Golden Heights Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Daly City, California.
- Location
- 35 Escuela Drive, Daly City, California 94015
- CMS Provider Number
- 055968
- Inspections on file
- 26
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Golden Heights Healthcare during CMS and state inspections, most recent first.
The facility did not document required monitoring for emotional harm in two residents following allegations of abuse by a CNA. Despite policy and DON expectations for 72-hour monitoring, medical records lacked evidence that staff assessed mood or emotional well-being after the incidents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
A resident reported that a male CNA performed pericare in a rough manner, causing pain but no injury. The facility's investigation included interviews with the resident and ten staff members, but did not include interviews with other residents or their responsible parties, nor did it assess non-interviewable residents for signs of abuse. The facility's policy lacked direction for investigating when residents are non-interviewable, resulting in an incomplete investigation.
The facility failed to properly label thawed chicken and monitor the temperature of chocolate mousse, potentially affecting all residents receiving meals. The DFS acknowledged incorrect use of the labeling system, leading to a 30-day discard date instead of four days. Additionally, chocolate mousse was served at temperatures above the required 41°F, despite instructions to cool it further. The Administrator and DON emphasized the need for adherence to food safety guidelines.
A resident with diabetes did not receive timely FSBS checks as per physician's orders. An LPN performed the check after the resident began eating lunch, citing a delayed return from a lunch break. The DON confirmed that FSBS checks should occur before meals to ensure accurate readings.
Two residents were found with unauthorized medications at their bedside, indicating a failure in the facility's medication storage and administration policies. One resident with cognitive impairment was using Vicks VapoRub without a physician's order, while another resident with intact cognition was left with stool softeners to self-administer, contrary to policy. Staff interviews revealed a lack of adherence to protocols, resulting in unsecured medications accessible to residents.
A resident refused to take their medications, but an LPN documented them as administered, contrary to facility policy. The resident, with a history of renal dialysis dependence, was observed with the medications left on their table. The DON and Administrator confirmed that the MAR should reflect the refusal, not administration.
A resident with a history of atrial fibrillation and other health issues was not properly monitored by the night shift nurse, who failed to document vital signs and nursing notes. This lack of documentation potentially delayed the identification of symptoms related to the resident's condition. The resident was later found unconscious and transferred to a hospital, where they passed away. The facility's policy required routine checks, but the night shift nurse did not comply.
The facility failed to ensure timely responses to call lights for five residents, leading to delayed care and services. Observations and interviews revealed that call lights were often left unanswered for extended periods, particularly at night. The facility's call light system relied on visual alerts, and staff did not consistently respond promptly. The lack of a specific policy for call light use contributed to the delays, negatively impacting residents' well-being.
A resident with multiple health issues was found restrained without a doctor's order by a CNA, who did not report the action. Despite the incident being reported, the CNA continued to work for two more shifts, maintaining access to the resident and others. The facility's policy requires immediate suspension of staff accused of abuse, which was not followed.
A resident with multiple health conditions was found with her hand improperly restrained to prevent her from pulling out a nasogastric tube. Two CNAs failed to recognize this as a restraint due to lack of knowledge, and an LVN did not report the incident as abuse to the appropriate authorities. The facility's training program includes identifying restraints and reporting abuse, but staff were unaware of these protocols.
A resident with dementia and other medical conditions was improperly restrained by a CNA who tied her hand to the bed to prevent her from pulling out her NGT. This action was taken without a physician's order and was not reported to the charge nurse. The restraint was discovered by another CNA during the morning shift, and staff confirmed it was unauthorized and considered abuse.
A facility failed to report an alleged abuse incident involving a resident's hand being restrained without a physician's order to the CDPH and Ombudsman within the required two-hour period. The incident was discovered by an LVN, who released the resident and informed the DON. However, the DON did not report the incident until four days later, contrary to facility policy.
Failure to Monitor for Emotional Harm After Alleged Abuse
Penalty
Summary
The facility failed to monitor two residents for signs and symptoms of emotional harm following allegations of abuse. In the first case, a resident delivered a letter to the Administrator alleging abuse by a CNA. Despite the Director of Nursing's (DON) stated expectation that nurses should monitor alleged victims of abuse every shift for 72 hours, there was no documented evidence in the resident's medical record that such monitoring for emotional harm occurred. In the second case, a nurse reported witnessing a CNA slapping another resident on the arm. Again, upon review, the DON was unable to find documentation that the resident was monitored for emotional harm for 72 hours following the incident. The facility's policy, revised in March 2018, requires staff and physicians to monitor individuals who have been abused for issues related to their medical condition, mood, and function. However, record reviews for both residents did not show evidence that nursing staff followed this protocol after the alleged abuse incidents. The lack of documentation indicates that the required monitoring for emotional harm was not performed as per facility policy.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who reported that a male CNA performed pericare in a rough manner, causing pain but no injury. The resident, who was alert and able to communicate, stated that the incident occurred before lunch on a Thursday prior to her discharge, but could not recall the aide's name. The Administrator interviewed the resident and ten staff members who worked with her during the relevant period, but none recalled the event or any complaints. Assignment sheets showed multiple aides worked with the resident, making it difficult to identify the alleged perpetrator. The investigation did not include interviews with other residents who may have been present, as the Administrator stated they were non-interviewable, and there was no attempt to interview responsible parties or families of these residents. Additionally, the facility did not conduct assessments of non-interviewable residents for signs or symptoms of abuse, such as bruising or behavioral changes. The facility's abuse policy lacked guidance on investigating when residents in the area are non-interviewable. As a result, the investigation was incomplete and did not ensure that all residents were protected from potential abuse.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to accurately label and date thawed chicken breasts stored in one of the refrigerators, which could potentially affect all 88 residents receiving meals from the facility's kitchen. The Director of Food Service (DFS) acknowledged that the automatic labeling system was used incorrectly, resulting in a label that indicated a 30-day discard date instead of the correct four-day use-by date for thawed chicken. The error was not caught by the dietary supervisors during their rounds, and the Director of Nursing (DON) expressed concern about the potential risk of salmonella due to the incorrect labeling. Additionally, the facility did not conduct proper temperature monitoring for chocolate mousse before serving it to residents. The chocolate mousse was found to be at a temperature of 47.3 degrees Fahrenheit, which is above the required 41 degrees Fahrenheit for cold foods. Despite instructions to cool the mousse further, it was placed on resident meal trays without rechecking the temperature, which was still too high. Dietary staff, including Dietary Aide (DA) #4 and Dietary Supervisor (DS) #3, acknowledged the failure to ensure the chocolate mousse was served at the correct temperature. The Administrator and DON both emphasized the importance of adhering to food safety guidelines and ensuring that food is served at the correct temperatures. The Administrator stated that staff should not serve food that does not meet temperature requirements and expected the DFS and supervisors to monitor and supervise food handling practices. The report highlights the facility's failure to follow established policies for food labeling and temperature control, which could pose a risk to resident safety.
Failure to Conduct Timely Blood Sugar Checks
Penalty
Summary
The facility failed to conduct finger-stick blood sugar (FSBS) checks in accordance with physician's orders for a resident with type two diabetes mellitus and diabetic chronic kidney disease. The resident's care plan indicated a risk for hyperglycemia or hypoglycemia, and an active order required FSBS monitoring before meals and at bedtime. However, during an observation, a Licensed Practical Nurse (LPN) performed the FSBS check after the resident had already started eating lunch, contrary to the physician's order. The LPN admitted to delaying the FSBS check due to taking a lunch break, despite being trained to perform the checks before meals. The Director of Nursing (DON) confirmed that the FSBS checks should be conducted before meals, specifically between 11:00 AM and 11:30 AM for lunchtime, to ensure accurate results. The DON emphasized that performing the FSBS check during a meal could lead to inaccurate readings, which would not align with the physician's intent. The Administrator also stated that FSBS checks should be completed before meals as per the physician's order, highlighting the importance of timing in obtaining accurate blood sugar levels.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely, as evidenced by two residents having unauthorized medications at their bedside. Resident #2, who had a history of dementia and moderate cognitive impairment, was observed using a jar of Vicks VapoRub without a physician's order or a self-administration assessment. The resident was seen applying the ointment to their nostrils and storing it in their nightstand, which was accessible and visible. Staff members, including RNs and CNAs, were unaware of the ointment's presence until it was pointed out during observations, indicating a lapse in the facility's medication storage policy. Resident #27, who had intact cognition, was found with a medicine cup containing docusate sodium and senna on their over-bed table. The resident had declined to take the medication when initially offered by an LPN, who then left the medication for the resident to self-administer later. This action was against the facility's policy, as there was no physician's order or assessment allowing the resident to self-administer medications. The DON confirmed that the medication should not have been left at the bedside and should have been offered again by the nurse. Interviews with staff, including the DON and Administrator, revealed a lack of adherence to the facility's policies regarding medication administration and storage. The staff members involved did not follow the protocol of removing unauthorized medications from residents' rooms and ensuring that medications were administered in the presence of a nurse. The facility's failure to comply with these policies resulted in medications being left unsecured and accessible to residents who were not assessed for self-administration.
Improper Documentation of Medication Refusal
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident who refused to take their medications. The facility's policy on administering medications requires that if a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should initial and circle the MAR space provided for that drug and dose. However, an LPN documented that medications were administered to a resident despite the resident's refusal to take them at the scheduled time. The resident, who had a medical history of dependence on renal dialysis, was observed with a medication cup containing the refused medications on their over-the-bed table. The LPN admitted to leaving the medications with the resident and signing off on the MAR as if the medications had been administered, trusting that the resident would take them later. The Director of Nursing and the Administrator both stated that the MAR should reflect the resident's refusal and that medications should not be documented as administered if they were not. This discrepancy in documentation was identified during an observation and interview process, highlighting a failure to adhere to the facility's medication administration policy.
Failure to Document Vital Signs and Nursing Notes
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice, as there was no evidence of nursing notes and vital signs recorded by the night shift nurse on a specific date. This oversight had the potential to delay the identification of symptoms related to atrial fibrillation, a condition the resident was diagnosed with. The resident had a medical history that included atrial fibrillation, hypertension, benign prostatic hyperplasia, diabetes, and a history of transient ischemic attack. The resident was admitted to the facility for rehabilitation after being diagnosed with new-onset atrial fibrillation at a hospital, where they were prescribed Amiodarone and Apixaban. The resident was found unconscious and vomiting by facility staff and was transferred to a hospital, where they later passed away. The death certificate indicated the cause of death as non-traumatic intracerebral hemorrhage and hypertension. Interviews and record reviews revealed that the night shift nurse failed to document the resident's vital signs and nursing notes. The Director of Nursing confirmed the absence of documentation for the night shift and stated that the facility's policy required routine resident checks at least once per shift. The facility's practice included taking vital signs at the beginning of each shift and under specific conditions, but the night shift nurse did not adhere to these practices.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for five of six residents, leading to delayed provision of care and services. Resident 1's daughter reported that call light issues were particularly severe at night, with waits of 35 minutes or more. This delay resulted in Resident 1 developing a urinary tract infection due to being left in a wet diaper for an extended period. Observations confirmed that Resident 1 was left waiting for assistance while holding her call light, and staff were aware of the delay but did not respond promptly. The facility's call light system displayed room numbers and wait times on a monitor, but staff did not consistently respond to these alerts in a timely manner. During interviews, staff acknowledged the delays and explained that the call light system did not produce sound alerts, relying instead on visual cues on a monitor. The receptionist was responsible for paging CNAs to respond to call lights, but this process was not always effective. Observations showed multiple instances where call lights were on for extended periods, with staff either not responding or turning off the lights without providing immediate assistance. The Director of Nursing confirmed that there was no specific policy and procedure for the use of call lights, only for the paging system. The facility's records and interviews with staff and residents indicated a pattern of delayed responses to call lights, particularly at night. The facility's policy required staff to respond to call lights within five minutes, but this was not consistently followed. The lack of a specific policy for call light use and the reliance on a visual monitoring system without sound alerts contributed to the delays in providing care. The facility's failure to address these issues resulted in negative impacts on residents' physical, mental, and emotional well-being.
Failure to Suspend CNA After Alleged Abuse Incident
Penalty
Summary
The facility failed to provide protection to a resident and other residents when a Certified Nursing Assistant (CNA) was not suspended immediately after an alleged abuse incident was reported. The incident involved a resident with multiple diagnoses, including dysphagia, dementia, rheumatoid arthritis, and osteoarthritis, who was found with her right hand bound with a mitten, surgical gloves, and a plastic bag, loosely secured to the side rail of her bed. This was done to prevent the resident from pulling out her nasogastric tube (NGT). The CNA responsible for this action did not inform anyone about the restraint, which was done without a doctor's order. The incident was discovered by another CNA and reported to a Licensed Vocational Nurse (LVN), who immediately released the resident from the restraint and informed the Director of Nursing (DON). The LVN confirmed that there was no order for restraint and recognized the action as abuse. The Interim Director of Nursing also confirmed that the use of a mitten and tying the resident's hand to the bed constituted a restraint without a doctor's order, which is considered abuse. Despite the report of the incident, the CNA continued to work for two consecutive night shifts, maintaining access to the resident and other residents under her care. The Director of Staff Development verified that the CNA worked these shifts and stated that the facility's policy requires immediate suspension of staff accused of abuse pending investigation. The Administrator was informed of the incident two days later and acknowledged that staff involved in abuse should be suspended immediately for the safety of the residents.
Inadequate Staff Competency and Reporting Awareness
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary knowledge and competency to provide appropriate care, resulting in a deficiency related to resident safety and well-being. Specifically, two Certified Nursing Assistants (CNAs) did not recognize the inappropriate use of a restraint on a resident. The resident, who had conditions including dysphagia, dementia, rheumatoid arthritis, and osteoarthritis, was found with her right hand bound with a mitten, surgical gloves, and a plastic bag, loosely secured to the side rail of her bed to prevent her from pulling out her nasogastric tube. The CNAs involved did not report this as a restraint due to their lack of knowledge, despite having observed the situation during their shifts. Additionally, the facility's nursing staff, including a Licensed Vocational Nurse (LVN) and a CNA, were unaware of their ability to report instances or allegations of abuse to the California Department of Public Health (CDPH) and the local Ombudsman's Office. This lack of awareness was evident when the CNA reported the restraint to the LVN, who acknowledged it as abuse but did not report it to the appropriate authorities. The facility's Director of Staff Development confirmed that training on identifying restraints and reporting abuse is part of the orientation and ongoing training for all nursing staff. However, the deficiency indicates a gap in the staff's understanding and application of this training.
Unauthorized Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were applied without a medical order. A Certified Nursing Assistant (CNA) placed a mitten on the resident's right hand and tied it to the bed's side rail to prevent the resident from pulling out her nasogastric tube (NGT). This action was taken during the night shift when the resident was restless and attempting to remove her NGT. The CNA did not inform anyone about the restraint, nor was there a physician's order for such an intervention. The resident involved had a medical history that included dysphagia, dementia, rheumatoid arthritis, and osteoarthritis. She was admitted with a feeding tube and was dependent on facility staff for activities of daily living. The incident was discovered when another CNA found the resident restrained during the morning shift. The restraint involved a mitten, surgical gloves, a plastic bag, and a towel, all used to secure the resident's hand to the bed. Interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Staff Development, confirmed that the restraint was applied without proper authorization and was considered abuse. The facility's policy on restraints clearly states that they should only be used to treat medical symptoms and never for staff convenience or discipline. The incident was not reported to the charge nurse, and the CNA involved admitted to tying the resident to prevent her from pulling out the NGT and to complete her rounds before the shift ended.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health (CDPH) and the local Ombudsman within the required two-hour period. The incident involved a Certified Nursing Assistant (CNA) who placed a mitten on the resident's right hand and tied it to the bed to prevent the resident from pulling out a Nasogastric Tube. This restraint was discovered by staff on January 13, 2024, but was not reported to the authorities until January 17, 2024, four days later. The resident involved had a medical history including dysphagia, dementia, rheumatoid arthritis, and osteoarthritis. Interviews with facility staff revealed that the incident was recognized as abuse, as there was no physician's order for the restraint. The Licensed Vocational Nurse (LVN) who discovered the restraint immediately released the resident and reported the incident to the Director of Nursing (DON). However, the DON failed to report the incident to the appropriate authorities within the required timeframe. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, leading to a delay in the investigation and potential risk to the resident and others.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
