Manresa Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Watsonville, California.
- Location
- 919 Freedom Blvd, Watsonville, California 95076
- CMS Provider Number
- 056178
- Inspections on file
- 17
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Manresa Healthcare Center during CMS and state inspections, most recent first.
The facility failed to submit a follow-up investigation report to the SSA within five days after an altercation between two residents. The Director of Nursing and the MDS Coordinator were unaware of the requirement, and the Administrator confirmed no report was sent, citing a lack of awareness of the policy. The facility's policy mandates a follow-up report within five business days, detailing investigation results and corrective actions.
The facility failed to ensure proper food safety, service, and sanitation practices, did not follow approved menus and recipes for therapeutic diets, and the Certified Dietary Manager lacked required state education on dietetic services. These deficiencies were observed during kitchen tours and interviews, revealing non-compliance with facility policies and state regulations.
The facility failed to ensure staff competency in the food and nutrition service, with kitchen aides improperly testing dishwasher sanitizer levels, dumping trash into sinks with dirty dishes, and washing hands inadequately. A cook incorrectly calibrated a thermometer and did not follow proper food cool down procedures, while a preparatory cook lacked knowledge of cooling techniques for cold foods. These deficiencies risked exposing residents to foodborne illnesses.
The facility failed to follow food safety practices, including storing a dirty utensil with clean ones, improper ice machine sanitation, unlabeled food in the refrigerator, lack of a 3-compartment sink, absence of air gaps to prevent backflow, and inconsistent dish machine temperatures. These issues could expose residents to foodborne illnesses.
The facility failed to submit the required PBJ staffing information to CMS for Q4 2023. The Payroll Clerk admitted to being late and missing the February 14th deadline. The facility's policy mandates daily collection and quarterly reporting of staffing information, which was not followed.
The facility failed to follow its oxygen administration policies for seven residents. One resident did not have an 'oxygen in use' sign outside his room, and six other residents had undated oxygen humidifier bottles and tubing, contrary to the facility's policy requiring weekly changes and proper labeling.
The facility failed to follow standardized recipes and menus approved by the RD, serving rice instead of sodium-free noodles for a Liberal Renal diet and inappropriate pureed vegetables for a puree diet. These deviations were confirmed through observations and interviews with the CDM and RD, highlighting non-compliance with facility policies.
The facility failed to implement proper infection control practices, including hand hygiene and the availability of PPE carts, for four residents. A nurse did not perform hand hygiene when handling a resident's PICC line, and PPE carts were missing outside the rooms of three residents requiring PPE.
The facility failed to follow its policies on medication self-administration for a resident with moderately impaired cognition. The resident used an expired Ventolin inhaler, which was ineffective, and the facility did not conduct an IDT assessment to determine if it was safe for the resident to self-administer medications. The expired medication was not removed from the resident's bedside as required by policy.
The facility failed to develop a care plan to address smoking for a resident admitted with multiple diagnoses, including cellulitis and arthritis. Despite the resident having a scheduled smoking routine, no care plan was developed, which was confirmed by the DON. Facility policies require comprehensive care plans within 48 hours of admission.
A facility failed to ensure a resident remained free from accident hazards due to the use of a bed rail without a proper assessment. The resident, admitted with palliative care, dementia, and diabetes, was observed with half side rails raised on the bed. The DON and an LVN confirmed that no assessment was conducted, contrary to the facility's policy on bed safety.
The facility failed to maintain a medication error rate of less than 5%, with an LVN administering brimonidine and dorzolamide eye solutions to a resident without waiting the required 5 minutes between different eye medications, resulting in an 8% error rate.
Failure to Submit Follow-Up Investigation Report to SSA
Penalty
Summary
The facility failed to submit a full investigation report to the State Survey Agency (SSA) within five days after an initial report of an altercation between two residents. This deficiency was identified during an interview and record review involving the Director of Nursing (DON) and the Minimum Data Services Coordinator (MDSC). The MDSC indicated that the person who witnessed the event should send the initial report to the SSA, but they assist in sending it. However, the MDSC was unaware of any follow-up report being done after five days, suggesting that the abuse coordinator, who is also the Administrator, would have that information. During an interview with the Administrator, it was confirmed that no report was sent five days after the initial report. The Administrator expressed a lack of awareness regarding the requirement to send a follow-up report within five days. The facility's policy, titled 'Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating,' last revised in September 2022, clearly states that a follow-up investigation report should be provided within five business days of the incident, detailing the results of the investigation and any corrective actions taken if the allegation was verified.
Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the Food and Nutrition Services Department staff were able to correctly demonstrate kitchen tasks in food safety, service, and sanitation. During observations, staff were unable to correctly test the sanitizer strength for the dish machine, and the cool down process for cooked food was not properly followed or documented. Additionally, the ice machine was not cleaned according to the manufacturer's guidelines, and a proper 3-compartment sink system for cleaning, rinsing, and sanitizing was not established. These failures were observed during multiple kitchen tours and interviews with staff, revealing a lack of adherence to facility policies and standards of practice. The facility also did not follow approved menus and recipes for residents with therapeutic diets. During meal preparation and service, staff served incorrect side dishes and did not use standardized recipes for pureed vegetables, which included inappropriate ingredients. These discrepancies were confirmed through observations, interviews, and record reviews, indicating a failure to meet the nutritional and dietary needs of residents as per the facility's policies. Furthermore, the Certified Dietary Manager (CDM) did not meet the required state of California education requirements for dietetic services. The CDM admitted to not having the necessary hours of education on Title 22 regulations and was unfamiliar with these requirements. This lack of proper qualifications and training was acknowledged by both the CDM and the Registered Dietitian (RD), highlighting a significant oversight in the facility's compliance with state regulations for dietary services supervision.
Deficiencies in Food and Nutrition Service Staff Competency
Penalty
Summary
The facility did not ensure that staff performed their job functions competently according to standards of practice in the food and nutrition service. Two kitchen aides were observed improperly testing the level of dishwasher sanitizer, with one aide using standing water on the counter and another using standing water in the dishwashing machine compartment. Both aides were unaware of the correct parts per million (PPM) levels required for effective sanitization. Additionally, one kitchen aide was seen dumping trash can debris into a sink compartment containing dirty dishes, and another was observed washing his hands with only water after handling garbage, then touching dishes needing to be cleaned. These actions indicate a lack of adherence to proper sanitization and infection control procedures as outlined in the facility's policies and job descriptions. A cook was observed calibrating a thermometer incorrectly and was unable to verbalize the proper cool down process for food. The cook believed the thermometer should read 30 degrees when calibrated, contrary to the facility's in-service training which specifies the boiling point method at 212 degrees Fahrenheit and the ice point at 32 degrees Fahrenheit. The cook also failed to mention the required time frames for cooling down food, which should be from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and from 135 degrees Fahrenheit to 41 degrees Fahrenheit within 6 hours. The facility's cool down log sheet for April 2024 was found to be blank, indicating a lack of proper documentation and monitoring. A preparatory cook was interviewed and did not specify time intervals or cooling techniques when preparing cold foods such as tuna salad or chicken salad. The facility's in-service training and FDA Food Code require that such foods be cooled down to 41 degrees Fahrenheit within 4 hours if prepared from ingredients at ambient temperature. The preparatory cook's lack of knowledge and adherence to these guidelines further highlights the deficiencies in staff training and competency. These failures to follow proper food safety and infection control procedures had the potential to expose residents to foodborne illnesses.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility did not ensure food safety practices were followed according to facility policy and standards of practice. A dirty cooking utensil was stored with clean utensils, and the ice machine reservoir tray had black colored debris and was not sanitized correctly. Additionally, food in the walk-in refrigerator was not labeled with an opened-on date and use-by date. The kitchen also lacked a 3-compartment sink system for manually washing, rinsing, and sanitizing dishes, and the 2-compartment sink used did not have an air gap to prevent backflow of dirty water. Furthermore, the low-temperature dish machine did not consistently reach 120 degrees Fahrenheit over three cycles. These failures had the potential to expose vulnerable residents to potential contaminants that may cause foodborne illnesses. During an initial kitchen tour, a whisk with brown food debris was observed hanging with other clean utensils. The kitchen aide and certified dietary manager acknowledged the whisk was dirty and should not have been stored with clean utensils. The ice machine reservoir tray was found to have black sediment residue, and the maintenance assistant admitted to not following the manufacturer's cleaning instructions. Food items in the walk-in refrigerator and a smaller refrigerator were found without proper labeling, and the certified dietary manager confirmed that all food must be labeled with an opened date and a use-by date. The kitchen was observed to have a 2-compartment sink instead of the required 3-compartment sink for manual dishwashing. The certified dietary manager was unaware of the need for three compartments. Additionally, the 2-compartment sink, ice machine, and vegetable washing sink did not have air gaps to prevent backflow. The low-temperature dish machine was observed to not consistently reach the required temperature of 120 degrees Fahrenheit, and the kitchen aide confirmed the temperature should be between 120-150 degrees Fahrenheit. These deficiencies indicate a failure to adhere to proper food safety practices, potentially exposing residents to foodborne illnesses.
Failure to Submit PBJ Staffing Information for Q4 2023
Penalty
Summary
The facility failed to submit the required Payroll Based Journaling (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS) for the last quarter of 2023, covering October, November, and December. This deficiency was identified during a review of the PBJ Staffing Data Report, which indicated that the data for the specified quarter was not submitted. During an interview, the Payroll Clerk responsible for submitting the data admitted to being late and failing to submit the information before the February 14th deadline. The facility's Policy & Procedure on Reporting Direct Care Staffing Information, dated 2022, mandates that staffing information be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting period, which was not adhered to in this instance.
Failure to Follow Oxygen Administration Policies
Penalty
Summary
The facility failed to follow its Policy and Procedure as well as professional standards of practice regarding oxygen administration for seven residents. Specifically, Resident 23 did not have an 'oxygen in use' sign outside his room, which is necessary to alert staff and visitors of the oxygen being used in the room. This was confirmed during an interview with an LVN who stated that Resident 23 had started receiving oxygen after returning from the hospital. The facility's policy on oxygen administration, dated 2010, requires 'No Smoking/Oxygen in Use' signs to be displayed when oxygen is being administered. Additionally, the facility did not properly label and promptly replace oxygen humidifiers and tubing for six other residents. Observations revealed that the oxygen humidifier bottles for Residents 2, 10, 16, 25, 46, and 157 were undated. Resident 16's nasal cannula was also found to be dated 3/30/24, indicating it had not been replaced in a timely manner. Interviews with LVNs and the DON confirmed that the humidifier bottles and tubing should be dated and changed weekly, as per the facility's policy on oxygen administration. The failure to adhere to these guidelines was evident in the observations and interviews conducted during the survey.
Failure to Follow Standardized Recipes and Menus
Penalty
Summary
The facility failed to follow standardized recipes and menus approved by the facility's Registered Dietitian (RD). Specifically, rice was served instead of sodium-free noodles for a resident on a Liberal Renal diet, and the puree diet did not receive an appropriate pureed vegetable for the lunch meal. These deviations from the approved menu and recipes were observed during meal times and confirmed through interviews with the Certified Dietary Manager (CDM) and the RD. The CDM admitted to having all necessary ingredients in stock but could not explain the substitution of rice for noodles. The RD confirmed that sodium-free noodles should have been served as per the menu for the Liberal Renal diet. Additionally, the CDM prepared a mixture of cooked broccoli and tomatoes for the pureed diet without following a standardized recipe. The facility's therapeutic menu spreadsheet and the pureed recipe preparation policy explicitly stated that fibrous vegetables like broccoli should be omitted from pureed diets. The RD acknowledged that the residents should not have received the pureed cooked broccoli and tomato mixture. The facility's policies on food preparation and menu planning were reviewed, indicating that approved recipes and standardized methods should be used to meet residents' nutritional needs. These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the residents' nutritional status.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection control practices for four of seven sampled residents. Specifically, a registered nurse did not perform hand hygiene when handling a resident's peripherally inserted central catheter (PICC) line. During a medication observation, the nurse administered an antibiotic via the PICC line and subsequently touched the overbed table and IV pump without performing hand hygiene. When an alarm indicated air in the IV line, the nurse disconnected the IV tubing from the PICC line without washing hands or applying new gloves. The nurse acknowledged the failure to perform hand hygiene during a concurrent interview. The facility's hand hygiene policy requires handwashing after contact with inanimate objects in the patient's vicinity, which was not followed in this instance. Additionally, the facility did not have personal protective equipment (PPE) carts outside the rooms of three residents who required PPE for care. Observations revealed that there were no PPE carts outside the rooms of these residents, despite signage indicating the need for PPE. Both a licensed vocational nurse and the infection preventionist confirmed the absence of PPE carts. The facility's policies and the Centers for Disease Control and Prevention (CDC) guidelines require the availability of PPE and hand hygiene at the point of care, which were not adhered to in these cases.
Failure to Implement Medication Self-Administration Policies
Penalty
Summary
The facility failed to implement their policies on medication self-administration for Resident 157. The resident, who had moderately impaired cognition with a BIMS score of 9, was found with an expired Ventolin inhaler in her slightly open purse on top of her bed. The resident confirmed using the expired inhaler for difficulty breathing, which was ineffective, leading to the need for supplemental oxygen. The facility did not conduct an IDT assessment to determine if it was safe for the resident to self-administer medications, and the expired medication was not removed from the resident's bedside as required by the facility's policy. During an observation and interview, the DON confirmed the expiration of the inhaler and acknowledged the importance of regularly checking medications stored at bedside. The resident was unaware of the expiration date and insisted the inhaler was still usable. The facility's policy mandates that the IDT assess each resident's ability to self-administer medications and ensure safe storage, which was not followed in this case. This oversight had the potential for unsafe and improper administration of medications.
Failure to Develop Smoking Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan to address smoking for Resident 255, who was admitted with diagnoses including cellulitis of the right lower limb, arthritis due to other bacteria in the right knee, an unspecified right hip open wound, and a history of smoking. Despite the resident having a scheduled smoking routine outside the facility, accompanied by staff, there was no care plan developed to address this need. The Director of Nursing (DON) confirmed that a smoking assessment was completed on 4/3/24, but a baseline care plan was not developed within the required 72-hour timeframe. The facility's policy and procedure titled 'Care Plans - Baseline' requires that a comprehensive care plan be developed within 48 hours of the resident's admission. Additionally, the policy titled 'Care Planning-Interdisciplinary Team' mandates that comprehensive, person-centered care plans be based on resident assessments and developed by an interdisciplinary team (IDT). The failure to develop a care plan for Resident 255's smoking needs was verified by the DON during a concurrent interview and record review.
Failure to Conduct Bed Rail Assessment
Penalty
Summary
The facility failed to ensure that Resident 30 remained free from accident hazards due to the use of a bed rail without a proper assessment. Resident 30, who was admitted with diagnoses including palliative care, unspecified dementia, and type 2 diabetes mellitus with diabetic nephropathy, was observed with half side rails raised on the bed. However, no assessment for the use of side rails was conducted, as confirmed by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). Both acknowledged that an assessment should have been done for the safety of the resident. The facility's policy on bed safety and bed rails indicates that the use of bed rails is prohibited unless specific criteria are met and alternatives have been attempted. Despite this policy, the necessary interdisciplinary evaluation and risk assessment for Resident 30 were not performed. This oversight had the potential to put Resident 30 at risk for entrapment and serious injury, as the required safety protocols were not followed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 2 medication errors out of 25 opportunities, resulting in an 8% error rate for one resident observed during medication administration. Specifically, a licensed vocational nurse (LVN) administered brimonidine and dorzolamide eye solutions to a resident without waiting the required 5 minutes between different eye medications. This action was contrary to the facility's policy and accepted professional standards of practice. The Director of Nursing confirmed that the nursing staff should wait 5 minutes between administering different eye medications, as per the facility's guidelines revised in January 2014.
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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