Diamond Ridge Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburg, California.
- Location
- 2351 Loveridge Road, Pittsburg, California 94565
- CMS Provider Number
- 555287
- Inspections on file
- 28
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Diamond Ridge Healthcare Center during CMS and state inspections, most recent first.
A resident who was cognitively intact and required substantial/maximal assistance with showering reported that a CNA did not wash the resident's buttocks during a shower, despite the resident's request and inability to reach that area. The CNA stated she avoided washing the buttocks because she was worried about hurting her back if she bent over and did not consider asking another CNA for help, leaving the resident feeling upset and angry until the area was cleaned later that day. The DSD and DON acknowledged the CNA should have completed the care to preserve the resident's dignity, consistent with the facility's Resident Rights policy requiring staff to be educated on residents' rights and proper care responsibilities.
A resident with unsteadiness on feet and a vertebral compression fracture, who was cognitively intact, fell from a Broda wheelchair and struck her face on the floor while being wheeled by a family member. The resident and the family member both reported that the facility had not provided instruction on the safe and proper use of the Broda wheelchair. Review of records and interviews with the PT, MDSC, and DON showed there was no care plan addressing safe use of the Broda wheelchair, no documentation of training for the family member on wheelchair safety, and no facility policy or procedure for Broda wheelchair use.
A resident with asthma experienced respiratory distress, and an LVN documented the event but did not notify the physician or responsible party as required by facility policy. The DON confirmed there was no documentation of notification, despite the policy mandating prompt communication for significant changes in condition.
The facility failed to maintain sanitary food storage and preparation practices, risking foodborne illness. Unlabeled sandwiches were found in the refrigerator, and expired food items were in dry storage. A resident had outdated sandwiches and moldy grapes on their bedside table, with staff acknowledging the risk of food poisoning. The facility's policy requires proper labeling and discarding of expired food.
The facility failed to develop baseline care plans within 48 hours for three residents, each with significant medical conditions, and did not provide written summaries to the residents or their representatives. Interviews with staff revealed that providing written summaries was not a standard practice, despite being required by the facility's policy.
The facility failed to maintain proper hygiene and grooming for four residents, including those with dementia and Parkinson's disease. Residents were found with long facial hair and dirty fingernails, despite being dependent on staff for personal care. The DON acknowledged the CNAs' responsibility in providing grooming services.
The facility failed to adhere to infection control practices, including a CNA not wearing a face shield in a COVID-19 isolation room, improper hand hygiene by staff, and inadequate cleaning of medical equipment. Personal care items were improperly stored, and an LVN did not perform hand hygiene during wound care, increasing the risk of infection spread.
A resident's discharge status was incorrectly coded on the MDS as being discharged to an acute care hospital, despite records and staff confirming the resident was discharged home. This resulted in incorrect data being sent to CMS.
A resident did not receive prescribed Cromolyn Sodium Ophthalmic Solution due to a failure in medication administration and follow-up. The LVN did not administer the eye drops, and the DON confirmed the medication was not delivered by the pharmacy. The resident experienced itchy eyes, and there was no documentation of follow-up with the pharmacy or notification to the MD, contrary to facility policy.
A resident with unspecified dementia was unnecessarily prescribed Risperidone, despite not having schizophrenia or exhibiting psychotic behaviors. The resident's MDS showed severely impaired cognition without indicators of psychosis, and staff confirmed the resident was non-violent. A pharmacy recommendation advised against Risperidone use due to increased risks, and the facility's policy required specific documentation for psychotropic drug use, which was not followed.
A facility failed to ensure proper medication storage and labeling, as observed during a survey. An inhalation medication was found undated, and an intravaginal medication was stored with oral medications, contrary to facility policies. The DON and a Consultant Pharmacist acknowledged the risks of these practices, including potential medication errors and infection.
A resident with dementia exhibited aggression towards others for most of May 2024, but the facility failed to revise the care plan until late in the month. Despite being on antipsychotic medication, the resident's aggressive behaviors persisted, and there was no documentation of an Interdisciplinary Team meeting to address the issue. The facility's policy required ongoing monitoring and revision of care plans, which was not followed.
A facility failed to protect a resident with Alzheimer's from physical abuse by a CNA who raised her arm as if to strike. The incident was witnessed by the resident's roommate, who reported previous aggressive behavior by the same CNA towards other residents. The facility's policy on abuse prevention was not effectively implemented.
Failure to Provide Dignified and Complete Personal Care During Shower
Penalty
Summary
The deficiency involves a failure to honor a resident's right to dignity and appropriate assistance with personal care during a shower. A cognitively intact resident, admitted with diagnoses that included a need for assistance with personal care, reported that on the morning of 12/27/25 a CNA did not wash her buttocks during a shower, despite the resident's request and her inability to reach that area herself. The resident stated the CNA told her she did not want to hurt her back by bending to wash the buttocks, which left the resident feeling upset and angry. The resident's MDS dated 11/7/25 documented a BIMS score of 15 and indicated the resident required substantial/maximal assistance for showering, meaning the helper provides more than half the effort and lifts or holds the resident's trunk and limbs. During an interview, the CNA confirmed she did not wash the resident's buttocks during the morning shower on 12/27/25 because she was worried about hurting her back if she bent over, and she acknowledged it did not occur to her to call another CNA for assistance. She stated she did not clean the resident's buttocks until later that afternoon, after the resident became upset about the incident. The DSD stated the CNA should not have refused to wash the resident's buttocks and should have asked another CNA for help, and the DON stated the CNA should have cleaned the resident's buttocks to preserve the resident's dignity and to prevent the risk of skin breakdown. The facility's Resident Rights policy, revised 12/19/22, indicated the facility will ensure all direct and indirect care staff are educated on residents' rights and the facility's responsibility to properly care for its residents.
Failure to Train Family Member on Safe Use of Broda Wheelchair Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident’s family member received proper training in the safe use of a Broda wheelchair, resulting in a fall. Resident 2, who had diagnoses including unsteadiness on feet and a vertebral compression fracture, had been using a Broda wheelchair in the facility. Her MDS showed a BIMS score of 13, indicating she was cognitively intact. On 12/16/25, while being wheeled by Family Member (FM) 1, Resident 2 fell from the Broda wheelchair and hit her face on the floor. In interviews, Resident 2 stated she fell hard, head first, and hurt all over, and further stated the fall could have been prevented if the facility had trained FM 1 on how to safely and properly wheel her in the Broda wheelchair. FM 1 also stated that the facility did not teach her how to properly use and wheel the Broda wheelchair. Record review and staff interviews showed there was no documented training for FM 1 on wheelchair safety prior to the fall, despite Resident 2’s use of the specialized Broda wheelchair. The SBAR note documented the witnessed fall while FM 1 was wheeling the resident. During review of Resident 2’s care plan and progress notes, the PT confirmed that Resident 2 had been using a Broda wheelchair and that there was no documentation that FM 1 was trained on its use, and also could not find a care plan addressing the resident’s safety while using the Broda wheelchair. The MDS Coordinator likewise confirmed there was no care plan on the safe use of the Broda wheelchair. The DON stated the facility did not have a policy and procedure on the use of the Broda wheelchair.
Failure to Notify Physician and Responsible Party of Resident's Respiratory Distress
Penalty
Summary
The facility failed to promptly notify both the physician and the responsible party when a resident experienced respiratory distress. According to the clinical record, the resident, who had a history of asthma, was noted by an LVN to have increasing difficulty breathing and shortness of breath. Despite this significant change in condition, the LVN did not contact the resident's physician or responsible party at the time of the event. During interviews and record reviews, it was confirmed that there was no documentation indicating that the physician or responsible party had been informed of the resident's respiratory episode. The Director of Nursing acknowledged the absence of notification and stated that facility policy requires informing the physician and responsible party of such changes in condition. The facility's policy specifically lists significant changes in physical condition, such as life-threatening events, as circumstances requiring immediate notification.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare foods in a sanitary manner, which could potentially expose residents to foodborne illness. During an observation in the kitchen, eleven unlabeled and undated sandwiches were found in the refrigerator, which the Dietary Supervisor acknowledged should have been discarded after their use-by date. The facility's policy requires that all food products be dated upon receipt, when opened, and when prepared, and that expired or outdated food products be discarded. Additionally, in the dry storage room, several food items, including pancake mix, dried cranberries, and hamburger buns, were found to be stored beyond their use-by dates, which the Dietary Supervisor agreed to discard. In Resident 54's room, two outdated sandwiches and a cup of grapes with mold were found on the bedside table. The Certified Nursing Assistant (CNA) confirmed the presence of these items and acknowledged the risk of food poisoning if consumed. The Director of Nursing stated that CNAs are responsible for removing old food items from residents' tables. Resident 54, who had a Brief Interview for Mental Status score indicating intact cognition, required partial assistance with eating. The facility's policy emphasizes that food items should be stored in accordance with good sanitary practices and that expired or outdated food products should be discarded.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and provide baseline care plans within 48 hours of admission for three residents, identified as Resident 108, 109, and 363. Resident 108 was admitted with diagnoses of hemiplegia and hemiparesis, and the baseline care plan was not developed within the required timeframe. Additionally, neither Resident 108 nor their representatives received a written summary of the baseline care plan. Similar deficiencies were noted for Resident 109, who was also admitted with hemiplegia and hemiparesis, and Resident 363, who had a diagnosis of a right femur fracture. In each case, the baseline care plans were not completed within 48 hours, and the residents and their representatives were not provided with the necessary written summaries. Interviews with facility staff, including a Registered Nurse/Supervisor, a Licensed Vocational Nurse/Case Manager, the Assistant Director of Nursing, and the Director of Nursing, revealed that it was not the facility's practice to provide written summaries of baseline care plans to residents and their representatives. This practice was contrary to the facility's policy and procedure, which required the development of a baseline care plan within 48 hours of admission and the provision of a written summary to the resident and their representative. The failure to adhere to these procedures had the potential to reduce the continuity of care and communication between the residents, their representatives, and the facility staff.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary care for four residents, resulting in poor grooming and personal hygiene. Resident 28, diagnosed with dementia and legal blindness, was observed with long facial hair and dirty fingernails. Despite being dependent on staff for personal hygiene, the resident's needs were not met, as confirmed by a CNA and LVN who acknowledged the resident's desire for grooming. Resident 21, with cerebrovascular disease and dementia, was also found with long, dirty fingernails. The resident was totally dependent on staff for personal hygiene, yet the care plan's goals for cleanliness and grooming were not achieved. A CNA noted the risk of infection due to the resident's habit of eating with her hands. Resident 63, diagnosed with Parkinson's disease, had long, thick facial hair and expressed a preference for trimming, which was not offered by the facility. Similarly, Resident 84, with dementia, had long facial hair on her chin and expressed discomfort, yet the facility did not provide grooming services. The DON acknowledged the responsibility of CNAs in maintaining residents' hygiene and the potential risks of neglecting these duties.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances. A CNA entered a COVID-19 isolation room without wearing a face shield, despite the resident being on droplet and airborne precautions. The CNA acknowledged the requirement for face protection, and the Infection Preventionist confirmed the necessity of adhering to PPE guidelines. Additionally, another CNA did not perform hand hygiene after picking up an ice cube from the floor and before entering a resident's room, which was against the facility's hand hygiene policy. In another instance, a glucometer stored in a medication cart was found with dried blood stains, indicating a failure to clean and disinfect the device after use. The Director of Nursing and the Infection Preventionist both acknowledged this as an unacceptable practice that could lead to the spread of infection. Furthermore, a Licensed Vocational Nurse (LVN) placed a tray with multiple single-use lancets on a resident's bed and did not disinfect it afterward, potentially causing contamination. Additional deficiencies included an LVN dropping a medication bottle cap on the floor and placing it back without disinfection, and the improper storage of personal care items such as toothbrushes and razors in shared bathrooms. These items were not labeled or stored correctly, increasing the risk of cross-contamination. Moreover, an LVN failed to perform hand hygiene during a wound care procedure, which could lead to infection. These actions and inactions demonstrate a lack of adherence to infection control protocols, posing a risk of infection spread among residents.
Incorrect MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure accurate coding of a resident's discharge status on the Minimum Data Set (MDS), resulting in incorrect data being transmitted to the Centers for Medicare and Medicaid Services (CMS). Specifically, the MDS for a resident, who was discharged home, was incorrectly coded as being discharged to an acute care hospital. This error was identified during a review of the resident's records, which included an admission record, order summary, post-discharge plan of care, and physician's discharge summary, all indicating the resident was discharged home. The Minimum Data Set Coordinator (MDSC) confirmed the incorrect encoding during an interview and record review, acknowledging that the resident was indeed discharged home and not to a hospital.
Failure to Administer Prescribed Eye Medication
Penalty
Summary
The facility failed to ensure that a resident received Cromolyn Sodium Ophthalmic Solution as prescribed by the physician. The resident, who had a mildly impaired mental status, was supposed to receive the eye drops twice daily to manage allergic eye conditions. However, during a medication pass observation, the Licensed Vocational Nurse (LVN) only administered oral medications and did not provide the eye drops. The LVN admitted that the medication had been out of order for some time and did not inform the physician or seek advice regarding the missing medication. The Director of Nursing confirmed that the medication had been reordered but not delivered by the pharmacy. The resident reported experiencing very itchy eyes due to the lack of medication. The facility's Consultant Pharmacist indicated that the Cromolyn Sodium Ophthalmic Solution was necessary to prevent inflammation and worsening of allergy symptoms. There was no documentation showing that the pharmacy was followed up with or that the physician was notified about the missing medication, which was against the facility's policy and procedure for medication orders.
Unnecessary Administration of Risperidone to a Resident Without Schizophrenia
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication when the resident was prescribed and administered Risperidone, a medication used to treat symptoms of schizophrenia, despite not having a diagnosis of schizophrenia. The resident, who had unspecified dementia without behavioral or psychotic disturbances, was given Risperidone for screaming, which was not a violent or threatening behavior. The resident's Minimum Data Set (MDS) indicated severely impaired cognition and did not show indicators of psychosis or behavioral symptoms that would justify the use of Risperidone. Interviews with facility staff, including a CNA and an LVN, confirmed that the resident was blind, forgetful, and confused but not physically abusive or threatening. The Director of Nursing stated that the medication was prescribed due to the resident's screaming, despite the resident being non-violent. A pharmacy recommendation advised against the use of Risperidone for dementia-related psychosis due to increased morbidity and mortality risks. The facility's policy required documentation of a specific condition for psychotropic drug use, which was not adhered to in this case.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. In one instance, a resident's inhalation medication, Symbicort, which has a limited shelf life after opening, was found undated in a medication cart. The Licensed Vocational Nurse (LVN) acknowledged that the medication should have been dated according to the facility's standard practice. The Director of Nursing (DON) confirmed that without an open date, it would be impossible for nurses to determine the expiration date of the medication, potentially leading to unsafe use. In another instance, a resident's intravaginal medication, Estradiol, was improperly stored with oral medications in a medication cart. The LVN recognized that the intravaginal medication should have been stored separately to prevent potential infection due to different administration routes. The DON stated that storing medications with different routes together was unacceptable due to the risk of infection. The facility's Consultant Pharmacist also noted that the improper storage of the Estradiol tablet posed a risk of it being administered orally, which could lead to medication errors. The facility's policies and procedures require medications to be labeled and stored according to state and federal regulations, with oral medications stored separately from other formulations.
Failure to Revise Care Plan for Aggressive Resident with Dementia
Penalty
Summary
The facility failed to develop new interventions to address behavioral care and treatment for a resident diagnosed with dementia who exhibited physical and verbal aggression towards others for 24 out of 31 days in May 2024. The resident, admitted with a diagnosis of dementia with behavioral disturbance, had a severely impaired cognition as indicated by a BIMS score of 5 out of 15. Despite being prescribed Quetiapine Fumarate for aggression, the resident continued to display aggressive behaviors, which were documented in the Medication Administration Record for 15 mornings and 24 evenings in May 2024. Interviews with the MDS Coordinator and the DON revealed that the resident's behavior care plan was not revised until late May 2024, despite multiple aggressive incidents. There was no documentation of the Interdisciplinary Team meeting to discuss the resident's dementia care since admission. The facility's policy required ongoing monitoring and revision of care plan goals and interventions, which was not adhered to in this case. Additionally, the Social Services Director conducted a psychosocial evaluation but could not find documentation of it.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) raised her arm at the resident as if to strike. The resident, who had a diagnosis of Alzheimer's disease and severely impaired mental status, required total care with activities of daily living. The incident was witnessed by the resident's roommate, who reported that the CNA had previously exhibited aggressive behavior towards other residents. The roommate, who had an intact mental status, stated that the CNA told her not to tell anyone about the incident, which she perceived as a threat. Further investigation revealed that the CNA had a history of being verbally and physically abusive to residents, including two other residents who reported rough handling and verbal aggression. The Director of Nursing and other staff members confirmed the CNA's history of aggressive behavior. The facility's policy on abuse, neglect, and exploitation was reviewed, indicating that the facility should have measures in place to prevent such incidents, but these measures were not effectively implemented in this case.
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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