Granada Rehabilitation & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, California.
- Location
- 2885 Harris Street, Eureka, California 95503
- CMS Provider Number
- 056300
- Inspections on file
- 29
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Granada Rehabilitation & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with BPH, diabetes, and an indwelling Foley for urinary retention had orders and a care plan requiring catheter care each shift and monitoring for pain and UTI symptoms, yet CNAs did not document catheter care and there was no evidence of catheter securement with a leg strap as required by facility policy and CDC-based practices. The resident, who was dependent for toileting and hygiene, was repeatedly documented as having no genital skin issues until an OT noted unsecured tubing, yellow drainage on clothing and the penis, and a split penile opening, prompting nursing assessment. LNs then documented a lacerated urethral meatus with purulent green-yellow exudate tracking down the catheter, and subsequent testing showed pseudomonas aeruginosa UTI associated with the indwelling catheter, while the MD indicated the tearing and infection had developed over time and should have been detected during ordered foley care.
The facility did not complete required baseline care plans (BCPs) within 48 hours of admission for two residents, including one with dementia and stage 2 PUs on both buttocks and another with dementia and muscle weakness. For the resident with PUs, the BCP and a skin care plan addressing the wounds were not completed until nearly a month after admission. During an interview and record review, the DON confirmed that facility policy requires BCPs within 48 hours and that this was not done for either resident, despite the policy stating that timely BCPs are needed to promote continuity of care, staff communication, resident safety, and to safeguard against adverse events.
A resident with COPD and moderate cognitive impairment was allowed to self-administer a nebulizer treatment without a physician order or a completed self-medication assessment, and more than 1 ml of medication remained in the nebulizer cup when the nurse stopped the treatment. The resident also reported not receiving a prescribed laxative, despite the EMAR showing it as administered. An LN initially asserted the laxative had been given but, after failing to find the expected used cup in the trash, acknowledged it had not been administered and that documentation had been completed contrary to facility policy requiring documentation only after actual administration.
A resident with CHF, hypertensive heart disease, and muscle weakness was involved in an altercation with a roommate, and nursing staff failed to follow abuse and COC procedures. Although a nurse noted the altercation and the plan to monitor the resident, there was no immediate documented assessment for injury or distress, no timely COC entry, and no contemporaneous documentation of MD or family notification. The DON later entered a backdated COC note and 72-hour behavior monitoring notes were completed 48–72 hours late, and the DON confirmed that required 72-hour checks and assessments were incomplete and below expected standards, despite prior staff training and written policies requiring prompt assessment, notification, care plan updates, and 72-hour monitoring.
The facility failed to report an allegation of verbal abuse within the required timeframe. A cognitively intact resident with developmental delay, rheumatoid arthritis, MDD, and anxiety reported that a CNA told her he wanted to clean her vagina, which made her uncomfortable with male CNAs providing this care. The ADM and DON stated the incident was reported internally the same evening it occurred and that CDPH was called, but they could not provide documentation of timely reporting. Review of the SOC 341 showed that CDPH, the Ombudsman, and law enforcement were notified the following day, contrary to facility policy requiring notification of law enforcement and submission of SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours of any abuse allegation.
A licensed nurse gave a dose of a resident's prescribed propranolol to a staff member experiencing anxiety, in violation of facility policy and professional standards. The staff member did not take the medication and disposed of it, resulting in the loss of a resident's dose. The incident was confirmed through staff interviews and security camera footage.
A resident with multiple risk factors, including hemiplegia, dementia, and a history of falls, was not provided with a fall risk care plan upon admission despite being identified as high risk. The lack of a care plan led to an unwitnessed fall resulting in a rib fracture and significant pain, with staff and the DON confirming that required protocols were not followed until after the incident.
A facility failed to conduct a Level II PASARR for a resident who received new mental illness diagnoses of bipolar disorder and schizoaffective disorder. Despite the facility's policy requiring PASARR updates, staff interviews revealed a lack of awareness and action, with the only PASARR on file being from the resident's initial admission. The MDS Coordinator was responsible for ensuring updates, but this was not done, resulting in the deficiency.
A facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with multiple pressure ulcers. Despite the facility's policy requiring EBP for wound care, a nurse did not wear a gown, citing the wound's lack of exudate. Interviews revealed inconsistent understanding among staff about when EBP should be applied, contributing to the deficiency.
Failure to Provide and Document Proper Catheter Care Resulting in Meatal Injury and CAUTI
Penalty
Summary
Staff failed to provide appropriate urinary catheter care and monitoring for a male resident with benign prostatic hyperplasia (BPH) and diabetes mellitus who had an indwelling urinary catheter for urinary retention. The resident’s care plan identified the catheter and included a goal to be free from catheter-related trauma, with expectations that staff monitor, document, and report pain or discomfort and signs and symptoms of UTI to the physician. Orders were in place for insertion of an indwelling catheter and for catheter care starting on 1/4/26, and the MAR showed LNs documented catheter care every shift from 1/13/26 through 1/19/26. Earlier skin assessments and shower sheets documented no genital skin concerns, and the resident was documented as dependent for toileting hygiene, lower body dressing, and personal hygiene. On 1/19/26, an OT noted drainage from the catheter site while assisting the resident with a transfer and observed that the catheter tubing was not secured to the resident’s thigh. The OT saw a large smear of yellowish drainage on the resident’s pants and the tip of the penis, and observed that the opening of the penis appeared split, which she reported immediately to nursing. Subsequent nursing assessment documented that the resident’s urethra was split down the middle, approximately 1/2 inch thick, with purulent green and yellow exudate inside the urethra and extending down the catheter tubing. The resident reported that the catheter hurt, that it had been like that “for a while,” and that he had pain in the area when moving or when catheter care was provided. A skin assessment later that day identified a new, facility-acquired laceration on the urethra of the penis, measuring approximately 1.5 cm by 0.5 cm, with erythema, edema, increased exudate, and sharp pain. A UA and C&S subsequently showed turbid urine, 3+ leukocyte esterase, positive blood, positive nitrites, and many bacteria, with pseudomonas aeruginosa identified as the causative organism. An ED exam documented pus around the meatus, enlarged testicles with swelling, erythema, and tenderness, and diagnosed a UTI associated with the indwelling urethral catheter. The DON stated that CNAs were responsible for catheter care, including cleaning around the meatus, and confirmed there was no documented evidence in the EMR that CNAs had provided catheter care for this resident. The DON also acknowledged there was no documentation of use of a leg strap or other securement device for the catheter, despite facility policy and CDC guidance requiring securement and daily meatal assessment and cleaning. The physician stated the meatal tearing likely occurred in small increments over time and that the infection should have been detected by nursing staff given that foley care was ordered every shift. Facility policies on indwelling catheters and pressure injury prevention required securement of catheters to the thigh and daily observation for signs of potential or active pressure injury related to medical tubes and catheters. CDC guidance referenced by the facility emphasized proper catheter securement to prevent urethral traction, daily meatal cleaning during bathing, and assessment of the meatus for redness, irritation, drainage, and encrustation. Despite these expectations, there was no evidence that catheter securement devices were used or documented for this resident, and no CNA documentation of catheter care was found. The failure of LNs and CNAs to provide and document appropriate catheter care, to secure the catheter, and to identify and report progressive meatal injury and infection resulted in a facility-acquired mucosal membrane injury to the urinary meatus and a severe UTI with pseudomonas aeruginosa associated with the indwelling catheter.
Failure to Complete Timely Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to complete baseline care plans (BCPs) within 48 hours of admission for two residents, contrary to its policy and regulatory expectations. Resident 1 was admitted on 1/7/2026 with dementia and documented stage 2 pressure ulcers on both sides of the buttocks. Although the BCP noted that the resident was admitted with stage 2 pressure ulcers, the BCP itself was not completed until 2/5/2026, nearly one month after admission. Additionally, Resident 1’s skin care plan/care plan for the pressure ulcers was not initiated until 2/5/2026, despite the presence of existing pressure ulcers at admission. Resident 2 was admitted on 2/2/2026 with dementia and muscle weakness, but the BCP for this resident was also not completed until 2/5/2026, exceeding the 48-hour requirement. During an interview and concurrent record review on 2/5/2026 at 11:17 a.m., the DON confirmed that facility policy required BCPs to be completed within 48 hours of admission and acknowledged that neither resident’s BCP met this timeframe. The DON also confirmed that the absence of a timely BCP and skin care plan could increase the risk of unsafe care, including risk for skin breakdown and wound worsening. A review of the facility’s Person-Centered Care Planning policy, revised 4/24/2025, indicated that the baseline care plan was to be developed and implemented within 48 hours of admission to promote continuity of care, communication among staff, resident safety, and safeguard against adverse events.
Failure to Ensure Safe Self-Administration and Accurate Medication Documentation
Penalty
Summary
The facility failed to ensure services met professional standards of quality for a resident with COPD and moderate cognitive impairment. The resident, admitted in November 2025 and scoring 12 on the BIMS, was observed on the morning of 2/5/26 self-administering a nebulizer treatment alone in her room without staff present. The resident reported she had always given herself the nebulizer treatment. During an interview and observation, LN B confirmed the resident had administered the nebulizer treatment herself, acknowledged there was no physician order for self-administration, and that no self-medication administration assessment had been completed. LN B also verified that more than 1 ml of medication remained in the nebulizer cup when the treatment was stopped. The DON later confirmed there was no order or assessment authorizing the resident to self-administer medications, despite facility policy requiring both before self-administration. The facility also failed to ensure accurate medication documentation for the same resident. Review of the EMAR for 2/5/26 showed that polyethylene glycol had been documented as administered at 9:00 a.m. The resident stated she had not received her laxative, which she expected to be mixed with water in a disposable cup. When challenged by the resident to locate the used cup in the trash, LN B checked the trash can, found no cup, and then recalled she had not actually given the laxative. During a concurrent record review, LN B verified that the EMAR indicated the polyethylene glycol had been administered and acknowledged she had not followed facility policy, which required documenting medication administration on the EMAR only after the medication was actually given. The DON confirmed the facility policy required immediate documentation after administration and stated that documenting a medication as given when it was not could mislead clinical decisions and put resident safety at risk.
Failure to Implement Abuse Policy and Change of Condition Procedures After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention and management policy and its change of condition documentation procedures following an alleged altercation involving one resident. The resident was admitted with chronic systolic CHF, hypertensive heart disease, and generalized muscle weakness, and had no documented memory impairment. On 12/25/25, a health status note by a licensed nurse recorded that the resident was in an altercation with his roommate and would be on alert charting and monitored for changes or concerns. However, there was no documented immediate assessment of the resident for physical injuries or emotional distress, no timely change of condition (COC) entry, and no contemporaneous documentation of physician or family notification as required by facility policy and the facility’s COC lesson plan. The DON later entered a COC note effective 12/25/25 but written on 12/26/25, documenting that the MD was notified and recommended monitoring, and stated she wrote it because she realized it had not been done and was needed to trigger alerts. Progress notes reflecting behavior monitoring for 72 hours after the alleged abuse incident, with effective dates of 12/27/25 and 12/28/25, were documented 48–72 hours late on 12/30/25. The DON confirmed that the 72-hour checks were incomplete, the assessments were not written to the expected standard, and there were no documented assessments immediately after the altercation. This occurred despite the DSD’s statement that nurses had been trained to chart assessments, COC, and 72-hour checks immediately after a resident was identified as a victim of an abuse allegation, and despite written policies requiring immediate assessment, MD and responsible party notification, care plan updates, and 72-hour monitoring documentation.
Failure to Timely Report Alleged Verbal Abuse to Required Agencies
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse involving one resident was reported to the California Department of Public Health (CDPH) within the required timeframe. The resident had been admitted with diagnoses including developmental delay, rheumatoid arthritis, major depressive disorder, and anxiety disorder, and had a BIMS score of 13, indicating cognitively intact status. During an interview, the resident reported that a CNA said to her that he wanted to clean her vagina. The resident stated that this disturbed her, that she did not feel comfortable having male CNAs clean her, and that she wanted to keep her dignity. The Administrator and DON stated that the resident reported the event to the Nurse Supervisor on the evening of 12/6/25, and that the Nurse Supervisor then notified them. The DON stated she called the incident in to CDPH that same evening; however, the Administrator and DON were unable to provide documented evidence that the event was reported to CDPH on that date. A review of the SOC 341 form showed that CDPH, the Ombudsman, and law enforcement were notified of the alleged abuse on 12/7/25. The facility’s Abuse Prevention and Management policy required the administrator or designee to notify law enforcement by telephone immediately or as soon as possible, but no longer than two hours after an initial report, and to send a written SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours, for all allegations of abuse.
Nurse Administers Resident Medication to Staff Member
Penalty
Summary
A licensed nurse failed to follow professional standards by removing a dose of propranolol, a prescription medication intended for a resident with hypertension, from the medication cart and offering it to an unlicensed staff member who reported experiencing anxiety. The staff member took the medication from the nurse but ultimately disposed of it in a hopper without ingesting it. The medication was specifically labeled for a resident who had an active physician's order for propranolol 40 mg three times daily for hypertension. The nurse had full access to the medication cart and did not have a physician's order to administer the medication to the staff member. Facility policy and the nurse's job description both require that medications be administered only as ordered by a physician and only to the intended resident. Interviews with staff confirmed that nurses are not permitted to give resident medications to staff, as these medications are not prescribed for them and could cause unknown side effects. The incident was observed on security cameras and verified through interviews with the involved staff, including the nurse who admitted to giving the medication to the staff member.
Failure to Initiate Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a fall risk care plan for a resident with multiple risk factors, including hemiplegia, morbid obesity, muscle weakness, dementia, and a history of falls. Upon admission, the resident was identified as high risk for falls due to recent hospitalization, incontinence, multiple diagnoses, and medication use. Despite this, no fall risk care plan was initiated at the time of admission or prior to a significant fall event. The resident experienced an unwitnessed fall, resulting in a closed rib fracture and significant pain. Documentation shows that the resident was found on the floor after calling for help, and subsequently required transfer to an acute care hospital for evaluation and treatment. The resident continued to experience pain after returning to the facility, necessitating stronger pain management interventions. Interviews with nursing staff and the DON confirmed that a fall risk care plan was not in place prior to the fall, despite facility policy requiring such plans to be developed upon admission for residents identified as high risk. The care plan was only initiated after the fall occurred, contrary to established procedures and expectations for resident safety.
Failure to Conduct Updated PASARR for New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was conducted for a resident who received new mental illness diagnoses. The resident, admitted on 05/05/2011, had a medical history including hemiplegia, hemiparesis, ataxia, protein-calorie malnutrition, and an unspecified mental disorder. The resident was later diagnosed with bipolar disorder on 11/20/2015 and schizoaffective disorder on 11/23/2018. However, the facility did not complete a PASARR evaluation following these new diagnoses, as required. Interviews with facility staff revealed a lack of awareness and action regarding the need for updated PASARR evaluations. The Social Services Director, who had been with the facility for several years, stated she had never conducted any PASARR-related activities. The Director of Nursing confirmed that the only PASARR on file for the resident was from the initial admission in 2011 and was unaware that a new PASARR should be completed with new mental illness diagnoses. The facility's policy indicated that the MDS Coordinator was responsible for ensuring PASARR updates, but this was not adhered to, leading to the deficiency.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) during wound care for a resident with multiple pressure ulcers and severe cognitive impairment. The resident, admitted with a diagnosis of a Stage 2 pressure ulcer in the sacral region, also had two unstageable pressure ulcers and two unstageable deep tissue injuries. During an observation of wound care, a Licensed Vocational Nurse (LVN) did not wear a gown, which is required under the facility's policy for EBP when performing wound care on residents at risk of transmission or acquisition of multi-drug resistant organisms (MDROs). Interviews with staff revealed inconsistencies in understanding and implementing EBP. The LVN believed EBP was not necessary due to the lack of exudate from the wound, while a Registered Nurse (RN) and the Director of Nursing stated that EBP should be applied for any wound care. The Infection Control Preventionists (ICPs) also indicated that EBP was not required for the resident's wound due to its dry state and healing progress. This discrepancy in staff education and understanding led to the failure to adhere to the facility's policy on EBP during wound care for the resident.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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