Community Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 4070 Jurupa Avenue, Riverside, California 92506
- CMS Provider Number
- 055409
- Inspections on file
- 43
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Community Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy and Alzheimer’s disease, assessed as having decision-making capacity and a short-term stay, was discharged to a room and board with home health RN follow-up, but the facility failed to document the events leading to the discharge. The SSA reported that the resident was adamant about leaving, asked daily about discharge, and was referred to a placement agency representative who discussed options and arranged a room and board placement that the resident accepted, yet none of this was recorded in the clinical record. The facility’s discharge planning policy required documentation of referrals to outside agencies and complete, timely documentation of discharge needs and plans, which was not followed.
A resident with a history of cerebral infarction and bladder incontinence was started on an indwelling Foley catheter by an LVN, with orders citing urinary retention and later neurogenic bladder, but the medical record contained no documented clinical findings to support these diagnoses or the need for the catheter. No care plan addressing the catheter was initiated, and staff, including a CNA and the LVN, could not explain or document the rationale for its use. The resident was later transferred to a hospital with the catheter in place, where lethargy, sedimented urine, and urinalysis findings led to a diagnosis of altered mental status secondary to UTI. The DON confirmed the absence of a catheter-related care plan despite facility policy requiring documentation of catheter necessity and inclusion in the plan of care.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
Nursing staff failed to monitor and document respiratory rates for a resident with COPD and emphysema as required by the care plan, and did not rotate insulin injection sites for several residents with diabetes according to facility policy and provider orders. Additionally, staff did not notify the physician when blood sugar levels were below 70 mg/dl for two residents, as required by sliding scale insulin orders. These failures were confirmed through record review and staff interviews.
Nursing staff failed to document the administration of controlled substances on the Medication Administration Record (MAR) for three residents, despite signing out the medications on the Controlled Drug Record. This resulted in missing documentation and inaccurate accountability of controlled medications, as confirmed by staff interviews and record reviews.
Food and Nutrition Services staff, including the RD and Dietary Supervisor, did not follow proper cleaning and sanitizing procedures for food contact surfaces, often using only sanitizer instead of the required wash, rinse, and sanitize steps. Several staff members were unable to accurately state or demonstrate the correct sanitizer concentration, and one dietary aide did not follow manufacturer instructions for test strip use. Staff also lacked knowledge of the correct dishwasher sanitizer concentration and failed to recognize when the dishwasher was operating below the required temperature, impacting all residents receiving food from the kitchen.
Dietary staff did not follow standardized recipes when preparing meals, including cheese quesadillas, pureed bread, and buttered carrots. Ingredients were not measured as required, and recipes were not referenced during preparation, which the Registered Dietitian confirmed could alter the nutritional value of the meals provided to residents.
Two residents on Soft and Bite-Sized diets were served regular bread stuffing without gravy instead of the required pureed version, despite clear dietary orders and tray card indications. The kitchen did not have the appropriate food texture available, and staff did not follow the facility's dietary guidelines, as confirmed by the RD and policy review.
Staff did not follow physician-ordered therapeutic diets, resulting in residents on Heart Healthy, Renal, and Liberal House Renal diets receiving incorrect food items, such as regular bread stuffing instead of seasoned pasta and wheat rolls instead of the specified bread. The RD and DON confirmed that dietary staff are required to follow the prescribed diets, and observations showed that only wheat rolls were available and served, except for one resident with a wheat allergy.
Surveyors identified multiple deficiencies in food service operations, including improper thawing of raw meat, unclean kitchen equipment and surfaces, worn storage shelves, gaps in screened doors, unauthorized staff in the kitchen without hairnets, personal belongings stored near food, use of dry storage as a break room, and expired or unlabeled food in a resident's refrigerator. These findings were based on direct observation, staff interviews, and policy review.
Surveyors found that dumpsters at the facility were repeatedly left open, overflowing, and surrounded by trash, including used gloves and beverage cans. The lids did not close properly, and the surrounding areas were not kept clean, contrary to facility policy. The Dietary Supervisor acknowledged that dumpsters should be closed and the area maintained to prevent pest attraction.
Nursing staff did not properly disinfect shared BP cuffs and a glucometer according to manufacturer instructions, and failed to store a resident's oxygen nasal cannula tubing in a plastic bag as required by facility policy. These lapses in infection control practices created the potential for cross-contamination among residents.
The facility did not maintain an adequate audible call light system in one station, resulting in delayed staff response to residents' calls for assistance. Residents reported ongoing issues with response times, and direct observation confirmed that the call light panel was not audible, even when illuminated. Staff interviews revealed the sound was too faint to be effective, and maintenance checks had not addressed this issue.
Three residents received psychotropic medications, including venlafaxine and Seroquel, without required monitoring for adverse effects or the development of care plans to guide staff in managing side effects. Facility staff confirmed that care plans and monitoring orders were missing, and manufacturer-specified assessments for Seroquel were not documented, contrary to facility policy.
Two residents with significant medical needs did not have comprehensive care plans developed or implemented. One resident with a right ankle fracture and persistent edema lacked a care plan for edema management, despite ongoing symptoms and staff awareness. Another resident receiving Effexor XR for depression had no care plan addressing the medication's use or monitoring for side effects. Staff confirmed these omissions, which were not in accordance with facility policy requiring individualized, measurable care plans.
Two residents assessed as independent smokers did not keep their smoking materials secured in lock boxes as required by facility policy. One resident left cigarettes on an open shelf, while another kept a lighter and cigarettes on his person and in a drawer, with the lock box unused. Staff and care plan reviews confirmed both residents were to store smoking materials in lock boxes, but this was not followed.
A resident with schizoaffective disorder was prescribed Seroquel without documentation of required monitoring for lipids, TSH, or Free T4, as specified by the manufacturer. The Consultant Pharmacist did not identify or report this irregularity during monthly medication regimen reviews, despite facility policy and prescribing information requiring such monitoring.
A resident with heart and kidney conditions was found to have lubricant eye drops, brought from home by family, stored at bedside and self-administered without a physician's order or assessment. Nursing staff were unaware of the medication's presence, and facility policy requiring locked storage of all drugs was not followed.
The facility failed to ensure that the Dietary Supervisor responsible for daily dietary operations met the required educational and certification standards, as the individual in the role had only work experience and lacked any of the qualifications mandated by state regulations. The Registered Dietitian confirmed her role was limited to clinical duties and oversight, while the Administrator was unaware of the DSS's lack of qualifications. Facility policies and job descriptions also required compliance with state standards, which was not met.
A resident with moderate cognitive impairment reported to the charge nurse that a male therapist had touched her breast during a therapy session, identifying the staff member and stating it was a repeated incident. The COTA involved did not notify facility leadership or report the allegation as required, and the incident was not reported to CDPH within the mandated two-hour timeframe. Facility staff interviews confirmed the COTA did not follow abuse reporting policy, and the required immediate suspension and reporting procedures were not followed.
The facility did not ensure that bedrooms shared by multiple residents met the required minimum of 80 square feet per resident, with several rooms falling below this standard. Despite the deficiency, residents and staff reported no issues with space, and no complaints or negative impacts on resident health or safety were observed during the survey.
A resident's family member was not informed of a room change, leaving them unaware of the resident's location. Despite the resident's alertness, facility policy required notifying family members of such changes. The Social Service Director did not notify the family member, and the Director of Nursing confirmed this oversight, which was against the facility's policies.
A resident reported a new wound on her left leg, but the LTC facility failed to assess and treat it according to policy. Despite the resident's alertness and decision-making capacity, there was no documentation of physician notification or treatment initiation. A CNA claimed to have informed an LVN, but this was not documented, and the LVN could not recall the report. The DON confirmed the lack of documentation, highlighting a failure to follow the facility's skin assessment policy.
A CNA entered the room of a COVID-19 positive resident without wearing the required PPE, despite posted signs indicating the need for contact and droplet precautions. The CNA wore only a surgical mask and gloves, failing to use an N95 mask, gown, and eye protection as required by the facility's policies. The Infection Preventionist Nurse and DON confirmed the expectations for PPE use in such situations.
A resident experienced a significant delay in receiving toileting assistance due to a malfunctioning call light. Despite the resident's attempts to get help, including banging on the wall, assistance only arrived after the resident's daughter called the facility. The CNA confirmed the call light malfunction but did not document the frequent checks performed. The DON noted the absence of a policy for handling such malfunctions.
A resident with high risk for pressure injuries developed a stage 3 pressure injury due to the facility's failure to assess and treat an open area on the sacrum in a timely manner. Despite daily monitoring, documentation and treatment were delayed, leading to the discovery of the injury during a skin sweep. The facility's procedures for skin assessments and documentation were not followed, resulting in a delay in treatment.
The facility failed to provide a notice of proposed discharge to a resident transferred to a general acute care hospital. Despite being medically cleared to return, the resident was not allowed back due to a lack of isolation beds. The facility did not notify the resident, the resident's family member, or the LTC Ombudsman, as required.
The facility failed to readmit a resident to the first available bed after hospitalization, despite the availability of isolation rooms. This violated the resident's right to be readmitted and had the potential to cause emotional distress.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly coded as being discharged to a hospital instead of home, and another resident's serious mental illness was not accurately reflected in the MDS. Interviews with staff confirmed the errors and the importance of MDS accuracy for billing and care provision.
The facility failed to ensure that eight resident rooms met the minimum square footage requirements, with room sizes ranging from 70 to 78 square feet per resident instead of the required 80 square feet. Despite no resident complaints and CNAs reporting no issues in providing care, the DON and Administrator acknowledged the importance of meeting these standards.
Failure to Document Resident-Initiated Discharge and Placement Coordination
Penalty
Summary
The deficiency involves the facility’s failure to follow its discharge planning policy and to document the discharge process for one resident. The resident was admitted with metabolic encephalopathy and Alzheimer’s disease and was assessed as a short-term stay with capacity to understand and make decisions. An interdisciplinary care conference documented that the resident attended and that the discharge plan was to a room and board setting. A progress note later documented that the resident was discharged to a specified room and board with home health RN evaluation and treatment to follow. However, further review of the medical record showed no documented evidence of the events leading to the discharge. The Social Service Assistant (SSA) reported that she assists residents with placement to a lower level of care, coordinates home health and DME, and that the facility uses placement agencies whose representatives come to the facility. She stated that this resident was adamant about going home, asked daily about leaving, and that she referred the resident to a placement agency representative who discussed options, found a room and board, and that the resident agreed to that placement. The SSA acknowledged she did not document the resident’s repeated requests to leave or her referral and coordination with the placement agency representative, and stated she should have documented the discharge process and related communications. The DON stated he did not know if the SSA documented the resident’s request and referral, and believed that resident agreement and a care plan would be sufficient. The facility’s discharge planning policy required documentation of referrals to local contact agencies or other entities, updating the care plan and discharge plan based on referral information, and complete, timely documentation of the discharge needs evaluation and discharge plan in the clinical record, which was not done in this case.
Failure to Document Foley Catheter Necessity and Care Plan Leading to UTI
Penalty
Summary
The deficiency involves the facility’s failure to document clinical findings supporting the need for an indwelling Foley catheter (IFC) and to initiate a care plan addressing its use for one resident. The resident was admitted with right-sided weakness and paralysis following a cerebral infarction and was documented on a Minimum Data Set as always incontinent of bladder without an indwelling catheter. Subsequent physician orders entered by an LVN initiated IFC care and catheter orders first for urinary retention and later for neurogenic bladder, but these orders were later discontinued and then re-entered for neurogenic bladder. The resident’s care plan did not contain any care plan addressing IFC use, and there was no documented evidence in the medical record of urinary retention, neurogenic bladder, or other clinical findings demonstrating the necessity for the IFC. The resident was later transferred to a general acute care hospital with an IFC in place and was found to have lethargy, yellow urine with sediment draining from the catheter, and a urinalysis showing signs of infection; he was admitted for altered mental status secondary to a urinary tract infection. A CNA reported that the resident had an IFC “for a while” and did not know why it was in place. The LVN who entered the catheter orders stated that residents may need an IFC for urinary retention or a diagnosis requiring it, but he could not recall why this resident needed an IFC and acknowledged there was no documentation to support the need. The DON confirmed there was no care plan for the IFC and stated that a change in urinary status should have prompted a change-of-condition assessment, physician and family notification, and initiation of a care plan. The facility’s own policy required documentation of clinical or medical conditions demonstrating the need for an indwelling catheter and inclusion of catheter use in the plan of care, which was not done in this case.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Respiratory Status and Adhere to Insulin Administration Protocols
Penalty
Summary
Nursing staff failed to provide necessary care and services to several residents, resulting in multiple deficiencies. For one resident with chronic respiratory conditions, including COPD and emphysema, the care plan required monitoring and documentation of respiratory rate at least once per shift. However, on three consecutive days, there was no documentation of the respiratory rate, despite the resident's care plan and facility policy specifying this requirement. Interviews with staff, including CNAs, LVNs, the Director for Staff Development, and the DON, confirmed that vital signs, including respiratory rate, should have been taken and documented for residents with lung disease. Additionally, for four other residents with diabetes, nursing staff did not rotate subcutaneous insulin injection sites as required by facility policy and provider orders. Review of medication administration records (MARs) showed repeated administration of insulin in the same anatomical locations over extended periods, rather than rotating sites for each dose. This practice was confirmed by the DON during record review and interviews, who acknowledged that injection sites should have been rotated for every dose. Furthermore, for two of these residents, nursing staff did not notify the physician when blood sugar results were below 70 mg/dl, as required by the provider's insulin sliding scale orders. Documentation review revealed multiple instances where blood sugar readings fell below the threshold, but there was no evidence of physician notification or documentation of such communication. The DON and LVN interviewed confirmed that staff were expected to notify the physician and document the communication when low blood sugar levels occurred, but this was not done.
Failure to Document Controlled Substance Administration on MAR
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substance (CS) medications for three of five residents reviewed. In each case, nursing staff signed out CS medications from the Controlled Drug Record (count sheet) but did not document the administration on the Medication Administration Record (MAR). For one resident, a tablet of hydrocodone-acetaminophen was signed out but not recorded on the MAR. For another, three instances were found where oxycodone-acetaminophen tablets were signed out on the count sheet but not documented on the MAR. A third resident had a similar discrepancy with a Norco tablet. In each instance, the responsible LVN acknowledged the missing documentation and confirmed that the medication should have been recorded on both the count sheet and the MAR immediately after administration. The Director of Nursing (DON) confirmed the expectation that CS medication administration must be documented on both the count sheet and the MAR, and acknowledged the discrepancies for the residents involved. Facility policies reviewed indicated that all controlled substances must be recorded on the designated usage form and that the dose recorded must match the MAR and the Controlled Drug Record. The lack of documentation resulted in inaccurate accountability of CS medications, as directly observed and confirmed by staff interviews and record reviews.
Deficient Food and Nutrition Services Staff Training and Sanitation Practices
Penalty
Summary
The facility failed to ensure that Food and Nutrition Services staff were trained and competent to safely and effectively carry out the functions of the department. Multiple staff members, including the Registered Dietitian and Dietary Supervisor, did not follow professional standards of practice for cleaning and sanitizing food contact surfaces. Observations revealed that staff routinely used only sanitizer to clean soiled equipment and surfaces, omitting the required three-step process of washing, rinsing, and sanitizing. Interviews confirmed that both the Registered Dietitian and Dietary Supervisor described incorrect procedures, and several staff members demonstrated improper cleaning techniques during surveyor observations. Further deficiencies were identified in staff knowledge and practice regarding the correct concentration of sanitizing solutions. Several staff members, including cooks and dietary aides, were unable to accurately state or demonstrate the required sanitizer concentration as specified by manufacturer guidelines. Additionally, a dietary aide did not follow the manufacturer's instructions for using test strips to check sanitizer concentration, dipping the strip for only three seconds instead of the required ten seconds. Interviews with the Registered Dietitian confirmed that not following these guidelines could result in inaccurate readings of sanitizer concentration. The facility also failed to ensure that staff were aware of and adhered to the manufacturer's guidelines for dishwasher sanitizer concentration and operating temperature. Multiple dietary aides incorrectly stated the required chlorine concentration for the dishwasher, and observations showed that the dishwasher was operating below the minimum required temperature of 120°F. Review of facility policies and interviews with staff confirmed a lack of understanding and adherence to these critical procedures, affecting all residents who received food from the kitchen.
Failure to Follow Standardized Recipes During Meal Preparation
Penalty
Summary
Dietary staff failed to follow standardized recipes during meal preparation, as observed on multiple occasions. One cook was seen preparing a cheese quesadilla as an alternative meal without using a measuring scoop or referencing the recipe, instead using her hands to estimate the amount of shredded cheese. The Registered Dietitian confirmed that not measuring ingredients could alter the nutritional value of the meal, potentially resulting in residents not receiving the correct amount of calories, protein, and nutrients as intended by the physician-ordered diet. Another incident involved the preparation of pureed bread, where the cook did not follow the facility's standardized recipe. The cook added an unmeasured amount of soy milk and thickener to the bread, deviating from the specified quantities and instructions in the recipe. The Registered Dietitian stated that failure to follow the recipe could result in changes to the nutritional content of the pureed bread, which is critical for residents who rely on modified texture diets. Additionally, during the preparation of buttered carrots, a cook was observed pouring an unmeasured amount of margarine into the carrots, rather than using the amount specified in the standardized recipe. The Registered Dietitian reiterated that not measuring ingredients as directed in recipes can alter the nutritional value of the food served. Facility policies reviewed indicated that all menu items should be prepared according to standardized recipes to preserve or enhance residents' nutrition, but these procedures were not followed during the observed meal preparations.
Failure to Provide Appropriate Food Texture for Residents on Modified Diets
Penalty
Summary
The facility failed to provide food in the appropriate texture for two residents who were prescribed a Soft and Bite-Sized diet due to limited swallowing ability. On the specified date, both residents were observed being served regular bread stuffing without gravy, instead of the required pureed bread stuffing with smooth thick gravy as indicated on the facility's dietary spreadsheet. Observations at the kitchen steam table confirmed that no pureed bread stuffing was available for service. Both residents' tray cards clearly indicated the need for a Soft and Bite-Sized diet, yet they received regular texture food items. Interviews and policy reviews further established that the dietary staff did not follow the facility's written menus and dietary guidelines, which require food to be prepared and served in a form that meets each resident's individual needs as per their assessment and care plan. The Registered Dietitian confirmed that cooks are expected to follow the dietary spreadsheet and that serving regular texture food to residents on a Soft and Bite-Sized diet could pose a risk of choking and decreased meal intake. Facility policies also specify that texture-modified diets must be prepared and served as prescribed by the attending physician and as indicated on the daily spreadsheet.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to follow physician-prescribed therapeutic diet orders for multiple residents, as evidenced by observations, interviews, and record reviews. On specific dates, residents on a Heart Healthy diet were served food items not consistent with the facility's dietary spreadsheet, such as being given regular bread stuffing instead of the prescribed seasoned pasta. The Registered Dietitian (RD) and Director of Nursing (DON) both confirmed that dietary staff are required to follow the cook spreadsheet and physician orders for therapeutic diets, and that deviations could affect residents' health. Six residents were identified as being on a Heart Healthy diet according to physician orders, and the facility's own policies require strict adherence to these orders. Additionally, residents on Renal and Liberal House Renal diets were served wheat rolls instead of the bread or roll (no whole grain) specified in the dietary spreadsheet. Multiple observations and interviews with kitchen staff revealed that wheat rolls were prepared and served to all residents except those with a wheat allergy, despite the RD's statement that renal diet residents should not receive wheat rolls due to potential effects on blood electrolytes. The Assistant Dietary Supervisor and kitchen staff confirmed that only wheat rolls were available and served, except for one resident with a wheat allergy who received white bread. The facility's policies and procedures, as well as the dietary spreadsheets, clearly state that therapeutic diets must be prepared and served as prescribed by the attending physician and planned by the RD. The failure to follow these orders and serve the correct food items for therapeutic diets was confirmed through direct observation, staff interviews, and review of physician diet orders and facility policies.
Multiple Food Safety and Sanitation Deficiencies in Food Service Operations
Penalty
Summary
The facility failed to maintain a sanitary environment and did not prepare or serve food in accordance with professional standards for food service safety. Surveyors observed raw meats, specifically beef patties, being thawed in the walk-in refrigerator for extended periods, with one tray held for up to seven days. Facility policy required meat to be thawed no more than three days prior to service. Additionally, there was evidence of bloody liquid in the packaging, and staff interviews confirmed that holding raw meat for extended periods could result in microbial growth. Multiple pieces of kitchen equipment, including a hot water dispenser, microwave, plate-based warmer, and stationary mixer, were found with visible grime and buildup. The walk-in refrigerator's gasket and storage shelves also had significant grime and debris. Nonfood-contact surfaces such as door frames and fans were covered in dust, with a fan in the dishwashing area blowing dust toward clean dishes. Storage shelves in the dry storage area were worn, with surfaces that were no longer smooth or easily cleanable, and a screened door in the dry storage area had a gap that could allow insect entry. Additional deficiencies included non-dietary staff entering the kitchen without hairnets, personal belongings stored in the dry storage area, and the use of the dry storage area as a break room for dietary staff. Expired food items and unlabeled food were found in a resident's refrigerator, contrary to facility policy requiring labeling and timely disposal. These failures were observed by surveyors through direct observation, interviews with dietary staff, and review of facility policies and the FDA Food Code.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse, as trash was found outside on the ground surrounding dumpsters in multiple locations. On several occasions, a green waste dumpster in the overflow parking lot was found widely open with tree branches, cardboard, and various trash items such as used gloves, empty beverage cans, and papers scattered around it. These observations were made on consecutive days and at different times, indicating an ongoing issue. Additionally, the lids of the dumpsters did not close properly, and some dumpsters were observed to be overflowing. Interviews with the Dietary Supervisor confirmed that the dumpsters' lids should be closed to prevent attracting pests, and that the surrounding area should be kept clean. The facility's policy on garbage and refuse disposal requires that outside refuse containers and dumpsters have tightly fitting lids and that the surrounding area be kept free of debris. Despite this policy, the surveyors repeatedly found dumpsters with open lids and trash accumulating around them.
Failure to Follow Infection Control Practices for Shared Equipment and Oxygen Devices
Penalty
Summary
Nursing staff failed to implement proper infection prevention and control practices in multiple instances involving shared resident care equipment and oxygen delivery devices. During observations, staff did not disinfect shared blood pressure cuffs and a glucometer according to the manufacturer's specified contact time using Sani-Cloth disposable wipes. Specifically, staff were seen wiping equipment but not allowing the required two-minute wet contact time, and in some cases, did not disinfect the equipment between uses on different residents. Additionally, a resident with a history of deep vein thrombosis and an as-needed order for oxygen via nasal cannula was found to have the oxygen tubing stored inside the upper drawer of the bedside nightstand, rather than in a plastic bag as required by facility policy. The resident reported not having used the oxygen for two weeks, and staff interviews confirmed the tubing should have been stored in a plastic bag when not in use to prevent infection. Facility policies reviewed indicated that reusable resident-care equipment must be cleaned and disinfected after each use, and that oxygen delivery devices should be kept covered in a plastic bag when not in use. Staff interviews further confirmed expectations for following these procedures, but observations revealed lapses in adherence, creating the potential for cross-contamination and infection among vulnerable residents.
Inadequate Audible Call Light System in Station 2
Penalty
Summary
The facility failed to ensure that the call light system in Station 2 had an adequate audible sound, which could prevent residents from receiving timely assistance from staff. Resident Council meeting minutes from March and April 2025 documented ongoing concerns about delayed call light responses, particularly during the evening shift in Station 2. During a meeting, a resident reported having to get out of bed and call out for help due to unaddressed call lights. Direct observation confirmed that the call light panel in Station 2 was illuminated for a resident's room, but no audible sound was heard, even with two LVNs present at the nurse's station. Interviews with staff revealed that the call light system in Station 2 produced only a faint sound, which was not sufficient in the noisy environment of the nurse's station and was not audible outside the station. The maintenance staff confirmed that the sound from the call light panel in Station 2 was much fainter compared to other stations. The Maintenance Director stated he was unaware of any issues with the call light's audibility and had only checked for visual functionality. The Administrator was aware of concerns about response times but not about the call light system's sound issue. The facility's preventative maintenance policy required equipment to be maintained in a safe and operable manner, but the lack of attention to the audible function of the call light system led to this deficiency.
Failure to Monitor and Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications and that appropriate monitoring and care planning were in place during the administration of these medications. Two residents were administered venlafaxine for depression without documented monitoring for potential adverse effects. In both cases, there were no care plans developed to guide nursing staff on how to monitor for side effects or evaluate the effectiveness of the medication, and provider orders to monitor for side effects were either missing or not implemented. The Quality Assurance nurse and the Director of Nursing confirmed the absence of care plans and monitoring orders, acknowledging that staff would not have clear guidance on managing or identifying side effects. Another resident was administered Seroquel for schizoaffective disorder without the required manufacturer-specified monitoring, such as lipid panels and thyroid function tests (TSH and Free T4). The medical record lacked documentation of these assessments, and both the QA nurse and DON confirmed that the necessary monitoring was not performed or recorded. The consultant pharmacist also acknowledged that the required monitoring should have been conducted during Seroquel use. The facility's own policy required ongoing evaluation of the effects of psychotropic medications, including monitoring for adverse consequences and following manufacturer specifications. However, the records reviewed showed that these procedures were not followed for the residents in question, resulting in the administration of psychotropic medications without appropriate monitoring or care planning as required by both facility policy and clinical standards.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with identified needs. One resident, who was admitted following a trimalleolar fracture of the right ankle and subsequent surgical repair, was observed multiple times with persistent right leg edema and skin discoloration. Despite these ongoing symptoms and documentation in the medical record regarding the need to elevate the extremity to address edema, there was no care plan initiated to address the edema. Both the QA nurse and LVN confirmed the absence of a care plan for this issue, acknowledging that it should have been developed by the licensed staff who observed and assessed the edema. Another resident, admitted with a diagnosis of depression and receiving Effexor XR for this condition, also did not have a care plan developed for the use of this psychotropic medication. The resident's medical record included provider orders for Effexor XR and instructions to monitor for side effects, but there was no care plan outlining how staff should monitor for side effects or evaluate the effectiveness of the medication. The QA nurse and DON both confirmed the lack of a care plan for depression and the use of Effexor XR, stating that such a plan was necessary to guide nursing staff in providing appropriate care. The facility's policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to meet identified needs. In both cases, the failure to initiate and develop care plans for the residents' specific conditions and treatments resulted in deficiencies in meeting the facility's own standards and regulatory requirements.
Failure to Secure Smoking Materials for Independent Smokers
Penalty
Summary
The facility failed to ensure that safe smoking practices were observed and implemented for two residents who were assessed as independent smokers. In the first instance, a resident was observed sleeping in his room with a pack of cigarettes left on the open shelf of his nightstand, rather than secured in the lock box provided by the facility. Staff interviews confirmed that the resident was supposed to keep his smoking materials locked as per facility policy, and the cigarettes were subsequently removed for safekeeping. The resident's care plan and smoking safety assessment indicated he was allowed to smoke independently and had been provided a lock box for this purpose. In the second instance, another resident was found with a lighter and a cigarette on his person, and a pack of cigarettes stored in his nightstand drawer, rather than in the lock box provided. During an interview, the resident stated he was allowed to keep his smoking materials and smoke unsupervised. The lock box was eventually located in the resident's room, but it was unlocked and being used to store a watch instead of smoking materials. The resident's care plan and smoking safety assessment also indicated he could smoke independently and had been given a lock box for his smoking materials. Facility policy required that all independent smokers be provided with a lock box and that all smoking materials be kept locked when not in use. Staff interviews and record reviews confirmed that both residents were assessed as capable of independent smoking and had been instructed on the policy, but the required safety measures were not followed. These lapses were identified through direct observation, interviews with staff and residents, and review of care plans and facility policy.
Consultant Pharmacist Failed to Identify Missing Seroquel Monitoring
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for a resident who was prescribed Seroquel, an antipsychotic medication. The resident, who had a diagnosis of schizoaffective disorder, had been receiving Seroquel in various doses since February 2022. Despite manufacturer guidelines requiring monitoring of lipids, TSH, and Free T4 during Seroquel use, there was no documentation of these tests in the resident's medical record. The CP's monthly MRRs from January through April 2025 did not include any recommendations or notations regarding the absence of this required monitoring. Interviews with the QA nurse and the DON confirmed that the required monitoring was not documented and that the CP should have identified and reported this irregularity. The CP also acknowledged during an interview that the monitoring should have been performed and reported when missing. The facility's policy on psychotropic medication use required ongoing evaluation and monitoring in accordance with clinical standards and manufacturer specifications, which was not followed in this case.
Unsupervised Resident Use and Improper Storage of Non-Ordered Eye Drops
Penalty
Summary
A lubricant eye drops solution was found stored on top of a resident's overbed table, which was brought in by a family member and used by the resident without a physician's order, self-administration assessment, or supervision. The resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including heart failure and kidney disease, reported using the eye drops as needed for her left eye. Multiple observations confirmed the eye drops remained at the bedside over two days, and the resident stated she had used them for years. The medication was not listed in the resident's electronic Medication Administration Record, which only included an order for a different ophthalmic solution. Licensed nursing staff, including an LVN, the ADON, and the DON, acknowledged during interviews that the eye drops should not have been stored at the bedside and that it was the responsibility of licensed nurses to ensure no medications from home were present at the bedside. The facility's policy required all drugs and biologicals to be stored in locked compartments, accessible only to authorized personnel. The failure to follow these procedures resulted in the resident having unsupervised access to and use of a medication not ordered by a physician.
Dietary Supervisor Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the individual serving as the Dietary Supervisor (DSS), who was responsible for the day-to-day operation and supervision of the dietary department, met the educational and qualification requirements as outlined in both Federal Regulation and the California Health and Safety Code. During interviews, the DSS confirmed that he had been working in the facility for five years but only had work experience and did not possess any of the required qualifications or certifications specified by state regulations for the position. Further interviews with the Registered Dietitian (RD) clarified that while the RD was employed full-time at the facility, her responsibilities were limited to clinical nutrition duties and general oversight, such as monthly kitchen sanitation inspections, test trays, and in-service training when requested. The RD confirmed that the DSS was the person responsible for the daily management and supervision of the dietetic services department. The Administrator also confirmed that the DSS was in charge of the department and was unaware that the DSS did not meet the required state qualifications. A review of the facility's policies and job descriptions indicated that the Director of Food and Nutrition Services, which corresponds to the DSS role, is required to meet state standards for education and certification. However, the DSS did not have any of the qualifications listed in the California Health and Safety Code, such as a relevant degree, completion of an approved training program, or certification as a dietary manager. This lack of compliance with regulatory requirements for the position led to the cited deficiency.
Failure to Timely Report Alleged Abuse and Suspend Staff
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment, who was admitted with diagnoses including dysphagia following a stroke and aphasia. The resident clearly verbalized to the charge nurse that a male therapist had touched her breast during a therapy session, identifying the individual and stating this was the second occurrence. The incident was not reported to the California Department of Public Health (CDPH) immediately, as required by facility policy, which mandates reporting within two hours of the allegation. The Certified Occupational Therapy Assistant (COTA) involved did not notify the Director of Rehab, the Registered Nurse Supervisor, or the Administrator about the allegation, despite being aware of the resident's complaint and discussing it with a family member. Interviews with facility staff, including the Director of Rehab, Registered Nurse Supervisor, Nurse Educator, Director of Nursing, and Administrator, confirmed that the COTA failed to follow the facility's abuse reporting policy. The Director of Rehab and Director of Nursing both stated that the COTA should have reported the allegation immediately and that the COTA should have been suspended pending investigation. The facility's policy, reviewed as part of the investigation, clearly outlines the requirement for immediate reporting of all alleged violations to the Administrator and state agency, but this procedure was not followed in this case.
Failure to Meet Minimum Square Footage Requirements for Multi-Resident Rooms
Penalty
Summary
The facility failed to ensure that bedrooms occupied by multiple residents met the required minimum of 80 square feet per resident. During the survey, it was observed that eight bedrooms did not comply with this standard, with room sizes ranging from 69 to 78 square feet per resident. Specific examples included rooms with two, three, or four residents where the total square footage divided by the number of occupants fell below the regulatory requirement. These findings were based on direct measurement and review of room assignments. Interviews with residents occupying these rooms revealed that they did not express concerns about the available space, and staff reported that rooms were sometimes not filled to capacity to allow for more space. The DON confirmed that rooms with waivers were managed to ensure staff had enough space to work and that residents were comfortable, with no bariatric beds placed in these rooms. Throughout the survey, there were no observed negative impacts on resident health or safety, and no complaints were received regarding room size.
Failure to Notify Family Member of Room Change
Penalty
Summary
The facility failed to notify the family member of a resident about a room change, which resulted in the family member being unaware of the resident's location within the facility. The resident, who was admitted with a neck fracture and required assistance with personal care, was moved from one room to another without the primary contact, listed as FM 2, being informed. Despite the resident having decision-making capacity, the facility's policy required notification of family members or legal representatives in the event of a room change. The Social Service Director (SSD) acknowledged that the resident was informed of the room change, but the family member was not notified because the resident was alert and oriented. The Director of Nursing (DON) confirmed that the SSD should have notified the family member and documented the notification in the resident's medical record. The facility's policies on room changes and notification of changes clearly state that family members or legal representatives should be informed of room changes, which was not adhered to in this case.
Failure to Assess and Treat Resident's Open Wound
Penalty
Summary
The facility failed to ensure that a resident's open wound was assessed and treated after she informed a staff member about it. The resident, who was alert and had decision-making capacity, reported having wounds on her right lower leg and a new wound on her left leg after bumping it at a clinic. Despite the resident's report, there was no documented evidence that the physician was notified or that treatment was initiated for the left leg wound on the days following the incident. During interviews, a CNA stated that she informed an LVN about the resident's left leg wound, but there was no documentation to support this claim. The LVN could not recall receiving the report, and the Director of Nursing confirmed that there was no documentation in the resident's medical record addressing the wound. The facility's policy required documentation and notification of any skin problems, which was not followed in this case, leading to a delay in the assessment and treatment of the resident's wound.
Inadequate PPE Use by CNA in COVID-19 Positive Resident's Room
Penalty
Summary
The facility failed to ensure proper infection control practices when a Certified Nurse Assistant (CNA) entered the room of a COVID-19 positive resident without wearing the appropriate personal protective equipment (PPE). On March 7, 2025, signs were posted outside the resident's room indicating the need for contact and droplet precautions, which required staff to wear gloves, a gown, and an N95 mask, along with eye protection. Despite these clear instructions, CNA 2 entered the room wearing only a surgical mask and gloves, failing to adhere to the necessary precautions. During interviews, CNA 2 admitted to not noticing the precautionary signs and acknowledged the need to wear additional PPE, including goggles, an N95 mask, and a gown, to prevent contamination and the spread of infection. The Infection Preventionist Nurse and the Director of Nursing confirmed that staff are expected to follow these precautions as outlined in the facility's policies. The facility's policies, dated December 19, 2022, emphasized the importance of using appropriate PPE to prevent pathogen transmission, particularly in cases of suspected or confirmed COVID-19 infection.
Call Light Malfunction Leads to Delayed Assistance
Penalty
Summary
The facility failed to ensure a functioning call light system for one resident, resulting in the resident waiting for an extended period to receive assistance with toileting hygiene. On the evening of March 5, 2025, the resident, who was alert and wearing a neck brace, pressed the call light for help but waited for three to four hours without response. The resident resorted to banging on the wall, and eventually, her daughter had to call the facility to get assistance. It was discovered that the call light bulb outside the resident's room was not lighting up, indicating a malfunction. The Certified Nursing Assistant (CNA) assigned to the resident did not notice the call light on and was informed by another source that the resident needed help. The CNA checked the call light and confirmed the malfunction but did not document the frequent checks she performed on the resident that night. The Director of Nursing (DON) acknowledged that the staff should have taken immediate action, such as switching out call lights or transferring the resident to another room, but there was no existing policy for handling call light malfunctions.
Failure to Prevent and Treat Pressure Injury
Penalty
Summary
The facility failed to implement its policy and procedures to prevent and identify the development of a pressure injury for a resident, resulting in the resident developing a stage 3 pressure injury. The resident, who was admitted with conditions including paraplegia, post-polio syndrome, bullous pemphigoid, and dementia, was identified as high risk for pressure injuries. Despite this, an open area on the resident's sacrum was not assessed or treated when first identified on August 30, 2024. Interviews with facility staff revealed that the resident's skin condition was monitored daily, and any new skin conditions were supposed to be reported to the charge nurse. However, the documentation and treatment for the skin issues identified on August 10 and August 30, 2024, were missing. A skin sweep conducted on September 13, 2024, discovered the stage 3 pressure injury, which had not been documented or treated in a timely manner. Further investigation showed that the facility's procedures for skin assessments and documentation were not followed. The Director of Nursing confirmed that weekly summaries were not completed for the resident in August 2024, and the treatment for the pressure injury was delayed until September 15, 2024, two days after it was discovered. The facility's policy required prompt assessment and treatment of pressure injuries, which was not adhered to in this case.
Failure to Provide Discharge Notification
Penalty
Summary
The facility failed to provide a notice of proposed discharge to Resident 2 when the resident was discharged after being transferred to the general acute care hospital (GACH). Resident 2, who had diagnoses including cerebral infarction, hypertension, depression, schizoaffective disorder, and convulsions, was transferred to the GACH due to being unresponsive. Despite being medically cleared to return, Resident 2 was not allowed back to the facility because there was no isolation bed available. The facility initiated Resident 2's discharge without providing the required notification to Resident 2, the resident's family member, or the Long-Term Care (LTC) Ombudsman. Interviews with the Admissions Director and the Social Services Director confirmed that the facility did not document or provide the necessary discharge notifications. A review of Resident 2's medical record and facility policies further revealed that there was no evidence of a written notice of discharge being provided to the LTC Ombudsman or Resident 2's family member. This failure to notify placed Resident 2 at an increased risk of being discharged without proper advocacy or understanding of appeal and discharge rights.
Failure to Readmit Resident to First Available Bed
Penalty
Summary
The facility failed to ensure that Resident 2, who was transferred to a General Acute Care Hospital (GACH) on March 27, 2024, was readmitted back to the facility on the first available bed. Despite the availability of isolation rooms from April 25, 2024, the facility did not readmit Resident 2, who required isolation, until April 29, 2024. This failure violated Resident 2's right to be readmitted to the first available bed and had the potential to cause emotional distress. Resident 2 had multiple diagnoses, including cerebral infarction, hypertension, depression, schizoaffective disorder, and convulsions. The facility's Director of Business Development and Admissions Director confirmed that beds were available, but an isolation room was not provided for Resident 2. The Infection Preventionist indicated that two isolation rooms were available from April 25, 2024, which could have been used for Resident 2. The facility's policy stated that residents should be readmitted to their previous room if available or to the first available bed in a semi-private room, provided they still require the services and are eligible for Medicare or Medicaid services.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for two residents. For Resident #147, the facility incorrectly coded the resident as being discharged to a short-term general hospital instead of home with home health services. This discrepancy was identified through a review of the resident's admission record, care plan, order summary report, notice of transfer/discharge, and progress notes, all of which indicated that the resident was discharged home. Interviews with the RN MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the importance of MDS accuracy for billing and ensuring appropriate care, and acknowledged the error in Resident #147's MDS coding. For Resident #9, the facility did not accurately code the resident's level II preadmission screening and resident review (PASARR) status. The resident, who had diagnoses including schizophrenia, major depressive disorder, and anxiety disorder, was incorrectly coded as not having a serious mental illness on the annual MDS assessment. Interviews with the RN MDS Coordinator, DON, and the Administrator confirmed the error and emphasized the significance of accurate MDS assessments for providing necessary care and services. The RN MDS Coordinator acknowledged that Resident #9's MDS was incorrect regarding the resident's PASARR status.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms, as required by their policy. During a tour of the facility, it was observed that eight rooms did not meet the minimum square footage requirement. The Maintenance Supervisor confirmed the dimensions of these rooms, which ranged from 70 to 78 square feet per resident, falling short of the required 80 square feet. Despite this, no residents voiced concerns about the size of their rooms during the tour, and CNAs reported no issues in providing care due to room size. Interviews with the Director of Nursing (DON) and the Administrator revealed that both were aware of the minimum square footage requirements and expected the rooms to meet or exceed these standards. The DON emphasized the need for rooms to be large enough to accommodate residents and their belongings properly. The Administrator reiterated that rooms should provide a comfortable living area for residents, allowing space for their belongings and ensuring that staff could provide care without hindrance. However, the facility's failure to meet these requirements in eight rooms indicates a deficiency in adhering to their own policies and regulatory standards.
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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