Arrowhead Healthcare Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in San Bernardino, California.
- Location
- 4343 N Sierra Way, San Bernardino, California 92407
- CMS Provider Number
- 555896
- Inspections on file
- 23
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arrowhead Healthcare Center, Llc during CMS and state inspections, most recent first.
The facility did not have an RN onsite for at least eight hours on three separate days, leaving 58 residents without required RN oversight. The DON, the only full-time RN, was absent due to illness, and the part-time RN was not scheduled to cover the gaps, resulting in noncompliance with staffing regulations.
The facility failed to maintain an effective infection prevention and control program. The infection control policies were not reviewed annually, and staff did not follow disinfectant guidelines, risking the spread of infections. Additionally, housekeeping staff did not adhere to Enhanced Standard Precautions, failing to wear required PPE when cleaning designated rooms.
The facility failed to accurately code the RAI-MDS for four residents, leading to potential unmet care needs and inaccurate clinical records. Errors included incorrect documentation of hearing loss and hearing aid use, PASRR status, insulin administration, and the presence of an indwelling urinary catheter. The MDS nurse acknowledged these errors, and it was noted that the facility lacked a specific policy for RAI-MDS assessments.
The facility failed to maintain food safety standards, as the walk-in refrigerator and freezer temperatures were not monitored, a kitchen staff member worked without a hair net, and shelves in the refrigerator were dirty. These issues could lead to foodborne illness among the 49 residents served by the kitchen.
A cockroach was observed in the kitchen behind the steam table, indicating a failure in the facility's pest control program. The Dietary Supervisor acknowledged the non-compliance with the State Operations Manual, and the Infection Preventionist noted the infection control risks posed by cockroaches. The facility's pest control policy required reporting and action, but the recent Service Inspection Report lacked detailed documentation.
A facility failed to discuss and document advance directives for a resident, as evidenced by an incomplete POLST form and lack of an Advance Directive Acknowledgement form. Interviews with the DON, RNS, and SSD confirmed the absence of required documentation, contrary to facility policy.
Two residents were not provided with necessary beneficiary liability notifications, including estimated costs on the SNF ABN and timely NOMNC forms. The BOM acknowledged the errors, which left the residents uninformed about their financial responsibilities and rights to appeal.
A facility failed to provide written notification to a resident's representative about a transfer to the hospital. The resident, diagnosed with schizophrenia and metabolic encephalopathy, was transferred due to vomiting dark liquid. The representative was informed verbally, but no written notice was given, violating regulatory requirements.
A resident with existing pressure ulcers did not receive appropriate care as specified in their care plan and physician's orders. The resident's low air loss mattress was set to an incorrect pressure, and heel protectors were not applied while in bed. Additionally, the resident's weekly nursing summary inaccurately reported intact skin, failing to acknowledge a deep tissue injury. These deficiencies were confirmed by the DON, highlighting a failure to adhere to the facility's care planning and assessment protocols.
A resident at high risk for falls was found without a fall mat next to her bed, contrary to her care plan. Despite the facility's policy on fall prevention, staff were unaware of the missing mat, and the Director of Nursing confirmed it should have been in place to minimize injury risk.
The facility failed to provide adequate room size for residents in five rooms, each housing four residents, with measurements showing less than the required 80 square feet per resident. This deficiency was confirmed by the Maintenance Supervisor and Administrator, who acknowledged the potential risks of accidents and delays in emergency evacuations due to limited space for wheelchairs and Hoyer lifts. The facility also lacked a policy on minimum room size requirements.
The facility did not post daily staffing information in an area accessible to residents, affecting all 55 residents. The information was placed near the main entrance, which was inaccessible due to a locked door and restricted access behind the nurses' station. The DSD and DON confirmed the oversight, which contradicted the facility's policy requiring visibility to residents and visitors.
The facility failed to provide residents with easy access to the most recent survey results, as the binder was placed in a locked lobby area. This restricted access was confirmed by nursing staff and acknowledged by the Administrator, violating the facility's policy on residents' rights.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present onsite for at least eight hours a day, seven days a week, as required by regulation. Specifically, there was no RN coverage on three separate days within the review period. On April 10, 2025, it was observed that no RN was on duty, and the Administrator confirmed that the Director of Nursing (DON), who is the only full-time RN, was absent due to illness. The only other RN on staff was part-time and only scheduled for two days per week, leaving gaps in RN coverage. A review of timecards and interviews with the Administrator confirmed that there was no RN present on March 19, March 27, and April 10, 2025. The facility's own policy requires an RN to be present for eight hours each day to meet resident needs and regulatory requirements. The census at the time was 58 residents, and the absence of RN coverage on these days constituted a failure to comply with both facility policy and regulatory standards.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by several deficiencies. Firstly, the facility did not conduct an annual review of its infection control program's policies and procedures, which were last revised in June 2021. This oversight was confirmed during an interview with the Administrator, who acknowledged that the policies should be reviewed and updated at least annually. The lack of an updated review had the potential to leave the facility out-of-date with current best practices and overlook potential gaps in their procedures. Additionally, the facility's laundry and housekeeping staff did not adhere to the manufacturer's guidelines for the disinfectants used. During an observation, a laundry staff member described using a multi-use cleaner instead of the recommended disinfectant for cleaning laundry barrels, and did not allow the disinfectant to remain wet for the required 10 minutes on laundry baskets. Similarly, housekeeping staff did not follow the guidelines for disinfecting resident rooms, failing to keep surfaces wet for the necessary time and using a multi-use cleaner on floors instead of the disinfectant. These actions were contrary to the instructions provided by the Infection Preventionist and had the potential to cause the development and transmission of communicable diseases and infections. Furthermore, housekeeping staff did not follow Enhanced Standard Precautions (ESP) when cleaning designated rooms. During an observation, a housekeeping staff member was found cleaning an ESP room without wearing a gown, which is a required form of Personal Protective Equipment (PPE) for such tasks. The staff member admitted to forgetting to wear the gown, and the Housekeeping Supervisor confirmed the oversight. This failure had the potential to cause the transmission of multidrug-resistant organisms (MDROs) to the staff member's clothing and subsequently to other residents.
Inaccurate RAI-MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS) for four residents, leading to potential unmet care needs and inaccurate clinical records. Resident 25's assessment incorrectly indicated minimal hearing loss and no hearing aid, despite the resident's communication difficulties and the presence of hearing aids stored in the Social Services Director's office. The MDS nurse acknowledged the error, noting the resident's hearing had worsened and the assessment needed correction. Resident 27's assessment inaccurately reflected the resident's Pre-Admission Screening and Resident Review (PASRR) status, marking them as not requiring a Level 2 PASRR, despite documentation indicating a Level 2 evaluation had been conducted. The MDS nurse admitted to the mistake, which contradicted the PASRR Determination Report that should have been incorporated into the resident's care plan. Resident 32's assessment erroneously recorded insulin administration, which was not supported by the Medication Administration Record. The MDS nurse confirmed the error upon review. Similarly, Resident 56's assessment incorrectly noted the presence of an indwelling urinary catheter, which had been removed months prior. The MDS nurse acknowledged the mistake, and it was revealed that the facility lacked a specific policy and procedure for completing RAI-MDS assessments, relying instead on the RAI-MDS assessment manual.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed during a survey. Firstly, the walk-in refrigerator and freezer temperatures were not being monitored daily, as there was no thermometer present, and the logs for temperature checks were missing. This lack of monitoring could lead to food being stored at unsafe temperatures, increasing the risk of bacterial growth. The Dietary Supervisor acknowledged the absence of these critical items and the importance of maintaining temperature records. Additionally, a kitchen staff member was observed working without a hair net, which is a violation of the Federal FDA 2017 Food Code that requires food employees to wear hair restraints to prevent contamination. The Dietary Supervisor admitted to forgetting to wear a hair net. Furthermore, the walk-in refrigerator had shelves with black residue, indicating a lack of cleanliness. The Dietary Supervisor confirmed the need for cleaning. These deficiencies posed a potential risk for foodborne illness among the 49 residents who consumed food from the kitchen.
Cockroach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as evidenced by the observation of a cockroach on the wall behind the steam table. This incident was noted during an observation and interview with the Dietary Supervisor, who acknowledged that there should not be any bugs or cockroaches in the kitchen. The presence of the cockroach was a direct violation of the State Operations Manual S483.90(i)(4), which mandates an effective pest control program to ensure the facility is free of pests and rodents. The Dietary Supervisor admitted that the facility was out of compliance due to this issue. Further interviews and record reviews revealed that the facility's policy and procedure for pest control required staff to report any pest sightings to the food services manager, who would then take appropriate action. However, the Service Inspection Report from December 12, 2024, only indicated pest control maintenance without any detailed comments or explanations of actions taken. The Infection Preventionist expressed concern about the potential for cockroaches to spread disease, highlighting the infection control risks associated with the presence of pests in the kitchen.
Failure to Discuss and Document Advance Directives
Penalty
Summary
The facility failed to provide evidence that staff discussed with Resident 32 whether the resident had an existing advance directive and did not educate the resident on their rights to establish a new advance directive if desired. During an interview and record review, the Director of Nursing (DON) was unable to provide evidence of an advance directive for Resident 32, only presenting a Physician Orders for Life-Sustaining Treatment (POLST) form signed by the resident in 2020. The POLST form had a section regarding advance directives that was left unanswered, indicating a lack of documentation on whether Resident 32 had an advance directive in place. Further interviews with the Registered Nurse Supervisor (RNS 1) and the Social Services Director (SSD) confirmed that the section on the POLST regarding advance directives was incomplete and that there was no Advance Directive Acknowledgement form in Resident 32's clinical record. The facility's policy required that residents be provided with information about their rights to accept or refuse medical treatment and to formulate an advance directive, but there was no evidence that this was done for Resident 32. The responsibility for completing these forms was attributed to the social worker, but the necessary documentation was not found in the resident's records.
Failure to Provide Beneficiary Liability Notifications
Penalty
Summary
The facility failed to provide two residents with the necessary beneficiary liability protection notifications, which are crucial for informing residents about their financial responsibilities and rights to appeal. Resident 17 was not given an estimated cost on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), which is meant to inform residents about potential non-coverage and the option to continue services with the resident accepting financial liability. The Business Office Manager (BOM) acknowledged that the SNF ABN form for Resident 17 incorrectly indicated 'NA' for the estimated cost, instead of the actual daily room rate of $325. Similarly, Resident 28 was not provided with an estimated cost on their SNF ABN, and the Notice of Medicare Non-Coverage (NOMNC) was not given at least two days before the end of their Medicare-covered Part A stay. The BOM confirmed that the SNF ABN form for Resident 28 also showed 'NA' for the estimated cost, and the NOMNC form was not provided in a timely manner. The BOM admitted that the NOMNC should have been given three days in advance, but it was not, and there was a different business office manager at the time. The facility's policy and procedure titled 'Medicare Termination Notification' requires that residents be notified no later than two days prior to the last day of coverage. This policy was not followed for Resident 28, as the NOMNC was not provided within the required timeframe. The failure to provide these notifications had the potential to leave Residents 17 and 28 uninformed about their financial liabilities and their rights to appeal.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to a resident's representative regarding the transfer of the resident to a hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff and the resident's representative. The resident, who has a diagnosis of schizophrenia and metabolic encephalopathy, was transferred to the hospital due to vomiting dark liquid. The resident's representative was informed of the transfer via a phone call, but no written notice was provided as required by regulations. During the investigation, it was confirmed that the facility's notice of proposed transfer/discharge was communicated verbally to the resident's representative, but not in writing. The State Operations Manual S483.15(c)(3) mandates that such notifications be provided in writing and in a language and manner understandable to the resident and their representative. The Social Services Director acknowledged that the written notice was not provided, which is a violation of the regulatory requirements.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, identified as Resident 51, who was at risk for skin breakdown due to existing pressure ulcers and deep tissue injuries. The resident's care plan and physician's orders specified the use of a low air loss mattress set to a specific pressure range and the application of heel protectors while in bed. However, during an observation, it was noted that the resident's mattress was set to an incorrect pressure of 80 mmHg, significantly lower than the prescribed range of 155-165 mmHg. Additionally, the resident was not wearing heel protectors, contrary to the care plan requirements. The deficiency was further compounded by inaccurate documentation in the resident's Electronic Medical Record (EHR). A nursing weekly summary inaccurately reported that the resident's skin was intact, failing to acknowledge the existing deep tissue injury to the heel. This incorrect documentation was confirmed by the Director of Nursing (DON), who acknowledged that the nurse responsible for the assessment did not accurately identify the resident's skin condition. The facility's policy and procedure for resident assessment and care planning emphasized the importance of comprehensive, person-centered care plans and accurate weekly assessments to detect changes in condition and identify new or altered resident needs. However, the failure to adhere to these protocols resulted in the potential for worsening pressure ulcers and delayed identification and treatment of new pressure ulcers for Resident 51.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure that a fall mat was placed next to the bed of a resident, as specified in the resident's care plan. This deficiency was identified during an observation where the resident, who was nonverbal and had a history of falls, was found without a fall mat next to her bed. The resident's care plan, which was designed to prevent falls and minimize injury, clearly indicated the need for a fall mat due to the resident's high risk for falls related to conditions such as dementia, legal blindness, and balance problems. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed a lack of awareness and understanding of why the fall mat was not in place. The facility's policy on fall prevention emphasized the importance of assessing residents for fall risks and implementing appropriate measures, yet this was not adhered to in the case of the resident. The absence of the fall mat was acknowledged by the Director of Nursing, who confirmed that it was supposed to be part of the resident's fall prevention strategy.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to ensure that five rooms, each occupied by four residents, met the minimum required square footage per resident. The rooms in question were Rooms 102, 105, 106, 107, and 112, which were observed to have less than the required 80 square feet per resident. Measurements taken by the Maintenance Supervisor and verified by the surveyor showed that the rooms ranged from approximately 71.35 to 75.4 square feet per resident after accounting for the space occupied by moveable wardrobe cabinets. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the rooms did not meet the required space standards. The deficiency was identified through observations, interviews, and record reviews conducted by the surveyors. During the survey, it was noted that the limited space in these rooms posed potential risks, including increased chances of accidents and injuries due to restricted space for wheelchairs and Hoyer lifts, limited room for resident care activities, and potential delays in emergency evacuations. The Administrator agreed that the inadequate room sizes could lead to negative outcomes such as falls and accidents. Additionally, the facility lacked a policy and procedure regarding the minimum required square footage for resident rooms. A review of the facility's document indicated that out of the 20 residents housed in the affected rooms, 10 required the use of a Hoyer lift, nine used wheelchairs, and seven used Geri chairs. This further highlighted the inadequacy of the room sizes in accommodating the needs of residents with mobility aids.
Failure to Post Staffing Information in Resident-Accessible Area
Penalty
Summary
The facility failed to ensure that daily staffing information was posted in an area accessible to residents, affecting all 55 residents. On December 17, 2024, it was observed that the staffing information, including Direct Care Service Hours Per Patient Day (DHPPD), was posted near the facility's main entrance. However, this area was not accessible to residents as it required passing through a locked door or going behind the nurses' station, both of which were restricted to residents. During interviews, the Director of Staff Development (DSD) confirmed that he was responsible for posting the DHPPD information and acknowledged that it was only posted at the front entrance, which residents could not access. The Director of Nursing (DON) also stated that the DHPPD information should be posted in an area accessible to both residents and visitors. The facility's policy and procedure indicated that the information should be posted on a bulletin board in a conspicuous place visible to residents and visitors, which was not adhered to in this instance.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to post the results of its most recent survey in a location that was readily accessible to residents. The survey results were placed in a binder on a front lobby wall, but access to this area was restricted due to a locked door between the residents' living area and the lobby. This door was kept locked to prevent residents from leaving the building unmonitored, as confirmed by a Registered Nurse Supervisor and a Licensed Vocational Nurse during an observation and interview. The facility's Administrator acknowledged that the residents did not have free access to the survey results binder, which was contrary to the facility's policy on residents' rights. The policy, dated January 2019, stated that residents have the right to examine the results of the most recent survey conducted by Federal or State surveyors. This deficiency was identified during an observation, interview, and record review, affecting all 55 residents in the facility.
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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