Highland Care Center Of Redlands
Inspection history, citations, penalties and survey trends for this long-term care facility in Redlands, California.
- Location
- 700 E Highland Ave, Redlands, California 92374
- CMS Provider Number
- 055650
- Inspections on file
- 29
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Highland Care Center Of Redlands during CMS and state inspections, most recent first.
A CNA took a resident's credit card out of the facility to make purchases, contrary to facility policy that prohibits staff from using residents' credit cards. This action was confirmed by both the CNA and the DON. Later, the resident experienced fraudulent charges on the card. The facility's abuse prevention policy, which includes safeguards for resident property, was not followed in this instance.
A resident with multiple risk factors and total dependence for mobility developed a right heel pressure ulcer after the facility failed to initiate a care plan for pressure injury prevention, such as offloading and daily skin assessments, despite policy requirements and the absence of a wound at admission.
A resident with dementia eloped from the facility due to inadequate supervision and failure to reset the alarm system. Despite being brought back after an initial attempt, the resident managed to leave again, requiring police intervention. Staff interviews revealed lapses in monitoring and adherence to the facility's safety policy.
The facility failed to maintain sanitary conditions in the kitchen, with food crumbs, trash, and grime found under equipment and in storage areas. Food equipment and utensil bins were dirty, and the ice machine had black spots and discoloration. These conditions were observed by the Dietary Services Supervisor and Registered Dietician, who acknowledged the need for cleanliness according to facility policies and FDA guidelines.
Two residents experienced a lack of dignity during dining observations. An LVN stood over a resident while feeding her, contrary to policy requiring staff to be at the same level. A CNA pulled a resident in a wheelchair with feet dragging, failing to secure them properly. Both actions violated the facility's dignity policy.
A resident with hemiplegia and hemiparesis was not wearing a physician-ordered hand splint to prevent contractures, as observed during multiple checks. The splint was found in the nightstand instead. Interviews with the resident, family, and staff confirmed the splint was not applied as required, violating the facility's policy on assistive devices.
A resident with COPD did not receive proper oxygen therapy as their oxygen tubing was disconnected from the concentrator for 15 minutes. The resident, who was supposed to receive continuous oxygen, reported feeling tired and not sensing the oxygen flow. The facility's policy on oxygen administration was not followed, as confirmed by the DON, posing a health risk to the resident.
The facility failed to maintain accurate records of controlled medications for a narcotic medication cart, with missing signatures on the Narcotic Count Record for several shifts. This oversight, confirmed by the DON, indicated non-compliance with the facility's policy for verifying narcotic counts, posing a risk of medication diversion for 38 residents in Unit Station A.
A facility failed to follow its policy for self-administration of medications, resulting in unsecured pills found in a resident's room. The resident, with multiple sclerosis and other conditions, was deemed capable of self-administering medications. However, pills were discovered on the floor and under the bed, indicating a breach in secure storage protocols. The DON and Administrator confirmed the policy was not adhered to, risking exposure to other residents.
A resident with Alzheimer's and schizoaffective disorder did not receive their physician-ordered finger food diet, instead being served a regular diet. The diet order, revised in 2023, specified a fortified/high protein diet with finger foods, which was not followed, as confirmed by the RD. This failure was observed during a dining observation and contradicted the facility's menu policy.
The facility failed to follow infection control practices, with two residents having unlabeled oxygen nasal cannula tubing, and a coffee cup found on an IV medication cart. These oversights were confirmed by staff and acknowledged by the DON, posing a risk of cross-contamination among vulnerable residents.
The facility failed to maintain essential equipment safely, with a refrigerator missing screws, another with condensation, and an unlocked electrical panel in the memory care unit. These issues were confirmed by staff and violated facility policies, posing risks to residents.
A resident with hemiplegia and other medical conditions was found to have their call light placed inside a drawer, making it inaccessible. This was confirmed by a CNA and was against the facility's policy, which requires call lights to be within reach. The Director of Nursing acknowledged the failure to adhere to the policy.
The facility did not meet the required minimum of 80 square feet per resident in four rooms, as confirmed during an environmental tour. The rooms measured between 71.8 and 75.24 square feet per resident. Despite having room waivers, the rooms were not crowded, posed no safety hazards, and residents did not complain about space issues.
A resident with epilepsy did not receive their prescribed Keppra medication due to unavailability, as it was not ordered in time. This oversight, contrary to facility policy, led to the resident experiencing a seizure and being transferred to a hospital for evaluation.
A resident with a history of falls and mobility issues was not moved closer to the nursing station as required by their care plan, leading to two fall incidents. The resident was left unattended in the bathroom, resulting in injuries and hospital transfers. Facility staff confirmed the care plan was not followed, and the fall risk assessment policy was not adhered to.
Failure to Implement Abuse Prevention Policy for Resident Property
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to follow facility policy by taking a resident's credit card out of the facility to make purchases on two occasions, after the resident requested assistance in buying cigarettes. The CNA acknowledged that this action was against facility policy, which prohibits staff from using residents' credit cards or making purchases on their behalf with credit cards or checks. The facility's Social Services staff confirmed that only Social Services or Activities staff are permitted to make purchases for residents, and only with cash, not credit cards. The Director of Nursing (DON) and the CNA both confirmed that the CNA took the card despite knowing it was not allowed under facility policy. Subsequently, the resident reported fraudulent charges totaling approximately $833 on her credit card, which occurred after the CNA had returned the card. The facility's policy on incidents of theft and misappropriation of resident property requires prompt and thorough investigation of all reports and includes measures to safeguard resident valuables, such as controlled access and locked safes. The DON stated that staff did not follow the established policy in this matter, resulting in a failure to implement abuse prevention procedures designed to prohibit misappropriation of resident property.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide proper care to prevent the development of a right heel pressure ulcer for a resident who was clinically compromised and totally dependent on staff for mobility. Upon admission, the resident had multiple diagnoses, including muscle wasting, spastic quadriplegic cerebral palsy, and impaired lower extremities, making them at high risk for pressure injuries. The admission assessment did not identify any existing pressure sores or wounds on the right heel, and there was no care plan initiated to prevent pressure injuries, such as offloading the feet or conducting daily skin assessments. The deficiency was identified when the wound treatment nurse discovered a darkened area with 100% necrosis on the resident's right heel during wound care, which was not present at admission. Interviews with staff confirmed that a care plan for pressure injury prevention, including offloading and daily skin checks, was not in place at the time of admission. The facility's policy required daily skin inspections and individualized interventions based on risk factors, but these were not implemented for this resident prior to the development of the pressure ulcer.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident who eloped from the facility without the staff's knowledge. The resident, who was admitted with diagnoses including dementia, hypertension, and mood affective disorder, was in the Memory Care Unit. On the night of the incident, the resident attempted to leave the facility and was found wandering outside. Although the resident was initially brought back inside, he managed to elope again shortly after, prompting the facility to call the police to return him. The nursing notes indicated that the alarm system was not activated during the second elopement attempt, allowing the resident to leave the premises undetected. Interviews with staff revealed that the alarm system was not reset in a timely manner after the resident's first elopement attempt. The Registered Nurse and the Director of Nursing both acknowledged that the resident was not adequately monitored after being brought back to the facility. The facility's policy on resident safety and supervision, which emphasizes the importance of monitoring based on individual needs and environmental hazards, was not adhered to in this instance. The failure to reset the alarm and monitor the resident contributed to the deficiency in supervision.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The floors under kitchen equipment were found to have an accumulation of food crumbs, trash, and black grime. The food prep sink drain had residue build-up on the drainpipe and adjacent wall. The dry storage room also had food crumbs and trash underneath the shelves, with a spill of a powder substance on the shelves. Additionally, broken tiles were present in the dry storage room and main kitchen, providing surfaces for food crumbs to accumulate. Food equipment, including a food processor, plate warmer, blender, and can opener, were stored with food crumbs and build-up. The clean utensil bins had food splash and crumbs inside. The ice machine had black spots in the ice bin ceiling and yellow discoloration in the ice chute. These conditions were observed during interviews and inspections with the Dietary Services Supervisor and Registered Dietician, who both acknowledged the need for cleanliness and adherence to facility policies and procedures. The facility's policies and procedures, as well as the U.S. Food and Drug Administration Food Code, require that nonfood-contact surfaces of equipment be kept free of dust, dirt, food residue, and debris. The presence of food debris or dirt on these surfaces can provide an environment for the growth of microorganisms, which may be transferred to food. The facility's failure to maintain cleanliness in these areas has the potential to compromise food safety and increase the risk of foodborne illness for the residents receiving food from the kitchen.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain the dignity of two residents during dining observations. In the first instance, a Licensed Vocational Nurse (LVN) was observed standing over a resident while feeding her lunch in the Memory Care Unit's dining room. This action was contrary to the facility's policy, which requires staff to be at the same level as residents to ensure their comfort and dignity. Interviews with staff confirmed that the expectation was to sit beside residents while feeding them, and the facility's policy emphasized the importance of not standing over residents during meals. In the second instance, a Certified Nursing Assistant (CNA) was observed pulling a resident in a wheelchair into the dining room with the resident's feet dragging on the floor. This action did not align with the facility's policy, which requires staff to ensure residents' feet are elevated and secured on the wheelchair footrest before moving them. Interviews with staff confirmed that the proper procedure was not followed, which compromised the resident's dignity and comfort. The facility's policy on dignity emphasizes treating residents with respect and ensuring their well-being and self-esteem.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to implement its policy for assistive devices and equipment for a resident with limited range of motion (ROM) due to hemiplegia and hemiparesis following a cerebral infarction. The resident was ordered by a physician to have a resting hand splint applied to the left upper extremity seven times a week to decrease the risk of contracture. However, during multiple observations, the resident was found not wearing the hand splint, which was instead located in the nightstand drawer or on top of the nightstand. Interviews with the resident, the resident's mother, and staff members, including a restorative nurse assistant (RNA), a physical therapist (PT), a certified nursing assistant (CNA), and a licensed vocational nurse (LVN), confirmed that the hand splint was not being applied as ordered. The Director of Nursing (DON) reviewed the facility's policy and procedure for assistive devices and equipment, which requires staff to demonstrate competency in the use of such devices and to assist and supervise residents as needed. The DON acknowledged that the facility staff failed to follow the policy, as the hand splint was not applied to the resident as per the physician's order, potentially leading to further contractures and impacting the resident's quality of life.
Failure to Ensure Proper Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, identified as Resident 16, who was admitted with chronic obstructive pulmonary disease (COPD), dysphagia, and hypertension. According to the physician's orders, Resident 16 was to receive continuous oxygen therapy at 2-5 liters per minute via nasal cannula. However, during an observation, it was noted that Resident 16's oxygen tubing was disconnected from the oxygen concentrator for approximately 15 minutes during lunchtime, which was confirmed by the Director of Nursing (DON). This disconnection occurred despite the resident expressing that they did not feel the oxygen was running and feeling very tired. The facility's policy and procedure for oxygen administration, which includes checking the tubing for kinks and ensuring the oxygen is turned on, was not followed. The DON acknowledged that the policy was not adhered to, as the oxygen tubing was found disconnected, posing a serious health risk to Resident 16, including potential desaturation. The failure to ensure the oxygen tubing was properly connected and the oxygen therapy was administered as ordered placed Resident 16's health at risk.
Failure to Maintain Accurate Narcotic Records
Penalty
Summary
The facility failed to maintain accurate records of controlled medications for one of the narcotic medication carts, specifically Unit Station A Cart Number 2. This deficiency was identified through observation, interview, and record review, revealing missing signatures on the Narcotic Count Record (NCR) for several shifts between February 1, 2025, and February 20, 2025. The missing signatures were from both oncoming and off-going shifts, indicating that the required verification of narcotic medication counts was not consistently performed by the nursing staff. The Director of Nursing (DON) confirmed the discrepancies in the NCR and acknowledged that the facility's policy and procedure for controlled substances, which mandates that both oncoming and off-going nurses sign the form to verify the narcotic count, was not followed. The failure to adhere to this policy had the potential for diversion of controlled medications, posing a risk to the 38 residents in Unit Station A. The facility's policy, dated November 2022, emphasizes the importance of monitoring and reconciling controlled substance inventory to prevent loss or diversion, which was not effectively implemented in this instance.
Failure to Securely Store Self-Administered Medications
Penalty
Summary
The facility failed to implement its policy for the self-administration of medications for a resident, leading to a deficiency. The resident, who was admitted with multiple sclerosis, anemia, and osteomyelitis, was assessed as a candidate for safe self-administration of medications. However, during an observation, a white elongated pill with no markings was found on the floor after falling from the resident's bedding. Further inspection revealed two additional pills in the resident's room, one under the bed and another next to the bedside table. The facility's policy required that self-administered medications be stored in a safe and secure place, inaccessible to other residents. The interdisciplinary team was responsible for ensuring that the resident could safely store medications. During an interview, the Director of Nursing and the Administrator acknowledged that the policy was not followed, as the medications were not stored securely, posing a risk to other residents in the facility.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to adhere to the physician-ordered diet for a resident, identified as Resident 40, who was supposed to receive a finger food diet. Instead, during a dining observation, the resident was served a regular diet. This discrepancy was noted during a review of the facility's diet order list, which confirmed that the resident had an active order for a fortified/high protein diet with regular texture, thin consistency, and finger foods with large portions for all meals. This order was initially placed on September 19, 2022, and revised on October 26, 2023. Resident 40, who was admitted to the facility with diagnoses including dehydration, Alzheimer's disease, and schizoaffective disorder, did not receive the prescribed diet on February 18, 2025. The Registered Dietician confirmed on February 20, 2025, that the resident should have been receiving the finger food diet. The facility's policy on menus, revised in October 2017, mandates that menus meet the nutritional needs of residents, including their dietary preferences and requirements, which was not followed in this instance.
Infection Control Lapses in Oxygen Tubing and Medication Cart
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the unlabeled and undated oxygen nasal cannula tubing for two residents. Resident 10, who was admitted with acute respiratory failure, malignant neoplasm of the cerebellum, and was receiving palliative care, had an oxygen nasal cannula tubing that was not labeled or dated, contrary to the physician's order and facility policy. Similarly, Resident 16, diagnosed with chronic obstructive pulmonary disease, dysphagia, and hypertension, also had unlabeled oxygen tubing. Both instances were confirmed by nursing staff, who acknowledged the oversight and the importance of labeling for infection control purposes. Additionally, a warm coffee cup was found on top of an intravenous medication cart, which is against the facility's policy for maintaining medication storage areas in a clean and sanitary manner. This was observed by a CNA and confirmed by the DON, who acknowledged that the policy was not followed. These lapses in infection control practices had the potential to cause cross-contamination and preventable infections among the facility's vulnerable residents.
Equipment Maintenance Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed during a survey. One of the three refrigerators in the kitchen had missing side screws on the front grill, causing it to hang and potentially compromise its functionality. This was confirmed during an interview with the Dietary Services Supervisor, who acknowledged the issue. Additionally, the Registered Dietitian expressed that equipment should be clean, intact, and working properly. The facility's maintenance policy requires the maintenance department to keep equipment in a safe and operable manner, but this was not adhered to in this instance. Another deficiency was noted with a resident refrigerator that had condensation on the back wall, indicating improper functioning. The Registered Dietitian stated that the refrigerator should not have condensation, aligning with the U.S. Food and Drug Administration Food Code, which emphasizes proper maintenance to ensure equipment operates as designed. Furthermore, an electrical panel in the memory care unit was found open and unlocked, posing a risk of accidental electrical shock to residents. The Maintenance Supervisor confirmed the panel should be locked, and the facility's policy on electrical safety was not followed, as acknowledged by the Administrator.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident had adequate access to their call light system, which is a critical component for requesting assistance. Resident 28, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, and hypertension, was found to have their call light placed inside the first drawer of the bedside nightstand, making it inaccessible. This observation was confirmed by a Certified Nursing Assistant (CNA) during an interview, who acknowledged that the call light was not within the resident's reach. The facility's policy, which mandates that call lights be within reach upon admission and as needed, was not followed, as confirmed by the Director of Nursing during a review of the policy and procedure.
Room Size Deficiency in Four Resident Rooms
Penalty
Summary
The facility failed to ensure that four rooms, specifically Rooms 119, 122, 124, and 125, met the required minimum of 80 square feet per resident. During an interview and record review with the Administrator, it was revealed that the facility had room waivers for these rooms, which were below the required square footage. An environmental tour confirmed that the rooms measured between 71.8 and 75.24 square feet per resident, which did not meet the regulatory requirement. Despite this, the rooms were not crowded, did not pose safety hazards, and there were no complaints from the residents about space or room issues.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to administer medication according to its policies and procedures for a resident diagnosed with epilepsy and hemiplegia. The resident was admitted with a prescription for Keppra, a medication used to treat seizures, to be taken twice daily. On May 2, 2024, the medication was not administered at 9:00 AM, as indicated in the Medication Administration Record (MAR). The Minimum Data Set Coordinator confirmed that the reason for not administering the medication was marked as 'Other,' but no further explanation was documented. The Licensed Vocational Nurse responsible for the resident's medication on that day stated that the Keppra was not available due to pending shipment and acknowledged that medication should be ordered before it runs out, as per facility policy. The policy requires medications to be ordered within seven days before the last dose. This oversight potentially led to the resident experiencing a tonic-clonic seizure on May 3, 2024, resulting in the resident being unresponsive and requiring transfer to a hospital for seizure evaluation.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who was at high risk for falls. The resident, who had a history of repeated falls and was diagnosed with degenerative disease of the nervous system, osteoporosis, and other mobility issues, was not moved closer to the nursing station as specified in the care plan following a fall incident. This oversight occurred despite the resident's known high risk for falls, as communicated by the resident's daughter and documented in the interdisciplinary team meeting summary. On two separate occasions, the resident experienced falls that resulted in transfers to an acute general hospital for evaluation and treatment. The first fall occurred shortly after admission, and the second fall happened when the resident was left unattended in the bathroom by a CNA. The resident's room was one of the farthest from the nursing station, contrary to the care plan's directive to move the resident closer for frequent visual monitoring. Interviews with facility staff, including the administrator, director of rehabilitation, and director of nursing, confirmed that the care plan was not followed. The CNA admitted to leaving the resident unattended, and the director of nursing acknowledged that the facility's fall risk assessment policy was not adhered to. The resident sustained injuries, including a clavicular fracture and a laceration with significant swelling, as a result of the falls.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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