Mercy Retirement & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, California.
- Location
- 3431 Foothill Blvd., Oakland, California 94601
- CMS Provider Number
- 555189
- Inspections on file
- 25
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mercy Retirement & Care Center during CMS and state inspections, most recent first.
A resident with leukemia, severe sepsis, acute kidney failure, and malnutrition experienced ongoing diarrhea with several large loose stools per day and reported feeling punished and mistreated by staff related to frequent bathroom use. Physician orders directed Colace BID, to be held for loose stools, and PRN loperamide after each loose stool, but review of the MAR showed that Colace doses were repeatedly held on multiple days without administration of loperamide. Nursing staff acknowledged the resident continued to have loose stools, that Colace and Ensure were on hold, and that no care plan addressed the diarrhea. The DON confirmed there was no documentation that the physician was notified of the repeated loose stools as a change in condition, despite facility policy requiring physician notification when medications are refused two or more consecutive times.
A resident with multiple chronic conditions did not receive scheduled medications, including antihypertensives and supplements, within the required time frame due to unfamiliarity of new nursing staff with the medication routine. The resident reported delays and inconsistencies, and review of the MAR showed missed and late doses, as well as elevated blood pressure readings. Facility policy requiring timely and accurate medication administration was not followed.
The facility did not complete required reference checks for a CNA before hire, despite policy requiring screening for abuse, neglect, and mistreatment history. After hire, the CNA received multiple complaints from staff and residents, including rough care, poor attitude, and failure to respond to call lights. The lack of reference checks was confirmed by both HR and leadership, and the issue was identified during review of the CNA's employment file and interviews with staff and residents.
Two residents with significant care needs reported incidents of rough care and verbal mistreatment by a CNA. The DSD delayed interviewing the CNA and did not report the allegations to the State Survey Agency, Ombudsman, or law enforcement within the required timeframe, instead waiting until after speaking with the CNA. Both incidents were reported several days after the initial allegations, contrary to facility policy requiring immediate reporting.
The facility failed to follow professional food service safety standards, with an opened tub of ice cream stored without a lid and multiple food items in refrigerators not labeled or dated. These practices violate the facility's policy and could lead to cross-contamination and foodborne illnesses.
The facility failed to follow infection control procedures during medication administration and in droplet precaution rooms. An LVN did not change gloves or perform hand hygiene between tasks, risking contamination. Additionally, staff did not wear appropriate PPE in droplet precaution rooms, increasing the risk of infection spread.
A facility failed to honor a resident's right to self-determination by enforcing a new smoke-free policy, requiring the resident to stop smoking or face discharge. The resident, who had been living at the facility since 2016, was informed of the policy change and its consequences, despite having a history of smoking and a preference for going outside. The facility's actions led to a deficiency in respecting the resident's rights and preferences.
A resident with epilepsy did not receive their prescribed anti-seizure medication, levetiracetam, for five days due to a transition to an EHR system, where the medication order was marked as pending confirmation. The DON confirmed the medication was an active order, but it was not included in the resident's scheduled medications, leading to a lapse in care.
A facility failed to provide proper pharmaceutical services, resulting in a resident not receiving a prescribed Lidoderm patch due to insurance and delivery issues, while an LVN incorrectly documented a refusal. Additionally, hazardous drug handling protocols were breached when an LVN handled finasteride without gloves, posing health risks. The facility's policies for medication administration and safety were not followed, leading to these deficiencies.
The facility failed to act on the Consultant Pharmacist's recommendations for two residents. One resident did not receive necessary thyroid assessments to monitor Levothyroxine therapy, while another resident's pain levels were not documented for PRN narcotic use. The facility did not follow its policy to address these medication therapy irregularities.
Two residents in an LTC facility experienced medication administration errors. One resident with congestive heart failure received pantoprazole after breakfast instead of before, potentially reducing its effectiveness. Another resident with chronic kidney disease did not receive a prescribed Lidoderm patch due to unavailability, and the LPN failed to notify the pharmacy or doctor. The facility's medication error rate was 6.45%, exceeding the acceptable threshold.
The facility failed to ensure proper medication storage and labeling, with an opened box of thickened lemon-flavored water stored at room temperature and various medications stored together in a medication cart without separation by administration route. This practice did not align with the facility's policies and could lead to medication errors.
A resident with a left-hand contracture was injured due to improper placement of a Finger Contracture Cushion, resulting in a severe injury to the pinky finger. The resident was left unattended for over seven hours with the finger tightly inserted in the cushion's ring, leading to discoloration, pain, and an open wound. Staff interviews revealed a lack of awareness and understanding of the proper use of the hand roll, contributing to the oversight.
Failure to Manage and Report Resident Diarrhea and Follow PRN Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services according to professional standards and physician orders for a resident with acute myeloblastic leukemia, severe sepsis, acute kidney failure, and malnutrition. The resident, who had a BIMS score indicating moderately impaired cognition, reported ongoing diarrhea with up to three large loose stools in 24 hours and stated feeling punished due to staff frustration with frequent bathroom use. The physician’s orders included Colace 100 mg, two capsules by mouth twice daily, to be held for episodes of loose stool, and loperamide 2 mg by mouth as needed after each loose stool, with a maximum of 8 mg in 24 hours. Review of the MAR and progress notes for March showed that the 9 a.m. Colace dose was held for loose stools on multiple dates, and both 9 a.m. and 5 p.m. doses were held on additional dates, yet loperamide was not administered on any of those occasions. The resident also reported refusing Colace because it worsened already loose stools. The facility also failed to recognize and report the resident’s multiple episodes of diarrhea as a change in condition to the physician. The DON confirmed there was no documentation that the physician was informed of the repeated loose stools between early February and late March, despite acknowledging that multiple episodes of diarrhea represent a change of condition requiring prompt reporting. RN 1 stated the resident continued to have loose stools and that Colace and Ensure were on hold, but there was no care plan in place for the diarrhea. LVN 1 stated that multiple diarrhea episodes require a change of condition report and that he would not have known about the loose stools unless they were documented in the 24-hour report. The facility’s policy on change in a resident’s condition or status indicated that the nurse should notify the attending physician when a resident refuses a medication two or more consecutive times. Social services notes documented that the resident felt mistreated by a CNA during care, particularly in response to several episodes of diarrhea.
Failure to Administer Scheduled Medications Timely
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including major depressive disorder, anxiety disorder, and essential hypertension, did not receive scheduled medications in a timely manner. The resident reported having to ask repeatedly for medications, and new nursing staff were unfamiliar with the medication administration routine. Observation confirmed that the resident had not received morning medications, including carvedilol, aspirin, ferrous sulfate, multivitamins, and vitamin C, as scheduled. The registered nurse on duty admitted to missing the scheduled administration time due to being new and unfamiliar with the shift routine. Review of the Medication Administration Record (MAR) showed that the resident's blood pressure readings were elevated on several occasions, and that medications were not administered within the facility's required two-hour window. The Director of Staff Development confirmed that delays in medication administration could result in medical conditions not being addressed promptly. Facility policy requires medications to be administered safely, accurately, and in a timely manner, adhering to the six rights of medication administration, which was not followed in this instance.
Failure to Conduct Required Employee Reference Checks Prior to Hire
Penalty
Summary
The facility failed to develop and implement written policies and procedures for screening prospective employees, specifically by not conducting reference checks for a Certified Nursing Assistant (CNA) prior to hire. Although the CNA's employment application listed a former employer and three personal references, Human Resources did not require or complete reference checks, despite the facility's policy stating that all potential employees should be screened for a history of abuse, neglect, exploitation, or mistreatment, including attempts to obtain information from previous employers and references. The Assistant Executive Director confirmed that reference checks were still required and should have been completed by the Director of Staff Development. Following the CNA's hire, multiple complaints were documented regarding the CNA's work performance and behavior, including discrepancies in vital sign documentation, refusal to follow infection control protocols, use of personal devices during work hours, and reports from residents and staff of rough or non-caring behavior and failure to respond to call lights. One resident with moderate cognitive impairment and dependence on renal dialysis reported rough and aggressive care, while another resident filed a grievance about delayed response to call lights. Staff interviews corroborated concerns about the CNA's attitude and lack of responsiveness.
Failure to Timely Report Alleged Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure that allegations of abuse or mistreatment involving two residents were reported to the appropriate authorities within the required timeframe. One resident, admitted with anxiety disorder and requiring assistance with personal care, reported during a resident council meeting that a CNA was rough and aggressive during perineal care. The Director of Staff Development (DSD) did not interview the CNA until four days after the allegation was made, waiting until the CNA was next scheduled to work. The incident was not reported to the State Survey Agency, Long-Term Care Ombudsman, or law enforcement until nine days after the initial report. A second resident, admitted with dependence on renal dialysis and muscle weakness, filed a grievance alleging that the same CNA pointed a finger and made a dismissive comment after the resident expressed frustration over a delayed response to a call light. The DSD received this grievance the day after the alleged incident but delayed interviewing the CNA for two days, again waiting until the CNA was scheduled to work. Both incidents were reported to the required authorities only after the DSD had spoken with the CNA, contrary to the facility's policy, which requires immediate reporting, but not later than two hours after an allegation is made.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. An opened tub of ice cream was found in the freezer without a proper lid, covered only with brown parchment paper. Kitchen staff indicated that the lid was being washed and later admitted they could not find it, opting to temporarily cover the ice cream with paper. This practice does not align with the facility's policy, which requires all opened food items to be properly closed and labeled. Additionally, multiple food items in walk-in refrigerators #1 and #2 were not labeled or dated, which is a violation of the facility's policy. In refrigerator #1, a pan of brown-colored puree food was loosely covered and unlabeled, and several opened boxes of food items lacked opened-on dates. In refrigerator #2, various opened bags of cheese were found without opened-on dates. The Registered Dietician acknowledged these issues and removed the opened bags of cheese, indicating they would be discarded. These lapses in food storage practices have the potential to lead to cross-contamination and foodborne illnesses.
Infection Control Lapses in Medication Administration and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control procedures during medication administration and while managing residents under droplet precautions. On February 11, 2025, a Licensed Vocational Nurse (LVN) was observed administering oral medications to a resident without changing gloves or performing hand hygiene between tasks. The LVN touched the resident's tray table and assisted with drinking before administering eye drops, all without changing gloves, which could lead to contamination. The Director of Nursing (DON) confirmed that the LVN should have changed gloves and performed hand hygiene to prevent the risk of bacterial infection. Additionally, multiple staff members did not wear appropriate Personal Protective Equipment (PPE) in droplet precaution rooms, which are necessary to prevent the spread of infections like the flu. A Housekeeping Aide entered a resident's room, which had signage indicating droplet precautions, without wearing a face shield or protective eyewear. Similarly, a Certified Nursing Assistant (CNA) was observed providing care to a resident in a droplet precaution room with only a mask, which was improperly worn. The Infection Preventionist confirmed that the CNA did not follow the facility's infection control protocol for droplet precautions.
Facility Fails to Honor Resident's Right to Self-Determination in Smoking Policy
Penalty
Summary
The facility failed to honor a resident's right to self-determination by enforcing a new smoke-free policy that required the resident to stop smoking or face discharge. The resident, who had been living at the facility since January 2016, was informed on January 19, 2025, that smoking would not be allowed effective February 19, 2025, and non-compliance would result in discharge. The resident expressed feelings of unfairness due to the sudden change in policy after being a long-term resident. The facility's administrator confirmed the issuance of a letter to the resident, stating the new policy and the consequences of non-compliance, but acknowledged that the resident should be grandfathered in due to their long-standing smoking habit prior to the policy change. The resident's Minimum Data Set (MDS) indicated an intact cognitive status with a Brief Interview for Mental Status (BIMS) score of 15, and a preference for going outside to get fresh air. The facility's Smoke Free Policy, revised on January 10, 2025, required a 30-day notice for residents who were smokers before the policy's implementation. The resident's Safe Smoking Assessment allowed for independent or unsupervised smoking in designated areas, which were no longer available under the new policy. The facility's actions led to a deficiency in respecting the resident's rights and preferences, as the resident was not accommodated under the new policy despite their long-term residency and previous smoking permissions.
Failure to Administer Anti-Seizure Medication
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident diagnosed with epilepsy. The resident did not receive a routine anti-seizure medication, levetiracetam, for five consecutive days as per the physician's order. This lapse occurred after the facility transitioned to an electronic health record (EHR) system, during which the medication order was marked as pending confirmation. The Director of Nursing (DON) acknowledged that the medication should have been administered and that the order was not discontinued by the physician. The Licensed Vocational Nurse (LVN) did not administer the medication because it was not listed in the resident's scheduled medications. The DON confirmed that the medication was an active order and should have been included in the resident's medication administration record. The facility's policy and procedure on medication administration and quality of care emphasize that medications should be administered as ordered by the physician and in accordance with professional standards of practice. The failure to administer the medication as ordered had the potential to cause adverse effects, such as seizures, for the resident.
Deficiencies in Medication Administration and Hazardous Drug Handling
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for its residents. Resident 108, who was admitted with chronic kidney disease and had a BIMS score indicating intact cognitive status, did not receive the prescribed Lidoderm 5% patch for pain relief. The medication was not available because it was not approved by the insurance, and the pharmacy had not delivered it due to a lack of prior authorization and a back order. Despite this, the LVN documented that the resident refused the medication, which was not the case according to the resident's statement. The Director of Nursing acknowledged that the LVN should have notified the doctor and requested an alternative medication. Additionally, the facility did not adhere to proper handling procedures for hazardous drugs. During a medication pass, an LVN handled finasteride, a hazardous drug, without wearing gloves, which is against the facility's policy. The LVN admitted to the oversight, acknowledging the potential risk of unwanted side effects from handling the medication without protective measures. The Director of Nursing emphasized the importance of wearing gloves to prevent direct exposure to hazardous drugs, which could pose significant health risks. The facility's policies and procedures for pharmacy services and handling hazardous drugs were not followed, leading to deficiencies in medication administration and safety protocols. The Consultant Pharmacist confirmed that the facility should have sought an alternative for the unavailable Lidoderm patch and highlighted the risks associated with improper handling of hazardous medications like finasteride. These failures could have resulted in physical discomfort for Resident 108 and health risks for staff handling hazardous drugs.
Failure to Act on Pharmacist's Medication Therapy Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the Consultant Pharmacist (CP) in the medication therapy of two residents were acted upon. For Resident 4, who had multiple diagnoses including hypothyroidism, the facility did not conduct a thyroid assessment to monitor the current therapy with Levothyroxine. Despite recommendations from the CP in November and December 2024 to perform routine thyroid profiles and other blood tests, there was no record of these tests being conducted, and no response from the prescribing physician was documented. For Resident 10, the facility did not clarify the pain assessment and pain level for each PRN narcotic pain medication use with the prescribing physician. The CP's Medication Regimen Review recommended assessing pain using a 1-10 scale and clarifying the pain level for each PRN dose. However, the Medication Record for December 2024 and January 2025 showed that oxycodone-acetaminophen was administered multiple times without documenting the pain level for each dose. The facility's policy and procedure on Medication Regimen Review and Reporting required that findings be communicated to the Director of Nursing and the Medical Director, and that recommendations be documented and acted upon within 30 days. However, the facility did not follow up on the CP's recommendations, leading to a failure in addressing the identified irregularities in medication therapy for both residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents received their medications without error, resulting in a medication error rate of 6.45%. Resident 37, who was admitted with congestive heart failure, had an order for pantoprazole to be administered 30 minutes before breakfast and dinner. However, during a medication pass observation, the LVN administered the pantoprazole after the resident had already eaten breakfast, which could have reduced the medication's effectiveness. The LVN acknowledged the error, and the Director of Nursing confirmed the importance of administering pantoprazole on an empty stomach. Resident 108, diagnosed with chronic kidney disease, had an order for a Lidoderm patch to be applied in the morning for pain relief. During the medication pass, the LVN did not apply the patch because it was not available and did not contact the pharmacy or notify the doctor about the missing medication. The LVN incorrectly documented that the resident refused the patch, which the resident later denied. The Director of Nursing noted that the LVN failed to document the reason for the supposed refusal and should have sought an alternative from the doctor. The facility's medication administration policy requires medications to be administered as ordered and within specified time frames.
Improper Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. An opened box of thickened lemon-flavored water was found on top of a medication cart at room temperature, with a handwritten date indicating it was opened five days prior. The manufacturer's instructions specified that the product should be refrigerated after opening to prevent bacterial growth. Interviews with the LVN and DON revealed a lack of awareness regarding the proper storage requirements and the correct dating of the product upon opening. The facility's policy on food storage emphasized the importance of maintaining appropriate temperatures to prevent foodborne illness, which was not adhered to in this instance. Additionally, the medication cart was found to have various medications stored together without separation by administration route. This included oral medications, eye drops, injectable solutions, and suppositories, which were all stored in the same bin. The DON acknowledged that this practice did not align with the standard of practice, which requires medications to be stored separately to prevent confusion and potential medication errors. The facility's policy on medication storage also highlighted the need for proper organization to maintain medication integrity and support safe administration.
Improper Use of Hand Roll Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper placement of a Finger Contracture Cushion, commonly known as a hand roll, on a resident's left hand. The resident, who had a diagnosis of a left-hand contracture and was at high risk of developing skin injuries, was left unattended with the pinky finger tightly inserted in the last ring of the cushion for over seven hours. This improper placement led to the resident sustaining an injury to the left pinky finger, characterized by purplish discoloration, pain, bleeding, and an open wound, necessitating a transfer to an acute care hospital for further treatment. The incident occurred when the resident was under the care of different staff members throughout the day. The Restorative Nursing Aide (RNA) responsible for placing the hand roll was not on duty on the day of the incident. Certified Nursing Assistant (CNA) 1, who was on the morning shift, stated that she placed the hand roll on the resident's left hand but did not insert the fingers into the loops. CNA 2, who was on the evening shift, discovered the issue when she noticed the resident's discomfort and observed the pinky finger inserted in the tight ring, causing discoloration. Despite the presence of staff, the resident's condition went unnoticed for several hours. Interviews with the nursing staff revealed a lack of awareness and understanding of the proper use of the hand roll. RN 1, who was alerted by CNA 2, was unsure if the pinky finger was supposed to be in the ring and struggled to remove it safely. RN 2, the charge nurse, was unaware of the resident's need for a hand roll and did not notice its use during his shift. The progress notes documented by RN 1 indicated the severity of the injury, with the finger almost falling off and bone visible, leading to the resident's transfer to the hospital for treatment of an acute infection at the wound site.
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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