistant observed the resident walking in the hallway without a walker and expressed a need to use the bathroom. The CNA's back was turned when the resident fell, indicating a lack of supervision. Subsequently, the resident was found in distress with a deformed left hip and severe pain, necessitating emergency medical attention and transfer to an acute care hospital. The resident underwent surgery for a hip fracture, highlighting the facility's failure to provide adequate supervision and prevent accidents for a high-risk resident.
Resident Falls Due to Nonfunctional Bathroom
Penalty
Summary
The facility failed to provide a functioning toilet for a resident, leading to a potential fall incident. The resident, who was admitted with dementia, muscle weakness, and mobility issues, had a bathroom that was out of order. The resident's Annual Minimum Data Set (MDS) assessment indicated occasional bladder incontinence and a moderately impaired mental status. On the day of the incident, the resident attempted to find an alternate bathroom due to the nonfunctional toilet in her room, which resulted in a fall in the hallway. The Certified Nursing Assistant (CNA) observed the resident walking in the hall without a walker and expressed the need for a bathroom. The CNA confirmed the bathroom was out of order and noted the absence of a bedside commode. While the CNA was looking for an alternate bathroom, the resident fell. The Maintenance Supervisor later confirmed the bathroom issue was not logged, and the Director of Nursing stated that a bedside commode should have been provided, and staff should have been more attentive to the resident's needs.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse when another resident yelled and punched him in the face, resulting in a skin tear. The incident occurred in the courtyard, where there was no staff presence to intervene. The injured resident expressed increased anger and fear for his safety following the altercation. The facility's records indicated that the injured resident had no history of physical or verbal behavioral symptoms, while the aggressor had a documented history of behavioral problems, including previous altercations with other residents. During the incident, the aggressor became angry after being called a derogatory name by the injured resident and responded by hitting him. The facility's interdisciplinary team notes and interviews with staff confirmed that the altercation was not witnessed by staff, and the injured resident's care plan was not updated to address the incident or the injury sustained. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of staff oversight in the courtyard and the failure to revise the care plan to address the resident's injury and safety concerns.
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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