National City Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in National City, California.
- Location
- 220 East 24th Street, National City, California 91950
- CMS Provider Number
- 055954
- Inspections on file
- 32
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at National City Post Acute during CMS and state inspections, most recent first.
The facility failed to provide and document required bed-hold notifications and ombudsman transfer notices for two residents who experienced unplanned hospital transfers due to respiratory issues, including shortness of breath and hypoxia. One resident with DM and moderate cognitive deficits was sent to the hospital after a decline in respiratory status, but the 24-hour bed-hold notification was not signed and there was no documented ombudsman notification. Another resident with CHF and severe cognitive deficits was transferred to the hospital for hypoxia, yet the record lacked evidence of bed-hold notification and ombudsman transfer notice. Staff interviews confirmed that, despite established roles for nursing, Social Services, and Medical Records in providing bed-hold information and faxing transfer notices, these notifications were not completed or documented as required.
A resident with a history of Paroxysmal Atrial Fibrillation experienced an unwitnessed fall that was documented in clinical notes but not coded on the quarterly MDS assessment. The MDSN and DON confirmed the fall should have been coded according to RAI guidelines, resulting in inaccurate reporting of the resident's fall history and health status.
A resident with a history of cervical disc disorder was found to have head lice and received appropriate treatment, but staff did not initiate contact precautions or monitor the resident’s former or new roommates for lice during a room change. Both LNs and the DON confirmed that required infection control procedures, including roommate assessment and isolation, were not followed according to CDC guidelines and facility policy.
A resident with glaucoma did not receive prescribed Latanoprost eye drops on multiple occasions because LNs failed to administer the medication and did not notify the DON or ADM about the pharmacy delivery delay, resulting in missed doses and lack of documentation.
Multiple residents and staff reported significant delays in call light response and personal care due to insufficient CNA staffing, particularly when CNAs were assigned to 1:1 monitoring. Family members and private caregivers sometimes had to provide care themselves. Staff interviews and resident council minutes confirmed ongoing issues with unmet care needs, especially during periods of short staffing and lack of a dedicated shower aide. Facility leadership was not fully aware of the extent of these problems.
Surveyors found that two residents' room had insects present and a sliding door screen in disrepair, with one resident using an insect trap due to concern about insects entering. The maintenance supervisor confirmed the insect presence and noted the sliding door was open, which could allow insects inside. These conditions did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with limited mobility and recent surgical wounds developed a stage 2 pressure injury on the coccyx that was not identified until it was already open, and did not consistently receive prescribed wound care treatments. Multiple CNAs and LNs confirmed the resident required assistance with repositioning and that wound care duties were performed by medication nurses without formal wound management training, leading to missed treatments and worsening of the resident's condition.
A resident who preferred a vegan diet and specifically requested tofu did not receive it during her stay, as the CDM failed to obtain the item despite being aware of the request. The facility's policy requires accommodation of resident dietary preferences, but the resident was only provided with some vegan food and not the requested tofu.
A resident with chronic pain conditions did not receive prescribed pain medication for several days because the prescription expired and was not renewed in time. Staff interviews and record reviews confirmed that the resident, who was cognitively intact, repeatedly requested pain relief but was told the medication was unavailable. The process for reordering and renewing the prescription was not followed, and the issue was compounded by the timing over a weekend, resulting in unmanaged pain.
A resident was discharged with opioid medication that was not part of the Nurse Practitioner's plan, due to a failure by the Licensed Nurse to verify the discharge plan. The resident, admitted with a lumbar fracture, was supposed to receive pain management with Gabapentin and acetaminophen. However, the resident was given 12 tablets of hydrocodone/acetaminophen upon discharge, contrary to the NP's instructions. The facility's policy did not require verification of opioid medications with the provider, leading to this oversight.
A resident with End Stage Renal Disease sustained a fracture to the left humerus during a transfer from bed to wheelchair due to the failure of facility staff to use a gait belt, as required by the resident's care plan and facility policy. The incident led to severe pain and the need for hospitalization to place a new dialysis access site. Interviews revealed that the CNAs involved did not adhere to the proper transfer protocol, compromising the resident's safety.
A facility failed to implement appropriate isolation precautions for a resident diagnosed with Covid-19. Upon returning from the hospital, the resident was placed in a room with two roommates without wearing a face mask, and the room was not set up for contact droplet isolation. The Manager of Staff Development and the Director of Infection Prevention acknowledged the oversight, which was contrary to the facility's policy requiring N95 respirators, gloves, gowns, and eye protection. This delay in implementing precautions placed others at risk of exposure.
Failure to Provide Bed-Hold and Ombudsman Transfer Notifications for Unplanned Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required notifications related to emergent hospital transfers and bed-hold rights for two residents. For Resident 1, who had diabetes mellitus and moderate cognitive deficits with a BIMS score of 12/15, nursing staff identified a change in condition when the resident complained of shortness of breath late at night. A licensed nurse obtained orders for a STAT chest X-ray and a breathing treatment, but the resident’s condition continued to decline, and the resident requested transfer to the hospital. Emergency medical services transported the resident to the hospital in the early morning hours. Review of the medical record showed that the 24-hour bed-hold notification section was not signed, and there was no documentation that a Notice of Transfer was sent to the California Long-Term Care Ombudsman Program. Interviews with staff clarified the facility’s internal process and confirmed the lack of required notifications for Resident 1. The Medical Records Director stated that the former Social Services Director was responsible for discharge and transfer notifications, including ombudsman notification, and that Medical Records was responsible for completing and faxing the Notice of Transfer to the ombudsman for unexpected hospital transfers. The Medical Records Director acknowledged that this process was not completed for Resident 1. The Social Services Director stated that Social Services handled advance discharge notifications and obtained fax confirmations, while Medical Records was responsible for ombudsman notification for unplanned hospital transfers, and that nursing staff were responsible for notifying residents and/or responsible parties of the 24-hour bed-hold policy. For Resident 2, who had congestive heart failure and severe cognitive deficits and was rarely or never understood, a licensed nurse reported that the resident experienced hypoxia and that the physician and the resident’s conservator were notified. The resident was assessed by a nurse practitioner, labs were ordered, and the resident was later transferred to the hospital due to hypoxia. Record review for this resident showed there was no documentation of a bed-hold notification or a Notice of Transfer to the ombudsman in the requested records. Although the Medical Records Director stated that the ombudsman was notified of Resident 2’s transfers, the record lacked evidence of such notification. The facility’s transfer or discharge policy indicated that appropriate notice was to be provided to the resident and/or legal representative, but the survey findings showed that required notifications and confirmations related to bed-hold rights and ombudsman notification were not documented for these unplanned hospital transfers.
Failure to Accurately Code Resident Fall on MDS Assessment
Penalty
Summary
The facility failed to accurately code a fall incident on the Minimum Data Set (MDS) for one resident. The resident, who had a history of Paroxysmal Atrial Fibrillation, experienced an unwitnessed fall in her room, as documented in both the Intradisciplinary (IDT) note and a progress note. The fall was not coded on the resident's quarterly MDS assessment, which instead indicated that no fall had occurred since admission or the prior assessment. This omission was confirmed during interviews with the MDS Nurse (MDSN) and the Director of Nursing (DON), both of whom acknowledged that the fall should have been coded according to the Resident Assessment Instrument (RAI) guidelines. The inaccurate coding resulted in the resident's fall not being reflected in the federal database, which is used for care planning and monitoring of fall risks. The resident's care plan had previously identified a risk for falls, but the failure to code the incident on the MDS meant that the assessment did not accurately represent the resident's health status or fall history at the time of the deficiency.
Failure to Implement Infection Control Measures for Lice Infestation
Penalty
Summary
The facility failed to follow proper infection control procedures for a resident who was identified with pediculosis (lice). Upon admission, the resident complained of an itchy scalp and was found to have head lice, for which treatment with permethrin 1% shampoo was ordered and administered. Despite this, the facility did not initiate contact precautions or isolation measures as required by CDC guidelines, and there was no documentation that the resident’s former or new roommates were assessed, screened, or monitored for lice during or after the room change. Both licensed nurses involved confirmed that contact precautions were not implemented and that there was no evidence of monitoring or assessment of the roommates for lice. The Director of Nursing acknowledged that the facility did not follow its own policy or CDC recommendations, which require contact precautions for at least 24 hours after initiation of effective therapy for lice. The DON also confirmed that no monitoring of roommates occurred during the resident’s room transfer and that a sign for precautions was not placed on the door. The facility’s policy indicated that the interdisciplinary team should implement measures to eliminate infestation and prevent spread, but these steps were not documented or carried out in this instance.
Failure to Administer Prescribed Ophthalmic Medication Due to Pharmacy Delay and Lack of Notification
Penalty
Summary
Licensed Nurses (LNs) failed to consistently administer prescribed eye drop medication to a resident diagnosed with glaucoma, as ordered by the physician. The resident was readmitted with a diagnosis that included glaucoma, and the physician's order specified the use of Latanoprost ophthalmic solution for both eyes. A review of the medication administration record (MAR) revealed that the resident did not receive the prescribed eye drops on several dates, and there was no documentation of administration for those days. During a joint review and interview, it was confirmed that the missed doses were due to a delay in the delivery of the medication from the pharmacy. The nurses' notes indicated the medication was not available, but the LNs did not notify the Director of Nursing (DON) or the Administrator (ADM) to expedite the delivery. The facility's policy provided did not address the requirement to follow physician's orders, contributing to the failure to ensure the resident received treatment and care in accordance with professional standards of practice.
Insufficient Staffing Leads to Delayed Resident Care and Unmet Needs
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the daily care needs of residents, resulting in significant delays in responding to call lights and providing personal care. Multiple residents and their family members reported waiting 30 minutes to an hour for assistance with incontinence care and other needs. Certified Nursing Assistants (CNAs) were frequently unavailable due to being assigned to one-on-one (1:1) monitoring of other residents, leaving their assigned residents unattended for extended periods. In some cases, family members or private caregivers had to step in to provide care due to staff unavailability. Observations and interviews revealed that CNAs were responsible for both their assigned residents and those of colleagues who were on 1:1 monitoring, at times resulting in a single CNA being responsible for up to 19-20 residents. CNAs reported being unable to complete their duties, including providing showers, due to the additional burden of 1:1 monitoring and the lack of a dedicated shower aide. Licensed Nurses (LNs) did not assist with call lights or transfers, further exacerbating the delays in care. Resident council meeting minutes from recent months documented ongoing complaints from multiple residents about excessive wait times for assistance and staff not responding to their needs. The Director of Staff Development (DSD) confirmed that there were days when staffing levels were below the minimum required to provide adequate care, particularly on weekends with call-ins. The DSD and CNAs acknowledged that the current staffing practices, including the rotation of CNAs for 1:1 monitoring and the absence of a dedicated shower aide, resulted in neglect of other residents' needs. Facility leadership was unaware of the extent of the issue and the impact on resident care, despite documented complaints and staff concerns.
Insects Observed and Damaged Screen Door Compromise Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and comfortable homelike environment for residents when insects were found in a resident room and the screen of the sliding door was in disrepair. During an unannounced visit, two residents reported the presence of insects, with one resident stating she had placed an insect trap due to fear of insects entering the room. The maintenance supervisor confirmed the presence of a large black insect in the trap and noted that the sliding door was open, which could allow insects to enter. The resident was unsure if the screen door was broken, and the maintenance supervisor indicated that residents sometimes open the sliding door. The facility's policy requires providing a safe, clean, and homelike environment, but these conditions were not met in this instance.
Failure to Timely Identify and Treat Pressure Injuries and Surgical Wounds
Penalty
Summary
The facility failed to timely identify and treat the development of pressure injuries for a resident who was at moderate risk due to limited mobility and required assistance with repositioning. Upon admission, the resident had no pressure wounds on the coccyx, and skin assessments confirmed the absence of such wounds in the following weeks. However, the resident later developed an open wound on the buttocks, which was not identified or reported until it had progressed to a stage 2 pressure injury. Multiple certified nursing assistants confirmed that the resident could not reposition independently and did not refuse assistance, and one CNA reported noticing redness but could not recall to whom it was reported. The facility also failed to consistently provide prescribed treatments for the resident's existing surgical wounds on the right foot and knee. Treatment administration records showed several missed treatments for the resident's surgical sites, including post-amputation and wound vacuum therapies. Interviews with licensed nurses revealed that, due to the absence of a dedicated treatment nurse, medication nurses—who lacked formal wound management training—were responsible for wound care. These nurses reported being overwhelmed with multiple duties, making it unlikely that all treatments were administered as ordered. As a result of these lapses, the resident's surgical wounds did not heal properly, became infected, and ultimately led to further amputations. The director of nursing confirmed that the expectation was for CNAs to report skin changes promptly and for licensed nurses to ensure timely assessment and treatment, which did not occur in this case. The facility's policy emphasized the importance of structured risk assessment and individualized care planning, but these procedures were not effectively implemented for this resident.
Failure to Provide Requested Vegan Food Option
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's stated dietary preferences. The resident, who was admitted following surgery, informed the Certified Dietary Manager (CDM) of her preference for a vegan diet and specifically requested tofu. Despite this request, the CDM acknowledged that tofu was not available in the facility and, although some vegan food was purchased, tofu was not obtained for the resident during her stay. The CDM admitted fault for not fulfilling the resident's preference for tofu. During a review of the resident's clinical and dietary records, facility leadership, including the Administrator, confirmed that the facility is responsible for meeting residents' dietary needs and preferences, including ordering specific requested items such as tofu. The facility's own policy states that menus should be developed to meet resident choices, including religious, cultural, and ethnic needs, while ensuring nutritional adequacy. The failure to provide the requested tofu resulted in the resident not receiving her preferred diet.
Failure to Provide Timely Pain Medication Due to Lapsed Prescription
Penalty
Summary
The facility failed to ensure that a resident with chronic pain conditions, including a chronic left foot ulcer and gout, had access to prescribed pain medication. The resident, who was cognitively intact and able to make decisions, reported running out of pain medication and experiencing pain for several days, which affected his sleep. The care plan instructed staff to medicate the resident as ordered and to advise him to request pain medication before pain became severe. However, staff interviews and record reviews confirmed that the prescription for the resident's pain medication had expired and was not renewed in a timely manner, resulting in the resident not receiving pain relief as needed. Licensed nurses and a CNA confirmed that the resident regularly requested pain medication and that there was no pain medication available for several days. The process for medication reordering was not followed, as no renewal or authorization form was sent to the attending physician before the prescription expired. Staff also indicated that the lack of medication was exacerbated by the timing of the prescription running out over a weekend, making it more difficult to obtain a physician's signature for renewal. The Director of Nursing acknowledged the expectation that pain medications should be available to prevent resident suffering.
Failure to Verify Opioid Discharge Plan
Penalty
Summary
The deficiency involved a failure by Licensed Nurse (LN) 1 to verify a provider's discharge plan regarding opioid medication for Resident 1 upon discharge. Resident 1, who had been admitted with a lumbar fracture, was discharged to a board and care facility. The Nurse Practitioner (NP) had documented a discharge plan that included pain management with Gabapentin and acetaminophen, but not opioids. However, LN 1's discharge summary notes indicated that Resident 1 was discharged with 12 tablets of hydrocodone/acetaminophen, which was not part of the NP's plan. Interviews with LN 2 and LN 3 revealed that the Case Manager was responsible for initiating the discharge process, and LN 1 was responsible for Resident 1's discharge, including medication instructions. LN 2 stated that LNs should verify with the attending physician whether opioid medication should continue upon discharge. The Director of Nursing (DON) confirmed that LNs are expected to verify the discharge plan and reconcile medications, especially opioids, for safety. The facility's policy on discharge did not include verification of opioid medications with the provider, contributing to the oversight.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility staff failed to safely transfer a resident, who was reviewed for pain, from the bed to a wheelchair using a gait belt, resulting in a fracture to the resident's left humerus. The resident, who was admitted with diagnoses including End Stage Renal Disease and dependence on renal dialysis, required total assistance for transfers as per their care plan. On the day of the incident, two CNAs assisted in transferring the resident without using a gait belt, contrary to the facility's policy and the resident's care plan. During the transfer, the resident began to slip, and one of the CNAs grabbed the resident's hand, resulting in a popping sound and subsequent injury. The incident led to the resident experiencing severe pain and the cancellation of their dialysis session, necessitating hospitalization for the placement of a new dialysis access site. Interviews with the CNAs involved revealed a lack of adherence to the proper transfer protocol, as they did not use a gait belt and instead lifted the resident by her arms. The facility's policies clearly stated the requirement for using a gait belt for residents needing assistance with transfers, which was not followed in this case. The Director of Nursing acknowledged the failure to use a gait belt, which compromised the safety of the transfer.
Failure to Implement Covid-19 Isolation Precautions
Penalty
Summary
The facility failed to implement appropriate isolation precautions for a resident diagnosed with Covid-19, which was identified during an annual recertification survey. Upon returning from the hospital, the resident was placed in a room with two other roommates without wearing a face mask, and the room was not set up for contact droplet isolation as required for Covid-19 cases. Instead, one of the roommates was on Enhanced Barrier Precautions (EBP), which did not provide adequate protection against Covid-19, as it did not require a specialized face mask or eye protection. The Manager of Staff Development and the Director of Infection Prevention both acknowledged that the resident should have been placed on contact droplet isolation immediately upon return from the hospital. The facility's policy on Covid-19 management and isolation precautions clearly indicated the need for N95 respirators, gloves, gowns, and eye protection, along with appropriate signage to notify personnel and visitors of the necessary precautions. The delay in implementing these measures placed other residents, staff, and visitors at risk of exposure to Covid-19.
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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