Inspire Behavioral Health
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 401 Ridge Vista Avenue, San Jose, California 95127
- CMS Provider Number
- 05A277
- Inspections on file
- 28
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Inspire Behavioral Health during CMS and state inspections, most recent first.
A resident with multiple diagnoses and on psychotropic medications was not accurately assessed for fall risk, resulting in a lower-than-appropriate risk score. After an initial fall, a care plan intervention to encourage the resident to wait in her room for meals was not implemented or monitored, leading to a second fall that caused a femur fracture. Additionally, required orthostatic blood pressure measurements were not completed or documented after the second fall, contrary to facility policy.
A maintenance director entered the kitchen, handled grease trap lids outside, and touched kitchen surfaces before washing his hands, contrary to facility policy and staff expectations for hand hygiene upon kitchen entry.
A resident at high risk for elopement due to mental illness and substance abuse successfully left the facility without authorization. The staff failed to follow the conservator's instructions to restrict visitation from friends and did not update the care plan with necessary interventions. During a visit, the resident was able to exit the facility when a CNA did not monitor her proximity to the exit door, leading to her elopement with the assistance of visitors.
A resident with a history of schizoaffective disorder and bipolar type eloped from the facility but was returned safely. The resident's elopement risk assessment was inaccurately coded by an RN, who failed to review the Psychiatry Discharge Summary indicating a history of elopement attempts. The DON confirmed the oversight, which contradicted the facility's policy on admission assessments.
Two residents with schizoaffective disorder eloped from the facility due to staff and visitors failing to ensure the area was clear before opening locked exit doors. Despite being identified as high risk for elopement, one resident managed to leave the facility on three occasions, engaging in unsafe behaviors. Another resident eloped when nursing students entered the unit, despite prior orientation on elopement risks. The facility's policy to prevent such incidents was not adhered to.
The facility did not conduct annual performance reviews for three CNAs, leading to unaddressed training needs. CNA A, hired in 2020, missed reviews in 2021, 2022, and 2023, while CNA B and CNA C, hired in 2013 and 2012, respectively, missed reviews in 2021 and 2022. The DSD confirmed these omissions, which are contrary to the facility's Employee Handbook guidelines.
A resident with schizophrenia and moderate cognitive impairment left the facility without permission, walking towards the parking lot. Staff failed to follow the facility's elopement prevention policy, which requires ensuring exit doors are locked and no residents are nearby when opened. The resident was safely redirected back without injury.
A facility failed to report a sexual allegation within the required timeframe and did not prevent further incidents involving a resident with a history of inappropriate behavior. A resident reported being inappropriately touched by another resident, but the incident was not reported to authorities within the required two hours. The resident involved in the incident had a history of similar behavior, yet the facility's interventions were ineffective in preventing further occurrences.
The facility failed to notify the Ombudsman of resident transfers or discharges to a hospital, as required by policy. This deficiency involved three residents who were hospitalized. The facility's administrator admitted that documentation of notifications was missing due to the previous Social Services Director's disorganized departure. The DON was not involved in the notification process but expected timely notifications. The Ombudsman confirmed not receiving the required notifications.
A facility failed to ensure staff washed their hands before applying gloves during food preparation. A Dining Services Aide was observed applying new gloves without handwashing after answering the kitchen door, contrary to the facility's Glove Use Policy. Interviews with staff confirmed the expectation of handwashing after touching high-contact surfaces and before handling food.
The facility's Station 2 dining room was insufficient to accommodate all residents wishing to dine, leading to wait times of 5-15 minutes. Observations and interviews confirmed the room's capacity was limited to 24 residents, while the facility housed 116. Residents with intact cognition expressed dissatisfaction, and staff acknowledged the issue. Attempts to adjust meal settings were unsuccessful, resulting in a first-come, first-served system that did not meet residents' needs.
A registered nurse failed to document the administration of benztropine mesylate to a resident, as required by facility policy. The resident had intact cognition and an active order for the medication. Attempts to interview the nurse were unsuccessful, but other staff confirmed the importance of immediate documentation to prevent errors.
The facility did not follow its policy for handling soiled linen, as observed when a resident's heavily soiled clothing was left soaking in buckets outside the laundry exit. The policy required soaking in a machine or sink with a degreasing presoak or detergent for at least an hour before washing. Interviews with staff, including the Laundry Aid, interim Laundry Manager, Administrator, and DON, confirmed the policy was not followed.
A facility failed to accurately document a resident's use of oxygen therapy in the MDS assessment. The resident, with a history of COPD and other respiratory issues, was observed using supplemental oxygen, which was not reflected in the MDS. Staff interviews confirmed the oversight, acknowledging the resident's ongoing oxygen therapy since 2018.
A resident with PTSD did not receive trauma-informed care at the facility. Despite having a care plan, the resident's PTSD and triggers were not addressed, and staff were unaware of the diagnosis. The facility lacked a trauma-informed care policy, and no trauma assessments were conducted, leading to a deficiency in care.
Failure to Accurately Assess Fall Risk and Implement Care Plan Interventions
Penalty
Summary
The facility failed to provide resident-centered care and services for a resident by not accurately assessing the resident's fall risk prior to two fall events. The resident, who had diagnoses including schizophrenia, anxiety disorder, and type 2 diabetes mellitus, was marked as low fall risk in the facility's assessments, despite being prescribed multiple psychotropic medications and using a wheelchair. The assessments did not reflect the resident's actual medication regimen or mobility status, resulting in a fall risk score that was lower than appropriate. The DON confirmed that the assessments were inaccurate and that all residents on psychotropic medications should be considered high fall risk. After the resident experienced a fall, the interdisciplinary team recommended an intervention for staff to encourage the resident to wait in her room for her meal tray, which was added to the care plan. However, there was no documented evidence that this intervention was implemented or monitored by staff between the first and second fall events. The resident subsequently fell again while attempting to get her breakfast tray, resulting in a left femur fracture and transfer to an acute care hospital. The facility's policy required staff to monitor and document the resident's response to fall interventions, but this was not done. Additionally, following the second fall, the facility failed to complete and document orthostatic blood pressure measurements as indicated in the post-fall SBAR and required by facility policy. There were no recorded orthostatic blood pressure readings for the resident between the time of the fall and her transfer to the hospital. The DON confirmed that the required measurements were not documented, and the SBAR response was not accurate. Facility policy required documentation of blood pressure measurements, including date, time, and the name of the person recording the data, but this was not followed.
Failure to Follow Hand Hygiene Protocol Upon Kitchen Entry
Penalty
Summary
The facility failed to implement proper infection control practices when the maintenance director (MD) entered the kitchen without washing his hands. Observation showed that the MD put on a hair net and entered the kitchen, then handled the lids of the grease trap outside the kitchen with his bare hands. Upon returning inside, the MD touched the front and top edge of the two-compartment sink before proceeding to the hand washing sink to wash his hands. During interviews, the MD confirmed he did not wash his hands upon entering the kitchen and acknowledged the requirement to do so. The certified dietary manager (CDM) also stated that staff are expected to put on a hair net and wash their hands when entering the kitchen. Review of the facility's handwashing policy indicated that hand washing is required before starting work in the kitchen.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to implement effective safety measures to prevent the elopement of a high-risk resident. The staff was aware of the resident's desire to leave the facility, as she had expressed a wish to go home prior to a friend's visit. Despite this knowledge, the facility did not follow the conservator's instructions to restrict visitation from friends, which was crucial given the resident's history of mental illness and substance abuse. The care plan for elopement was not updated to include necessary interventions such as checking visitor IDs and restricting visits from friends. On the day of the incident, a Certified Nursing Assistant (CNA) did not ensure the resident was kept away from the exit door during a visitor's departure. This lapse allowed the resident to exit the facility and run outside when the door was opened for the visitor. The staff's failure to monitor the resident's proximity to the exit and to follow the conservator's visitation restrictions contributed to the resident's successful elopement. The facility's policies and procedures for preventing elopement were not adequately followed. The staff did not check the identification of the resident's visitors on multiple occasions, and the interdisciplinary team was not informed of the conservator's instructions. As a result, the resident was able to leave the facility with the assistance of visitors, and her whereabouts remained unknown, posing a significant risk to her health and safety.
Inaccurate Elopement Risk Assessment
Penalty
Summary
The facility failed to accurately code the elopement risk assessment for a resident, which had the potential to compromise the resident's health and safety. The resident, who had a history of schizoaffective disorder and bipolar type, was involved in an elopement incident where he left the facility unsupervised and was later returned safely. Despite this incident, the resident's readmission initial elopement risk assessment was incorrectly coded by a registered nurse, who failed to acknowledge the resident's history of elopement attempts as documented in the Psychiatry Discharge Summary from a previous hospital stay. The registered nurse admitted to not reviewing the Psychiatry Discharge Summary, which clearly indicated the resident's history of leaving unlocked residential facilities to use drugs. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the nurse should have read the discharge summary and accurately coded the resident's elopement risk. The facility's policy and procedure for admission assessment emphasize the importance of reviewing an individual's recent medical history, including hospitalizations and relevant medical history, which was not adhered to in this case.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents from eloping due to inadequate supervision and failure to adhere to established protocols. Resident 1, diagnosed with schizoaffective disorder, was identified as high risk for elopement. Despite this, she managed to elope on three separate occasions. On each occasion, Resident 1 took advantage of moments when the exit door was opened by staff or visitors, allowing her to leave the facility unsupervised. These incidents occurred on 12/20/23, 1/7/24, and 1/27/24, during which Resident 1 engaged in unsafe behaviors such as walking on the street and attempting to board a bus. Law enforcement was involved in returning her to the facility. Similarly, Resident 2, also diagnosed with schizoaffective disorder, eloped on 5/24/24 when nursing students entered the unit and inadvertently allowed her to exit through the open door. Despite prior orientation about the risk of elopement, the nursing instructor and students failed to ensure the area was clear of residents before opening the door. Resident 2 was found walking unsafely on the street and attempting to acquire matches and cigarettes from a store. The facility's policy clearly stated that staff should not open exit doors if residents are nearby, and they should check through the glass window before entering, which was not followed in these instances.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three certified nursing assistants (CNAs), identified as CNA A, CNA B, and CNA C. CNA A, hired on August 14, 2020, did not receive performance reviews in 2021, 2022, and 2023. Similarly, CNA B and CNA C, hired on April 15, 2013, and August 22, 2012, respectively, did not have performance reviews in 2021 and 2022. This lack of performance evaluations resulted in the facility's inability to identify and address the training needs of these CNAs to enhance their skills in resident care. The Director of Staff Development (DSD) confirmed these omissions during interviews conducted on September 23 and 24, 2024. The facility's Employee Handbook, dated February 2024, stipulates that performance evaluations should occur annually around the anniversary date of employment.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from leaving the premises without staff's knowledge and permission. The resident, who was admitted with unspecified schizophrenia and had a moderate cognitive impairment, was observed walking towards the parking lot outside the facility. This incident occurred despite the facility's policy that requires staff to ensure exit doors are locked and no residents are nearby when doors are opened. Interviews with the Program Consultant and the Social Service Director confirmed that the resident did not have permission to leave and should not have been able to exit the facility. The facility's policy on preventing elopement was not followed, as staff did not ensure the door was locked and that no resident was in proximity when the door was opened. The resident was safely redirected back to the facility without injury.
Failure to Timely Report and Prevent Recurrence of Sexual Allegations
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the timely reporting of a sexual allegation involving two residents. Resident 1 reported that Resident 2 had inappropriately touched her breast while she was playing poker near the nursing station. Despite Resident 1's immediate report to staff, including certified nursing assistants and a licensed vocational nurse, the incident was not reported to the appropriate authorities within the required two-hour timeframe. The delay in reporting was confirmed by the registered nurse supervisor, who acknowledged the late reporting and the lack of specific details provided by the staff. Additionally, Resident 2 had a history of inappropriate behavior, having been involved in two other incidents of sexual assault within a week. Despite these incidents, the facility did not implement effective interventions to prevent further occurrences. The care plan for Resident 2, which included monitoring and notification to various authorities, was deemed ineffective by the program director, who admitted that the current plan did not prevent further incidents of sexual abuse. The facility's policy on preventing, investigating, and reporting alleged sexual assault and abuse violations clearly states that all employees are responsible for immediately reporting any reasonable suspicion of a crime or abuse. However, the failure to report the incident involving Resident 1 within the stipulated timeframe and the lack of preventive measures for Resident 2's recurring behavior highlight significant lapses in the facility's adherence to its own policies.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman when residents were transferred or discharged to a hospital, as required by their policy. This deficiency was identified for three residents who were hospitalized. The facility's policy, revised in September 2012, outlines the procedures for emergency transfers or discharges, including notifying the resident's attending physician, the receiving facility, and the resident's representative or family member. However, the policy also requires notifying the Ombudsman, which was not done in these cases. The deficiency was discovered during interviews and record reviews. The facility's administrator acknowledged that the previous Social Services Director, who was terminated in May 2024, did not leave the office in good order, resulting in the inability to locate documentation of Ombudsman notifications for transfers or discharges from January to May 2024. The Director of Nursing stated he was not involved in the notification process but expected the Ombudsman to be notified timely. The Ombudsman confirmed that their office did not receive notifications for the transfers or discharges of the three residents in question.
Failure to Wash Hands Before Glove Use in Food Preparation
Penalty
Summary
The facility failed to ensure that staff washed their hands before applying gloves during food preparation, as observed during a survey. A Specialist Dining Services Aide (SDSA) was seen applying a new pair of gloves without washing his hands after answering the kitchen door, while in the process of making peanut butter and jelly sandwiches. This action was contrary to the facility's Glove Use Policy, which mandates handwashing when changing to a fresh pair of gloves and specifies that gloves should not replace handwashing. Interviews with the SDSA, Dining Services Manager, Director of Nursing, and the Administrator confirmed the expectation that staff should wash their hands after touching high-contact surfaces and before handling food. The SDSA acknowledged the importance of handwashing to prevent contamination, and the Dining Services Manager, Director of Nursing, and Administrator reiterated the requirement for staff to follow infection control procedures, including handwashing after touching surfaces like doors or trashcans and before food preparation.
Inadequate Dining Space for Residents
Penalty
Summary
The facility was found to have a deficiency in providing adequate dining space for residents, as observed during a survey. The Station 2 dining room was not large enough to accommodate all residents who wished to eat their meals there, leading to a queue of residents waiting outside the dining room. Observations and interviews with staff and residents confirmed that the dining room could only accommodate 24 residents, while the facility housed 116 residents. This resulted in residents having to wait between five to fifteen minutes to be seated for meals, which was not in line with the facility's policy of providing a structured environment for social dining. Interviews with multiple residents, all of whom had intact cognition as indicated by their BIMS scores, revealed dissatisfaction with the waiting times and the lack of space in the dining room. Staff members, including CNAs and the Dining Services Manager, acknowledged the limited capacity of the dining room. The Director of Nursing expressed the expectation that all residents should be able to eat when they are hungry or ready, but the current first-come, first-served system was not meeting this expectation. The Administrator noted that previous attempts to adjust meal settings had failed, leading to the current system that inadequately addressed the residents' needs for dining space.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for a resident, as observed during a survey. The facility's policy required that the licensed nurse who prepared the medication should administer and document the administration accordingly. However, during an observation, a registered nurse administered benztropine mesylate to a resident but did not sign the medication administration record (MAR) to indicate that the medication had been given. The resident, who had intact cognition, was admitted to the facility in October 2023 and had an active order for benztropine mesylate since January 2021. Attempts to interview the registered nurse responsible for the medication administration were unsuccessful, as the nurse was not available during the surveyor's visits. The Director of Nursing and other staff members acknowledged that the nurse should have documented the administration immediately after the medication was given. Licensed Vocational Nurses interviewed during the survey confirmed that immediate documentation is necessary to prevent errors in medication administration records.
Failure to Follow Linen Soaking Policy
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not following the established policy for handling soiled linen. The policy required that kitchen linen, towels, aprons, and similar items be soaked in a machine or sink using a degreasing presoak or detergent for at least an hour before washing to remove grease and stains. However, during an observation and interview, it was found that two buckets filled with liquid and clothing, covered with a trash bag, were left outside the laundry exit. These clothes belonged to a resident who had heavily soiled their pants, and the staff allowed the items to soak from the previous day, contrary to the policy. Interviews with the Laundry Aid, interim Laundry Manager, Administrator, and Director of Nursing confirmed that the soiled items should have been washed according to the policy. The Laundry Aid admitted to allowing the items to soak, while the interim Laundry Manager and Director of Nursing stated that staff should follow the policy. The Administrator also expressed the expectation that staff adhere to the policy.
Inaccurate MDS Assessment for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident who was receiving respiratory care. The resident, admitted on 07/21/2017, had a medical history of chronic obstructive pulmonary disease (COPD) and was on oxygen therapy due to decreased oxygen levels, acute respiratory failure, and a history of COVID-19 and pneumonia. Despite these conditions, the quarterly MDS assessment dated 06/27/2024 did not reflect that the resident was receiving oxygen therapy, which was a significant oversight given the resident's ongoing treatment. Observations and interviews confirmed the deficiency. On 07/09/2024, the surveyor observed the resident using a nasal cannula with supplemental oxygen. Interviews with Registered Nurse #18 and the Director of Nursing revealed that the resident had been receiving supplemental oxygen therapy since 11/29/2018, and both acknowledged that the MDS should have indicated the resident's use of oxygen therapy. The Administrator also confirmed awareness of the resident's oxygen use and expected the MDS to be accurate, highlighting a lapse in the facility's documentation process.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, admitted on June 1, 2022, had a medical history including schizoaffective disorder, mood disorder, and depression, alongside PTSD. Despite these diagnoses, the resident's care plan and psychosocial assessments did not address trauma-informed care or identify triggers related to PTSD. Interviews with the resident revealed that their trauma and PTSD were not discussed upon admission, and no trauma interview was conducted. The resident expressed that interactions with people of the opposite sex and crowded spaces triggered their PTSD anxiety, yet these concerns were not addressed by the facility. Interviews with various staff members, including CNAs, nurses, and mental health workers, indicated a lack of awareness regarding the resident's PTSD diagnosis and the necessary care to avoid re-traumatization. The Director of Nursing and the Administrator acknowledged the absence of a trauma-informed care policy and assessments for the resident's PTSD. The Administrator expected social services to conduct trauma assessments, but this was not done, leading to a deficiency in providing appropriate care for the resident's condition.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
