Citrus Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Citrus Heights, California.
- Location
- 7807 Uplands Way, Citrus Heights, California 95610
- CMS Provider Number
- 555337
- Inspections on file
- 30
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Citrus Heights Post Acute during CMS and state inspections, most recent first.
A resident with paraplegia and a skin infection was transferred due to a conflict of interest with an NP, but the facility failed to obtain a physician order, complete a discharge summary, or provide a notice of discharge as required. Staff interviews confirmed the absence of these documents in the medical record, despite facility policy mandating their completion for all discharges.
Two residents with chronic wounds and skin conditions did not consistently receive prescribed wound care treatments, including hydrocortisone cream, Aquaphor ointment, and zinc oxide paste, as documented in treatment administration records. Staff interviews confirmed that wound care orders were not followed as directed and that required documentation was lacking when treatments were missed.
A resident with COPD, CHF, and sleep apnea received oxygen therapy multiple times without an active physician's order, as documented in clinical records and confirmed by staff interviews. Facility policy requires a physician's order for oxygen administration, but staff provided oxygen when the resident experienced breathing difficulties, resulting in care that did not follow established procedures.
Two residents with chronic pain conditions did not receive pain medications as ordered by their physicians, with staff administering medications intended for different pain levels than those documented. Medication administration records and staff interviews confirmed that pain management orders were not consistently followed, contrary to facility policy and professional standards.
Surveyors identified failures in emergency medication documentation and controlled substance management, including missing entries in the E-Kit log after medications were removed, retention of expired insulin from a previous pharmacy, and a discrepancy in the narcotic count for a resident's pain medication. The ADON and LNs confirmed that these actions did not follow facility policy for medication tracking and reconciliation.
Surveyors found that food service equipment, including steam table pans, a food processor, and a blender, were stored wet and with food residue, contrary to facility policy and FDA Food Code. Additionally, the dry storage area floor was observed to have food packets and debris, with the Dietary Supervisor confirming the need for cleaning. These failures demonstrate noncompliance with professional standards for food storage and preparation.
Surveyors identified infection control deficiencies involving three residents: an incentive spirometer was left unlabeled and uncovered, enhanced barrier precautions were not followed during personal care for a resident with a chronic wound, and a nasal cannula used for oxygen therapy was left uncovered when not in use. Staff interviews and facility policies confirmed these lapses in required infection prevention practices.
Two residents who were dependent on staff for ADLs did not receive necessary nail care, resulting in one having long, curling toenails and another with long fingernails containing debris. Both residents expressed discomfort and a desire for nail care, but staff either deferred care to the podiatrist or did not initiate referrals, despite facility policy requiring assistance with hygiene and grooming for residents unable to perform these tasks independently.
Surveyors found that drugs and biologicals were not stored properly, with loose pills present in a medication cart and a Drug Buster bottle observed with a brown substance on its exterior and in the drawer. A nurse confirmed these findings, and facility policy requires medication storage areas to be kept clean and safe.
A resident with chronic kidney disease and hypertension, who was prescribed a No Added Salt (NAS) diet, was served a salt packet with her meal despite clear dietary orders and care plan instructions. Staff interviews and policy reviews confirmed that the NAS diet should have excluded extra salt, and the error was acknowledged by both dietary and nursing staff.
Two residents with cognitive and mobility impairments were found without accessible call light buttons, as the devices were placed out of reach in their rooms. Staff and facility leadership confirmed that call lights should be within reach, and facility policy requires this practice.
A licensed nurse did not wear a gown or perform hand hygiene during a G-tube dressing change for a resident on Enhanced Barrier Precautions, contrary to facility policy requiring these infection control measures for high-contact care activities.
The facility failed to follow food safety standards by improperly thawing pork loin without running water and storing expired food items in the refrigerator. The Kitchen Supervisor confirmed these practices, which were against the facility's policy and the FDA Food Code, posing a risk of foodborne illness.
Missing Required Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure that required documentation for discharge was present in the medical record for one resident. The resident, who had paraplegia and a local skin infection, was admitted with intact cognition. During the resident's stay, a conflict of interest arose when the nurse practitioner (NP) recognized the resident as being involved in a lawsuit with the NP. The resident agreed to be transferred to another facility due to this conflict. Upon review, it was found that there was no physician or provider order indicating the basis for the resident's discharge, no discharge summary, and no notice of discharge in the resident's medical record. Multiple staff interviews confirmed that these required documents were missing. The case manager, social services director, assistant director of nursing, medical records director, and administrator all acknowledged the absence of the necessary discharge documentation. Facility policy required that a physician or provider's order be obtained for all discharges, that a discharge summary be completed, and that a notice of proposed discharge be provided to the resident and documented in the medical record. Despite these requirements, none of these steps were completed for the resident in question, resulting in a lack of proper documentation and communication regarding the discharge.
Failure to Consistently Administer Wound Care Treatments as Ordered
Penalty
Summary
Two residents did not receive wound care treatments as ordered by their physicians, in accordance with professional standards of practice and the facility's policies and procedures. One resident, with diagnoses including peripheral vascular disease, venous insufficiency, and major depressive disorder, had physician orders for hydrocortisone cream and Aquaphor ointment to be applied to chronic ulcers on both lower legs. Review of treatment administration records showed that these treatments were frequently missed or not administered at the prescribed frequency over a period of nearly two months. The resident reported not receiving treatments consistently, and staff confirmed that the wound care orders were not followed as directed. Another resident, with diagnoses including vascular parkinsonism, adult failure to thrive, morbid obesity, and overactive bladder, was at risk for skin breakdown and had open sores on the back. This resident had physician orders for zinc oxide paste to be applied to the rear thighs and right buttock twice daily for moisture-associated skin damage (MASD). Treatment administration records indicated that these treatments were also missed or not performed at the required frequency. The resident reported that staff were not properly caring for the sores, and staff interviews confirmed the inconsistency in following wound care orders. Interviews with nursing staff, the Director of Staff Development, and the Director of Nursing confirmed that wound treatments were not consistently performed as ordered and that documentation was lacking when treatments were not administered. Facility policy required that wound care be provided according to physician orders and that the care plan be reviewed for special needs, but these procedures were not followed for the two residents identified.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sleep apnea was provided with oxygen therapy without an active physician's order. The resident's care plan indicated the need for oxygen as ordered, and multiple clinical records, including vital summaries and progress notes, documented the use of oxygen via nasal cannula on several occasions. During interviews, both the licensed nurse and the Director of Staff Development confirmed that oxygen was administered to the resident when she experienced difficulty breathing, despite the absence of a current physician's order for this treatment. Facility policy and procedures for oxygen administration require verification of a physician's order prior to providing oxygen therapy. Both the Director of Staff Development and the Director of Nursing stated that an active physician's order is necessary to safely administer oxygen to residents. The failure to obtain and verify a physician's order before administering oxygen resulted in the delivery of respiratory care that was not consistent with facility policy and standard practice.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to ensure that two residents received appropriate pain management services in accordance with professional standards of practice, facility policy, and physician orders. For one resident with vascular parkinsonism and osteoarthritis, pain medication orders specified different medications for mild, moderate, and severe pain levels. However, medication administration records showed that this resident was given acetaminophen, intended for mild pain, when experiencing moderate pain, and was also administered hydrocodone-acetaminophen, intended for severe pain, during episodes of moderate pain. These discrepancies were confirmed by the nurse supervisor during record review. Another resident with multiple fractures and osteoarthritis had physician orders for acetaminophen for mild pain and varying doses of Norco for moderate and severe pain. Medication administration records indicated that this resident received 1 tablet of Norco, intended for moderate pain, during episodes of severe pain, and 2 tablets of Norco, intended for severe pain, during episodes of moderate pain on multiple occasions. The nurse supervisor confirmed that the pain medication orders were not consistently followed for this resident as well. Interviews with staff, including the Director of Staff Development, Consultant Pharmacist, and Director of Nursing, all confirmed that pain medications should be administered according to physician orders. The facility's policies and procedures also require that pain medications be administered as ordered and in accordance with the resident's care plan. The failure to follow these orders was observed in the medication administration records and confirmed by staff interviews.
Deficiencies in Emergency Medication Documentation and Controlled Substance Management
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its policies and procedures, as evidenced by several deficiencies related to emergency medication management and controlled substance documentation. During inspections of the medication rooms and carts, it was observed that emergency kits (E-Kits) had been opened and resealed with red color-coded locks, but there was no documentation in the Emergency Kit Log regarding which medications were removed or the dates of removal. Multiple white slips in the narcotic E-Kit indicated repeated access, yet the required log entries were missing. The Assistant Director of Nursing (ADON) confirmed that licensed nurses were expected to record all medication removals in the log and notify the pharmacy for kit replacement, as outlined in the facility's policy. Additionally, an expired insulin E-Kit from a previous pharmacy provider was found in the refrigerator, and the ADON acknowledged it should have been removed or destroyed after the pharmacy change, in accordance with policy requirements for handling discontinued or outdated medications. Further, a discrepancy was identified in the controlled drug record for a resident receiving narcotic pain medication. The on-hand count of Percocet tablets did not match the documented record, with one less tablet present than recorded. The licensed nurse attributed the discrepancy to a missed documentation by the night nurse, who had administered the medication but failed to record it. The ADON stated that both outgoing and incoming staff were expected to reconcile and sign off on narcotic counts at each shift change, as per facility policy. These findings demonstrate lapses in medication documentation, storage, and accountability.
Improper Food Storage and Equipment Cleaning in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations. Three steam table pans were found stored while still wet, with one pan containing food residue, in the ready-to-use area. Additionally, both a food processor and a blender were stored with their lids on, wet, and with food residue inside. The Dietary Supervisor confirmed during interviews that these items were expected to be clean and air-dried before storage, and acknowledged that improper washing and drying could lead to foodborne illness. Review of the facility's dishwashing policy and the FDA Food Code confirmed that all dishes and equipment should be properly sanitized, free of food residue, and air-dried before storage. Further observations revealed that the dry storage area floor contained food packets, a piece of plastic wrap, and paper debris. The Dietary Supervisor confirmed that the floor needed to be swept. According to the FDA Food Code, food must be stored in a clean, dry location, protected from contamination. These findings demonstrate that the facility did not consistently follow professional standards for food storage, preparation, and cleanliness, as required by both facility policy and federal regulations.
Infection Control Lapses in Device Labeling, PPE Use, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices for three residents. For one resident with chronic respiratory failure, an incentive spirometer was observed on a shared shelf, unlabeled and not contained in a protective covering. Both the resident and a licensed nurse confirmed that the device was not labeled or bagged, despite facility policy requiring labeling and storage in a bag. The resident had a physician's order for use of the spirometer multiple times per week. Another resident with a history of cellulitis of the lower limb was on enhanced barrier precautions (EBP) due to a chronic wound. During personal care, a certified nursing assistant provided direct care without wearing the required personal protective equipment (PPE), even though signage at the room entrance indicated EBP and the care plan specified the use of gown and gloves for high-contact activities. The CNA acknowledged not wearing PPE, and the infection preventionist confirmed that PPE was required for such care. A third resident, admitted with chronic obstructive pulmonary disease, congestive heart failure, and sleep apnea, was observed with an oxygen concentrator and nasal cannula. The nasal cannula was left uncovered on top of the concentrator when not in use. Both the resident and a CNA confirmed the cannula was not bagged, and the director of staff development stated that respiratory tubing should be placed in an antimicrobial bag when not in use to prevent contamination. Facility policy also required safe storage of oxygen administration equipment.
Failure to Provide Nail Care Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents who were unable to perform this activity of daily living independently. One resident, with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, dermatophytosis, and varicose veins with ulcer, was dependent on staff for bathing, personal hygiene, and required assistance with dressing and footwear. Observations revealed that this resident had thick, long, and curling toenails. The resident expressed a desire to have her toenails trimmed, but staff indicated that due to her diabetes diagnosis, only the podiatrist could perform this care, and she was not currently on the podiatrist's list. The podiatrist only visited every two months, and the resident was at risk for ingrown toenails and skin injury if her nails were not trimmed. Another resident, with a history of stroke, muscle wasting, diabetes, and major depressive disorder, required substantial to maximal assistance with personal hygiene and was dependent on staff for several ADLs. During observation, this resident was found to have long fingernails with a grayish substance underneath. The resident stated discomfort and a desire for nail care. A CNA confirmed the condition of the nails and stated that they should be trimmed and cleaned to prevent infection. The resident had not been referred for podiatry care, and staff interviews revealed that nail care was considered an implied daily task for nurses, with referrals to the podiatrist as needed for complex cases. Review of facility policy indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, including hygiene and grooming. Despite this, both residents did not receive necessary nail care, as observed and confirmed by staff and record review. The lack of timely nail care for these dependent residents constituted a failure to meet their basic hygiene needs as outlined in their care plans and facility policy.
Improper Storage and Handling of Medications and Disposal System
Penalty
Summary
Surveyors observed that drugs and biologicals were not properly stored according to facility policy and accepted professional standards. During an inspection of a medication cart, multiple loose pills were found inside the cart, and a bottle of Drug Buster, used for medication disposal, was noted to have a brown substance on its exterior and on the bottom of the drawer where it was stored. The licensed nurse present confirmed the presence of the loose pills and the brown substance. The Assistant Director of Nursing later stated that the expectation was for loose pills to be destroyed and for any Drug Buster bottle with spilled contents to be discarded. The facility's policy requires nursing staff to maintain medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Follow Physician-Ordered No Added Salt Diet
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered No Added Salt (NAS) diet was served a packet of iodized salt with her lunch meal. The resident, who had a history of multiple fractures, chronic kidney disease, and hypertension, was admitted in February 2025 and had a care plan and physician's order specifying the NAS diet. Despite these orders, the resident received a salt packet on her meal tray, which she did not request. Observations and interviews confirmed that the meal ticket indicated the NAS diet, and both the Certified Nurse Assistant and Registered Dietician acknowledged that the resident should not have received extra salt. The Registered Dietician stated that nursing staff are expected to check meal trays before serving them to residents, and the Director of Nursing confirmed that prescribed diets should be followed. Facility policies also required that therapeutic diets be provided as ordered by the physician.
Call Light System Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for two residents. For one resident with dementia, gait abnormalities, and muscle weakness, the call light button was found on the floor, approximately three feet away from the bed, and the resident was unaware of its location. This resident required substantial to maximal assistance with daily activities and had a care plan intervention to reinforce the need to call for assistance. A certified nurse assistant confirmed the call light was not within reach and acknowledged it should have been accessible to the resident. For another resident with Alzheimer's disease, dementia, muscle weakness, and difficulty walking, the call light button was placed inside a bedside drawer about four feet from the bed. This resident was dependent on staff for most activities of daily living and had a care plan intervention to keep the call light within reach. A certified nurse assistant confirmed the call light was not accessible and stated it should have been within the resident's reach. Both the Director of Staff Development and the Director of Nursing confirmed that call light buttons should be accessible to residents, as outlined in the facility's policy.
Failure to Follow Enhanced Barrier Precautions During G-Tube Dressing Change
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow proper infection control practices during a dressing change for a resident with a G-tube. The resident, who had a history of dysphagia and cerebral infarction, was on Enhanced Barrier Precautions (EBP) as indicated in their care plan. The facility's policy required staff to don a gown and gloves for high-contact care activities, such as G-tube care, and to perform hand hygiene after glove removal and after contact with potentially contaminated surfaces. During the observed dressing change, the nurse did not wear a gown and did not perform hand hygiene after removing the old dressing or after removing gloves. The nurse confirmed these lapses during the interview. The infection preventionist also confirmed that these actions were not in accordance with facility policy and increased the risk of spreading infectious organisms.
Improper Food Storage and Thawing Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety in two significant instances. Firstly, four large cuts of pork loin were observed thawing improperly in a sink without running water. The Kitchen Supervisor confirmed this method of thawing, which did not comply with the facility's policy that requires meat to be thawed under running cold water. The Registered Dietitian emphasized the importance of proper thawing to prevent the growth of bacteria that could lead to foodborne illnesses. Secondly, during the same observation, expired food items, including a container of plain low-fat yogurt and a pre-cooked ham, were found in the walk-in refrigerator. The Kitchen Supervisor acknowledged that these items were past their expiration and use-by dates and should have been discarded. The Registered Dietitian reiterated that expired foods pose a risk of foodborne illness, aligning with the US Food and Drug Administration Food Code, which mandates that time/temperature control for safety refrigerated foods must be consumed, sold, or discarded by their expiration date.
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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