Coastal View Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ventura, California.
- Location
- 4904 Telegraph Road, Ventura, California 93003
- CMS Provider Number
- 055566
- Inspections on file
- 37
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Coastal View Healthcare Center during CMS and state inspections, most recent first.
A resident with a high fall risk and on anticoagulant therapy experienced three falls in one day. The facility did not complete required post-fall reassessments, failed to update the care plan after each fall, and did not notify the physician about the resident's use of blood thinners or the subsequent falls. The lack of communication and documentation was confirmed by staff interviews and record review, and the resident was later found unresponsive and pronounced deceased.
Nursing staff failed to obtain and document accurate vital signs for multiple residents as ordered for COVID-19 precautions, instead duplicating previous entries in the electronic MAR. Several nurses admitted to using a system function to copy prior vital signs due to workload, resulting in inaccurate records and noncompliance with physician orders.
The facility did not update care plans to include fall prevention recommendations made by the IDT after multiple residents experienced falls. Despite documented interventions such as keeping beds in the lowest position, using non-skid socks, and providing a clutter-free environment, these were not incorporated into the care plans. The DON confirmed that care plans were not revised as required by facility policy, and there was no documentation of updates or completion of post-fall assessments.
Staff failed to respond promptly to resident call lights, with some lights remaining unanswered for extended periods despite being visible and audible at the nursing station. A resident reported frequent delays of up to 30 minutes for assistance, and staff interviews confirmed inconsistent response practices. The DON stated that all staff are expected to answer call lights within five minutes, but observations showed this was not consistently followed.
A resident admitted with chronic respiratory failure, aphasia, and anxiety disorder did not have floor mats placed as required by their care plan and physician orders, increasing fall risk. Both the DON and an LN confirmed the absence of mats, contrary to facility policy on comprehensive care planning.
A resident with multiple health issues, including a rectal abscess and major depressive disorder, experienced unnecessary pain due to the facility's failure to follow prescribed pain management orders. Despite orders for Oxycodone for moderate to severe pain, Tylenol was administered instead, as confirmed by the MAR and staff interviews. The facility's Pain Management Protocol was not adhered to, resulting in inadequate pain management for the resident.
A resident with dementia consistently refused hygiene care, and the facility failed to report this to the doctor or responsible party. Despite the resident's cognitive impairment and refusal of care, there were no notifications or care plan revisions. Staff interviews revealed a lack of documentation and reporting systems for CNAs, and the DON acknowledged the failure to follow procedures for documenting changes in condition.
A resident with dementia and chronic kidney disease was observed with bilateral quarter side rails raised in bed without a physician's order, as required by facility policy. A review of the care plan and physician orders confirmed the absence of the necessary order, which was acknowledged by an LPN during an interview.
The facility did not meet the nutritional needs of 72 residents by failing to follow the recipe for meatball sub sandwiches, using insufficient ground beef and incorrect measurements of Italian dressing due to inadequate measuring utensils. This resulted in altered nutritional value of the meals served.
A facility failed to ensure a resident's advanced directive matched their POLST, leading to potential treatment inaccuracies. The advanced directive indicated a choice not to prolong life, while the POLST aimed to prolong life by all means. The discrepancy was noted by staff, but the facility did not update the documents to reflect the resident's current wishes.
A facility failed to review the risks and benefits of bed rails with a resident or their representative and did not obtain informed consent before installing bed rails. A resident was observed with side rails raised, and a nurse confirmed that informed consent was not obtained. The facility's policy required informed consent for the use of side rails, which was not followed, leading to a deficiency.
The facility failed to label and date a multidose vial of tuberculin PPD after it was opened. During an inspection, a licensed nurse found the vial in the medication refrigerator without a date label, contrary to facility policy. The product box indicated it should be discarded after 30 days.
The facility failed to ensure proper sanitary and food handling practices, as observed with a male employee working without a beard net, food being prepared in a kitchen sink, and an uncovered trash can being wheeled around the kitchen. The dietary supervisor acknowledged these issues, and the Registered Dietician confirmed the need for proper practices.
The facility failed to clean and disinfect a glucometer, as observed during an inspection of a medication cart. Two LNs confirmed the presence of red stains on the glucometer, which was stored dirty, contrary to the facility's policy requiring cleaning and disinfection between resident use. This oversight had the potential to spread disease among residents.
A facility failed to accurately assess a resident's wandering behavior and the use of a wander alarm. The MDS assessment incorrectly indicated no wandering behavior, despite documentation of an incident and the placement of a wander alarm. The MDS Coordinator acknowledged the errors, which could delay treatment.
Failure to Complete Post-Fall Assessments and Notify Physician for High-Risk Resident on Anticoagulant
Penalty
Summary
The facility failed to provide a safe environment and appropriate care services for a resident with a high risk of falls and on anticoagulant therapy. The resident, an elderly male with a history of atrial fibrillation and generalized weakness, experienced three falls within a short period. Despite a documented high fall risk and care plan interventions requiring ambulation with assistance and careful handling due to anticoagulant use, the facility did not complete post-fall reassessments or update the care plan after each incident as required by policy. Additionally, the facility did not notify the resident's physician after the second and third falls, nor did they communicate the resident's use of heparin, a blood thinner, which increased the risk of bleeding complications. Interviews with nursing staff revealed a lack of communication regarding the resident's medication status and the absence of physician notification following multiple falls. The physician confirmed not being informed about the resident's anticoagulant use or the subsequent falls, which could have influenced clinical decisions. Record reviews showed no evidence of post-fall assessments or care plan revisions after each fall, and the Director of Nursing was unaware of the required post-fall assessment form referenced in facility policy. The facility's policies required significant information, such as changes in condition and fall incidents, to be reported to the attending physician and documented in the clinical record, which was not done in this case. The resident was later found unresponsive and pronounced deceased the morning after the falls.
Failure to Accurately Assess and Document Resident Vital Signs
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment reflective of their status at the time of assessment, as required by physician orders for COVID-19 prevention. Specifically, for all 10 sampled residents, vital signs were not monitored and recorded as prescribed. Instead, duplicate vital sign entries were documented across multiple shifts and dates, with identical values being recorded hours apart, which is not clinically plausible. This was observed in the Medication Administration Records (MARs) and confirmed through review of physician orders that required vital sign monitoring every shift or every four hours for COVID-19 precautions. Interviews with multiple licensed nurses revealed that the 'insert previous vitals' option in the electronic MAR system was used to duplicate vital sign entries, rather than obtaining and recording new measurements as ordered. Several nurses admitted to using this function due to high workload and time constraints, acknowledging that this resulted in inaccurate documentation. Some nurses recognized that this practice could be considered falsification of medical records and was not in compliance with physician orders. The Director of Nursing and other staff also acknowledged that it is not possible for vital signs to remain exactly the same over multiple hours, and that such duplication should not occur. The review of facility policy indicated that vital signs are to be taken and recorded according to the resident's condition and physician orders. Despite this, the MARs for all sampled residents showed repeated instances of duplicate entries, with some nurses stating they did not review previous vital signs before documenting, and others expressing discomfort or lack of recall regarding the practice. The deficiency was identified through record review and staff interviews, which confirmed that the required assessments were not performed as ordered, and inaccurate information was entered into the residents' medical records.
Failure to Update Care Plans with Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that care plans for three residents were revised to include fall prevention recommendations made by the Interdisciplinary Team (IDT) following multiple falls. For each resident, the IDT conducted meetings after fall incidents and documented specific recommendations such as keeping the bed in the lowest position, using non-skid socks, providing a clutter-free environment, using floor mats, and implementing bowel and bladder retraining programs. However, these recommendations were not incorporated into the residents' care plans, as confirmed by a review of the care plans and interviews with the Director of Nursing (DON). Resident 1 experienced multiple falls and had IDT recommendations documented after each incident, but these were not reflected in the care plans. Similarly, Resident 2 had several falls and repeated IDT meetings with recommendations, including additional interventions like bolster mattresses and x-rays, none of which were updated in the care plans. Resident 3 also had multiple falls, and the IDT's recommendations were not incorporated into the care plans. In each case, the DON acknowledged during interviews that the care plans had not been updated as required. The facility's policy and procedure on falls required that care plans be updated following a fall and that a post-fall assessment be completed, documenting that the care plan was revised to reflect new interventions. Despite this policy, there was no documentation that the care plans for these residents were updated after their falls, and the DON was unaware of the required post-fall assessment form referenced in the policy.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely responses to resident call lights, as required by its own policy and procedure, which states that call lights should be answered promptly. During observations, multiple call lights in resident rooms were illuminated and accompanied by a loud buzzing noise at the nursing station, with some remaining unanswered for extended periods. Staff interviews revealed that call lights are sometimes answered by non-nursing staff, such as a respiratory therapist, particularly when residents require suctioning. One resident reported that staff response to call lights typically takes about 30 minutes, indicating a persistent issue. Further observations showed a licensed nurse present at the nursing station while call lights continued to buzz, but the nurse did not respond, citing being occupied with an admission and the presence of three CNAs, none of whom were observed nearby. The Director of Nursing confirmed that the facility's expectation is for call lights to be answered within five minutes and that all staff are responsible for responding. These findings demonstrate a pattern of delayed responses to resident call lights, with staff either not present or not responding in a timely manner.
Failure to Implement Fall Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention and follow physician orders for a resident, which had the potential to lead to negative outcomes in the event of a fall. The resident was admitted to the facility with diagnoses including chronic respiratory failure, aphasia, and anxiety disorder. During an observation and interview, it was noted that there were no floor mats on either side of the resident's bed, despite physician orders and the care plan indicating that floor mats should be present to mitigate fall risks. The Director of Nursing and a Licensed Nurse both confirmed that the resident's care plan and physician orders required floor mats to be placed on both sides of the bed. The facility's policy on comprehensive care planning emphasizes the need for a resident-centered care plan with measurable objectives and timeframes to meet each resident's needs. However, the absence of floor mats as per the care plan and physician orders indicates a failure to adhere to these guidelines, potentially compromising the resident's safety.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility failed to ensure proper pain management for a resident, resulting in the resident experiencing unnecessary pain. The resident, who was admitted with a rectal abscess, a newly placed colostomy, general muscle weakness, difficulty walking, legal blindness, and major depressive disorder, reported that his pain medication took a long time to work and that his pain was not well managed. The physician's order specified that Oxycodone should be administered every four hours as needed for moderate to severe pain, but the Medication Administration Record (MAR) showed that Tylenol was given instead for pain levels that required Oxycodone, indicating a failure to follow the prescribed pain management orders. Interviews with facility staff, including a CNA and a licensed nurse, confirmed that the resident was receiving pain medication, but the Director of Nursing acknowledged that the pain medication orders were not followed as prescribed. The facility's Pain Management Protocol emphasized the importance of assessing pain, educating staff, and intervening before pain becomes severe, but these procedures were not adhered to in this case. The failure to follow the pain management orders led to the resident experiencing unnecessary pain, as confirmed by the review of the resident's care plan and medication records.
Failure to Report Resident's Refusal of Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident received necessary hygiene care when the resident consistently refused such care, and this refusal was not reported to the doctor or responsible party. The resident, who was admitted with dementia and other behavioral disturbances, had a Brief Interview for Mental Status (BIMS) score of 2, indicating significant cognitive impairment. Despite the availability of cue cards in English and Cantonese, the resident refused diaper changes and showers, as observed and corroborated by other residents with higher BIMS scores. The resident's care plan noted a risk for injury or decline due to non-compliance with care, but there were no notifications to the doctor or revisions to the care plan to address the ongoing refusals. Interviews with staff revealed that the Certified Nurse Aides (CNAs) reported the resident's refusals to Licensed Nurses (LNs), but there was no system for CNAs to document these refusals. The Director of Nursing (DON) confirmed that the process for documenting a change of condition and notifying the responsible party and doctor was not followed. The facility's policy required that any change in a resident's condition be promptly reported to the Nurse Supervisor/Charge Nurse, but this was not adhered to in the case of the resident's consistent refusal of care.
Failure to Obtain Physician Order for Side Rails
Penalty
Summary
The facility failed to obtain a physician order for the use of bilateral quarter side rails for one resident, identified as Resident 25. This deficiency was identified during a review of the resident's care plan and physician orders, which revealed that there was no documented physician order for the side rails, despite their use being observed. The facility's policy requires a comprehensive assessment, physician's order, informed consent, and a care plan for the use of any device attached to a bed. During an interview, a licensed nurse confirmed the absence of a physician's order for the side rails. Resident 25, who was admitted with diagnoses including dementia and chronic kidney disease, was observed in bed with the side rails raised, but without the necessary physician's order documented.
Failure to Follow Recipe Leads to Nutritional Deficiency
Penalty
Summary
The facility failed to meet the daily nutritional needs of 72 out of 92 residents by not adhering to the recipe card for meatball sub sandwiches. During an observation and interview, it was found that the cook used only 10 pounds of ground beef instead of the required 11 pounds and 4 ounces for the meatball recipe. The Dietary Supervisor confirmed that the facility only had 5-pound packages of ground beef, which led to the use of an insufficient amount of meat, altering the nutritional value of the meal provided to the residents. Additionally, the facility's kitchen staff demonstrated an inability to accurately measure ingredients, specifically Italian dressing, due to a lack of proper measuring utensils. The cooks used a 1-cup measuring utensil without calibration marks for smaller measurements, leading to incorrect estimations. The facility's policies and procedures emphasized the importance of following specific recipes to ensure residents receive a nourishing and well-balanced diet, which was not adhered to in this instance.
Discrepancy in Resident's Advanced Directive and POLST
Penalty
Summary
The facility failed to ensure that a current copy of an advanced directive was present in the medical record of one resident. During a review of the resident's medical record, it was found that the advanced health care directive, dated 2017, indicated a choice not to prolong life, while the POLST form, dated 2024, indicated a primary goal of prolonging life by all medically effective means. This discrepancy was acknowledged by a Licensed Nurse, who noted that the advanced directive and POLST should match. Further investigation with the Director of Nursing revealed that the resident had filled out the advanced directive upon admission, but it was not updated when the POLST was completed to reflect the resident's and family representative's wishes. The facility's policies on advanced directives and POLST forms require that any conflicts between these documents should be resolved by honoring the most recent expression of the resident's wishes. However, this procedure was not followed, leading to the potential for inaccurate treatment during an emergency medical situation.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with a resident or their representative and did not obtain informed consent prior to the installation of bed rails for one of the sampled residents. This deficiency was identified during a survey involving Resident 25, who was observed with bilateral quarter side rails raised in the middle section of the bed. The resident's care plan indicated that the resident and family were aware of the benefits and potential risks associated with the use of side rails, including entrapment, and that informed consent should be obtained for anything attached to a normal bed. During a concurrent record review and interview, a registered nurse confirmed that informed consent had not been obtained prior to the installation of the side rails for Resident 25. The facility's policy and procedure on informed consent, dated April 2017, required obtaining informed consent for the use of side rails as restraints, enablers, or assistive devices. The failure to adhere to this policy resulted in a deficiency related to the use of bed rails without informed consent.
Failure to Label and Date Opened Multidose Vial
Penalty
Summary
The facility failed to properly label and date a multidose vial of tuberculin purified protein derivative (PPD) after it was opened. During an observation and interview with a licensed nurse, it was found that the medication refrigerator in the west side medication storage room contained an open vial of PPD without a yellow sticker indicating the date it was opened. The licensed nurse acknowledged that the vial should have been labeled with the date it was opened. The product box specified that the opened product should be discarded after 30 days. A review of the facility's policy and procedure on preparation and general guidelines indicated that the date opened and the initials of the first person to use the vial should be recorded on multidose vials.
Improper Sanitary and Food Handling Practices
Penalty
Summary
The facility failed to maintain proper sanitary and food handling practices in the kitchen, as observed during a survey. A male employee, identified as Dietary 1, was seen working in the kitchen with facial hair but without a beard net on multiple occasions. The dietary supervisor acknowledged the absence of beard nets and mentioned that they were on order, but no temporary solution was implemented in the meantime. This lack of proper attire for kitchen staff with facial hair was confirmed by the Registered Dietician, who stated that beard nets should be worn. Additionally, improper food preparation practices were noted when Cook 1 was observed preparing meatballs using an ice cream scoop from a container of seasoned ground beef placed inside a kitchen sink. The dietary supervisor admitted that the sink area was used for food preparation when not in use, despite the Registered Dietician's assertion that food should not be prepared in the sink. Furthermore, Dietary 1 was seen pushing an uncovered trash can on wheels around the kitchen, collecting food scraps, which the dietary supervisor confirmed should have been covered.
Failure to Clean and Disinfect Glucometer
Penalty
Summary
The facility failed to properly clean and disinfect a glucometer, which is an instrument used to measure blood glucose levels. During an observation and interview with two licensed nurses, a medication cart was inspected, and a glucometer with red stains was found inside. Both nurses confirmed that the glucometer was stored dirty in the medication cart and acknowledged the need for it to be cleaned and disinfected. The facility's policy, dated January 2017, requires glucometers to be cleaned and disinfected between resident use, but this procedure was not followed, potentially leading to the spread of disease among residents.
Inaccurate MDS Assessment for Wandering and Alarm Use
Penalty
Summary
The facility failed to accurately assess and document the status of a resident's wandering behavior and the use of a wander alarm, as required by the Minimum Data Set (MDS) assessment tool. The resident's MDS assessment incorrectly indicated no wandering behavior, despite documentation and staff confirmation of an episode of wandering and an attempt to exit the facility. Additionally, a wander alarm was ordered and placed on the resident following this incident, but the MDS assessment inaccurately recorded the alarm as being used daily, rather than less than daily, during the 7-day look-back period. The inaccuracies in the MDS assessment were acknowledged by the MDS Coordinator, who is responsible for ensuring the accuracy of resident assessments before submission to the Centers for Medicare & Medicaid Services (CMS). The facility's policy and procedure for MDS assessments, as well as the coding instructions for wandering behavior and alarm use, were not followed correctly, leading to the discrepancies in the resident's documented status. These errors in assessment could potentially delay and affect the treatment of the resident.
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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