Woodcrest Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8133 Magnolia Avenue, Riverside, California 92504
- CMS Provider Number
- 055474
- Inspections on file
- 43
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Woodcrest Post Acute & Rehabilitation during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with multiple complex medical conditions was discharged without a complete post-discharge plan of care, missing critical information such as responsible party contacts, wound care instructions, and follow-up appointment details. Gaps in communication and documentation by the case manager and nursing staff led the resident's family to seek emergency care within 24 hours of discharge.
A deceased resident's body was left in a shared room for 12 hours, causing trauma to two other residents. Despite the death being pronounced in the morning, the body was not removed until the evening, leading to distress and negative psychosocial outcomes for the roommates. Staff interviews revealed a lack of communication and adherence to protocol, and the facility's policies on dignity and resident rights were not followed.
The facility failed to respond promptly to call lights for three residents, resulting in unmet needs. A resident with osteoarthritis reported no response to her call light for restroom assistance. Another resident with a fracture waited over 10 minutes for help, expressing frustration over previous delays. A third resident with cognitive impairment had his call light on for over 15 minutes, needing to be changed. Staff interviews confirmed the policy for prompt responses, but observations showed staff ignoring activated call lights.
The facility failed to ensure accurate PASARR screenings for two residents, leading to deficiencies. One resident was admitted with dementia, schizophrenia, and major depressive disorder, but the screening inaccurately reported no serious mental disorders. Another resident with psychosis and major depressive disorder also had an inaccurate screening. The facility relied on hospitals for accurate screenings and did not verify them upon admission, leading to potential care issues.
A facility failed to notify the state-designated authority after a resident was diagnosed with schizophrenia. The resident, admitted with psychosis and major depressive disorder, received the new diagnosis from a psychiatrist. Staff interviews revealed confusion about the PASARR process, with Social Services and an RN unsure if a new Level I screening was needed for the diagnosis, leading to the oversight.
The facility exceeded the acceptable medication error rate of 5%, with errors affecting two residents. One resident received the wrong iron supplement, while another received incorrect constipation medication. The DON and Administrator expected adherence to physician orders and a medication error rate below 5%.
The facility failed to administer medications on time for three residents, with medications being given beyond the allowed time frame. Residents reported having to seek out nurses for their medications, and records showed multiple instances of late administration without documented reasons. The facility's policy on medication timing was not consistently followed.
A facility failed to provide sufficient nursing staff, leading to inadequate care for residents. Staff reported being consistently short-staffed, with CNAs managing an unmanageable number of residents. A resident expressed dissatisfaction due to delays in personal care and lack of showers. The facility did not meet the required Direct Care Service Hours per Patient Day (DHPPD), resulting in increased workloads and inadequate care.
The facility did not update or post daily staffing information, including actual hours worked by nursing staff, as required. The document 'Census and Direct Care Service Hours Per Patient Day (DHPPD)' was not updated with necessary details for multiple dates. The Interim Director of Staff Development was responsible for these calculations but lacked access to payroll data, leading to non-compliance with the facility's policy.
A resident with a history of stroke and aphasia was found unable to reach her call light, as it was placed on her roommate's TV mount. This was confirmed by a CNA, LVN, and the DON, all of whom stated that the call light should be within the resident's reach. The facility's policy also required call lights to be accessible, but it was not followed in this case.
A facility failed to notify a resident's responsible party (RP) when the resident was transferred to a hospital due to chest pain. Despite the facility's policy requiring notification of the RP during a change of condition (COC), there was no documentation of such notification. The resident had a history of supraventricular tachycardia and hypertension and could not make medical decisions independently. Interviews with staff confirmed the oversight, and the Director of Nursing acknowledged the failure to follow protocol.
A facility failed to communicate a physician's order for physical therapy to a hospice provider for a resident under hospice care, resulting in the resident not receiving the prescribed therapy. The resident, with conditions including supraventricular tachycardia and rheumatoid arthritis, was under hospice care, and the order was not communicated as required by facility policy.
A resident with a full code status was found unresponsive, without a pulse, and not breathing. Despite the resident's condition, LVN 2 and RN 2 did not initiate CPR, citing the resident's body as cold and stiff. Interviews with other staff and the DON confirmed that CPR should have been performed according to the facility's policy and the resident's full code status.
A resident missed multiple doses of prescribed medications, including apixaban and amiodarone, with no documentation or reason provided. Interviews with the DSD and DON confirmed the lack of documentation and administration, contrary to the facility's policy.
A resident fell and broke his hip after the facility failed to repair a loose toilet seat that was reported to staff. The issue was not recorded in the maintenance log or addressed, leading to the resident's fall and subsequent surgery.
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge for a resident and her family member. The resident, with a history of multiple medical conditions, expressed a desire to go home, but her family member was not adequately prepared for her discharge. There was no documented evidence of discharge preparations between the issuance of the discharge notice and the planned discharge date, leading to inadequate preparation and orientation.
The facility failed to notify the family member designated as the Power of Attorney (POA) for a resident about a change in the resident's condition. Despite the POA being effective immediately, the Treatment Nurse only informed the resident and the physician, neglecting to notify the POA. This oversight prevented the POA from fulfilling their duties effectively.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Provide Complete Post-Discharge Plan of Care
Penalty
Summary
The facility failed to ensure that a resident received a comprehensive post-discharge plan of care containing all necessary information for the continuation of care after discharge. The resident, who had a complex medical history including a left above-the-knee amputation, COPD, and cirrhosis with ascites, was discharged without complete documentation regarding responsible party contact information, activity levels, equipment and supplies, home health agency details, wound care instructions, ombudsman information, follow-up appointments, and pharmacy information. The discharge summary also lacked documentation of discharge diagnosis and prognosis. Interviews with facility staff revealed that while the case manager and social service staff attempted to coordinate discharge planning, there were gaps in communication and follow-through. The case manager did not make follow-up appointments as ordered, nor did she discuss the possibility of applying for additional services through Medi-Cal. The home health agency and insurance care coordinator were notified of the resident's needs, but no appointments were scheduled prior to discharge. The resident's family was left without clear instructions, leading them to contact the facility for advice when the resident experienced swelling in his leg after discharge. As a result of the incomplete discharge planning and lack of necessary information, the resident's family sent him to the emergency room within 24 hours of discharge. Facility policy and job descriptions indicated that nursing services and case management were responsible for preparing and communicating the post-discharge plan, but these requirements were not met in this instance, resulting in a breakdown in the continuity of care.
Failure to Remove Deceased Resident Promptly
Penalty
Summary
The facility failed to treat residents with respect and dignity when a deceased resident's body was left in the room with two other residents for approximately 12 hours. This incident involved Residents A and B, who shared a room with Resident C, who passed away early in the morning. Despite the death being pronounced at 8:57 a.m., Resident C's body was not removed until 7:30 p.m. that evening. During this time, Residents A and B experienced negative psychosocial outcomes, including trauma and distress, as they were forced to remain in the room with the deceased. Interviews with Resident B revealed that the presence of the deceased body was traumatic and disrespectful, as staff entered the room without acknowledging the living residents. Resident B's family requested that meals be served elsewhere due to the smell, but this was not accommodated. Resident A also expressed anger and distress over the situation, stating that the staff did not offer a room change. Medical records and social service notes confirmed the residents' distress and the offer of psychological support and room changes after the incident. Staff interviews indicated a lack of communication and adherence to protocol. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) acknowledged the inappropriate delay in removing the body and the failure to offer room changes to the living residents. The Director of Nursing (DON) admitted that the situation was not handled efficiently and that staff expectations were not met. The facility's policies on dignity and resident self-determination were not followed, as staff failed to promote a dignified environment and respect the residents' rights.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights within a reasonable time for three residents, leading to unmet needs. Resident 5, who has osteoarthritis, muscle wasting, and a history of falling, reported to her family that she activated her call light for restroom assistance, but no one responded. Resident 6, with a fracture, hypertension, and difficulty walking, was observed with an activated call light for over 10 minutes without response. He expressed frustration over waiting more than an hour for assistance earlier in the day. Resident 7, with metabolic encephalopathy, osteoarthritis, and moderate cognitive impairment, had his call light on for over 15 minutes without response, needing to be changed. Staff interviews revealed that the facility's policy is to answer call lights promptly, and all staff are responsible for responding, regardless of resident assignment. However, observations showed staff walking past activated call lights without checking on residents. The Director of Nursing confirmed the expectation for timely responses and that call lights should be within residents' reach. The facility's policy, dated March 2021, emphasizes the importance of timely responses to residents' requests and needs.
Inaccurate PASARR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I preadmission screening and resident review (PASARR) for two residents, leading to deficiencies in the screening process. Resident #3 was admitted with a medical history of dementia, schizophrenia, and major depressive disorder, yet the PASARR Level I screening inaccurately indicated that the resident did not have any serious diagnosed mental disorders. Interviews with facility staff, including Social Services, a Registered Nurse, the Director of Nursing, and the Administrator, confirmed the inaccuracy of the screening. Similarly, Resident #59 was admitted with diagnoses of psychosis and major depressive disorder. The PASARR Level I screening for this resident also inaccurately reported no serious diagnosed mental disorders. Interviews revealed that the facility relied on the hospital to complete the screenings accurately and did not review them for accuracy upon admission. The Director of Nursing and the Administrator acknowledged the inaccuracies in the screenings and the potential for misleading the facility about the residents' needs. The deficiency arose from the facility's reliance on hospitals to conduct accurate PASARR screenings without verifying the information upon admission. This oversight led to inaccurate screenings for both residents, potentially affecting the care and services they required. The facility's policy required all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders, but the lack of verification contributed to the deficiency.
Failure to Notify State Authority of New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to notify the appropriate state-designated authority after a resident was diagnosed with a new mental illness, specifically schizophrenia. The resident, who was admitted on December 15, 2023, had a medical history that included psychosis and major depressive disorder, both diagnosed on the day of admission. On December 29, 2023, the resident received a new diagnosis of schizophrenia from a psychiatrist. Despite this new diagnosis, there was no evidence in the resident's medical record that a referral was made to the state-designated authority as required by the preadmission screening and resident review (PASARR) requirements. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASARR process. Social Services (SS) #7 indicated that Level I screenings were typically completed at the hospital before admission and that a new screening would only be necessary if there was a change in the resident's condition. SS #7 believed that the resident's mental status had not changed, and therefore, a new Level I screening was not required. Registered Nurse (RN) #8 also expressed uncertainty, stating that a new Level I screening would be completed for a new order of psychotropic medication, but not necessarily for a new diagnosis. This confusion and lack of action led to the failure to notify the appropriate authority about the resident's new diagnosis of schizophrenia.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by two medication errors out of 33 opportunities, resulting in a 6.06% error rate. This affected two residents during medication administration. Resident #10, who was admitted with a diagnosis of unspecified anemia, was prescribed ferrous fumarate 324 mg to be taken three times a day. However, during an observation, LVN #6 administered ferrous sulfate 325 mg instead of the prescribed medication. Resident #39, admitted with diagnoses including adult failure to thrive and unspecified dementia, was prescribed Senna-S for chronic constipation. The order specified two tablets of Senna-S to be given twice daily. During medication administration, LVN #6 gave one Geri-kot 8.6 mg tablet and one docusate sodium 100 mg capsule instead of the prescribed combination. Interviews with the DON and the Administrator revealed expectations for nurses to administer medications as per physician orders and maintain a medication error rate below 5%.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure medications were administered on time as prescribed by the physician and according to the facility's policy for three residents. During an unannounced visit, it was observed that medications due at 9:00 a.m. were still being administered by an LVN at 11:42 a.m., well beyond the two-hour window allowed by the facility's policy. Interviews with the LVNs revealed inconsistencies in understanding the time frame for medication administration, with some stating a two-hour window and others a one-hour window. Resident 1, who was alert and conversant, reported having to look for the nurse when it was time for his pain medication. A review of Resident 1's medication administration record showed multiple instances of late administration, including critical medications such as Imatinib and Aspirin. Similarly, Resident 2, who also had the capacity to understand and make decisions, received medications like Metformin and Hydralazine late, with no documentation explaining the delays. Resident 3, who had been discharged, also experienced late medication administration, including Aspirin and Atenolol, with no documented reasons for the delays. The facility's policy required documentation for early, late, or omitted medications, but this was not adhered to. The Director of Nursing acknowledged the difficulty in predicting outcomes from late medication administration, depending on the medication type and frequency.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as observed during an unannounced visit on July 23, 2024. Interviews with staff, including CNAs and LVNs, revealed ongoing staffing issues, with reports of being consistently short-staffed across all shifts. CNAs reported being assigned an unmanageable number of residents, with one CNA stating they had 26-27 residents to care for. This shortage was corroborated by the staffing coordinator, who noted that the facility did not meet the required Direct Care Service Hours per Patient Day (DHPPD) on several occasions, leading to increased workloads and inadequate care. Resident 4, who was interviewed during the visit, expressed dissatisfaction with the care received due to staffing shortages. The resident reported that staff were often too busy to respond promptly to call buttons and that there were significant delays in receiving personal care, such as being changed or showered. The resident had not received a shower since May 28, 2024, despite preferring showers over bed baths. A review of the resident's medical records confirmed the lack of showers and no documented evidence of refusal or preference for bed baths. The facility's staffing coordinator and Director of Nursing acknowledged the staffing deficiencies, noting that the required DHPPD was not consistently met, and CNAs were often overburdened with too many residents. The facility's policy, which mandates sufficient staffing to meet residents' needs, was not adhered to, resulting in inadequate care and potential resident dissatisfaction. The facility was actively recruiting more staff and asking current staff to work additional hours to address the staffing shortfall.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that updated staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff, was posted in a prominent place readily available to residents and visitors. During an observation, it was noted that the document titled 'Census and Direct Care Service Hours Per Patient Day (DHPPD)' was posted in the facility lobby but was not updated with the necessary information. The forms lacked details such as the actual total direct care service hours, actual total CNA direct care service hours, the average patient census, the actual DHPPD, and the actual CNA DHPPD for multiple dates. Interviews with the Staffing Coordinator and the Interim Director of Staff Development (IDSD) revealed that the IDSD was responsible for calculating and posting the actual direct care service hours and DHPPD. However, the IDSD stated that these calculations were done weekly based on data from payroll, to which she did not have access. Consequently, the documents from July 1 to July 14 were not updated. The facility's policy required daily posting of staffing numbers within two hours of each shift's start, but this was not adhered to, as confirmed by the Administrator.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 2, had her call light within reach, which is a violation of her rights to a dignified existence and self-determination. During unannounced visits, it was observed that Resident 2, who was alert but had unclear speech due to aphasia, was unable to reach her call light as it was hanging on the TV mount of her roommate. This was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the call light was not within Resident 2's reach, which would prevent her from calling for help. Resident 2's medical record indicated she was admitted with a diagnosis of stroke, resulting in right-sided weakness and aphasia, and her care plan specified that the call light should be within her reach due to her self-care deficit. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) all confirmed that the call light should always be accessible to Resident 2. The facility's policy on answering call lights, dated March 2021, also stated that call lights should be within easy reach of residents when they are in bed. The DON acknowledged that the policy was not followed in this instance.
Failure to Notify Responsible Party of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident when there was a change of condition (COC) and the resident was transferred to a general acute care hospital (GACH). This deficiency was identified during unannounced visits conducted on June 24 and 25, 2024. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the facility's protocol required notifying the doctor and RP when a resident experienced a COC or was sent to the hospital. However, a review of the resident's records showed no documentation that the RP was informed of the transfer to the hospital for chest pain on July 15, 2023. The resident in question had a history of supraventricular tachycardia and hypertension and was unable to make medical decisions independently. Despite this, there was no evidence in the resident's chart that the RP was notified of the hospital transfer. The facility's policy, dated December 2023, clearly stated that a nurse should notify the resident's representative in such cases and document the information in the medical record. The DON acknowledged that the facility did not adhere to its policy, resulting in the RP being unaware of the resident's health condition.
Failure to Communicate PT Order to Hospice
Penalty
Summary
The facility failed to ensure that a physician's order for physical therapy was communicated to the hospice provider for a resident under hospice care. This oversight resulted in the resident not receiving the prescribed physical therapy. The resident, who was admitted with diagnoses including supraventricular tachycardia and rheumatoid arthritis, was under hospice care since November 29, 2023. A physician's order for physical therapy was issued on December 5, 2023, following an orthopedic appointment, but there was no documented evidence that this order was communicated to the hospice provider. During interviews, the Director of Rehabilitation (DOR) confirmed that the order for physical therapy was not communicated to him, which was against the facility's protocol. The Director of Nursing (DON) stated that hospice managed all care for residents under hospice, implying that the hospice provider might have declined the therapy. However, the facility's policy required communication with the hospice provider to ensure resident needs were met. The failure to communicate the physician's order for physical therapy to the hospice provider was a deficiency identified during the survey.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive, despite being designated as a full code. The resident, who had a medical history including atrial fibrillation and hypertension, was admitted to the facility and had the capacity to understand and make decisions. The resident's Minimum Data Set indicated a full code status, meaning CPR should have been initiated if the resident was found without a heartbeat or not breathing. On the day of the incident, the resident was found unresponsive, without a pulse, and not breathing by LVN 2, who was the charge nurse at the time. Despite the resident's body being cold and stiff, LVN 2 acknowledged that CPR should have been initiated but did not proceed with it. RN 2, the supervisor, was informed of the situation and also decided against performing CPR, citing the resident's condition as cold and lifeless. Both LVN 2 and RN 2 failed to initiate CPR, contrary to the facility's policy and the resident's full code status. Interviews with other staff members, including RN 3 and the Director of Nursing (DON), confirmed that CPR should have been initiated for a full code resident found unresponsive. The facility lacked a written policy for CPR, relying instead on the POLST forms in residents' charts. The DON stated that the staff should have assessed the situation, checked the POLST, and initiated CPR if the resident was a full code. The failure to perform CPR resulted in the resident not receiving necessary life-saving measures.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to ensure pharmacy services were provided to meet the needs of the residents when four medications were not administered during the scheduled time with no documentation for one resident. Resident 1, who was alert and oriented, reported missing doses of apixaban and amiodarone. A review of Resident 1's medical record revealed that the 9 pm dose of amiodarone was not given on three occasions, the 5 pm dose of apixaban was not given once, the 5 pm dose of ascorbic acid was not given once, and the 9 pm dose of atorvastatin was not given on three occasions. There was no documentation for these missed doses, and no reason was provided for not administering the medications as ordered by the physician. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the lack of documentation and administration for the missed doses. Both the DSD and DON acknowledged that the medications should have been administered as ordered and that any missed doses should have been documented with a reason. The facility's policy on medication administration documentation, which requires documentation of all administered medications and reasons for any missed doses, was not followed in this instance.
Failure to Repair Loose Toilet Seat Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident (Resident 3) by not repairing a loose toilet seat that was reported as needing repair. This failure led to Resident 3 falling off the loose toilet seat and sustaining a broken hip, which required surgical repair. The incident occurred after Resident 3 had informed the Social Service Assistant (SSA) about the loose toilet seat the day before the fall, but the issue was not recorded in the maintenance log or addressed in a timely manner. Resident 3, who was alert and conversant, reported the loose toilet seat to the SSA on April 2, 2024. Despite this, the SSA did not record the issue in the maintenance log or verbally alert the maintenance staff. On April 3, 2024, Resident 3 fell while attempting to use the toilet, resulting in a broken hip. The resident was assessed by nursing staff and subsequently transferred to the hospital for surgical repair. The resident's medical history included hypertension, end-stage renal disease, and a stroke, and he was previously independent with toilet transfers and walking. Interviews with staff revealed that the maintenance logs were not utilized properly, and the SSA was not initially aware of their existence. The Director of Nursing (DON) confirmed that the maintenance department was notified of the loose toilet seat only after the fall occurred. The facility's policy on safety and supervision emphasized the importance of identifying and reporting accident hazards, but this protocol was not followed in this instance.
Inadequate Discharge Preparation and Orientation
Penalty
Summary
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge for Resident 2 and her family member. Resident 2, who had a history of encephalopathy, cerebrovascular accident with left-sided weakness, type 2 diabetes, and chronic kidney disease, expressed a desire to go home by the end of February 2024. However, her family member was not adequately prepared for her discharge, and there was no documented evidence that the family member was notified of the discharge notice issued on February 9, 2024, due to non-payment. The notice was effective on March 10, 2024, but Resident 2's family member was not informed until February 27, 2024, and requested more time to make arrangements at home. Despite this, the facility did not provide sufficient discharge preparations between February 9 and February 27, 2024. Interviews with the Certified Nurse Assistant (CNA) and the Social Services Director (SSD) revealed that Resident 2 required assistance with personal hygiene, had poor balance, and would benefit from assistance if discharged home. The SSD stated that Resident 2 was self-responsible and had been provided with personalized resources on March 8, 2024, including home health, transportation, and pharmacy referrals. However, the SSD also mentioned that some services required private pay, and Resident 2 needed to agree to the expenses. The SSD believed that the three-day period between March 8 and March 10, 2024, was sufficient for Resident 2 to arrange private caregivers and other options, but Resident 2's family member filed an appeal on March 9, 2024, delaying the discharge. Further review of Resident 2's records indicated that she required supervision and assistance with various activities of daily living, as documented in her Minimum Data Set (MDS) dated February 14, 2024. The facility's policy on preparing residents for discharge, dated December 2023, stated that residents should be prepared in advance for discharge and that a post-discharge plan should be developed. However, the facility did not adhere to this policy, as there was no documented evidence of discharge preparations with Resident 2 and her family member between February 9 and February 27, 2024, leading to inadequate preparation and orientation for a safe and orderly discharge.
Failure to Notify POA of Resident's Condition Change
Penalty
Summary
The facility failed to ensure that the family member (FM) designated as the Power of Attorney (POA) for Resident 2 was notified about a change in the resident's condition. Resident 2, who had diagnoses including type 2 diabetes mellitus with a right foot ulcer, end-stage renal disease on dialysis, and Alzheimer's disease, experienced a deterioration of a diabetic ulcer on February 6, 2024. Despite the POA being effective immediately as of September 16, 2022, the Treatment Nurse (TN) only notified Resident 2 and the physician about the condition change, failing to inform the FM who was the designated POA. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) both stated that the responsible party should be notified of any changes in condition, but this protocol was not followed in this instance. Interviews with the Director of Staff Development (DSD) and a review of Resident 2's records confirmed that the FM should have been notified of the change in condition. The facility's policy indicated that a resident representative, including a POA, should be notified to support the resident in decision-making. However, the TN was unaware of the POA status and did not notify the FM. The DON acknowledged that the POA should have been notified and could not explain why the TN failed to do so. This oversight resulted in the FM being unable to fulfill their POA duties effectively, as they were not informed of the resident's deteriorating condition.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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