Oakland Healthcare & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, California.
- Location
- 3030 Webster Street, Oakland, California 94609
- CMS Provider Number
- 055215
- Inspections on file
- 26
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Oakland Healthcare & Wellness Center during CMS and state inspections, most recent first.
The facility failed to prevent unauthorized entry or resident exit when staff left an alarmed emergency exit door open and unarmed for 35 minutes. The door, leading to public streets, did not trigger an alarm, contrary to facility policy. Staff interviews confirmed the doors were never locked but should have been alarmed to alert staff. The facility's policy required regular checks of the alarm system, but the system was not armed, posing a risk of unauthorized entry or resident elopement.
A facility failed to ensure nursing staff had the necessary competencies for safe resident care. An LVN without IV and blood withdrawal certification provided care for a resident's PICC line, despite the resident's complex medical needs requiring certified care. The DON confirmed the LVN's lack of certification, which was against facility policy and state regulations.
The facility failed to maintain a homelike environment, with issues such as missing window coverings, non-functional bathroom fixtures, and unclean bathrooms. A resident's room had a window that couldn't close, allowing smoke to enter, while another resident's bathroom had a faulty hot water knob. Multiple rooms had unclean bathrooms, and requests for cleaning were ignored. These deficiencies compromised resident comfort and safety.
The facility failed to complete necessary PASRR evaluations for several residents, including those with schizophrenia and bipolar disorder, potentially preventing them from receiving required mental health services. The facility did not resubmit Level I PASRR screenings for two residents after 30 days, did not complete a PASRR for a resident with bipolar disorder, and failed to conduct a Level II evaluation for a resident with schizophrenia.
The facility failed to employ a full-time qualified Dietary Services Supervisor to oversee food operations, as required by California Health and Safety Code. The Kitchen Manager, who was supposed to fulfill this role, worked part-time and lacked necessary qualifications, holding only a ServSafe certification. The Registered Dietitian was onsite only two days a week, indicating insufficient oversight, potentially jeopardizing the health of 92 residents.
The facility failed to store, prepare, and serve food safely, with issues including unrefrigerated Teriyaki sauce, expired and unlabeled dry food bins, scratched cutting boards, a sticky knife rack, dusty air vents, and unclean kitchen floors. These deficiencies were acknowledged by the Kitchen Manager and Registered Dietitian, posing risks of foodborne illness and contamination.
The facility failed to manage pest control effectively, as two residents reported roaches in their rooms. Despite complaints, the issues were not logged in the maintenance system, leading to a lack of action. Observations confirmed roaches in a resident's room and shared bathroom, and pest control services were not provided as needed.
Two residents in an LTC facility experienced deficiencies in pain management. One resident did not receive a pain assessment or medication before a wound dressing change, despite showing non-verbal pain cues. Another resident was given Tylenol instead of Norco for a pain level that required stronger medication, and staff failed to reassess and notify the physician for a pain management reevaluation. These actions were inconsistent with the facility's pain management policies.
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. A resident with heart failure did not receive two prescribed medications during an observed medication pass due to unavailability and oversight. Another resident did not receive prescribed eye drops for glaucoma for two days, as confirmed by the DON, due to the medication being unavailable.
A facility failed to maintain a medication error rate of 5% or less, with an observed rate of 8.1%. An LVN was unable to administer potassium chloride to a resident due to a pharmacy delay, administered double the ordered dose of Vitamin D3, and omitted Minoxidil. These errors were confirmed during an observation and interview, contributing to the facility's non-compliance.
The facility failed to properly store and dispose of medications, as observed by surveyors. An emergency medication kit was found open and not replaced, containing controlled substances, insulin, and temperature-sensitive suppositories. Additionally, three boxes of expired Bisacodyl suppositories were stored with other medications. A nurse confirmed the risk of residents receiving ineffective treatment. The facility's policy requires immediate removal and disposal of outdated medications, which was not followed.
A facility failed to document hospice visits and assessments for a resident with cerebrovascular disease in their electronic medical record. Despite regular hospice visits, notes were only found in a Hospice Communication Binder, contrary to the facility's policy requiring inclusion in progress notes. This deficiency was confirmed by a LVN and the Hospice Clinical Director, highlighting a gap in maintaining complete clinical records.
Failure to Secure Emergency Exit Door
Penalty
Summary
The facility failed to ensure the safety of 90 sampled residents by not preventing unauthorized visitor entry or resident exit. This occurred when staff left the alarmed emergency exit back door open and unarmed for 35 minutes during the evening shift. Observations revealed that the door, which led to an access ramp with direct access to public streets, was opened without triggering an audible alarm. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, confirmed that the emergency exit doors were never locked, but were equipped with alarms intended to alert staff when opened. However, the alarm was not functioning as expected during the observed period. The facility's policy and procedure on wandering and elopement required staff to ensure doors closed properly and that the maintenance department regularly checked the alarm system. A review of the facility's plan of correction from a previous survey indicated that door alarms should be engaged at all times, and staff were instructed to respond to alarms. Despite these measures, the alarm system was not armed, and staff did not respond to the open door, posing a risk of unauthorized entry or resident elopement.
Inadequate Competency in PICC Line Care
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to safely meet the care needs of a resident. Specifically, a Licensed Vocational Nurse (LVN) without an intravenous (IV) and blood withdrawal certification provided care for a resident's peripherally inserted central catheter (PICC). This resident had been admitted with diagnoses including surgical aftercare following digestive system surgery, short bowel syndrome, nutritional deficiency, and acquired absence of parts of the digestive tract. The resident's medical orders required specific PICC care and monitoring for signs of infection or bleeding. The Director of Nursing confirmed that three LVNs documented providing care to the resident during specific shifts, but only two had the necessary IV competency certificates. The LVN in question, who lacked the certification, was documented as providing care and monitoring for the resident's PICC line on multiple occasions. According to the Board of Vocational Nursing and Psychiatric Technicians, only LVNs certified in intravenous therapy are permitted to perform certain tasks related to PICC lines. The facility's policy also stipulated that only IV certified LVNs could perform specific procedures related to central lines, which the LVN in question was not certified to do.
Facility Maintenance Deficiencies Impact Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as evidenced by several maintenance issues that were not addressed in a timely manner. Resident 39's room had a missing window covering, which the resident had requested multiple times for privacy and protection from heat. Despite the Maintenance Supervisor being aware of the issue and having the necessary blinds available, the installation was delayed due to time constraints. Resident 41's bathroom sink hot water knob was not functioning, and the issue was not documented in the Maintenance Logbook, leading to a delay in repairs. The Maintenance Supervisor acknowledged the problem but had not addressed it, resulting in the resident's care being compromised as staff had to obtain hot water from another location. Resident 58's room had a window that could not be closed completely, allowing outside air and cigarette smoke to enter the room. The family member expressed concern for the resident's health due to the smoke exposure. The Maintenance Supervisor was aware of the issue for over a month and had attempted in-house repairs before contacting an external company for window replacement. Temporary measures were planned to seal the window until the replacement could be completed. Additionally, the facility's smoking policy aimed to protect non-smoking residents, but observations showed residents smoking near bedroom windows, increasing the risk of second-hand smoke exposure. Multiple rooms, including Rooms 5, 6, 10, 11, 12, 16, and 19, had unclean bathroom environments with cracked flooring and blackish discoloration. Resident 85, who used one of these bathrooms, reported discomfort and stated that requests for cleaning were ignored. The Environmental Supervisor confirmed awareness of the issues but did not indicate any immediate action taken. The facility's policy emphasized providing a safe, clean, and comfortable environment, but these deficiencies demonstrated a failure to uphold these standards, potentially impacting residents' quality of life and well-being.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening Resident Review (PASRR) process was properly followed for four residents, potentially preventing them from receiving necessary mental health services. Resident 32 and Resident 67 were admitted with Level I PASRR screenings completed from the hospital, indicating no serious mental illness. However, both residents had diagnoses of schizophrenia, a serious mental disorder. The facility did not resubmit a new Level I PASRR screening for these residents after they remained in the facility for more than 30 days, as required. Resident 47 was admitted and readmitted to the facility with a PASRR coded zero, indicating no serious mental illness, despite having a diagnosis of bipolar disorder and being prescribed medication for it. The facility did not complete a PASRR for Resident 47, nor did they refer the resident to the State Mental Authority for specialized mental health services after the resident stayed in the facility for over 30 days. This oversight was confirmed during a review of the resident's clinical records by the MDS Coordinator and the Director of Nursing. Resident 57's records showed a diagnosis of schizophrenia and a requirement for a Level II Mental Health Evaluation Referral, as indicated by a positive result for mental illness on the Level I PASRR completed prior to admission. However, the facility did not complete the necessary Level II PASRR evaluation or set up a follow-up appointment for the evaluation. This deficiency was identified during a review of the resident's clinical records, where it was confirmed that no Level II PASRR was completed.
Failure to Employ Qualified Dietary Services Supervisor
Penalty
Summary
The facility failed to ensure proper oversight of its food service operations by not employing a full-time qualified Dietary Services Supervisor (DSS) to manage and oversee food operation services. According to the California Health and Safety Code, a health facility that employs a registered dietitian less than full-time must also employ a full-time dietetic services supervisor. The Kitchen Manager (KM), who was supposed to fulfill this role, was found to be working part-time and did not possess the necessary qualifications, as she was still in school for the DSS certification and only held a ServSafe certification. The Registered Dietitian (RD) was only onsite two days a week, further indicating insufficient oversight. A review of the KM's timecard report revealed that she worked less than the required 35 hours per week for several weeks, with hours ranging from 12.82 to 34.99 per week. The facility's policy and procedure for the DSS position required a graduate of a California State approved DSS course or CDM certification, which the KM did not have. During an interview, the Administrator acknowledged the part-time status of the RD and KM and confirmed that the ServSafe certification was not adequate for overseeing the facility's Dietary Services Department. This deficiency had the potential to jeopardize the health and well-being of 92 out of 93 residents who received food prepared in the kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner, as observed during a survey. A full container of Teriyaki sauce, labeled to be refrigerated after opening, was found stored in an unrefrigerated dry-goods storage area. The Kitchen Manager (KM) acknowledged that some unrefrigerated liquids could spoil and cause resident illness. Additionally, a dry food bin labeled polenta was found with an expired use-by date, and other bins for flour, thickener, and grain rice lacked use-by dates, which the KM admitted could lead to foodborne sickness and affect food quality. Further observations revealed that two of five cutting boards had deep white scratches, which could harbor food particles and lead to foodborne illness. The KM and Registered Dietitian (RD) confirmed that cutting boards should be changed frequently to prevent such risks. A knife rack was also found with a sticky brown residue, and the KM noted that this unclean area could transfer dirt and germs onto knives and subsequently onto resident food. The survey also identified an air conditioner unit with thick grey dust on top and in the vents, which was blowing air into the kitchen. The KM stated that the dust was cleaned to prevent contamination. Additionally, a corner of the kitchen floor had a buildup of food debris, which the KM acknowledged should have been cleaned thoroughly to prevent pest infestation. The facility's policies and procedures for food storage, handling, and maintenance were reviewed, highlighting the need for proper labeling, cleaning, and sanitation to avoid contamination and ensure food safety.
Failure in Pest Control Management
Penalty
Summary
The facility failed to provide effective pest control for two residents, resulting in complaints about roaches in their rooms. Resident 88 reported seeing a roach under her lunch tray and informed the MDS Coordinator, who communicated the issue in a facility meeting and group message. However, the report was not recorded in the maintenance log, which is crucial for ensuring follow-up actions. Similarly, Resident 55 reported roaches in his room multiple times to staff, including a Licensed Vocational Nurse, but his room was not listed on pest control invoices, indicating a lack of action. Observations confirmed the presence of roaches in Resident 55's room and a shared bathroom, along with a buildup of dirt. The Maintenance Staff acknowledged the importance of logging such reports to prevent oversight. The Pest Control Technician confirmed that only rooms listed on invoices were treated, and Resident 55's room was not among them, despite his willingness to have pest control services. The facility's policy requires staff to report pest sightings to the Housekeeping Supervisor for immediate action, but this protocol was not effectively followed.
Deficiencies in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and care services in accordance with professional standards of practice for two residents, leading to deficiencies in pain management. For Resident 41, a licensed nurse did not assess or offer pain medication before performing a wound dressing change. This resident, who was on palliative care and had a sacral pressure ulcer, exhibited non-verbal cues of pain during the procedure, such as tensing and moving away. The facility's policy required pain assessment and medication administration prior to such treatments, which was not followed in this instance. Resident 85 did not receive pain medication as ordered by the physician. Despite having a pain level that warranted the administration of Norco, the resident was given Tylenol instead. The resident frequently complained of pain, and the medication administration records showed inconsistencies with the physician's orders. Licensed nurses failed to reassess the routine use of as-needed pain medication and did not notify the physician for a reevaluation of the resident's pain management plan, as required by the facility's policy. Interviews with staff, including licensed vocational nurses and the director of nursing, revealed a lack of adherence to the facility's pain management policies. The staff acknowledged the expectation to follow physician orders and assess pain levels accurately before administering medication. However, documentation errors and misjudgments about the resident's pain levels led to inappropriate pain management, contributing to the deficiencies identified in the report.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered for two residents, leading to a deficiency in pharmaceutical services. Resident 54, who was admitted with a diagnosis of heart failure, did not receive two prescribed medications during an observed medication pass. The Licensed Vocational Nurse (LVN) was unable to locate the potassium chloride in the medication cart and stated that it had been ordered but not yet arrived. Additionally, the LVN confirmed that Minoxidil, prescribed to lower blood pressure, was not administered to Resident 54 during the same medication pass. Resident 58, who had an order for Latanoprost Ophthalmic Solution for glaucoma, did not receive the prescribed eye drops for two consecutive days. The Director of Nursing (DON) reviewed the Medication Administration Record (MAR) and noted that the medication was unavailable at the time of administration on those days, which was acknowledged as a medication error. These failures in medication administration had the potential to result in the worsening of the residents' medical conditions.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in an observed error rate of 8.1%. During a medication pass, a Licensed Vocational Nurse (LVN) was unable to administer potassium chloride to a resident because the medication had not arrived from the pharmacy. Additionally, the LVN administered two tablets of Vitamin D3, totaling 2000 units, instead of the ordered 1000 units. Furthermore, the LVN did not administer Minoxidil, a medication intended to lower blood pressure, to the resident. These errors were identified during an observation and interview with the LVN, where the medication orders were reviewed. The LVN acknowledged the errors, confirming that the Minoxidil was not administered and that two tablets of Vitamin D3 were given instead of one. These actions and inactions during the medication pass contributed to the facility's failure to maintain the required medication error rate, potentially impacting the resident's medical condition.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications, as observed by Health Facilities Evaluators. During an inspection of the medication storage room, an emergency medication kit was found open and not replaced, containing controlled substances, insulin, and temperature-sensitive suppositories. Additionally, three boxes of Bisacodyl suppositories were discovered to be expired, yet they were stored with other over-the-counter medications. This was confirmed by a Licensed Vocational Nurse, who acknowledged that the expired medications posed a risk of residents receiving ineffective treatment. A review of the facility's policy and procedure on medication storage revealed that outdated, contaminated, or deteriorated medications should be immediately removed from stock, disposed of according to procedures, and reordered from the pharmacy. However, this protocol was not followed, leading to the potential for residents to receive ineffective medication.
Incomplete Documentation of Hospice Care for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident receiving hospice care. The resident, who was admitted to the facility in 2019, was placed under hospice care in May 2024 due to a terminal diagnosis of cerebrovascular disease. However, the resident's electronic medical record did not contain any documentation of hospice visits or assessments. This lack of documentation was identified during a review of the resident's records and an interview with a Licensed Vocational Nurse (LVN), who confirmed that hospice visits occurred regularly but were not recorded in the facility's electronic medical record. The facility's policy required that hospice notes be included in the facility's progress notes and maintained in the resident's medical record. Despite this policy, hospice notes were only found in a Hospice Communication Binder, and there were no progress notes entered by facility nurses in the electronic medical record. The Hospice Clinical Director confirmed that hospice nurses were expected to document each visit in the Hospice Communication Binder and that the facility could request copies of hospice progress notes. This deficiency had the potential to impact the resident's care due to the lack of available information for the interdisciplinary team.
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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