Northvine Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 446 Arrowood Dr, Santa Rosa, California 95407
- CMS Provider Number
- 056259
- Inspections on file
- 40
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Northvine Postacute Care during CMS and state inspections, most recent first.
A resident with respiratory failure, recent pulmonary emboli, muscle weakness, and impaired mobility had MD orders and a care plan for skilled PT five times per week for four weeks, including therapeutic exercises, activities, neuro re-ed, gait training, and training. During a transition from a contracted rehab provider to in-house rehab, the facility ended its external contract and had only an OT available, with no PT on staff and a PTA not yet started. The OT confirmed that only OT services could be provided and that the resident did not receive the ordered PT. The DON verified the active PT order, and RNA staff reported the resident was not on the restorative list. The resident reported not having PT appointments despite expressing a need to walk, while facility policy required therapy to be scheduled per the treatment plan.
Multiple residents and staff reported and observed flies in common areas and resident rooms, with torn window screens found in several rooms. Flies were seen on fly paper, windowsills, and buzzing around, and residents expressed annoyance at their presence. The maintenance worker had no record of screen repairs or proactive pest prevention, and the administrator was unaware of the issue until informed.
Three pleather chairs in a hallway were found to be cracked, worn, and unable to be properly disinfected, with one used by a resident and another moved by a guest. The IP confirmed the chairs' poor condition and infection control concerns, stating the issue had been reported to the previous Administrator without action.
A resident with Alzheimer's disease and behavioral disturbances exhibited physical aggression toward two other residents when staff were unable to consistently implement or verbalize the care plan interventions designed to manage her aggression. Staff interviews revealed a lack of familiarity with the resident's triggers and care plan, and the resident was not removed from congested areas as required, resulting in multiple incidents of aggression.
Three residents with muscle weakness and personal care needs were observed to have long, jagged, and dirty fingernails, with some nails containing brown debris. Staff confirmed that nail care was inconsistent and not prioritized, despite facility policy requiring regular cleaning and trimming. One resident had scratches from self-inflicted nail injuries, and staff acknowledged the deficiency in providing necessary grooming assistance.
A resident with severe cognitive impairment and multiple diagnoses developed a UTI and experienced constipation, but nursing staff did not initiate or implement care plans for these conditions. Despite being prescribed antibiotics and having bowel care protocols in place, interventions were not documented or carried out, and staff acknowledged these omissions were not in line with facility policy.
The facility failed to follow professional standards for food safety, including serving sandwiches at unsafe temperatures, not monitoring food and storage temperatures, improper dishwashing and sanitation practices, and staff not wearing required protective clothing. These actions placed most residents at risk for foodborne illness.
Facility administration did not complete required kitchen repairs after a health inspection report identified a grease trap in disrepair and non-compliance with food safety codes. This inaction led to the suspension of the facility's food permit and interruption of food services for nearly all residents when wastewater overflowed in the kitchen.
The facility did not address a CDHS inspection report identifying a disrepair in the kitchen's grease trap, failing to include the issue in QAPI activities or initiate repairs. This inaction resulted in wastewater overflowing onto the kitchen floor and the suspension of the facility's Retail Food Permit, interrupting food services for nearly all residents.
The facility did not ensure an effective pest control program, resulting in rodent and fly infestations in both the offsite commissary kitchen and a temporary dietetic service space. Observations included chewed food packaging, rodent droppings, nesting materials, and flies present in food service areas, with improper storage and sanitation practices noted. These deficiencies had the potential to cause foodborne illness for nearly all residents receiving food from the kitchen.
A resident's abuse allegation was not reported to the appropriate agencies within the required 2-hour timeframe. The incident involved a staff member using vulgar language towards the resident, which was reported by the resident's brother-in-law. Despite the facility's policy, the report was delayed, and staff interviews confirmed the failure to adhere to reporting protocols.
A facility failed to suspend an unlicensed staff member accused of verbal abuse against a resident with muscle weakness and anxiety disorder. Despite the facility's policy requiring immediate suspension during abuse investigations, the staff member continued working, only being reassigned to another room. This action compromised the investigation and resident safety.
The facility failed to maintain an effective pest control program, leading to a fly infestation affecting residents' comfort and food safety. Flies were observed in residents' rooms and the kitchen, causing disturbances during meals and rest. Despite a pest control policy, the facility did not adequately address the fly issue, focusing instead on ants and rodents.
The facility failed to provide four residents with their Baseline Care Plans and medication lists upon admission, as required. This deficiency was confirmed through interviews with the residents and facility staff, revealing that the usual process was not followed due to the absence of social service staff.
A facility failed to follow the Restorative Nursing Assistant (RNA) process for a resident with hand contractures. The resident, dependent on staff for care, had a physician's order for splint application for 2 to 4 hours daily, but the RNA only applied it for 30 minutes. The Director of Rehabilitation confirmed the minimum effective time was 2 hours, and the RNA process, including documentation and meetings, was not followed, potentially risking further contracture.
A resident with depression and persistent mood disorder was not provided necessary behavioral health care services, despite exhibiting behaviors such as crying, self-isolation, and hallucinations. Staff were unable to determine the cause of her distress, and the facility lacked behavioral health services, leaving the resident's needs unmet.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, increasing the risk of MDRO transmission. Residents requiring wound care or with devices like Foley catheters and G-tubes were not placed on EBP, and staff were not trained. Additionally, a service technician entered the kitchen without a hairnet or beard cover, violating hygiene protocols.
A facility failed to notify the Ombudsman and provide an appropriate discharge notice when a resident with Alzheimer's and severe cognitive impairment was transferred to the ED. The Interim DON confirmed the oversight, and interviews revealed staff were unaware of the policy requiring Ombudsman notification. The facility's policy mandates notification within 24 to 48 hours, but this was not adhered to.
A facility failed to complete the MDS Discharge Assessment for a resident with Dementia and Alzheimer's Disease, who was mostly dependent on staff. The missing assessment was confirmed by the Interim Director of Nursing, and the MDS Coordinator acknowledged delays in MDS assessments, which could lead to inaccurate data. The facility's policy requires comprehensive assessments, which was not followed in this instance.
A resident experienced severe weight loss due to the facility's failure to notify the physician of the RD's recommendation for a nutritional supplement. Despite the RD's recommendation for Med Pass to aid in wound healing, the facility delayed implementation for nearly two months, resulting in continued weight loss. Communication breakdowns among staff contributed to the deficiency.
A facility failed to report an alleged abuse incident involving a resident with intact cognition and multiple diagnoses within the required 2-hour timeframe to CDPH, the Ombudsman, and the local PD. The incident occurred in the morning, but the local PD was notified later that afternoon, and the Ombudsman was informed days later. The facility's policy mandates immediate reporting of such incidents, which was not adhered to, as confirmed by the Administrator and Interim DON.
A resident with a complex medical history, including quadriplegia and bipolar disorder, was verbally abused by a staff member in an LTC facility. The staff member was recorded making derogatory remarks and threats, causing emotional distress to the resident. The facility's abuse prevention policy was not upheld, leading to this deficiency.
A facility failed to manage its phone system, leading to unanswered calls and communication breakdowns. This resulted in a resident not receiving Paxlovid for COVID-19 treatment for five days and a complainant unable to reach staff. The receptionist was unaware of the phone system's mailbox setup, and the facility's policy on phone answering was not effectively implemented.
Two residents experienced significant medication errors at the facility. One resident did not receive Paxlovid for COVID-19 due to a failure in pharmacy communication, while another received an incorrect dose of Duloxetine HCI, leading to distress and refusal of the correct dose. These incidents highlight a failure to adhere to medication administration policies.
A long-term care facility failed to provide a functioning call light system for two residents, one with muscle weakness and spinal cord disease, and another dependent on staff for personal care. Despite requests for a touch pad due to difficulty using the call button, no action was taken, leaving residents without a reliable means to call for assistance. Staff were unaware of the issues, and maintenance logs were not checked, leading to significant safety and communication concerns.
A resident with muscle weakness and spinal cord disease was allowed to vape in his room without supervision, contrary to the facility's smoking policy. Staff, including the SSD, ADM, CNAs, and LN, were aware of the resident's actions but did not enforce the policy, citing difficulty in getting the resident out of bed. The facility's policy prohibited smoking, including vaping, inside, yet the resident continued to vape indoors, exposing roommates to secondhand aerosol.
Two residents in an LTC facility had their attending physician changed without their consent, violating their right to choose. Despite being self-responsible, the residents were transferred to the care of the facility's Medical Director without documentation of their request or consent. Staff interviews confirmed the oversight, and facility policies were not followed.
A resident received an incorrect dosage of Duloxetine HCI Delayed Release from an RN, who administered 60 mg instead of the physician-ordered 30 mg. This error was discovered during a Care Conference when the resident expressed dissatisfaction with the physician's refusal to increase the dosage. The resident, admitted with conditions like sciatica and depression, refused the correct dosage after the error. Facility policies on medication administration were not followed.
A resident with a full code status unexpectedly expired, and the facility failed to follow its death protocol. An LVN pronounced the death instead of a registered nurse or physician, and staff did not perform CPR or call 911. Additionally, the mortuary was not informed about the need for an autopsy, contrary to the facility's policy for unexpected deaths.
Failure to Provide Ordered Physical Therapy During Rehab Service Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered rehabilitative services, specifically PT, to a resident in accordance with physician orders and the care plan. Resident 1 was admitted with acute and chronic respiratory failure, recent pulmonary emboli, muscle weakness, and a need for assistance with personal care. The MDS dated 1/6/26 indicated no memory impairment. Physician orders dated 12/30/25 directed skilled PT services five times per week for four weeks, including therapeutic exercises, therapeutic activities, neuro re-education, gait training, and patient/caregiver training. The resident’s care plan, initiated the same day, identified generalized weakness, impaired functional mobility, balance deficits, and increased need for caregiver assistance, with interventions that included the same ordered PT services. During interviews and record review, surveyors found that these PT services were not provided. The Administrator reported that the facility ended its contract with the outside rehab provider at the start of the year and was transitioning to in-house rehab staff, with only one OT hired from the former contractor and a PTA scheduled to start later. The OT confirmed that since the contract ended, no PT, OT, or SLT staff from the outside provider had come to the facility and that, at the time of the survey, the facility could only provide OT services. The OT stated the facility did not have a PT, so the resident did not receive the ordered PT. The DON acknowledged the PT order in the electronic record and stated most of the resident’s PT was due during the transition period. The RNA staff reported the resident was not on the restorative list and had not been discharged from PT to restorative services. The resident reported needing PT to be able to walk, stated she had not had any PT appointments, and recalled only possibly seeing a therapist once with a promise that therapy would start soon. The facility’s policy on scheduling therapy services required that therapy be scheduled in accordance with the resident’s treatment plan, which did not occur for PT in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in common hallways and multiple resident rooms, as well as torn window screens in four resident rooms. Observations included a strip of fly paper with dead and live flies in one resident's room, flies seen flying in other rooms, and dead flies on windowsills. Several residents reported frequent fly activity in their rooms, expressing annoyance and concern. In one instance, a resident's bedside table contained an open urinal and partially eaten food, which could attract pests, and the window screen in that room was torn. The maintenance worker was unable to locate any work orders for window screen repairs and confirmed that pest prevention was not proactively addressed. The administrator was unaware of the fly problem until interviewed and acknowledged that flies in the facility posed a significant issue. The facility's policy stated that an ongoing pest control program should be maintained to keep the building free of insects, but observations and interviews indicated this was not effectively implemented.
Worn and Unsanitary Chairs Compromise Clean, Homelike Environment
Penalty
Summary
Three wooden chairs with pleather seats and armrests located in the Garden Hall were observed to be cracked, flaky, and worn-out, exposing discolored and coarse fabric fibers. These chairs were available for use by residents and guests, with one chair being moved into a resident room by a guest and another being used by a resident. The condition of the chairs was confirmed during an interview and observation with the Infection Preventionist (IP), who stated that the chairs were torn and had worn-out cushions. The IP identified the chairs as an infection control concern, noting that their condition prevented proper disinfection. The IP explained that if a resident who was wet sat in the chair, moisture could seep through the cushion, making it impossible to clean and disinfect. The IP also stated that she had reported the issue to the previous facility Administrator, but no action had been taken. Facility policies reviewed indicated that environmental surfaces should be disinfected regularly and that infection prevention measures should be instituted, but the condition of the chairs did not meet these standards.
Failure to Protect Residents from Aggressive Behavior Due to Inadequate Implementation of Care Plan
Penalty
Summary
The facility failed to protect residents from aggressive behavior exhibited by a resident with Alzheimer's disease and dementia with behavioral disturbance. This resident had a documented history of striking, spitting, grabbing, refusing care, and throwing objects, with behaviors escalating in areas of increased stimulation or congestion. Despite these known behaviors and a care plan intervention to remove the resident from overstimulating environments, staff were unable to consistently articulate or implement the care plan strategies to manage the resident's aggression. On two separate occasions, the resident became physically aggressive with other residents. In one incident, the resident hit another resident when their wheelchairs became stuck together in a hallway. In another, the resident struck a different resident with a piece of paper while being moved through a congested area. Staff present during these incidents attempted to manage the situation but were unable to prevent the aggressive acts. Interviews with staff revealed a lack of familiarity with the resident's specific triggers and care plan interventions, with several staff members stating they simply tried to keep a close eye on the resident or distract her when agitated. Record review and staff interviews confirmed that the care plan included removing the resident from areas of increased stimulation to minimize agitation, but this intervention was not consistently followed. The facility's abuse and neglect policy required staff to be knowledgeable about residents' care needs and appropriate interventions for aggressive behaviors, but staff assignments changed daily and not all staff were aware of or able to verbalize the care plan. Leadership discussed the resident's behavior after the incidents, but there was no clear plan communicated to manage the aggression toward other residents.
Failure to Provide Adequate Nail Care and Grooming
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living, specifically in maintaining good grooming and nail care, for three residents who required help due to generalized muscle weakness and the need for personal care. Observations revealed that all three residents had long, jagged, and dirty fingernails, with some nails having brown debris underneath. One resident was noted to have multiple scratches on her forearm caused by scratching herself, and staff confirmed that nail care had not been provided as needed. Interviews with staff, including a CNA and the DON, confirmed that nail care was not consistently performed and was often deprioritized when staff were busy. The facility's own policy required regular cleaning and trimming of nails to prevent skin problems and injuries, but this was not followed. The lack of proper nail care was directly observed and acknowledged by staff, and records confirmed the residents' need for assistance with personal care.
Failure to Initiate and Implement Resident-Centered Care Plans for UTI and Constipation
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate and implement resident-centered care plans for a resident who developed a urinary tract infection (UTI) and experienced constipation. The resident, who had a history of hemiplegia, hemiparesis, vascular dementia, anxiety, and muscle weakness, was admitted with significant cognitive impairment. After leaving the facility with her sister, the resident was hospitalized for stomach pain and diagnosed with an acute UTI, receiving treatment before returning to the facility. Despite being prescribed antibiotics for the UTI, nursing staff did not initiate a care plan specific to the UTI or antibiotic treatment, as confirmed by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). Both acknowledged that a care plan was not created, which was not in line with facility policy, and that typical interventions such as increased hydration and monitoring for systemic infection were not formally directed. Additionally, the resident experienced three days without a bowel movement, but no bowel care medications were administered as per the facility's bowel protocol. The care plan for constipation included interventions such as administering Milk of Magnesia and Dulcolax suppository if needed, but these were not implemented or documented. The DON was unable to confirm whether the resident received bowel care management or if it was simply not documented. The LVN stated that bowel care interventions are triggered in the electronic health record after three days without a bowel movement, but there was no evidence that these interventions were carried out. Facility policies required that care plans be reviewed and updated when there is a significant change in a resident's condition, and that nursing staff adjust treatment based on ongoing assessment. In these instances, the lack of initiation and implementation of care plans for both the UTI and constipation represented a failure to provide resident-centered care as outlined in facility protocols.
Multiple Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that tuna and chicken salad sandwiches did not reach safe internal serving temperatures, with measurements showing temperatures well above the required 41°F for cold foods. The sandwiches were prepared hours before serving and attempts to cool them down were unsuccessful, as internal temperatures remained above safe levels. Additionally, the kitchen environment was excessively warm, with thermometer readings as high as 90°F, and food items such as bread were stored in these conditions. Staff were observed not following proper hygiene and food safety protocols. Food preparers and dishwashers were not wearing required aprons, and there was no touch-free garbage can by the handwashing sink, leading to potential hand contamination. Internal food temperatures were not consistently monitored prior to transporting meals to residents, and logs for cold storage and kitchen temperatures were not completed as required. Wet pots and pans were stacked without air drying, and the three-compartment sink manual dishwashing process was not performed correctly, with items not being fully submerged in sanitizer for the required time. Further deficiencies included improper use of the food production sink, where a dietary aide rinsed dirty pans instead of using the designated three-compartment sink. The facility's policies and procedures outlined correct practices for food cooling, dishwashing, sanitation, and storage, but these were not followed. These failures placed the majority of residents who received facility-prepared foods at risk for foodborne illness, as stated in the report.
Failure to Address Kitchen Repairs Leads to Food Service Interruption
Penalty
Summary
The facility administration failed to use its resources effectively and efficiently when it did not complete corrective actions following the County's Department of Health Services (CDHS) Site Review Inspection Report issued in October 2024. The report identified that the kitchen's grease trap was in disrepair and that the facility was not in compliance with the California Retail Food Code. Despite receiving the report, the necessary repairs were not made, and there was no communication about the outstanding issues during the transition between administrators. The Dietary Manager and Maintenance Manager were also aware of the report and the required repairs, but no follow-up actions were taken by the previous Administrator. As a result of these inactions, the CDHS suspended the facility's Retail Food Permit after discovering wastewater overflowing onto the kitchen floor from the unrepaired grease trap. This suspension required the facility to cease all food production operations, interrupting food services for 57 out of 59 residents who relied on the facility's kitchen. The deficiency was directly linked to the failure of the administration to address the cited kitchen repairs and ensure compliance with regulatory requirements.
Failure to Address Kitchen Code Violations in QAPI Led to Food Service Interruption
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by not addressing code compliance corrective actions related to the physical environment of dietetic services, as required by the County Department of Health Services (CDHS). Despite receiving a Site Review Inspection Report from CDHS indicating that the kitchen's grease trap was in disrepair and not in compliance with the California Retail Food Code, the facility did not take action to repair the issue. The report was received by the previous Administrator, the Dietary Manager, and the Maintenance Manager, but was not discussed in QAPI meetings or addressed in any QAPI documentation. The previous Administrator did not communicate the findings or initiate repairs, and the issue was not handed over to the interim Administrator. As a result of the facility's inaction, wastewater overflowed onto the kitchen floor from the grease trap, leading to a CDHS inspection and the immediate suspension of the facility's Retail Food Permit. This action required the facility to cease all food production operations, interrupting food services for 57 out of 59 residents who relied on the facility's kitchen. Review of facility policy confirmed that the QAPI committee is responsible for addressing such issues, but there was no evidence that the CDHS inspection report or required kitchen repairs were ever incorporated into the QAPI process.
Failure to Maintain Effective Pest Control in Food Preparation Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in evidence of rodent and fly infestations in areas where resident food was prepared and stored. All resident food was being prepared in an offsite commissary kitchen due to remodeling of the onsite kitchen. During inspections and interviews, staff and county health inspectors observed chewed food packaging, rodent droppings, and a hole in the ceiling of the commissary kitchen, indicating active rodent activity. Multiple dirty rodent traps and nesting materials were also found, and pest control reports confirmed significant rodent feces and nesting on top of refrigeration units. Additionally, a fly infestation was observed in the temporary dietetic service space, which was formerly the staff breakroom. Flies were seen on light fixtures, walls, and windowsills, and food items were improperly stored on the windowsill. The area lacked a lidded garbage can, and the screen on the window was damaged, allowing insect entry. The kitchen door was also found propped open due to heat, and there was no screen door, further facilitating the entry of pests. Facility policies required ongoing pest control, proper screening of doors and windows, and routine sanitation, but these were not consistently followed. Staff were not aware if the offsite commissary had a pest mitigation program, and there was a lack of communication with the kitchen owner regarding pest control. These failures had the potential to cause foodborne illness for nearly all residents receiving food from the facility's kitchen.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation to the appropriate agencies within the required 2-hour timeframe after the allegation was made. This involved a resident who was dependent on staff for most of his care, except for eating and oral hygiene, and had intact cognition. The incident occurred when the resident's brother-in-law reported to a licensed staff member that an unlicensed staff member used vulgar language towards the resident. Despite the facility's policy requiring immediate reporting of such allegations, the report was not made to the state, ombudsman, and local police department within the stipulated time. Interviews with staff, including unlicensed staff, a licensed nurse, the administrator, and the director of nursing, confirmed that the use of vulgar language constituted verbal abuse and should have been reported promptly. The administrator and director of nursing acknowledged that the facility's policy on abuse reporting was not followed, which could potentially put the resident's safety at risk. The facility's policy, updated in February 2024, mandates that alleged violations of abuse, neglect, exploitation, or mistreatment be reported to the proper agencies as per regulations.
Failure to Suspend Staff During Abuse Investigation
Penalty
Summary
The facility failed to protect a resident when an unlicensed staff member, accused of verbal abuse, was allowed to continue working during the investigation of the abuse allegation. The incident involved a resident who was admitted with diagnoses of muscle weakness and anxiety disorder, and who had intact cognition but required substantial assistance with care. The alleged verbal abuse occurred on 11/12/24, but the staff member was not suspended immediately as per the facility's policy. Instead, the staff member was only reassigned to another room, which did not align with the facility's procedures for handling such allegations. The facility's policy, updated in February 2024, clearly states that any employee accused of resident abuse should be suspended immediately pending the outcome of the investigation. Both the Administrator and the Director of Nursing confirmed that the staff member was not suspended immediately, acknowledging that this could compromise the investigation and put resident safety at risk. The failure to adhere to the policy reduced the facility's ability to protect the resident from further potential abuse while the investigation was ongoing.
Fly Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant fly infestation throughout the premises. Observations and interviews revealed that flies were present in multiple residents' rooms, causing discomfort and disturbance during meals and rest. Resident 30, who had a right foot ulcer, reported a persistent fly issue and had resorted to using a plug-in bug trap and sticky fly paper, both of which were filled with dead flies. Other residents, such as Resident 13 and Resident 108, also experienced fly problems, with flies landing on clothing and food, prompting them to use personal fly swatters. The presence of flies was not limited to resident rooms but extended to the kitchen, where flies were observed on food carts and near the dishwasher, raising concerns about potential food contamination. Interviews with staff, including the Administrator and various nursing staff, confirmed the ongoing fly issue, particularly in the [NAME] Hall and kitchen areas. The Administrator acknowledged the problem and mentioned that the pest control company attributed the fly increase to nearby compost but had not taken measures to address flies specifically, focusing instead on ants and rodents. A pest control report recommended keeping a back door closed to prevent fly entry, but the facility's pest control policy, dated 4/2018, was not effectively implemented to ensure the premises were free of pests, compromising the health, safety, and comfort of residents and staff.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide four residents with a summary of their Baseline Plan of Care upon admission, which is a requirement to ensure effective communication and care management. Resident 45, who was admitted with multiple serious health conditions including respiratory failure and a tracheostomy, did not receive a copy of his Baseline Care Plan or a list of his medications. The resident confirmed during an interview that he had not received any paperwork or signed his Baseline Care Plan. Similarly, Resident 48, who had a history of cerebrovascular disease and other significant health issues, did not receive a copy of his Baseline Care Plan or medication list. The resident's representative, who was involved in care discussions, also did not sign or receive the necessary documentation. This lack of documentation was confirmed during interviews with the resident and facility staff. Residents 54 and 108 also did not receive their Baseline Care Plans or medication lists. Resident 54, who had been in a motorcycle accident resulting in multiple fractures, and Resident 108, who had a concussion and other injuries, both confirmed they had not received the required documentation. Interviews with facility staff revealed that the absence of social service staff contributed to the failure to provide these documents, as the usual process of having residents sign and receive copies was not followed.
Failure to Follow Restorative Nursing Assistant Process
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Assistant (RNA) process was followed for a resident, identified as Resident 6, who did not have a weekly summary completed by the RNA, and there were no monthly summary meetings documented in the resident's electronic medical chart. This oversight was discovered during interviews and record reviews. Resident 6, who was admitted with diagnoses including muscle weakness, chronic pain syndrome, and spinal cord disease, was dependent on staff for all care. The resident had a physician's order for the RNA to apply a splint to both hands for 2 to 4 hours daily, or as tolerated, to manage hand flexion contractures. During an observation and interview, Resident 6 reported that the RNA only applied the splint for about 30 minutes daily, contrary to the physician's order. The resident expressed concern that this limited time was ineffective and felt that his contracture was worsening. The Director of Rehabilitation (DOR) confirmed that the minimum effective time for the splint was 2 hours and that any inability to tolerate the prescribed time should have been reported for potential adjustment. However, there was no documentation of such reports or adjustments, and the RNA process, including monthly meetings and weekly summaries, was not followed. The Interim Director of Nursing (IDON) and RNA B both acknowledged that the physician's order was not followed, with RNA B admitting that Resident 6 had only been tolerating 40 minutes of splint use for about a month. Despite recognizing this change in the resident's status, RNA B did not focus on reporting it to the DOR. The facility's policy required daily and weekly documentation of the RNA process, including any changes in a resident's status, but these were not completed for Resident 6, potentially placing the resident at risk for further contracture and decreased quality of life.
Failure to Provide Behavioral Health Care Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for Resident 27, who was admitted with active diagnoses of depression and persistent mood disorder. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition, and she was dependent on staff for all care. Despite being on antipsychotic and antidepressant medications, Resident 27 exhibited behaviors such as self-isolation, withdrawal, and hallucinations, as documented in her electronic medication administration record (EMAR) for August, September, and October 2024. Observations and interviews revealed that Resident 27 frequently cried, and staff were unable to determine the cause of her distress. Certified Nursing Assistant (CNA) K and Licensed Nurse (LN) D noted that the resident cried regardless of the situation, and attempts to comfort her were only sometimes effective. The Minimum Data Set Coordinator (MDSC) and other staff confirmed that Resident 27 was not receiving behavioral health care services, despite her ongoing behaviors and the potential benefits of such services. Interviews with staff, including the Interim Director of Nursing (IDON), highlighted that Resident 27's lack of access to behavioral health care services was due to the absence of such services in the facility. The IDON and MDSC acknowledged that the resident's behaviors could be addressed with appropriate behavioral health care, which was not being provided. The facility's policy on behavioral health services emphasized the importance of prevention and treatment of mental disorders, yet Resident 27's needs were unmet, placing her at risk for emotional distress and unmet needs.
Failure to Implement EBP and Ensure Kitchen Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, which are necessary to prevent the spread of multidrug-resistant organisms (MDROs). Specifically, two sampled residents and five unsampled residents who required dressing changes or had indwelling devices such as Foley catheters or G-tubes were not placed on EBP. The Interim Infection Preventionist (IIP) acknowledged that EBP had not been implemented due to the previous Infection Preventionist's departure, and staff had not been trained on EBP. Observations confirmed the absence of EBP signage and PPE carts outside residents' rooms. Resident 30, who had a diabetic pressure ulcer on his right heel, was not placed on EBP despite being seen by a wound nurse weekly. Similarly, Resident 212, with a stage four pressure ulcer and an indwelling catheter, and Resident 213, with a G-tube for enteral feeding, were not on EBP. The facility's policy, dated June 2022, outlined the need for EBP for residents with wounds or indwelling devices, regardless of MDRO colonization status, but this was not followed. Additionally, the facility failed to ensure proper attire for a service technician entering the kitchen, which could lead to food contamination. The technician entered the kitchen without a hairnet or beard cover, contrary to the facility's dress code policy. Observations noted hair in the kitchen handwashing sink and refrigerator, indicating lapses in hygiene practices. The Certified Dietary Manager confirmed the technician's attire was inappropriate and instructed him to wear the necessary protective gear.
Failure to Notify Ombudsman and Provide Discharge Notice
Penalty
Summary
The facility failed to provide an appropriate notice of discharge to a resident and their representative, and did not notify the Ombudsman when a resident was transferred to the emergency department. This deficiency was identified in the case of a resident with Alzheimer's Disease, Muscle Weakness, and Bipolar Disorder, who had severely impaired cognition. The Interim Director of Nursing confirmed that the Ombudsman was not notified when the resident was sent to the emergency department, and no notice of transfer was completed. The facility policy requires that a notice of transfer or discharge be provided to the resident or their representative, and the Ombudsman must be notified within 24 to 48 hours. Interviews with licensed staff revealed a lack of awareness regarding the facility's policy on notifying the Ombudsman during transfers and discharges. One licensed nurse stated she had never sent a copy of the notice of transfer to the Ombudsman, and another nurse was unaware of any policy requiring such notification. The facility's policy and procedure document, dated December 2016, specifies that an appropriate notice of discharge should be provided, including the contact information for the state long-term care Ombudsman. However, this policy was not followed in the case of the resident transferred to the emergency department.
Failure to Complete MDS Discharge Assessment for a Resident
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) Discharge Assessment (DCA) for one of the sampled residents, identified as Resident 28. This oversight was discovered during a review of Resident 28's records, which showed that the MDS DCA was missing upon her discharge. Resident 28 was admitted with diagnoses of Dementia and Alzheimer's Disease, and her Brief Interview for Mental Status (BIMS) indicated severely impaired cognition, making her mostly dependent on staff for care. The Interim Director of Nursing confirmed the absence of the MDS DCA and emphasized the importance of timely MDS assessments to ensure accurate representation of residents' status. The Minimum Data Set Coordinator acknowledged that some MDS assessments were delayed, which could lead to inaccurate data and errors in reports. The MDSC highlighted the significance of completing the DCA, as it provides essential information for residents reintegrating into the community and for home health services to understand the resident's current status and needs. The facility's policy on MDS Accuracy, updated in 2023, mandates comprehensive assessments per the guidelines set by the Resident Assessment Instrument manual, which was not adhered to in this case.
Failure to Implement Nutritional Supplement Recommendation
Penalty
Summary
The facility failed to notify a resident's physician of the Registered Dietitian's (RD) recommendation for a nutritional supplement, Med Pass, for a resident who experienced severe weight loss. The resident, identified as Resident 30, lost 16 pounds in one month, which is an 8.65% unplanned weight loss. This weight loss was significant enough to potentially impact the healing of the resident's right heel ulcer and overall physical wellbeing. Despite the RD's recommendation for protein supplementation to aid in wound healing, the facility did not act promptly to implement these recommendations. Resident 30 was admitted with multiple diagnoses, including cellulitis, muscle weakness, and type two diabetes, and experienced a pattern of severe weight loss over several months. The RD's notes indicated a need for increased protein intake and recommended the use of Med Pass to provide additional calories and protein. However, the recommendation made on August 23 was not acted upon until October 17, resulting in a delay of nearly two months before the nutritional supplement was administered. Interviews with facility staff revealed a breakdown in communication and follow-through on the RD's recommendations. The Interim Director of Nursing (IDON) received the RD's recommendations but failed to ensure they were communicated effectively to the nursing staff responsible for contacting the resident's physician. The Licensed Nurse (LN) assigned to follow up on the recommendation did not do so, leading to the delay in implementing the necessary nutritional intervention for Resident 30.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required 2-hour timeframe to the California Department of Public Health (CDPH), the Ombudsman, and the local Police Department (PD). The incident involved a resident with intact cognition, who was dependent on staff for all care, and had been diagnosed with muscle weakness, chronic pain syndrome, and spinal cord disease. The alleged abuse by a licensed nurse occurred at approximately 10:00 a.m. on 8/31/24, but the facility only notified the local PD at 4:10 p.m. on the same day, missing the 2-hour reporting requirement. The Ombudsman was not informed until 9/5/24, and there was no indication that CDPH was notified at all. During interviews, both the Administrator and the Interim Director of Nursing confirmed the failure to meet the 2-hour reporting requirement as per the facility's policy. The facility's policy, titled 'Abuse and Neglect Prohibition Policy,' mandates that all alleged violations involving abuse or serious bodily injury be reported immediately, but not later than 2 hours. The Administrator acknowledged this as a weak report and emphasized the importance of timely reporting to ensure resident safety and prevent further abuse. The Interim Director of Nursing also verified the lack of timely reporting to the necessary agencies, highlighting the importance of such actions to ensure resident safety and prevent recurrence of abuse.
Resident Subjected to Verbal Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, resulting in emotional distress for the resident. The incident involved a staff member, Licensed Staff A, who was recorded berating, cursing, and demeaning the resident. This recording was brought to the attention of the facility's administrator by another staff member, Licensed Staff B, who described the tone as badgering and filled with derogatory comments. The administrator confirmed the content of the recording, which included Licensed Staff A making derogatory remarks about the resident's bipolar disorder and threatening that the only way the resident would leave the facility was with police intervention. The resident involved had a complex medical history, including quadriplegia, bipolar disorder, dysphagia, and blindness due to the absence of eyes, following a motor vehicle accident. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, including verbal abuse, and outlines measures to prevent such incidents. However, the failure to protect the resident from verbal abuse by Licensed Staff A indicates a breach of this policy, leading to the resident's emotional distress as evidenced by crying during the incident.
Communication Breakdown Due to Unanswered Phones
Penalty
Summary
The facility failed to ensure proper access to residents by not adequately managing their phone system, which resulted in significant communication breakdowns. The phones in the facility were left unanswered, preventing a pharmacy from contacting nursing staff to clarify a physician's medication order. This led to a resident not receiving Paxlovid, a medication for treating mild-to-moderate COVID-19, for five days. Additionally, a confidential complainant was unable to reach staff to discuss an urgent matter due to the facility's phone system issues. The deficiency was observed when the facility's phone rang multiple times without being answered, eventually rolling over to a message system. The receptionist, who was responsible for answering calls during business hours, was unaware of the phone system's mailbox setup. The facility's phone system was new and rang throughout the facility, but neither the Administrator nor the Maintenance Director was aware that calls rolled over to a mailbox after a certain number of rings. The facility's policy indicated that phones should be answered from the business office or nurses' station, but this was not effectively implemented, leading to the communication failures.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two of the three sampled residents. Resident 5, who was diagnosed with conditions including autistic disorder, catatonic schizophrenia, and dementia, tested positive for COVID-19. Despite a physician's order for Paxlovid to treat COVID-19 symptoms, Resident 5 did not receive the medication from 9/17/24 through 9/21/24. The Interim Director of Nursing (DON) acknowledged that the previous DON was aware of the issue with the pharmacy not delivering the medication but did not follow through, resulting in Resident 5 not receiving the prescribed treatment. Resident 6, who had diagnoses including sciatica, chronic pain, migraines, and major depression, was prescribed Duloxetine HCI Delayed Release 30 mg daily. However, a licensed nurse administered 60 mg of the medication upon Resident 6's request, without a physician's order. This deviation from the prescribed dosage led to Resident 6 becoming upset and refusing to take the correct dose, potentially leading to withdrawal symptoms. The Interim DON discovered this error during Resident 6's Care Conference, where Resident 6 expressed dissatisfaction with the physician's refusal to increase the dosage. The facility's policies on medication administration and error prevention were not adhered to, as evidenced by these incidents. The policies require medications to be administered as prescribed, with verification of the right resident, medication, dosage, time, and method. The facility's job descriptions for nursing staff emphasize the importance of following physician orders and ensuring positive clinical outcomes, which were not achieved in these cases.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to ensure that a functioning call light system was available for two residents, leading to significant concerns about their ability to communicate with staff in emergencies. Resident 1, who was admitted with diagnoses including muscle weakness, chronic pain syndrome, and spinal cord disease, had a call light that was not functioning properly. Despite having intact cognition, Resident 1 was dependent on staff for care and expressed frustration and anxiety over the inability to call for help, resorting to yelling to get staff attention. The call light had been malfunctioning for about a week and a half, and despite requests for a touch pad due to difficulty using the call button, no action had been taken. Resident 7, also dependent on staff for personal care, was found without a call light in his vicinity. Observations confirmed the absence of a call light near Resident 7's bed, table, or drawer, and staff interviews revealed that his call light might have been taken to replace Resident 1's broken one. This left Resident 7 without a means to call for assistance, posing a risk to his safety and care needs. Staff acknowledged the importance of a functioning call light system for resident safety and communication but failed to ensure its availability for both residents. Interviews with staff, including CNAs and the interim DON, highlighted a lack of awareness and communication regarding the malfunctioning call lights. The maintenance director was unaware of the request for a touch pad for Resident 1 and had not checked the maintenance logbook recently. The facility's policy emphasized the importance of timely response to call lights and reporting defective systems, yet these procedures were not followed, resulting in the deficiencies observed.
Failure to Enforce Smoking Policy for Resident Vaping Indoors
Penalty
Summary
The facility failed to implement its smoking policy by allowing a resident to vape inside his room without supervision, despite the policy prohibiting smoking, including vaping, inside the facility. The resident, who was admitted with diagnoses of muscle weakness, chronic pain syndrome, and spinal cord disease, was assessed to be safe to smoke only with supervision due to contractures of his hands. However, the resident was observed with vaping devices in his room and admitted to vaping there for months without staff supervision. Interviews with facility staff, including the Social Services Director, Administrator, Certified Nursing Assistants, and a Licensed Nurse, revealed that they were aware of the resident's vaping activities in his room. The staff acknowledged that vaping was considered smoking and was not allowed inside the facility, yet they did not enforce the policy. The staff indicated that the resident was not supervised while vaping, and it was challenging to get him out of bed, which contributed to the lack of enforcement. The facility's smoking policy, released in January 2023, clearly stated that smoking was only permitted in designated areas outside the facility. Despite this, the resident continued to vape in his room, exposing his roommates to secondhand vape aerosol, which could pose health risks. The report highlights the facility's failure to adhere to its smoking policy and ensure the safety of all residents by preventing indoor vaping.
Violation of Residents' Right to Choose Physician
Penalty
Summary
The facility failed to honor the rights of two residents to choose their attending physician, as required by regulations. Resident 1, who was admitted with diagnoses including muscle weakness and spinal cord disease, had intact cognition and was self-responsible. Resident 2, readmitted with muscle weakness and dysphagia, had moderately impaired cognition but was also self-responsible. Both residents were transferred to the care of the facility's Medical Director without their consent or request, violating their right to choose their own physician. Interviews with staff, including a Licensed Nurse, the Minimum Data Set Coordinator, the interim Director of Nursing, and the Administrator, confirmed that the residents' rights were not honored, and there was no documentation indicating that the residents requested or were informed about the change in their attending physician. The facility's policy and procedure documents, titled 'Resident's Rights' and 'Choice of Attending Physician,' clearly state that residents have the right to choose their attending physician and must be informed in writing of any changes. Despite this, there was no evidence in the residents' medical records, including progress notes, interdisciplinary notes, change of condition notes, or care plans, to indicate that the residents were involved in the decision-making process or that their consent was obtained. The Administrator mistakenly believed that the residents had requested the change, but this was not documented in their charts.
Medication Administration Error for a Resident
Penalty
Summary
The facility failed to meet professional standards of quality for one of the sampled residents, Resident 6, when a licensed nurse, RN K, did not adhere to the rights of medication administration. Specifically, RN K administered Duloxetine HCI Delayed Release 60 mg to Resident 6, instead of the physician-ordered dose of 30 mg, upon the resident's request. This deviation from the prescribed dosage occurred without a change in the physician's order, as confirmed by the Interim Director of Nursing (DON) during interviews. The incident was discovered during Resident 6's Care Conference, where the resident expressed anger over the physician's refusal to increase the dosage, revealing that RN K had been administering the higher dose. Resident 6 was admitted with diagnoses including sciatica, chronic pain, migraines, major depression, and muscle weakness, and had a BIMS score indicating intact cognition. The resident's medication administration record showed that Duloxetine 30 mg was prescribed to be taken once daily, starting from a specified date. However, after receiving the incorrect dosage, Resident 6 refused to take the prescribed 30 mg dose until discharge. The facility's policies on medication administration and error prevention emphasize adherence to physician orders and verification of the correct medication details before administration, which were not followed in this case.
Failure to Follow Death Protocols for a Resident
Penalty
Summary
The facility failed to adhere to its policy on handling the death of a resident, specifically in the case of Resident 2. Resident 2, who had a diagnosis of muscle weakness and dysphagia, was readmitted to the facility and had a POLST indicating full code status, meaning CPR and full treatment were to be attempted in the event of a medical emergency. Despite this, when Resident 2 suddenly expired, the death was pronounced by an LVN instead of a registered nurse or physician, as required by the facility's policy. Additionally, the staff did not call 911 or perform CPR, which was contrary to the directives outlined in the POLST and the facility's procedures for handling unexpected deaths. Furthermore, the facility did not inform the mortuary about the need for an autopsy, which was necessary due to the unexpected nature of Resident 2's death. Interviews with various staff members, including the interim DON, revealed that the facility's policy required notifying the local police department and requesting an autopsy in such cases. The failure to follow these procedures could have resulted in missed diagnostic errors and missed opportunities to improve medical treatment. The interim DON confirmed that the facility's policy was not followed, as the LVN did not call 911, did not perform CPR, and did not request an autopsy, which could have led to an investigation to determine the cause of death.
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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