Almaden Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 2065 Los Gatos-almaden Road, San Jose, California 95124
- CMS Provider Number
- 056058
- Inspections on file
- 34
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Almaden Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident admitted with intracranial injury, subarachnoid hemorrhage, epilepsy, and cerebral edema did not receive ordered doses of levetiracetam, phenytoin, and trazodone on the admission day. Orders for these medications were sent to the pharmacy too late for a routine delivery, and only phenytoin was requested as a STAT medication. Pharmacy records showed levetiracetam and trazodone arrived after the scheduled administration times, while STAT phenytoin was delivered earlier and received by an LVN but was still not given at the scheduled time. The MAR lacked documentation for the missed doses, and the LVN later stated the medications were not administered and that she did not know how to enter notes in the updated medication administration system, despite facility policy requiring timely and accurate oral medication administration.
The facility failed to maintain a safe environment, with a resident's toilet clogged for weeks and a broken call light in their room. Additionally, three shower rooms had broken tiles. The MD was aware but did not document maintenance checks, compromising resident safety.
The facility failed to post required oxygen signage for four residents using oxygen concentrators, as observed during a survey. Nursing staff confirmed the absence of 'Oxygen in Use' signs on the doors of these residents, and one resident's nasal cannula lacked proper labeling. The facility's policy mandates such signage, which was not followed.
The facility failed to maintain safe food storage and sanitation practices. Kitchen staff did not wear proper hair restraints, and expired food items were found, including spices and canned goods. Additionally, cutting boards with deep cut marks were not replaced, and wrinkled produce was stored improperly. These issues could lead to food contamination and illness.
The facility failed to follow infection control practices, including improper cleaning of a glucometer by an LVN, incorrect handling of soiled laundry by housekeeping staff, and improper storage of a resident's breathing treatment mask. These actions were against the facility's policies and could lead to cross-contamination.
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches and spiders. Roach and spider carcasses were found in the kitchen and storage areas, and a resident reported seeing live roaches in her room. The facility's Pest Control/Sightings Log confirmed roach presence, but there were no written logs of deep cleaning actions. Staff interviews revealed inconsistencies in pest control measures and deep cleaning processes.
A resident with severe cognitive impairment was observed in a hallway with part of their lower back exposed while being wheeled in a shower chair by a CNA. Despite being covered with a blanket, the resident's buttocks were partially visible, compromising their dignity. The DON confirmed the exposure and acknowledged the need for complete coverage, as per the facility's policy on resident dignity and privacy.
A resident with moderate cognitive impairment and a history of falls was unable to reach their call light, which was found on a roommate's bed. This oversight was contrary to the care plan and facility policy, potentially affecting the resident's ability to request assistance.
A resident in an LTC facility received metformin late and not with a meal as prescribed. The LVN administered the medication at 10:12 a.m., despite the physician's order to give it with meals at 8:00 a.m. and 6:00 p.m. The resident had breakfast between 7:00 a.m. and 7:30 a.m., and no snacks were provided before the medication. The DON expects adherence to physician orders and facility policy.
The facility was found to have improper garbage disposal practices, with a dumpster lid not fully closed and waste scattered on the ground in the garbage storage area. This was confirmed by the DM and ADM, who acknowledged the need for proper waste management to prevent pest attraction, as outlined in the facility's Pest Control policy.
The facility did not maintain a safe environment as a window screen in the kitchen was broken, creating a gap that could allow pests to enter. The Director of Maintenance confirmed the issue, acknowledging that the screen should have been repaired to prevent potential health risks. The facility's Pest Control policy requires intact screens on windows that open.
The facility failed to adhere to infection control practices, including improper glove use by an LVN and a housekeeper, and inadequate PPE by a CNA in a COVID-19 isolation room. The LVN wore gloves in the hallway, the housekeeper used the same gloves in multiple rooms, and the CNA used a surgical mask instead of an N95 mask.
The facility's pest control program was ineffective, leading to a cockroach infestation in residents' rooms. Despite multiple treatments, a resident reported seeing cockroaches in his room, prompting him to use a trap that caught several dead cockroaches. The maintenance director confirmed the presence of live cockroaches, and another resident's room was also reported to have cockroaches.
A resident was transported from her room to the shower room with inadequate privacy, as her back and buttocks were exposed while sitting on a shower chair. The CNA responsible acknowledged the oversight, and the DON confirmed that staff should ensure residents are fully covered during transport, as per facility policy.
Failure to Administer and Document Ordered Seizure and Sleep Medications
Penalty
Summary
The facility failed to provide ordered pharmaceutical services when one resident did not receive multiple scheduled medications on the day of admission. The resident was admitted late in the evening with diagnoses including unspecified intracranial injury, nontraumatic subarachnoid hemorrhage, epilepsy, and cerebral edema. Physician orders dated 11/29/2025 included levetiracetam 1000 mg by mouth twice daily at 9:00 a.m. and 8:00 p.m. for seizures, phenytoin 50 mg chewable tablets, 2 tablets by mouth three times a day, and trazodone 75 mg, 0.5 tablet by mouth at bedtime (9:00 p.m.) for insomnia related to depression. Review of the Medication Administration Record for 11/29/2025 showed the resident did not receive levetiracetam 1000 mg at 8:00 p.m., phenytoin 50 mg at 8:00 p.m., or trazodone 75 mg at 9:00 p.m., and there was no documentation explaining why these medications were not administered. Pharmacy records showed levetiracetam 1000 mg and trazodone 75 mg were delivered to the facility at 1:04 a.m. after the scheduled administration times, while a STAT order for phenytoin was delivered at 5:48 p.m. and received by LVN A. The Pharmacy Manager stated that the resident’s medication orders were received too late to meet the 1:00 p.m. delivery and were therefore scheduled for the 9:00 p.m. delivery, and that the facility could have requested all medications as STAT orders but only phenytoin was ordered STAT. The Nursing Supervisor, who admitted the resident and sent the medication orders to the pharmacy, stated he was aware of the 1:00 p.m. delivery time and assumed the medications would arrive by bedtime, so he ordered only phenytoin as STAT. The DON confirmed that LVN A did not administer the three night medications at their scheduled times and that phenytoin, which had been delivered at 5:48 p.m., should have been administered at 8:00 p.m. LVN A stated the resident had not received medications by bedtime and acknowledged that phenytoin, trazodone, and levetiracetam were not administered and that she did not document the reason, citing unfamiliarity with entering notes in the updated medication administration system. The facility’s policy on oral medication administration required medications to be administered in an accurate, safe, and timely manner.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe and functional environment, compromising the safety and well-being of its residents. In Resident 9's room, the toilet was clogged for weeks despite being reported to the staff, and a sign indicated it was out of order. Additionally, the bathroom call light in Resident 9's room was broken, which was confirmed by an LVN and reported to the maintenance staff. The Maintenance Director (MD) admitted to conducting daily rounds but failed to identify the broken call lights, and he did not document his daily maintenance checks. Furthermore, three out of four shower rooms in the facility had multiple broken tiles. The MD was aware of the issue and stated plans to replace the tiles. The facility's policy on physical plant interior maintenance emphasized the importance of maintaining the interior to ensure safety, including checking and repairing ceramic/vinyl flooring. However, these maintenance issues were not addressed in a timely manner, leading to a compromised living environment for the residents.
Failure to Post Oxygen Signage for Residents Using Oxygen Therapy
Penalty
Summary
The facility failed to provide proper oxygen care and treatment services for four residents who were using oxygen concentrators. Observations revealed that Residents 168, 60, 268, and 29 had oxygen concentrators at their bedsides, but there was no oxygen signage posted on their doors. This lack of signage was confirmed during interviews with Licensed Vocational Nurses and the Director of Nursing, who acknowledged that an 'Oxygen in Use' sign should be posted on the doors of residents receiving oxygen therapy. Additionally, Resident 268's nasal cannula was not labeled with the date and time, which was also confirmed by the nursing staff. Resident 29's medical record indicated a physician's order for oxygen support via nasal cannula at 2 liters as needed, yet there was no 'No Smoking' sign posted at the entrance or inside the room. The facility's policy on oxygen administration requires posting an oxygen precaution sign on the resident's door, which was not adhered to in these cases.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe food storage practices and sanitary conditions in the kitchen, as observed during a survey. Kitchen staff, including the Dietary Manager and a cook, did not wear proper hair restraints, which is against the facility's policy and the FDA Food Code 2022. Additionally, the facility stored wrinkled and soft green peppers and cucumbers, which the Dietary Manager claimed were still usable because they would be cooked. However, this contradicts the facility's policy on proper food storage to preserve food quality. Further deficiencies were noted with expired food items and equipment. Three spice containers and a vanilla extract bottle were found with expired dates, and the Administrator confirmed these should have been discarded. Three cutting boards had deep cut marks, making them difficult to clean and sanitize effectively, as per FDA guidelines. In the emergency food supply storage, several cans were dented, and one can of nacho cheese sauce was expired, which the Dietary Manager acknowledged should be discarded. These practices potentially risked food contamination and the spread of food-borne illnesses to residents.
Infection Control Deficiencies in Equipment Cleaning, Laundry Handling, and Equipment Storage
Penalty
Summary
The facility failed to implement proper infection control practices in three distinct areas. Firstly, a Licensed Vocational Nurse (LVN) used alcohol pads instead of the recommended disinfectant wipes to clean a shared glucometer after use on a resident. This was contrary to the manufacturer's instructions and the facility's in-service training, which specified the use of Clorox or Sani-cloths with a three-minute dwell time for effective disinfection. The Director of Nursing confirmed that alcohol pads were not advised for cleaning equipment as they do not effectively kill bacteria. Secondly, a housekeeping staff member was observed transporting a soiled curtain without placing it in a plastic bag or closed bin, which is against the facility's policy for handling dirty laundry. The curtain had visible stains, and the staff member acknowledged the mistake. Lastly, a breathing treatment mask belonging to a resident was found improperly stored on a bedside drawer instead of in a plastic bag, as required by the facility's policy to prevent contamination. The Infection Preventionist confirmed the correct procedure for storing such equipment.
Ineffective Pest Control Program Leads to Roach and Spider Presence
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches and spiders within the premises. During a kitchen tour, roach carcasses were found in traps near the ice machine and behind kitchen containers, while spider carcasses were found in a trap in the dry storage room. Interviews with staff revealed that sightings of live and dead roaches had been reported, but the pest control company did not consistently replace traps unless deemed necessary. The facility's Pest Control/Sightings Log confirmed the presence of roaches in the kitchen, and the FDA's Food Code mandates that premises be free of pests and that dead pests be removed to prevent accumulation. Additionally, a resident reported seeing live roaches in her room on two occasions, but only one sighting was documented in the facility's log. The Maintenance Director was unaware of any reports regarding pests in resident rooms, and there were no written logs of deep cleaning actions taken in response to pest sightings. The facility's policy required maintaining a written report of pest sightings and remedial actions, which was not followed. Interviews with staff indicated inconsistencies in the deep cleaning process, with some staff not fully emptying rooms as required by the facility's plan of correction.
Resident's Dignity Compromised Due to Inadequate Privacy Measures
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident 52, during care. Resident 52, who was admitted with diagnoses including muscle wasting, dementia, and a psychotic disorder, was observed sitting in a shower chair in the hallway with part of their lower back exposed. Despite being covered with a blanket, the right side of Resident 52's buttocks was visible to the public. This incident occurred while a Certified Nursing Assistant (CNA) was wheeling the resident, and the Director of Nursing (DON) was present in the hallway. The DON confirmed the observation and acknowledged that Resident 52's buttocks should have been fully covered to prevent exposure. The facility's policy on Resident Dignity and Personal Privacy emphasizes the importance of draping and dressing residents appropriately to avoid exposure and embarrassment, as well as maintaining privacy during personal hygiene activities. The failure to adhere to this policy compromised Resident 52's dignity.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to accommodate the care needs of a resident when the resident's call light was not within reach, which is essential for requesting assistance. The resident, who was admitted with diagnoses including Parkinsonism, vascular dementia, and rhabdomyolysis, had a moderate cognitive impairment as indicated by a BIMS score of 9. The resident's care plan, updated in January 2025, highlighted the risk of falls and specified that the call light should be within reach to ensure safety. During an observation, the resident was found sitting in a wheelchair and repeatedly verbalizing the inability to find the call light. A CNA later found the call light on the bed of the resident's roommate and attached it to the resident's bed. The Director of Nursing confirmed that call lights should be within residents' reach, as per the facility's policy. This oversight had the potential to affect the resident's ability to request prompt assistance.
Medication Administration Not in Accordance with Physician's Order
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice when a Licensed Vocational Nurse (LVN) did not administer medication according to the physician's order for a resident. During a medication administration observation, the LVN prepared and administered seven medications to the resident, including metformin, which was supposed to be given with meals twice a day at 8:00 a.m. and 6:00 p.m. However, the metformin was administered late at 10:12 a.m., without being given with a meal or snack, as the resident had breakfast between 7:00 a.m. and 7:30 a.m. The LVN acknowledged that metformin should be given with meals or at least thirty minutes after eating, and confirmed that no snacks were offered to the resident before administering the medication. The Director of Nurses (DON) stated that it is expected for all nurses to administer medications according to physician orders and facility policy. The facility's policy on oral medication administration also indicated that medications should be administered with food according to the physician's order or manufacturer's specification.
Improper Garbage Disposal and Sanitation Issues
Penalty
Summary
The facility failed to maintain a sanitary environment as evidenced by observations during a facility tour. A dumpster used for garbage disposal was found with a broken lid that was not fully closed. Additionally, leftover foods, including cooked rice and food scraps, along with two empty food boxes, a green plastic bottle, and several cardboards and papers, were observed on the ground in the facility's garbage storage area. These conditions were confirmed by the Director of Maintenance, who acknowledged that the garbage lid should be fully closed and all waste should be placed inside the garbage bin to prevent attracting rodents and pests. The Administrator also confirmed during an interview that the dumpster lid should be fully closed and waste should be properly disposed of to prevent pest and rodent attraction. The facility's undated policy and procedures on Pest Control indicated the need to keep facility grounds free of trash and brush and to maintain a clean dumpster area with the lid closed.
Broken Window Screen in Kitchen
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring the integrity of a window screen in the kitchen area. During an observation with the Director of Maintenance, it was noted that the screen mesh covering the window leading to the kitchen sink was broken at the bottom, creating a small gap. This gap had the potential to allow rodents and pests to enter the kitchen, posing a risk to residents' health and safety. The Director of Maintenance confirmed the observation and acknowledged that the window screen should have been kept in good repair to prevent such issues. The facility's undated Pest Control policy indicated that screens on windows that open should be maintained intact.
Infection Control Lapses in PPE and Glove Use
Penalty
Summary
The facility failed to implement proper infection control practices in three observed instances. First, a Licensed Vocational Nurse (LVN B) was seen walking in the hallway with gloves on, which she acknowledged was against protocol. The Director of Nursing (DON) confirmed that staff should not wear gloves in the hallway. Second, a housekeeper (HKP C) was observed using the same gloves to clean two different resident rooms, Room AA and Room BB, without changing them in between. HKP C admitted to this oversight, and the DON reiterated that gloves should be changed after cleaning one room and before moving to another. Third, a Certified Nursing Assistant (CNA D) entered a COVID-19 isolation room to feed a resident while wearing a surgical mask instead of the required N95 mask. CNA D acknowledged the mistake, and the DON confirmed that an N95 mask should be worn when entering a COVID-19 isolation room. The facility's policies on standard precautions and the use of personal protective equipment (PPE) were reviewed, highlighting the need for proper glove use and the requirement of an N95 respirator in such situations.
Ineffective Pest Control Leads to Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in residents' rooms. Resident 4's room was inspected and treated for cockroaches and rodents on multiple occasions, including on 5/31/24, 6/12/24, and 7/2/24. Despite these treatments, Resident 4 reported seeing many cockroaches in his room, including on his bed side rails and under his bed. He resorted to placing a cockroach trap in his room, which caught five dead cockroaches, and observed five live cockroaches crawling out from under a basket. The maintenance director confirmed the presence of both dead and live cockroaches in Resident 4's room. Additionally, a registered nurse reported cockroaches in Resident 5's room after a CNA and the resident observed them. The maintenance director reviewed the maintenance work requests for both Resident 4's and Resident 5's rooms and acknowledged that the facility's pest control measures were ineffective. This ongoing issue of cockroach infestation, despite repeated treatments, indicates a significant deficiency in the facility's pest control program.
Resident Privacy Not Maintained During Transport
Penalty
Summary
The facility failed to treat a resident with respect and dignity when a certified nursing assistant (CNA) did not provide adequate privacy during transportation from the resident's room to the shower room. During an observation, the resident was seen sitting on a shower chair with only the front of her body covered by a linen sheet, leaving her back and buttocks exposed. This lack of coverage occurred as the resident was being transported through the hallway. In a concurrent interview, the CNA acknowledged the oversight, admitting that she missed covering the back of the resident's body and should have ensured the resident was fully covered before moving her. The director of nursing (DON) confirmed that staff are expected to cover residents' bodies to maintain privacy during such transport, as outlined in the facility's policy on tub baths and showers.
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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