Woodland Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodland, California.
- Location
- 678 3rd Street, Woodland, California 95695
- CMS Provider Number
- 056109
- Inspections on file
- 34
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Woodland Post-acute during CMS and state inspections, most recent first.
A resident with full cognitive understanding and a diagnosis of encephalopathy died, and the facility failed to return a $187.97 share of cost overpayment to the family within the 60-day period required by facility policy. The business office and administration confirmed the delay, and records showed the refund remained outstanding beyond the policy deadline.
A resident with a history of stimulant abuse and a recent positive drug screen for methamphetamine and fentanyl did not have a comprehensive, person-centered care plan developed or implemented. Despite staff awareness of the resident's substance use and unsupervised time outside with a significant other, no monitoring or interventions were put in place, and the facility's policy requiring individualized care planning for substance use disorder was not followed.
A facility failed to report an abuse allegation within the required timeframe. An allegation of verbal and physical abuse by a staff member towards a resident was reported to a licensed nurse but not communicated to the Administrator or the Department until several days later. Interviews confirmed the delay, and the Director of Nursing acknowledged the breach of the facility's policy, which requires reporting within two hours.
A resident with severe memory impairment was involved in an abuse allegation that was not documented by the nursing and social services departments. Despite a report of verbal and physical abuse, no nursing assessment, body check, or physician notification was completed. The facility's policies on abuse prevention and reporting were not followed, resulting in a failure to meet professional standards of care.
The facility failed to protect resident privacy by improperly disposing of tray tickets containing personal and health information in unsecured trash. A diet aide was observed discarding these tickets, which should have been shredded according to HIPAA regulations. This oversight potentially exposed the information of 87 residents.
A resident with gangrene in the left toe was readmitted to the facility without any wound care orders, monitoring, or care plans. Despite the resident's deteriorating toe condition, observations and interviews confirmed the absence of necessary treatment orders. Facility policies on wound care were not followed, leading to a lack of appropriate care for the resident's condition.
The facility failed to maintain proper pharmacy services by having an unsealed emergency kit and not replenishing medications in another kit after use. An unlocked e-kit was found with medications at risk for diversion, and another kit was accessed multiple times without notifying the pharmacy for replenishment, contrary to facility policy.
The facility failed to ensure residents were free from unnecessary antipsychotic medications. A resident was prescribed medications not FDA-approved for their condition, another was given antipsychotics without a documented mental health diagnosis, and a third received an antianxiety medication without a 14-day stop date. These actions were contrary to facility policy and placed residents at risk for adverse effects.
A LTC facility experienced a 17.2% medication error rate involving three residents. Errors included incorrect dosage of calcium and vitamin D, unavailability of hydroxyzine and buspirone, improper timing of sucralfate administration, and failure to administer famotidine as recorded. These issues were observed during medication administration and confirmed through interviews and record reviews.
The facility failed to properly store and label medications, including insulin pens and inhalers, leading to potential efficacy issues. Unopened insulin pens were stored at room temperature instead of being refrigerated, and opened inhalers lacked open dates. Personal items were improperly stored with medications, posing infection control and safety risks. Staff interviews confirmed these deficiencies, which violated the facility's policies on medication storage and labeling.
The facility failed to meet food safety standards, with wet-stored kitchen containers, improperly sealed food items, and unclean equipment. Observations included a steam table pan with food residue, a cutting board with deep grooves, a rusted shelf, and a discolored floor drain. These issues were acknowledged by the Dietary and Maintenance Supervisors as potential risks for bacterial growth and cross-contamination.
The facility failed to provide adequate storage and heating facilities for food brought in by family and visitors for residents. Staff confirmed that while residents could receive outside food, there was no refrigerator or microwave available for storing or reheating it. Leftover food was either discarded or taken home by family members. The facility's policy required food to be stored in resealable containers in a refrigerator, which was not being followed.
A facility failed to maintain an effective infection prevention and control program, as evidenced by uncovered and unlabeled nebulizers and oxygen equipment for three residents, and a urinary catheter touching the floor for another resident. Staff confirmed the equipment should have been covered and dated, and the catheter bag kept off the floor, but these protocols were not followed, increasing the potential for infection.
A resident with uncontrolled blood sugars did not receive prescribed Humalog insulin on three occasions when blood sugar levels exceeded 301, and the physician was not notified as required. The facility's policies for medication administration were not followed, as confirmed by staff interviews and record reviews.
A resident with diabetes and heel wounds was not provided with foam heel protectors as ordered, potentially worsening their condition. Observations showed the resident without the protectors, and staff did not offer assistance. The wound nurse confirmed the oversight, noting the importance of applying the protectors and floating the heels.
A resident experienced a significant weight loss of 14.5% over six months due to inadequate energy intake and a dislike of facility foods. Despite being on a regular diet with supplements, the resident's caloric intake was below the estimated needs. The interdisciplinary team failed to identify a definitive cause for the weight loss, and the facility did not implement effective interventions as per their weight monitoring policy.
The facility failed to maintain accurate medical records for two residents. One resident's MAR showed multiple instances of medications not being administered without explanation, while another resident's insulin administration was inconsistent with the prescribed sliding scale orders. The ADON confirmed these discrepancies, highlighting the importance of accurate documentation for patient safety.
The facility failed to report an alleged sexual abuse incident within the required timeframe involving two residents. A nurse witnessed one resident, diagnosed with dementia, unclothed and aggressive on top of another resident with schizophrenia. The incident was reported internally but not to the Department or law enforcement as required by policy, potentially compromising resident safety.
A resident with a history of aggressive behavior struck another resident in the head and chest during an altercation in the smoking area. The incident was witnessed by staff, and both the Social Services Director and the DON confirmed it as abuse. The facility's policy on protecting residents from abuse was not followed.
The facility did not report an abuse allegation within the required timeframe after a resident-to-resident altercation. The incident was documented but not reported to the Department until the following day, contrary to the facility's policy of reporting within two hours. The DON confirmed the delay, which had the potential to compromise resident health and safety.
Failure to Timely Refund Resident Share of Cost After Death
Penalty
Summary
The facility failed to follow its own policy and procedures regarding the timely refund of a resident's share of cost overpayment after the resident's death. Specifically, business office records showed that $187.97 was owed to the deceased resident's family, but this amount was not returned within the 60-day timeframe required by the facility's policy. The Business Office Manager (BOM) acknowledged being unaware of why the refund had not been processed, and both the BOM and the Administrator confirmed during interviews and record reviews that the refund remained outstanding beyond the policy's deadline. The resident involved had been admitted in 2020 with a diagnosis including encephalopathy and was documented as having full cognitive understanding at the time of assessment. The facility's own records indicated the overpayment and the requirement for a refund, and the issue was first raised by a complainant inquiring about the refund. The facility's policy, consistent with CMS regulations, required overpayments to be refunded within 60 days of identification, but this was not adhered to in this case.
Failure to Develop and Implement Care Plan for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a known history of stimulant abuse, despite the resident's recent positive urine drug screening for methamphetamine and fentanyl. Upon admission, the resident was diagnosed with a deep skin infection and stimulant abuse, and was found to be cognitively intact and capable of making decisions. Multiple nursing notes documented the resident spending unsupervised time outside with a significant other, and subsequent hospital records confirmed intoxication and positive toxicology results for methamphetamine and fentanyl. After returning from the hospital, there was no documentation of a care plan addressing the resident's substance use, nor evidence of staff monitoring or intervention related to the ongoing risk. Interviews with facility staff, including a licensed nurse, physical therapist, activities director, social service director, and the DON, revealed that the resident and her significant other were frequently unsupervised outside, and that staff were aware of the resident's substance use history and recent positive drug screening. Staff confirmed that no care plan had been developed or implemented to address the resident's substance use, and that there was no communication or coordinated approach among the interdisciplinary team regarding the situation. The resident herself confirmed recent drug use on facility premises, specifically in unsupervised outdoor areas. A review of the facility's policy and procedure for care of residents with substance use disorder indicated that an individualized care plan should be developed for residents with a history of substance abuse, including monitoring and risk management interventions. Despite this policy, the facility did not initiate a care plan or implement monitoring for the resident, resulting in a lack of coordinated care and oversight for a resident at risk for ongoing substance use and related complications.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe, as per their policy, for one of the sampled residents. The incident involved an allegation of verbal and physical abuse by a registry staff member towards a resident. The allegation was initially reported to a licensed nurse on January 9, 2025, but was not communicated to the Administrator, who is the Abuse Prevention Coordinator, nor was it reported to the Department until January 15, 2025. This delay in reporting was confirmed through interviews with the licensed nurse and two certified nursing assistants who were aware of the allegation but did not report it. The Director of Nursing confirmed that the facility's policy mandates reporting allegations of abuse to the Department within two hours. A review of the facility's policy titled 'Abuse Reporting and Investigation' corroborated this requirement, emphasizing the need for prompt reporting of all allegations of abuse, neglect, and mistreatment. The failure to adhere to this policy resulted in a delayed response by enforcement agencies, potentially compromising resident safety.
Failure to Document and Address Abuse Allegation
Penalty
Summary
The facility failed to ensure that a resident received care meeting professional standards following an allegation of employee-to-resident abuse. The resident, who was admitted with diagnoses including encephalopathy and dementia, was involved in an abuse allegation that was not documented by the nursing and social services departments. The Minimum Data Set indicated severe memory impairment, and there was no documented evidence of the abuse allegation in the Skilled Services Documentation. Additionally, there was no body check, physician notification, or nursing progress note on the resident's psychosocial well-being. Interviews with facility staff revealed that a report of verbal and physical abuse was made to a licensed nurse, but no nursing assessment or documentation was completed. The Social Services Director confirmed the lack of follow-up interviews, psychosocial support, and interventions. The Director of Nursing stated that such an allegation should be considered a change of condition, requiring an assessment and monitoring, which were not performed. The facility's policies on abuse prevention, reporting, and change of condition were not followed, as there was no examination for physical signs of injury, no notification to the attending physician, and no documentation of the resident's progress.
Improper Disposal of Tray Tickets Violates Resident Privacy
Penalty
Summary
The facility failed to protect the privacy of residents' personal and medical records when tray tickets containing sensitive information were improperly disposed of in the trash. During an initial kitchen tour, it was observed that the path taken by kitchen trash led to outside dumpsters in an unsecured parking lot, accessible to the public. On a subsequent visit, a diet aide was seen discarding tray tickets into the garbage can along with leftover food and paper products. These tray tickets contained personal and health information such as names, ID numbers, dining locations, diet orders, and other dietary needs. The Dietary Supervisor confirmed that the tray tickets should have been placed in a designated bin for shredding to comply with HIPAA regulations. The facility's policy on Protected Health Information (PHI) mandates that such information must be managed and protected to prevent unauthorized disclosure. The failure to follow this policy resulted in the potential exposure of 87 residents' personal and health information, as the tray tickets were not properly secured and disposed of according to the facility's procedures.
Failure to Provide Wound Care for Resident with Gangrene
Penalty
Summary
The facility failed to provide appropriate wound care for a resident who was readmitted with a diagnosis of gangrene in the left toe, among other conditions such as diabetes and vascular disease. Upon review of the resident's records, it was found that there were no wound care orders, monitoring, or care plans created for the resident's left great toe wound. This oversight was evident in the skilled nursing facility admission orders, admission nursing assessment, order summary report, skin integrity care plans, and wound physician consultation notes, none of which included any mention of treatment or monitoring for the toe wound. Observations and interviews conducted on January 9th revealed that the resident's left great toe was in a deteriorated state, with dry, shriveled, and discolored skin, yet no treatment orders were in place. Licensed nurses and a nurse consultant confirmed the absence of necessary treatment orders and care plans, emphasizing the importance of monitoring wounds to prevent infection and promote healing. The facility's policies on pressure ulcers and wound care were not adhered to, as they require examination, treatment orders, and documentation for wound care, which were not provided in this case.
Failure to Maintain Sealed and Replenished Emergency Kits
Penalty
Summary
The facility failed to maintain proper pharmacy services for its residents, as evidenced by two significant issues with the emergency supply kits (e-kits). Firstly, an unsealed e-kit was found in the medication storage room, which posed a risk for medication diversion and unauthorized use. During an observation, it was noted that the e-kit was unlocked, and a bag of yellow zip-ties was placed on top of prescription medications and medical supplies. Interviews with the Licensed Nurse (LN) and the Consultant Pharmacist (CP) confirmed that e-kits should be sealed with red zip ties and resealed with yellow ones after use. The Interim Director of Nursing (DON) also stated that e-kits should not be accessed without pharmacy approval and must be sealed after use. Secondly, another e-kit was accessed multiple times without the medications being replaced by the pharmacy, which could lead to a shortage of emergency medications for residents. The e-kit was accessed on four separate occasions for different medications, including antibiotics and blood pressure medication, without the pharmacy being notified to replace the used medications. Interviews revealed that the nurses did not fax for an e-kit refill, and the pharmacy was not automatically alerted to replace the e-kit upon providing an access code. The facility's policy required that the pharmacy be notified for replacement within 72 hours of opening an e-kit, but this procedure was not followed, as confirmed by the CP and DON.
Inappropriate Use of Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary antipsychotic medications. Resident 10 was prescribed antipsychotic medications for schizoaffective disorder, but the dosages and medications used were not FDA-approved for this condition. Quetiapine was prescribed at a dosage not approved for treating schizoaffective disorder, and divalproex sodium was used off-label without supporting literature. The Consultant Pharmacist and Director of Nursing acknowledged the inappropriate use of these medications, and there was no evidence of aggressive behavior from Resident 10 that would justify such prescriptions. Resident 30 was admitted with a new diagnosis of schizophrenia and was prescribed olanzapine and divalproex sodium without a documented history of serious mental illness. The facility records did not contain psychiatric evaluations to support the new diagnosis, and the Consultant Pharmacist recommended reevaluation of the medication use. Despite these recommendations, no action was taken to clarify the diagnosis or document the risk versus benefits of the medications. Observations and interviews indicated that Resident 30 did not exhibit behaviors that would necessitate the use of these medications. Resident 25 received an as-needed antianxiety medication, lorazepam, without a 14-day stop date, contrary to the facility's policy. The medication was administered beyond the 14-day period without a physician's review or documented rationale for continued use. The Assistant Director of Nursing confirmed the oversight and emphasized the importance of a stop date to reassess the resident's condition and medication needs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 17.2% error rate for three residents. For Resident 16, a Licensed Nurse administered an incorrect dosage of calcium and vitamin D, providing only one tablet instead of the prescribed two. This discrepancy was discovered during a medication reconciliation, and it was noted that the resident had a low calcium level, which necessitated the correct dosage to stabilize their condition. Resident 486 did not receive hydroxyzine as prescribed due to the medication not being available on the medication cart. The nurse attempted to administer the medication but found it missing and later borrowed it from another cart, which is against facility policy. This oversight was confirmed during interviews and record reviews, highlighting a failure to ensure medications were readily available and properly stocked. For Resident 55, multiple errors occurred. Buspirone was not administered due to unavailability, sucralfate was given after breakfast instead of on an empty stomach as recommended, and famotidine was marked as given in the electronic record but was not actually administered. These errors were observed during medication administration and confirmed through interviews and record reviews, indicating a lack of adherence to prescribed medication orders and facility policies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. Unopened insulin pens were found stored at room temperature instead of being refrigerated, as required by their labels. This improper storage was confirmed by interviews with staff, who were unsure of the open dates and the efficacy of the insulin pens. The facility's policy mandates that medications requiring refrigeration must be stored in a refrigerator, which was not adhered to in this case. Additionally, opened multidose inhalers lacked open dates, making it impossible to determine their expiration dates. This was observed during a medication cart check, where inhalers were found without open dates, contrary to the manufacturer's instructions. Interviews with staff confirmed the lack of open dates, which could lead to the use of expired medications. The facility's policy requires that all medications be properly labeled, including expiration dates, which was not followed. The facility also stored personal and non-pharmaceutical items in medication carts and rooms, posing infection control and safety risks. Items such as CDs, money, a lighter, and a knife were found in medication storage areas. Interviews with staff confirmed that these items should not have been stored with medications, as they could lead to contamination and safety hazards. The facility's policy requires that drugs and biologicals be stored in a safe and secure manner, which was not the case here.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Kitchen containers, carafes, and steam table pans were found stored wet, which the Dietary Supervisor acknowledged could lead to bacterial growth. The facility's policy requires dishes to be air-dried before storage, aligning with the US FDA Food Code that mandates equipment and utensils to be air-dried after cleaning and sanitizing. Additionally, several food items in the freezer and refrigerator were not securely closed, exposing them to potential freezer burn and cross-contamination. The Dietary Supervisor confirmed that frozen food items should be tightly sealed to prevent these issues. The facility's policy supports this by stating that frozen foods should be stored in airtight, moisture-resistant wrappers. Other deficiencies included a steam table pan with food residue, a red cutting board with deep grooves, a rusted and discolored storage shelf, and a floor drain with green build-up and worn flooring. These conditions were acknowledged by the Dietary Supervisor and Maintenance Supervisor as concerns for bacterial growth and cross-contamination. The US FDA Food Code specifies that food-contact surfaces should be smooth and free of imperfections, and nonfood-contact surfaces should be easy to clean and maintain.
Inadequate Food Storage Facilities for Resident Meals
Penalty
Summary
The facility failed to provide adequate storage and heating facilities for food brought in by family and visitors for residents. During a kitchen tour, the Dietary Supervisor confirmed that resident food was not stored in the kitchen, and there was no designated place for residents to store their food within the facility. Interviews with various staff members, including Licensed Nurses and Certified Nursing Assistants, revealed that while residents were allowed to receive food from outside, there was no refrigerator or microwave available for storing or reheating this food. Staff members indicated that leftover food was either discarded or taken home by family members, as there were no facilities to store it safely. The Director of Staff Development mentioned that perishable foods should be date-checked and could only be left out for one hour before needing to be discarded. The Activity Assistant confirmed that the refrigerator in the social dining/activities room was used solely for storing items related to activities, such as sodas. The facility's policy on foods brought by family or visitors stated that such food should be stored in resealable containers with tightly fitting lids in a refrigerator, which was not being adhered to. This lack of proper storage facilities had the potential to lead to poor food intake, weight loss, and foodborne illness among the 87 residents consuming meals.
Infection Control Deficiencies in Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations involving four residents. Resident 32's nebulizer was found uncovered and unlabeled, despite the resident's occasional use of the device for breathing treatments. Both a Certified Nurses Assistant (CNA) and a Licensed Nurse (LN) confirmed the nebulizer should have been covered and clean when not in use, but there was no clear protocol communicated to staff regarding labeling. Similarly, Resident 53 and Resident 61's oxygen equipment was observed uncovered and undated, with staff acknowledging the equipment should have been stored in a bag and dated when not in use. Resident 57's urinary catheter was observed touching the floor on multiple occasions, despite the facility's policy to keep catheter tubing and drainage bags off the floor to prevent infections. The resident, who had moderate memory impairment, was noted to lower his bed, causing the catheter bag to touch the floor. Staff confirmed the catheter bag should not be on the ground, but the resident's control over the bed height and resistance to staff instructions contributed to the issue. The facility's policies and procedures for infection control, specifically regarding the covering and dating of respiratory equipment and the proper handling of urinary catheters, were not effectively implemented or communicated to staff. The Interim Director of Nurses acknowledged the expectations for equipment handling, but the lack of adherence to these protocols increased the potential for infection among the residents involved.
Failure to Administer Insulin and Notify Physician
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was readmitted with a diagnosis of uncontrolled blood sugars. The physician's orders specified the administration of Humalog, a fast-acting insulin, based on a sliding scale for blood sugar levels. The orders also required notifying the medical doctor if the blood sugar was less than 70 or greater than 301. However, on three separate occasions, the resident's blood sugar levels exceeded 301, yet the insulin was not administered, and the physician was not notified. Interviews and record reviews revealed that the Licensed Nurse and the Assistant Director of Nursing confirmed the failure to administer the insulin and notify the physician as per the orders. The facility's policies and procedures for administering medications and insulin were not followed, as they require medications to be administered safely, timely, and as prescribed, with any discrepancies reported to the Director of Nursing Services and the attending physician before administering insulin.
Failure to Implement Wound Prevention Measures
Penalty
Summary
The facility failed to implement wound prevention measures for a resident, identified as Resident 65, who was admitted with diagnoses including diabetes and non-pressure open wounds on the heels. The resident had a stage three pressure ulcer on the left heel and a stage two pressure ulcer on the right heel. According to the Wound Physician Consultation Note, there was no change in the wound status since the last visit. The resident's treatment orders required the application of foam booties to prevent wound progression, to be worn as tolerated when in bed, three times a day. However, observations revealed that the resident was not wearing the foam heel protectors as ordered. During an observation, the resident was found lying in bed without the foam heel protectors, and the protectors were placed in the corner of the room. The resident stated that they had not worn the protectors in a while and that staff did not offer to put them on. The wound nurse confirmed the absence of the protectors and acknowledged that staff should have been applying them and floating the resident's heels. Further observation showed that the resident's heels were in contact with the bed surface, and a CNA did not encourage or offer to put on the heel protectors during their visit to the resident's room.
Failure to Maintain Resident's Weight
Penalty
Summary
The facility failed to maintain the weight of a resident, who experienced a significant weight loss of 14.5% over a six-month period. Observations revealed that the resident, who had a history of reflux, depression, dysphagia, failure to thrive, anxiety disorder, and dementia, was easily distracted during meals and consumed only partial portions of his meals. Despite being on a regular diet with high-calorie nutritional supplements, the resident's intake was consistently below the estimated caloric needs, averaging between 1000-1499 calories per day against a requirement of 1730-1900 calories per day. The interdisciplinary team noted the resident's dislike of facility foods and inadequate energy intake as potential factors for the weight loss, but no definitive cause was identified. The Registered Dietitian, who had recently joined the facility, confirmed the resident's variable intake and the lack of a clear reason for the weight loss. The facility's policy on weight monitoring required timely interventions for significant weight changes, but the report indicates that the necessary assessments and interventions were not effectively implemented to address the resident's nutritional needs.
Inconsistent Medication Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for two residents, leading to deficiencies in their care. For one resident, the Medication Administration Record (MAR) indicated that medications such as Metoprolol, Isosorbide, and Furosemide were not administered multiple times throughout December 2024. However, there were no corresponding progress notes explaining why these medications were withheld, as required by the facility's policy. This lack of documentation was confirmed by the Assistant Director of Nursing (ADON), who noted the importance of these medications in managing the resident's conditions, which included heart failure and high blood pressure. For another resident, inconsistencies were found in the documentation of insulin administration. The MAR showed that Humalog insulin was administered on three occasions when the resident's blood sugar levels were below 200, contrary to the sliding scale orders that required no insulin at those levels. Despite this, the MAR indicated the insulin was administered, and there were no progress notes to explain the discrepancy. The ADON confirmed the inconsistency and emphasized the need for accurate documentation to ensure patient safety. The facility's policy mandates that the method of administration and reasons for withholding or not administering medication must be documented, which was not adhered to in these cases.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required timeframe for two residents. Resident 4, diagnosed with paranoid schizophrenia, difficulty walking, spinal stenosis, and cognitive communication deficit, and Resident 6, diagnosed with unspecified dementia without behavioral disturbance, were involved in the incident. On the morning of September 2, 2024, a Licensed Nurse (LN 2) witnessed Resident 6, unclothed and aggressive, on top of Resident 4 in Resident 4's bed. The incident was reported to the Director of Nursing (DON) but not to the Department or local law enforcement as required by the facility's policy. During interviews, both the Administrator (ADM) and DON acknowledged the failure to report the incident within the mandated two-hour timeframe. The facility's policy, revised in December 2022, clearly states that any allegations of abuse must be reported to the Department, Local Ombudsman, and/or local law enforcement within two hours. This oversight had the potential to compromise the health and safety of vulnerable residents, as timely reporting is crucial in preventing further harm.
Resident-to-Resident Altercation Leads to Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when he was struck in the head and chest several times by another resident. Resident 1, who was admitted with diagnoses including Degeneration of the Nervous System Due to Alcohol and anxiety, was involved in an altercation with Resident 2. The incident occurred in the smoking area when Resident 2 attempted to obtain cigarettes and a lighter from other residents. Resident 1 told Resident 2 to stop, which led to Resident 2 hitting Resident 1 in the head. Resident 1 denied hitting Resident 2. Resident 2, who was admitted with diagnoses including Antiphospholipid Syndrome and stroke, confirmed hitting Resident 1 but claimed Resident 1 hit him first. Licensed Nurse 1 witnessed the altercation and noted Resident 2's history of aggressive behavior. The Social Services Director and the Director of Nursing both confirmed the altercation and agreed it constituted abuse. The facility's policy on Elder/Dependent Adult Abuse, revised in July 2017, states that the facility will protect residents from all forms of abuse, which was not adhered to in this incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for two residents involved in a resident-to-resident altercation. The incident was documented on a facility report dated 6/8/24, but the report was not received by the Department until 6/9/24. During an interview, the Director of Nursing (DON) confirmed that the facility's policy mandates reporting such allegations within two hours, but this was not adhered to in this case. The facility's policy, revised in 7/17, clearly states that reports of physical abuse should be made within two hours to the Department. This delay in reporting had the potential to compromise resident health and safety.
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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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