Windsor Care Center Of Sacramento
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 501 Jessie Avenue, Sacramento, California 95838
- CMS Provider Number
- 555717
- Inspections on file
- 52
- Latest survey
- December 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Windsor Care Center Of Sacramento during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nurse staffing levels, with Actual DHPPD and CNA DHPPD below required standards, leading to 10 resident falls over a week. The staffing shortfall was due to a loss of CNAs and numerous call-outs, as confirmed by the Staffing Coordinator. The Director of Nursing and a CNA acknowledged the impact on resident care, including challenges in implementing fall precautions.
The facility compromised resident privacy when a shred box containing meal tickets was overfilled, exposing sensitive information. Surveyors observed that the shred box in the dining room was full, allowing resident details to be read from the meal tickets. The Dietary Manager and Administrator acknowledged the issue, which violated the facility's confidentiality policy.
Two residents in an LTC facility were not adequately assisted with their ADLs, leading to potential health risks. A resident with dementia had a blackish substance under her fingernails, indicating a lack of personal hygiene assistance. Another resident, also with dementia, was not provided with the required oral care, resulting in white matter caked on their teeth. The facility's policy on ADLs was not followed, as confirmed by the DON.
Two residents in the facility were not provided with adequate activities to meet their interests and preferences. One resident with Alzheimer's was observed without activities despite a care plan indicating preferences for music and group interactions. Another resident with dementia and brain cancer did not receive activities meeting his psychosocial needs for 35 days. The facility's policies were not followed, and both the DON and AD acknowledged the deficiencies.
The facility failed to maintain effective infection control, with staff not sanitizing shared equipment, neglecting PPE protocols for residents on Enhanced Barrier Precautions, and not performing proper hand hygiene. These actions increased the risk of cross-contamination and infection transmission among residents.
The facility failed to maintain a safe and sanitary environment for 29 residents due to improper cleaning of bathroom exhaust fans, leading to dust buildup. Observations revealed that the fans were not cleaned, posing potential fire hazards and health risks. Staff interviews confirmed the issue, and a review of cleaning protocols showed a lack of adherence to daily cleaning requirements.
The facility failed to promote dignity for three residents during meal times. A CNA stood over two residents while feeding them, which was acknowledged as undignified and increased aspiration risk. Another resident received her meal later than others, causing frustration and a sense of exclusion. The facility's policy emphasizes dignity and respect, which was not upheld.
A resident, identified as a fall risk, did not have their call light within reach, contrary to their care plan and facility policy. This oversight was confirmed by a CNA and acknowledged by the DON, highlighting a failure to meet the resident's needs and prevent potential falls.
A facility failed to provide an accurate MDS assessment for a resident with dementia and major depressive disorder. The MDS inaccurately reported no behavioral symptoms, despite the resident exhibiting yelling behavior multiple times in October. Staff interviews confirmed the inaccuracy, and the facility's policy required MDS assessments to reflect resident observations, which was not met in this case.
A resident did not receive prescribed doses of spironolactone and venlafaxine for several days due to untimely reordering of medications. The nursing staff failed to notify the physician about the missed doses, leading to elevated blood pressure readings. Facility policies required medications to be administered as prescribed, but there was no evidence of a policy for handling missed medications.
A facility failed to provide trauma-informed care for a resident with PTSD, dementia, and major depressive disorder. The resident's trauma triggers were not identified, and her PTSD diagnosis was not included in her care plan. Staff members were unaware of the resident's trauma triggers and PTSD diagnosis, which was confirmed by the DON. The facility's policies require identifying trauma triggers and including them in the care plan, which was not followed, placing the resident at risk for re-traumatization.
A resident did not receive spironolactone for hypertension and the full dose of venlafaxine for depression for several days due to untimely medication reordering. The resident's blood pressure was elevated during this period, and the facility's staff did not inform the MD of the missed doses. The pharmacy delivered medications only after the missed doses were reported.
A resident with vascular dementia was prescribed risperidone without adequate indication or target behavior. The resident was calm with no behavioral issues, and the care plan lacked behavioral interventions. The facility's policy requires antipsychotic medications only when symptoms are due to mania or psychosis, or after behavioral interventions. The consultant pharmacist confirmed the medication's inappropriateness, as risperidone is not approved for dementia-related psychosis.
The facility failed to label and store medications correctly, as observed during inspections. In the medication room, latanoprost eye drops and a tuberculin vial lacked open or use-by dates, risking expired medication use. Similarly, a medication cart inspection revealed unlabeled glucose strips, a Spiriva inhaler, and a Humulin pen. The DON confirmed the expectation for proper labeling to prevent expired medication administration.
During a kitchen tour, improper food storage practices were observed, including wet steam table pans and an open bag of frozen spinach, which could lead to contamination. The Dietary Manager acknowledged these issues, which contravened the FDA Food Code and the facility's own policies.
A resident with dementia and depressive disorder was physically assaulted by another resident with similar conditions, resulting in harm. The incident was preceded by signs of agitation and aggression from the aggressor, which were not adequately monitored. Staff interviews confirmed a history of aggressive behavior in both residents, and the facility's policy on abuse prevention was not effectively implemented.
A resident with Alzheimer's and severe cognitive impairment was physically abused by a CNA, who slapped the resident's face, pulled their arm, and covered their face with a gown. This incident was witnessed by an RN who intervened. The facility's policy mandates protection from abuse, which was not upheld in this case.
A resident with a history of aggressive behavior physically assaulted two other residents, resulting in injuries. Despite the facility's awareness of the resident's potential for aggression, the incidents occurred, leading to a deficiency in protecting residents from abuse.
A facility failed to create a care plan for a resident prescribed Trazodone for depression, despite the resident's severe cognitive impairment and involvement in a physical altercation. The DON confirmed the absence of a care plan, which was required by the facility's policy on psychotropic medication management.
A resident with severe cognitive impairment was physically abused by another resident with dementia in an LTC facility. The incident occurred when the first resident, known for intrusive behaviors, attempted to enter the second resident's room, leading to the second resident kicking him. Staff were aware of both residents' behaviors but failed to prevent the conflict.
A resident with severe cognitive impairment physically harmed another resident, but the incident was not reported immediately as required by the facility's policy. The incident was witnessed by a CNA, who did not report it, assuming another CNA would do so. The responsible nurse was unaware of the incident until informed by the victim's family the next day, leaving the victim at risk of further harm.
A resident with severe memory impairment was physically abused by a CNA during mealtime, as confirmed by video evidence and interviews with facility staff. The resident was forcefully pulled into a chair, pushed down by the chest, and struck on the hand and arm, contrary to the facility's abuse prohibition policy.
Inadequate Staffing Leads to Resident Falls
Penalty
Summary
The facility failed to maintain sufficient nurse staffing levels for a census of 111 residents, as evidenced by the Actual Direct Care Service Hours Per Patient Day (DHPPD) falling below the required minimum standard of 3.5 DHPPD and 2.4 hours per patient day for certified nurse assistants (CNA DHPPD) from November 1 to November 7, 2024. During this period, the facility's DHPPD ranged from 2.64 to 2.98, and CNA DHPPD ranged from 1.69 to 1.93, which were below the mandated requirements. This staffing shortfall was confirmed by the Staffing Coordinator, who acknowledged the absence of a staffing waiver and attributed the deficiency to a loss of CNAs and numerous call-outs. The inadequate staffing levels coincided with 10 recorded resident falls during the same period, including incidents where residents fell from chairs, while walking, or from beds, with one fall resulting in a head injury requiring emergency room treatment. Interviews with staff, including a CNA and the Director of Nursing, highlighted the challenges faced due to low staffing, such as difficulty in providing adequate resident care and implementing fall precautions. The facility's policy on staffing emphasized the need to adhere to state-imposed minimum staffing requirements, which were not met during the reported period.
Resident Privacy Compromised Due to Overfilled Shred Box
Penalty
Summary
The facility compromised resident personal privacy and confidentiality when a shred box containing meal tickets was overfilled, exposing resident information. During the surveyor's initial setup, the survey team observed that the shred box, located in the large dining room off the kitchen, was full to the brim with meal tickets protruding from the box's opening. This allowed the survey team to read resident information directly from the meal tickets. The Dietary Manager confirmed the shred box was overfilled and unsuccessfully attempted to push the meal tickets back inside. The meal tickets, which were picked up every two weeks, contained sensitive information such as resident names, room locations, therapeutic diet orders, fluid textures, likes/dislikes, food allergies, and special instructions. Further observations revealed that the shred box continued to be overfilled with meal tickets, making resident information accessible to non-staff individuals. The Administrator acknowledged the issue, stating that the shred box should not be that full. The facility's policy and procedure on confidentiality and personal privacy, revised in October 2017, indicated that the facility would protect and safeguard resident confidentiality and personal privacy, including medical treatment and personal care. However, the overfilled shred box with exposed meal tickets demonstrated a failure to adhere to this policy, potentially compromising resident privacy.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, leading to potential health risks. Resident 72, who has dementia and major depressive disorder, was observed with a blackish substance under her fingernails on multiple occasions. Despite requiring assistance with personal hygiene, there was no documentation of refusals for hygiene assistance, and staff confirmed that nail care should be performed regularly to prevent hygiene and infection control issues. Resident 59, diagnosed with dementia and malnutrition, was not provided with the necessary oral care as outlined in their care plan. The care plan specified that oral hygiene should be performed twice daily, yet there were numerous missed opportunities for oral care in November and December. Observations revealed white matter caked on the resident's teeth, and staff misunderstood the requirements for oral care, thinking that wiping the mouth sufficed. The facility's policy on supporting ADLs was not adhered to, as evidenced by the lack of appropriate hygiene support for these residents. The Director of Nursing confirmed that the care plans were current and should have been followed, highlighting a failure in the facility's adherence to its own policies and procedures regarding resident care.
Inadequate Activity Provision for Residents
Penalty
Summary
The facility failed to provide adequate activities to meet the interests and preferences of two residents, Resident 35 and Resident 30. Resident 35, who was admitted with Alzheimer's disease, was observed multiple times over two days remaining in her room without engaging in any activities. Her care plan indicated a preference for activities such as music, animals, and group interactions, yet she was only offered activities once a week. The facility's policy required more frequent engagement, and the Activities Director acknowledged that the current level of activity was insufficient. Resident 30, diagnosed with dementia and brain cancer, was not provided with activities that met his psychosocial needs for a period of 35 days. His care plan suggested participation in group activities and interactions with peers, but observations showed him lying in bed unresponsive during this time. The Activities Director confirmed that Resident 30 did not receive the necessary activities, which was not in line with the facility's expectations for meeting residents' psychosocial needs. The facility's policies indicated that activities should be provided in accordance with residents' interests and care plans, yet both residents were not engaged as required. The Director of Nursing and Activities Director both acknowledged the deficiencies in meeting the residents' psychosocial needs, which could potentially affect their overall well-being.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper sanitation of shared medical equipment. A licensed nurse used a blood pressure cuff on multiple residents without sanitizing it between uses, acknowledging the risk of infection due to this oversight. The facility's policy required decontamination of resident-care items between uses, which was not followed in this instance. Another deficiency involved staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. For instance, two certified nursing assistants did not wear the necessary personal protective equipment (PPE) while transferring a resident who was on EBP. The staff admitted to not being sure about the PPE requirements, despite clear signage indicating the need for gloves and gowns. This lack of compliance with EBP guidelines posed a risk of spreading infections. Additionally, hand hygiene practices were not consistently followed by staff. A certified nursing assistant failed to perform hand hygiene between feeding multiple residents and handling meal trays. The facility's policy mandated the use of hand sanitizer before and after resident contact and handling objects, which was not adhered to. Furthermore, other staff members, including a hospice nurse, did not wear gowns while providing care to residents on EBP, such as during wound care and feeding tube management, contrary to the facility's infection control policies.
Improper Cleaning of Bathroom Exhaust Fans
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for 29 residents due to improper cleaning of bathroom exhaust fans, leading to dust buildup. Observations over several days revealed that the exhaust fans in shared bathrooms were not cleaned, resulting in potential fire hazards and exposure to mold and bacteria. Interviews with staff, including a Certified Nurse Assistant, Infection Preventionist, and Housekeeping Staff, confirmed the presence of dust buildup and acknowledged the potential health risks associated with it. The Housekeeping Manager indicated that rooms were scheduled for deep cleaning monthly, which included cleaning exhaust fans, but spot checks were expected daily. However, the Housekeeping Staff was unaware of any specific schedule for cleaning exhaust fans. A review of the Environmental Services Operations Manual indicated that vents should be cleaned daily, but this was not being followed. The Deep Clean Check Off List also included cleaning vents, but the exhaust fans were not cleaned during recent deep cleans, highlighting a gap in adherence to cleaning protocols.
Failure to Promote Dignity During Meal Times
Penalty
Summary
The facility failed to promote dignity and respect for three residents during meal times. Certified Nursing Assistant 9 (CNA 9) was observed standing over Resident 1 and Resident 33 while assisting them with their meals. Resident 1, who has hemiplegia and hemiparesis following a stroke, expressed discomfort with this approach, stating it made her feel less dignified. Resident 33, who has severe memory impairment due to dementia, was also fed in the same manner. The Director of Staff Development acknowledged that standing over residents while feeding them could increase the risk of aspiration and did not promote dignity. Additionally, Resident 14, who has moderate cognitive impairment and diabetes mellitus, was served her lunch tray later than other residents at her table, causing her frustration and a sense of being left out. The Director of Staff Development noted that serving meals at different times could affect food temperature and negatively impact residents' feelings of inclusion. The facility's policy emphasizes the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 89, by not ensuring their call light was within reach. Resident 89, who was admitted in January 2023 with multiple diagnoses including dementia, was identified as a fall risk in their care plan. The care plan specifically included an intervention to prevent falls by placing the call light within reach. However, during an observation on December 18, 2024, it was noted that Resident 89's call light was not visible or accessible, as it was found under the bed. This was confirmed by Certified Nursing Assistant 12, who acknowledged that the call light should have been within the resident's reach. The deficiency was further highlighted during an interview with the Director of Nursing, who stated that the expectation was for call lights to be within residents' reach to meet their needs and reduce the risk of falls. The facility's policy, revised in October 2024, also indicated that call lights should be accessible to residents. Despite these guidelines, the failure to ensure the call light was within reach had the potential to result in further falls for Resident 89, who had previously fallen and injured her head, requiring hospitalization.
Inaccurate MDS Assessment for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to provide an accurate Minimum Data Set (MDS) assessment for one of the sampled residents, identified as Resident 49. This resident, who was admitted in January 2024, had diagnoses including dementia and major depressive disorder. The MDS assessment dated October 22, 2024, inaccurately indicated that Resident 49 had severely impaired cognition but did not exhibit any physical or verbal behavioral symptoms. However, a review of the Medication Administration Record (MAR) for October 2024 showed that Resident 49 exhibited yelling behavior 17 times between October 14 and October 22, 2024. Interviews with facility staff, including a Certified Nurse Assistant (CNA), the MDS Assistant (MDSA), the Social Services Director (SSD), and the Director of Nursing (DON), confirmed the inaccuracy of the MDS assessment. The CNA described Resident 49 as loud and combative, often refusing care and exhibiting yelling and kicking behaviors. Both the MDSA and SSD acknowledged that the MDS assessment did not accurately reflect Resident 49's behavioral symptoms, and the DON stated that she expected MDS assessments to be accurate for appropriate patient care. The facility's policy indicated that MDS assessments should consistently reflect information in progress notes, care plans, and resident observations, which was not the case for Resident 49.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident diagnosed with hypertension and depression. The resident did not receive spironolactone, a medication for high blood pressure, for four consecutive days because the medication was not reordered in a timely manner. Additionally, the licensed nurse did not notify the physician about the missed doses. During this period, the resident's blood pressure readings were elevated, indicating a potential impact on their health. Furthermore, the resident did not receive the full prescribed dose of venlafaxine, an antidepressant, for four days due to the same issue of untimely medication reordering. Again, the physician was not informed about the missed doses. Interviews with the licensed nurses confirmed the medication was unavailable, and the physician acknowledged that he was not contacted regarding the missed doses, which could have led to uncontrolled blood pressure. The facility's policies required medications to be administered as prescribed, but there was no documented evidence of a policy for handling missed medications.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for one resident, identified as Resident 102, who was diagnosed with PTSD, dementia, and major depressive disorder. The deficiency was identified when it was found that the resident's trauma triggers were not identified, and her PTSD diagnosis was not included in her care plan. This oversight was confirmed during interviews with a Licensed Nurse and a Certified Nurse Assistant, both of whom were unaware of the resident's trauma triggers and PTSD diagnosis. The Director of Nursing acknowledged the importance of identifying trauma triggers to prevent re-traumatization and stated that the resident's PTSD diagnosis and triggers should have been care planned. The facility's policy on Trauma Informed Care, dated August 2023, requires the identification of triggers that may re-traumatize residents with a history of trauma and mandates that these triggers be included in the resident's care plan. Additionally, the facility's comprehensive care plan policy requires that a resident's care plan be developed within seven days of completing the comprehensive assessment. The failure to adhere to these policies resulted in the deficiency, placing Resident 102 at risk for re-traumatization and not achieving her highest physical, mental, and psychosocial well-being.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 91, who was admitted with diagnoses of hypertension and depression. The resident did not receive spironolactone, a medication for high blood pressure, for four consecutive days due to the medication not being reordered in a timely manner. This resulted in missed doses on specific dates, as documented in the Medication Administration Record (MAR). During this period, the resident's blood pressure readings were elevated, and the progress notes indicated that the facility was awaiting pharmacy delivery. A licensed nurse confirmed that the medication was unavailable during her shift. Additionally, the resident did not receive the full prescribed dose of venlafaxine, an antidepressant, for four days due to similar issues with timely medication ordering. The MAR showed that the medication was not administered as ordered, and the progress notes again cited awaiting pharmacy delivery. A licensed nurse confirmed the failure to administer the correct total dose. The medical doctor was not informed of the missed doses, which could have led to uncontrolled blood pressure, as acknowledged by the doctor. The pharmacy consultant indicated that medications were refilled and delivered only after the missed doses were reported. The facility's policies on medication administration and physician orders were reviewed, but the policy on missed medications was not provided.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically a psychotropic medication, which was prescribed without adequate indication or a target behavior. The resident, who was admitted with a diagnosis of vascular dementia, was prescribed risperidone, an antipsychotic medication, for aggressive behavior manifested by yelling out for needs. However, the resident's psychiatrist consult note indicated that the resident was calm with no behavioral issues, and the care plan did not include any behavioral interventions for aggressive behavior. Furthermore, the Minimum Data Set assessment showed no potential indicators for psychosis. The facility's policy on antipsychotic/psychotropic medication requires that such medications be used only when behavioral symptoms present a danger to the resident or others, and when symptoms are due to mania or psychosis, or after behavioral interventions have been attempted. The consultant pharmacist confirmed that risperidone may not be appropriate for the resident, as yelling out for needs is not a psychotic behavior. Additionally, the manufacturer's prescribing information and a nationally recognized drug information resource both indicated that risperidone is not approved for treating dementia-related psychosis, highlighting the inappropriate use of the medication in this case.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, which was identified during an inspection. In the medication room, three bottles of latanoprost eye drops and one vial of tuberculin were found without open or use-by dates. This oversight was confirmed by a licensed nurse, who acknowledged that the absence of these dates could lead to the administration of expired medications. Manufacturer guidelines specify that latanoprost should be used within six weeks of opening, and tuberculin vials should be discarded after 30 days of use. Additionally, during an inspection of a medication cart, a bottle of glucose testing strips, a Spiriva Respimat inhaler, and a Humulin 70/30 KwikPen were also found without open or use-by dates. The licensed nurse present confirmed that these items should have been labeled accordingly to prevent the risk of administering expired medications. Manufacturer instructions indicate that glucose strips are valid for three months after opening, the Spiriva inhaler should be discarded three months after cartridge insertion, and the Humulin pen should be disposed of after 10 days of use. The Director of Nursing confirmed the expectation for proper labeling and acknowledged the risk of using expired medications.
Improper Food Storage Practices Observed
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Three large steam table pans were found stored with water droplets on both their inner and outer surfaces. This condition was acknowledged by the Dietary Manager (DM), who confirmed that the pans were wet and recognized that such a condition could lead to contamination. According to the 2022 US Food and Drug Administration (FDA) Food Code section 4-901.11, items must be allowed to drain and air-dry before being stacked or stored, as stacking wet items can create an environment conducive to microorganism growth. Additionally, a bag of frozen spinach was observed to be improperly stored, as it was not closed, leaving the spinach exposed to the environment. The DM concurred that the bag should have been tightly closed to prevent contamination. The facility's policy and procedure for food receiving and storage, although undated, indicated that all foods stored in the refrigerator or freezer should be covered, labeled, and dated, with wrappers of frozen foods remaining intact until thawing. These lapses in food storage practices had the potential to result in food-borne illnesses for the 110 residents consuming facility-prepared meals.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 49, who has dementia and major depressive disorder, was physically assaulted by Resident 112, who also has dementia and a depressive episode. The incident occurred when Resident 112 grabbed Resident 49 by the hair, pulled her down, and hit her. This altercation resulted in Resident 49 getting hurt and posed a risk of physical and psychosocial harm to all residents in the facility. Prior to the incident, Resident 112 exhibited signs of agitation and behavioral symptoms, including verbal aggression towards staff, as noted in the progress notes. Despite these behaviors, there was no documentation of monitoring in Resident 112's Medication Administration Record (MAR) for November 2024. Similarly, Resident 49's MAR indicated episodes of yelling out after needs were met, suggesting potential triggers for altercations. The facility's failure to adequately monitor and address these behaviors contributed to the incident. Interviews with staff revealed that both residents had a history of aggressive behavior. Certified Nurse Assistant (CNA) 1 witnessed the altercation and intervened to separate the residents. CNA 2 and Licensed Nurse (LN) 1 confirmed that both residents could be loud and physically aggressive, which could lead to altercations. The Director of Nursing (DON) acknowledged the expectation that residents should be free from abuse, highlighting the facility's policy on abuse prohibition and prevention.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a Certified Nursing Assistant (CNA) engaged in abusive behavior towards a resident. The incident involved CNA 4 slapping the resident's face, aggressively pulling the resident's arm, and using a gown to cover the resident's face. This incident was witnessed by a Registered Nurse (RN) who was preparing medication nearby and heard the resident crying. Upon looking up, the RN observed the abusive actions and intervened to check on the resident. The resident involved in the incident was admitted with diagnoses including Alzheimer's Disease, dementia, and Major Depressive Disorder, and was assessed as severely cognitively impaired. The facility's policy clearly states that residents have the right to be free from abuse and neglect, and this incident represents a failure to uphold that policy. The Director of Nursing (DON) confirmed that all residents should be protected from abuse and neglect, emphasizing the facility's responsibility to ensure a safe environment for its residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse when another resident, who had a history of physical behaviors related to cognitive loss and dementia, physically assaulted them. Resident 1, who was admitted with severe cognitive impairment and a history of aggressive behavior, punched Resident 2 in the face, resulting in a scratch on the lower lip, and bit Resident 3 on the right hand, causing a skin tear. These incidents occurred despite the facility's awareness of Resident 1's potential to exhibit physical aggression. The events unfolded as Resident 1 approached Resident 2 in the hallway and punched him, causing a minor scratch. Shortly after, Resident 1 bit Resident 3 on the hand while Resident 3 was assisting another resident. Staff intervened to separate the residents, but the incidents resulted in physical injuries to both Resident 2 and Resident 3. Observations and interviews with staff and residents confirmed the sequence of events and the injuries sustained. The facility's policies on resident rights and abuse prevention emphasize the right of residents to be free from abuse by anyone, including other residents. However, the facility's failure to adequately protect Residents 2 and 3 from Resident 1's aggressive behavior indicates a deficiency in ensuring resident safety and preventing abuse, as outlined in their policies.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was prescribed Trazodone, a medication used to treat depression. The resident, who was admitted with diagnoses including dementia and depression, had severe cognitive impairment. Despite being prescribed Trazodone initially at 50 mg and later increased to 100 mg following a physical altercation with other residents, there was no care plan developed for the use of this psychotropic medication. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of a care plan and stated that the expectation is to have a care plan for any psychotropic medication use. The facility's policy on psychotropic medication management requires that when such medications are prescribed for specific conditions or targeted behaviors, the clinical record should reflect the diagnosis, reasons for use, and have a care plan in place. The lack of a care plan for the resident's use of Trazodone was a deviation from this policy, as the clinical record did not include a care plan with medication use and non-drug interventions that had been attempted to alleviate the condition.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident kicked him on the right side of his torso. The incident involved two residents with cognitive impairments. The first resident, who was admitted with encephalopathy and alcohol dependence with withdrawal delirium, had a severe cognitive impairment as indicated by a BIMS score of 3. This resident was known to exhibit intrusive behaviors, such as entering other residents' rooms and going through their belongings. The second resident, diagnosed with dementia and having a BIMS score of 5, became agitated when the first resident attempted to enter his room through a shared restroom. On the night of the incident, staff heard yelling and found the first resident on the floor, being kicked by the second resident. Interviews with staff revealed that the first resident's wandering and intrusive behaviors were known, as was the second resident's tendency to become angry when his space was invaded. The facility's policy on abuse prevention emphasized the need for ongoing assessments and care planning to address behaviors that could lead to conflict, but these measures were not effectively implemented to prevent the incident.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of abuse, neglect, exploitation, or misappropriation. This deficiency was identified when an incident involving two residents occurred, where one resident physically harmed another. The incident was witnessed by a Certified Nursing Assistant (CNA 1) but was not reported to the appropriate authorities or staff members on the day it happened. The Director of Nursing (DON) confirmed that the alleged abuse was not reported immediately, as required by the facility's policy. Resident 3, who was admitted with diagnoses including major depressive disorder and unspecified dementia, was involved in a peer-to-peer altercation as the aggressor. The incident was documented in various records, including the SBAR communication form and progress notes, indicating that Resident 3 physically twisted and hit Resident 2. Despite the documentation, the incident was not reported to the nurse on duty, the DON, the Assistant Director of Nursing (ADON), or the abuse coordinator on the day it occurred. Resident 2, who was bedbound and unable to communicate effectively, was left in the same room with Resident 3 until the following day, increasing the risk of further harm. Interviews with staff members revealed a breakdown in communication and reporting. CNA 1 witnessed the incident but did not report it, assuming CNA 2 would do so. CNA 2, in turn, did not report the incident, believing that the Licensed Nurse (LN 1) had heard the call for help. LN 1, who was responsible for both residents, was unaware of the incident until informed by Resident 2's responsible party the next day. This lack of immediate reporting and action violated the facility's policy, which mandates that any suspicion of abuse must be reported within two hours.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a Certified Nursing Assistant (CNA) forcefully handled the resident during mealtime. The resident, who had severe memory impairment due to Alzheimer's disease and dementia, was aggressively pulled into a chair, pushed down by the chest, and struck on the hand and arm by the CNA. This incident was confirmed through video evidence and interviews with the Health Information Director (HID), the Administrator (ADM), and the Director of Nursing (DON). The incident was documented in the resident's clinical records, including a Minimum Data Set (MDS) and an eInteract Change in Condition Evaluation, which noted increased agitation and confusion in the resident following the abuse. The facility's policy on abuse prohibition, which explicitly forbids any form of abuse, mistreatment, or neglect, was not adhered to in this case. The ADM and DON confirmed the physical abuse during their interviews, acknowledging that the CNA's actions were inappropriate and harmful to the resident.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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