Beachside Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 22520 Maple Avenue, Torrance, California 90505
- CMS Provider Number
- 055531
- Inspections on file
- 49
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Beachside Post Acute during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, and limited mobility sustained an acute distal femur fracture of unknown cause. The facility became aware of the injury through X-ray results but did not report the unusual occurrence to CDPH within the required 24-hour timeframe, as confirmed by staff interviews and record review. This delay was not in accordance with facility policy for reporting injuries of unknown origin.
The facility's kitchen staff, including a dietary supervisor assistant and a dietary aide, failed to follow proper food thawing procedures, leading to a deficiency. A box of chicken was improperly thawed and refrozen, contrary to facility policy and FDA guidelines. This placed 99 out of 106 residents at risk for foodborne illness due to potential bacterial growth.
The facility failed to maintain sanitary food storage and handling practices, risking foodborne illnesses for residents. Observations included expired cottage cheese, incomplete temperature logs, and improper thawing and refreezing of food. Additionally, the ice machine was inadequately cleaned, with no cleaning log maintained, increasing the risk of contamination.
A facility failed to maintain accurate and complete clinical documentation for two residents. One resident's records inaccurately documented IV access and fluids, despite observations confirming the absence of IV access. Another resident's records were incomplete regarding Restorative Nursing Aide services, with a missing RNA flow sheet. These deficiencies highlight a failure to adhere to documentation standards, potentially impacting resident care.
The facility failed to implement proper infection control measures, as evidenced by improper PPE use and maintenance of equipment. A resident on Enhanced Barrier Precautions (EBP) had a visitor not wearing PPE, and staff did not follow proper PPE protocols, increasing the risk of infection spread. Additionally, padded side rails on beds were inadequately maintained, with cracked duct tape exposing foam, compromising disinfection efforts.
A resident with a history of amputation, muscle weakness, and dependence on supplemental oxygen was found in a state of anxiety and hyperventilation due to difficulty breathing. The call light was out of reach, preventing the resident from calling for help as her oxygen supply was running low. Facility staff confirmed that the call light should have been within reach, as per the facility's policy and the resident's care plan.
A facility failed to monitor a resident's range of motion (ROM) in both legs by not performing an annual Joint Mobility Screen (JMS) as per policy, potentially leaving the resident without proper monitoring for 21 months. The resident had impaired ROM in hips, knees, and ankles, and the PT discharge recommended PROM exercises. However, the JMS did not assess the legs, leading to a gap in monitoring. Interviews confirmed the JMS was meant to track ROM decline and prevent complications, but the facility did not adhere to its policy.
A resident in hospice care with dementia and other conditions lost their dentures, and the facility failed to provide prompt dental services or adjust the diet to ensure adequate nutrition. Despite significant weight loss and poor oral intake, the resident's diet remained unchanged, and there was a lack of communication among staff regarding the resident's needs. The facility's policy for prompt dental referral was not effectively implemented.
A resident in hospice care with dementia and other conditions was not provided with her preferred puree diet, despite her inability to consume solid foods. The facility's staff, including CNAs and an LVN, were aware of her preference but failed to communicate this to the RD or update her care plan. The DON was also unaware of the resident's needs, which led to inadequate dietary accommodations.
A resident with dementia and osteoporosis sustained a femur fracture of unknown origin, which was not reported to the CDPH as required by facility policy. The DON did not report the injury, believing it was unavoidable due to the resident's condition. The Administrator later acknowledged the reporting failure, which hindered timely investigation by CDPH.
A resident with dementia and osteoporosis sustained a femur fracture of unknown origin, which was not investigated by the facility. Despite the resident's physician attributing the fracture to osteoporosis, the facility's policy required an investigation for injuries of unknown origin. The administrator acknowledged the need for an investigation to determine the root cause.
Failure to Timely Report Unexplained Fracture to State Agency
Penalty
Summary
The facility failed to follow its abuse prevention and unusual occurrence reporting policies when it did not report an acute, new distal femur fracture of unknown cause for a resident to the State Survey Agency (CDPH) within 24 hours of becoming aware of the incident. The resident, who had diagnoses including age-related osteoporosis, dementia, and right knee contracture, was dependent on assistance for activities of daily living and lacked capacity to make decisions. The fracture was identified via X-ray, and the results were reported to the facility on 5/4/2025. However, the facility did not notify CDPH of the unusual occurrence until 5/7/2025, exceeding the required 24-hour reporting timeframe. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the delay in reporting was not in accordance with facility policy, which requires reporting of such incidents within 24 hours. Review of the facility's policies further supported that all unusual occurrences and injuries of unknown origin must be reported promptly to appropriate authorities. The failure to report the incident in a timely manner was acknowledged by staff and documented in the facility's records.
Improper Thawing Practices in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff, including the dietary supervisor assistant (DSA) and dietary aide (DA 1), were competent in following the facility's food thawing policies. During an observation, a box of frozen chicken was found sitting by the food preparation sink, appearing partially thawed with wet cardboard from thawing juices. The DSA instructed DA 1 to place the chicken back into the main freezer, which was against the facility's policy. Later, the DSA instructed staff to remove the chicken from the freezer and place it back in the sink for thawing, initially without running water, which was also against the policy. The dietary supervisor (DS) later intervened, stating that refreezing chicken was not allowed. Interviews with DA 1 and the DSA revealed a lack of understanding of proper thawing procedures, as DA 1 followed the DSA's incorrect instructions despite knowing they were wrong. The facility's policies indicated that food should not be thawed at room temperature and should be submerged in cold running water. The U.S. Food and Drug Administration food code was also referenced, highlighting the risks of improper thawing, which can lead to bacterial growth and foodborne illness. This deficiency placed 99 out of 106 residents at risk for developing foodborne illnesses.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store food in a sanitary manner, which could lead to the growth of microorganisms and potential foodborne illnesses for 99 out of 106 residents. Observations revealed that cottage cheese in the reach-in refrigerator was past its use-by date, and the temperature log for the walk-in refrigerator was not consistently filled out. Additionally, improper food handling practices were noted, such as thawed frozen waffles being returned to the freezer and raw chicken being improperly thawed and refrozen. The dietary staff did not adhere to proper thawing techniques, as evidenced by chicken being left to thaw in a sink without running water. The dietary supervisor assistant instructed staff to refreeze partially thawed chicken, which was against facility procedures. The dietary supervisor later confirmed that thawed items should not be refrozen and should be placed in the refrigerator to continue thawing. These practices increased the risk of bacterial growth and potential food contamination. The facility's ice machine was also found to be inadequately maintained, with dust and a black substance observed in the upper portion. The maintenance supervisor admitted to cleaning the ice machine every six months but did not keep a cleaning log. The infection preventionist nurse highlighted the potential risk of illness due to the unclean ice machine. The facility's policies and procedures, as well as the U.S. Food and Drug Administration food code, were not followed, contributing to the deficiencies observed.
Inaccurate and Incomplete Clinical Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for two residents, leading to deficiencies in their care records. For one resident, the documentation related to intravenous (IV) access and fluids was inaccurate. The resident was admitted with severe cognitive impairment and conditions such as seizures and acute kidney failure. Despite physician orders indicating the completion of IV fluids on a specific date, subsequent notes inaccurately documented the resident as still receiving IV fluids. Observations confirmed the absence of IV access, and interviews with nursing staff revealed the documentation errors, highlighting the importance of accurate records to prevent infection risks and ensure proper hydration assessment. Another resident with limited range of motion and mobility issues had incomplete clinical records regarding the provision of Restorative Nursing Aide (RNA) services. The resident, diagnosed with dementia and functional quadriplegia, required passive range of motion exercises and the application of splints as per physician orders. However, the RNA flow sheet for a specific month was missing from the resident's clinical record. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed the absence of the flow sheet, indicating incomplete records for the resident's RNA services. The facility's policy and procedure on charting and documentation emphasized the need for complete and accurate medical records for all services provided to residents. The deficiencies in documentation for both residents reflect a failure to adhere to these standards, resulting in incomplete and inaccurate clinical records. This lack of proper documentation could potentially impact the quality of care provided to the residents.
Infection Control Deficiencies in PPE Use and Equipment Maintenance
Penalty
Summary
The facility failed to implement proper infection control measures, as evidenced by several observations and interviews. In the case of Resident 260, who was on Enhanced Barrier Precautions (EBP) due to a gastrostomy and an unstageable pressure ulcer, a visitor was observed not wearing the required Personal Protective Equipment (PPE) while interacting with the resident. Licensed Vocational Nurses (LVN) 2 and 3, who attended to Resident 260, did not instruct the visitor to wear PPE and were observed doffing their PPE incorrectly, potentially leading to self-contamination. The facility's policy and CDC guidelines were not followed, as gloves were not removed first, which is crucial to prevent the spread of infection. In another instance, Resident 8, who was also on EBP due to a gastrostomy and stage 3 pressure ulcer, received care from LVN 1, LVN 4, and CNA 1, none of whom wore the appropriate PPE. LVN 1 and CNA 1 entered the room and provided care without donning any PPE, while LVN 4 only wore gloves. This lack of adherence to PPE protocols during high-contact care activities increased the risk of cross-contamination and infection spread among residents and staff. Additionally, the facility failed to maintain the integrity of padded side rails on the beds of four residents, which were covered with duct tape that was cracked and peeling, exposing the foam underneath. This compromised the ability to properly disinfect the side rails, as the foam is a porous material that cannot be sanitized effectively. The maintenance supervisor acknowledged the issue, stating that the duct tape was used as a temporary measure, but it was not recommended by the bed manufacturer. The housekeeping supervisor confirmed that the exposed foam posed a risk for bacterial growth, as the disinfectant used was only effective on hard, non-porous surfaces.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for Resident 8, which had the potential to prevent the resident from receiving necessary care and services in a timely manner. Resident 8, who had a history of left leg above knee amputation, muscle weakness, dependence on supplemental oxygen, and a stage 3 pressure ulcer, was observed sitting in a wheelchair and experiencing hyperventilation and anxiety due to difficulty breathing. The call light was clipped on the left side of the bed, out of reach for Resident 8, who expressed fear and helplessness due to her inability to call for help as her oxygen supply was running low. Interviews with facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, confirmed that the call light should have been within reach at all times to accommodate residents' needs promptly. The facility's policy and procedure on answering call lights also indicated that the call light should be within easy reach of residents. Resident 8's care plan, which highlighted her risk for falls and impaired balance, also specified that the call light should be kept within easy reach, yet this was not adhered to, leading to the deficiency.
Failure to Monitor Resident's Range of Motion
Penalty
Summary
The facility failed to monitor the range of motion (ROM) in both legs of a resident with limited mobility, as they did not perform an annual Joint Mobility Screen (JMS) on the specified date in accordance with their policy. This oversight potentially left the resident without proper monitoring for 21 months, from the discharge from Physical Therapy (PT) to the next scheduled JMS. The resident, who was initially admitted in 2019 and readmitted in 2023, had diagnoses including dementia, functional quadriplegia, and contractures in multiple joints. The resident's PT evaluation in July 2023 indicated impaired ROM in both hips, knees, and ankles, with specific limitations noted in hip flexion, knee flexion, and ankle dorsiflexion and plantarflexion. The PT discharge summary recommended passive range of motion (PROM) exercises for both legs, except the right knee, to be performed by a Restorative Nursing Aide (RNA) five times per week. However, the annual JMS conducted in April 2024 did not assess the ROM in the resident's legs, leaving a gap in monitoring. Interviews with the Director of Rehabilitation (DOR) and the Director of Nursing (DON) confirmed that the JMS was intended to track ROM decline and prevent complications such as contractures and pressure injuries. The facility's policy required annual JMS for each resident, but the resident's legs were not assessed since the PT discharge, leading to a prolonged period without evaluation. The facility's policy and procedure indicated that residents with limited ROM should receive appropriate services to maintain or improve mobility, which was not adhered to in this case.
Failure to Provide Prompt Dental Services and Adequate Nutrition
Penalty
Summary
The facility failed to provide prompt dental services for a resident after the loss of dentures on 9/10/24. The resident, who was admitted under hospice care with multiple diagnoses including dementia and heart failure, was dependent on assistance for daily activities and had a mechanical soft diet ordered. Despite the loss of dentures, there was no dental consult ordered immediately, and the resident did not receive a dental evaluation until 9/25/24. During this period, the resident was unable to eat the mechanical soft diet adequately, leading to poor oral intake and significant weight loss. The facility's records indicate that the resident was referred to a dentist on 9/11/24, but the dental progress notes show that no treatment was indicated due to the resident's medical condition. The resident's diet remained unchanged despite the inability to chew properly, and there was no documentation of any interventions to ensure adequate nutrition. The interdisciplinary team discussed the resident's condition on 10/16/24, noting the weight loss, but did not adjust the diet consistency. Interviews with staff revealed a lack of communication and coordination regarding the resident's dietary needs and dental status. The Registered Dietitian was not informed of the denture loss and thus did not adjust the diet to a puree consistency, which could have been more suitable given the resident's inability to chew. The Director of Nursing was aware of the denture loss but did not initiate a change in diet consistency. The facility's policy required prompt referral to a dentist for lost dentures, but this was not effectively implemented, resulting in a delay in addressing the resident's nutritional needs.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident received food according to her preferences, which led to a deficiency in care. The resident, who was admitted under hospice care with multiple diagnoses including dementia and heart failure, was on a mechanical soft diet. However, it was observed that she preferred puree food, as she had no teeth and struggled with solid foods. Despite this preference, there was no discussion or action taken to change her diet to accommodate her needs. During observations and interviews, it was noted that the resident ate very little of her meals, consuming only about 25% of her food intake. The Certified Nursing Assistant (CNA) and Licensed Vocational Nurse (LVN) both acknowledged the resident's preference for puree food, yet this information was not communicated to the Registered Dietitian (RD) or reflected in the resident's care plan. The RD stated that if they had been informed of the resident's chewing difficulties, they would have downgraded the diet to a puree consistency to prevent the risk of weight loss. The Director of Nursing (DON) was unaware of the resident's dietary preferences and stated that a Speech Language Pathologist (SLP) would have been consulted to evaluate the resident if this information had been known. The facility's policy on resident food preferences requires staff to document dietary preferences and communicate any conflicts with therapeutic diets, but this was not adhered to in the case of this resident.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the California Department of Public Health (CDPH) for a resident who sustained a moderately displaced fracture of the distal diaphysis of the femur. The resident, who was admitted with diagnoses including encephalopathy, dementia, and generalized weakness, was unable to make consistent and reasonable decisions. On a specific date, the resident was noted to be groaning and screaming during assistance with lower body dressing, and swelling was observed in the right knee. A stat X-ray revealed a moderately displaced fracture, and the resident was subsequently transferred to a General Acute Care Hospital for evaluation and treatment. The Director of Nursing Services (DON) did not report the injury to CDPH, citing the physician's documentation that the fracture was unavoidable due to the resident's osteoporosis. However, the facility's policy requires that any injury of unknown source be reported immediately to the Administrator and state officials. The Administrator acknowledged that the facility should have reported the injury to CDPH. This oversight resulted in the inability of CDPH to investigate the injury in a timely manner, potentially leading to the loss of relevant facts related to the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who sustained a moderately displaced fracture of the distal diaphysis of the femur. The resident, who was admitted with diagnoses including encephalopathy, dementia, and generalized weakness, was unable to make consistent and reasonable decisions. On a specific date, the resident was noted to be groaning and screaming during assistance with lower body dressing, and swelling was observed in the right knee. A stat X-ray revealed the fracture, and the resident was subsequently transferred to a general acute care hospital for evaluation and treatment. The Director of Nursing Services did not investigate the injury, citing the resident's osteoporosis as the reason for the fracture being deemed unavoidable by the resident's physician. However, the facility's policy and procedure for reporting and investigating abuse, neglect, exploitation, or misappropriation, revised in April 2021, mandates that all reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility management. The facility's administrator acknowledged that an investigation should have been conducted to determine the root cause of the injury.
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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