Pacific Heights Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 2707 Pine Street, San Francisco, California 94115
- CMS Provider Number
- 056176
- Inspections on file
- 24
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Pacific Heights Transitional Care Center during CMS and state inspections, most recent first.
A resident with diabetes and obesity, who required moderate assistance, was left in a wheelchair in the lobby overnight after the elevator became inoperable. Staff were unable to return the resident to their room due to weight limitations and a non-functioning stair lift chair, resulting in the resident experiencing pain and fatigue. The facility lacked evidence of maintenance, staff training, and implementation of its elevator failure contingency plan.
The facility failed to notify physicians when medications were unavailable for administration to residents, leading to deficiencies in care. A resident with heart disease did not receive losartan and atorvastatin, another with diabetes missed Ozempic doses, and a third with heart failure did not receive Eliquis. Despite documentation of pending pharmacy deliveries, there was no evidence of physician notification, as confirmed by interviews with nursing staff and the DNS.
The facility failed to ensure timely delivery of medications for three residents, resulting in missed doses of critical medications such as losartan, atorvastatin, Ozempic, and Eliquis. Staff interviews revealed inadequate follow-up with the pharmacy and poor documentation practices.
A resident with intact cognition requested an additional window curtain for several months, but the facility failed to provide it, resulting in a deficiency. Despite a work order marked as ASAP, no action was taken until a later date, and the Environmental Services Manager confirmed the delay. The facility's policy emphasizes a homelike environment, but the resident's request was not fulfilled, as acknowledged by the administrator.
A resident on anticoagulant therapy for pulmonary embolism was not accurately coded in the MDS assessment to reflect their medication use. Despite documentation in the care plan and medication records, the MDS assessment failed to indicate the use of apixaban. The LTC MDS Coordinator admitted the error, noting it was missed by the responsible MDS staff. The DNS and Administrator were not involved in the MDS process but expected accurate assessments.
A facility failed to accurately complete a PASRR Level I Screening for a resident with bipolar disorder. The resident's diagnosis and psychotropic medication were not reflected in the screening, resulting in a negative Level I Screening. Facility staff, including the LTC MDS Coordinator and Medical Records Director, were unaware of the inaccuracy, and the oversight was acknowledged by the Director of Nursing Services and the Administrator.
A resident with a history of heart failure and pulmonary embolism was prescribed Eliquis, an anticoagulant, but the medication was not included in their care plan. Interviews with nursing staff confirmed that anticoagulant use should be documented in care plans, as per facility policy. The omission was identified as a deficiency during a survey.
A resident with a urinary catheter was not provided with proper catheter care, as observed in a facility. The CNA used incorrect cleaning techniques, such as wiping from the base to the tip of the penis and not cleaning the catheter tubing, contrary to the facility's policy. Interviews with staff, including the CNA, DSD, IP, DNS, and Administrator, confirmed the failure to adhere to proper procedures, increasing the risk of infection.
A resident with severe cognitive impairment and a history of heart failure and pulmonary embolism was prescribed Eliquis, an anticoagulant, without proper monitoring for side effects. The facility's staff confirmed that monitoring for bleeding and bruising should have been documented on the MAR, but this was not done, resulting in a deficiency.
A resident with multiple health conditions did not receive ordered weekly laboratory tests due to a breakdown in the facility's process. Nursing staff failed to verify the completion of a requisition form and specimen collection, resulting in missed testing. The DON acknowledged the procedural change requiring printed requisitions, but the nurse manager did not ensure compliance.
A facility failed to follow infection control procedures during medication administration for two residents. An RN was observed touching the lip-surface of water cups with bare hands, contrary to facility policy. Interviews with staff, including the IP and DNS, confirmed this practice could lead to cross-contamination and infection risk.
The facility did not post daily nurse staffing data in a location accessible to residents, as required by policy. Observations showed outdated data was only posted in the lobby, inaccessible to residents on upper floors. Staff interviews revealed that the Staffing Coordinator was on vacation, and the DNS failed to update the postings in her absence.
Resident Left Without Bed Due to Elevator Failure and Lack of Alternative Arrangements
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes and obesity, who was cognitively intact and required partial to moderate assistance with transfers, was left without access to a bed or bedroom for over thirteen hours. The resident was unable to return to his room after the facility's elevator became inoperable, and staff informed him that he was too heavy to be carried back to his floor. As a result, the resident spent the entire night sitting in a wheelchair in the facility lobby, experiencing back and leg pain and significant fatigue. Facility records and staff interviews revealed that the stair lift chair, which could have served as an alternative means of transport, was not operational due to a faulty battery, and there was no evidence of maintenance or staff training on its use. The facility's contingency plan for elevator failure was not implemented, and there was no documentation of alternative arrangements for residents unable to use the stairs. The Quality Assurance and Performance Improvement (QAPI) program did not address the elevator malfunction contingency plan, and the facility was unable to provide evidence of alternative arrangements as required by their own policy.
Failure to Notify Physician of Unavailable Medications
Penalty
Summary
The facility failed to notify the physician when medications were not available for administration to residents, leading to deficiencies in care. Resident #38, who had a medical history of hypertensive heart disease with heart failure and hyperlipidemia, did not receive prescribed medications, losartan potassium and atorvastatin calcium, on multiple occasions. The Medication Administration Record (MAR) indicated that the medications were not administered due to pending pharmacy delivery, but there was no documented evidence that the physician was notified of these missed doses. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the physician should have been informed, but this was not done. Resident #308, diagnosed with type two diabetes mellitus with hyperglycemia, also experienced a failure in medication administration. The resident's prescribed medication, Ozempic, was not available for administration on several scheduled dates. The MAR and progress notes indicated that the medication was on order, but there was no documentation of physician notification. Interviews revealed that the nurse manager was informed, but the physician was not directly notified, which was against the expected protocol. Resident #96, with a history of acute on chronic diastolic congestive heart failure and pulmonary embolism, did not receive the anticoagulant medication Eliquis as prescribed. The MAR showed that the medication was pending delivery, and there was no evidence that the physician was informed of the missed doses. Interviews with nursing staff and the DNS reiterated the expectation that the physician should be notified when medications are unavailable, but this was not adhered to in these cases.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely receipt of medications from the pharmacy for three residents, leading to missed doses of critical medications. Resident #38, who had a medical history of hypertensive heart disease with heart failure and hyperlipidemia, did not receive prescribed doses of losartan potassium and atorvastatin calcium on multiple occasions. The medication administration records indicated that the medications were pending or on order, but there was no documented evidence that the physician was notified about the unavailability of these medications. Interviews with staff revealed a lack of follow-up with the pharmacy and inadequate documentation of the issue. Resident #308, diagnosed with type two diabetes mellitus, did not receive the prescribed Ozempic injections on three separate occasions. The medication was identified as a high-cost drug requiring prior authorization, which was delayed. The facility did not realize the medication was missing until it was due to be administered, and there was a lack of consistent follow-up with the pharmacy to expedite the delivery. The Director of Nursing Services and other staff acknowledged the oversight and the need for better communication and documentation. Resident #96, with a history of acute on chronic diastolic congestive heart failure and pulmonary embolism, missed doses of the anticoagulant Eliquis. The medication was pending delivery, and there was insufficient follow-up with the pharmacy to ensure timely receipt. Interviews with nursing staff and the Director of Nursing Services highlighted the responsibility of charge nurses to ensure medication availability and the need for continuous follow-up until medications are received.
Failure to Provide Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident #55, who had requested an additional window curtain for several months. The resident, who was admitted on 05/27/2021 and had intact cognition as indicated by a BIMS score of 15, expressed the need for a curtain that fully covered the window in their room. Despite the resident's request, the facility did not fulfill this need, which was observed during a visit on 08/26/2024. The facility's policy on providing a homelike environment emphasizes the importance of a clean, comfortable, and personalized setting. However, a work order for the additional curtain, dated 07/26/2024, was marked as ASAP but was not completed, and no further work orders were recorded for the resident's room in August. The Environmental Services Manager confirmed that no replacement curtains or blinds were ordered until 08/28/2024, indicating a delay in addressing the resident's request. The facility's administrator acknowledged that residents should be able to fully close their curtains, highlighting the oversight in meeting the resident's needs.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident who was on anticoagulant therapy. The resident, admitted with a medical history of pulmonary embolism, was prescribed apixaban, an anticoagulant, to prevent thrombosis or embolism. Despite the resident's care plan and medication administration records indicating the use of apixaban, the admission MDS assessment did not reflect that the resident was taking an anticoagulant medication. This discrepancy was identified during a review of the resident's records. The Long-Term Care (LTC) MDS Coordinator acknowledged that the MDS assessment was incorrectly coded, as it failed to indicate the resident's anticoagulant use. The error was attributed to the other MDS Coordinator responsible for completing the assessment. Interviews with the Director of Nursing Services (DNS) and the Administrator revealed that neither was directly involved in the MDS process, although they expected the assessments to be accurate. The oversight in coding was recognized as a missed step in the assessment process.
Failure to Accurately Complete PASRR Level I Screening
Penalty
Summary
The facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was accurately completed for a resident with a serious diagnosed mental disorder. The resident, who was admitted to the facility from a hospital, had a documented diagnosis of bipolar disorder and was prescribed mirtazapine, an antidepressant medication. However, the PASRR Level I Screening completed by the hospital did not reflect the resident's diagnosis of bipolar disorder or the prescription of psychotropic medication, resulting in a negative Level I Screening and no requirement for a Level II evaluation. Interviews with facility staff revealed a lack of awareness and oversight regarding the accuracy of the PASRR Level I screenings. The Long-Term Care (LTC) MDS Coordinator, who was responsible for reviewing and updating inaccurate screenings, was not aware of any inaccuracies. The Medical Records Director confirmed the resident's diagnosis and medication but did not address the discrepancy in the screening. The Director of Nursing Services and the Administrator acknowledged the oversight, indicating that the admission team and the MDS Coordinator should have submitted an updated Level I screening for the resident.
Anticoagulant Medication Not Included in Care Plan
Penalty
Summary
The facility failed to ensure that the use of an anticoagulant medication was addressed in the comprehensive care plan for a resident with a history of acute on chronic diastolic heart failure and pulmonary embolism. The resident was admitted to the facility and initially was not on anticoagulant medication. However, an order for Eliquis, an anticoagulant, was placed and later adjusted following a hospitalization. Despite these changes, the resident's care plan did not include a focus area related to the use of anticoagulant medication. Interviews with nursing staff, including registered nurses and the Director of Nursing Services, confirmed that the use of anticoagulant medications should be included in a resident's care plan. The facility's policy on comprehensive, person-centered care plans requires that they incorporate identified problem areas and risk factors, and be updated as residents' conditions change. The omission of the anticoagulant medication from the care plan was identified as a deficiency during the survey.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure urinary catheter care was completed in a sanitary manner for Resident #202, who was sampled for urinary catheter use. The facility's policy on urinary catheter care, dated March 2021, outlined specific steps to prevent catheter-associated urinary tract infections, including washing the genitalia and perineum thoroughly with soap and water, rinsing well, and drying. The policy also specified the correct method for cleaning a male resident's penis and catheter tubing. However, during an observation, Certified Nursing Assistant (CNA) #12 did not follow these procedures. CNA #12 used the same washcloth to clean the resident's penis from the base towards the meatus, did not rinse the area before drying, and failed to clean the catheter tubing. Resident #202, admitted to the facility on October 21, 2021, had a medical history that included hydronephrosis, tubulo-interstitial nephritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and retention of urine. The resident's care plan, initiated on May 9, 2024, indicated a risk for complications, including urinary tract infections, due to the use of an indwelling urinary catheter. A physician's order required catheter care to be provided every shift, with specific instructions to cleanse the site with soap and warm water, rinse, and pat dry. Despite these directives, CNA #12 did not adhere to the proper cleaning technique, increasing the risk of infection. Interviews with staff, including CNA #12, CNA #13, the Director of Staff Development (DSD), the Infection Preventionist (IP), the Director of Nursing Services (DNS), and the Administrator, revealed a lack of adherence to the facility's catheter care procedures. CNA #12 admitted to not following the correct procedure due to the resident's sensitivity. Other staff members confirmed that the correct procedure involved cleaning from the tip of the penis towards the base and ensuring the catheter tubing was cleaned. The failure to follow these procedures was acknowledged as increasing the potential risk of urinary tract infections due to improper cleaning techniques.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor for potential side effects or adverse drug reactions related to the use of an anticoagulant for a resident with severe cognitive impairment. The resident, who had a medical history of acute on chronic diastolic heart failure and a personal history of pulmonary embolism, was admitted to the facility and prescribed Eliquis, an anticoagulant. Despite the prescription, there were no orders to monitor for side effects or adverse drug reactions, and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of such monitoring. Interviews with nursing staff, including registered nurses and the Director of Nursing Services, confirmed that residents on anticoagulants should be monitored for bleeding and bruising, and this should be documented on the MAR. However, it was acknowledged that the resident did not have an order for monitoring, and the necessary documentation was absent. The responsibility for ensuring the monitoring order was in place was attributed to the admitting nurse, but this was not executed, leading to the deficiency.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory testing as ordered by the physician for a resident with a history of cancer, diabetes, hypertension, anemia, and hyperlipidemia. The resident was admitted with a care plan that included monitoring for complications and following up on laboratory tests. An order was placed for weekly complete blood count (CBC) and basic metabolic panel (BMP) tests, but there was no documented evidence that these tests were completed on the specified date. Interviews with nursing staff revealed a breakdown in the process of ensuring laboratory tests were conducted. The night nurse was responsible for printing the requisition form, and the floor nurse was tasked with ensuring the specimen was collected. However, the nurse on duty assumed the laboratory staff completed the tests without verifying the requisition or specimen collection. The Director of Nursing Services acknowledged the change in procedure requiring the facility to print requisition forms, but the nurse manager failed to ensure the requisition was in place, leading to the missed laboratory testing.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to its infection prevention and control procedures during medication administration, as observed with two residents. The facility's policy on medication administration, dated August 18, 2022, requires staff to follow established infection control procedures, including handwashing and antiseptic techniques. However, during an observation on August 28, 2024, a registered nurse (RN) was seen placing her bare hand around the lip-surface of a water cup provided to Resident #305 for taking medications. This action was repeated with Resident #56, despite the RN sanitizing her hands beforehand. Interviews conducted with the RN, a nurse manager, the Infection Preventionist (IP), the Director of Nursing Services (DNS), and the Administrator confirmed that touching the lip-surface of water cups with bare hands is against infection control protocols. The IP and DNS emphasized that even after hand sanitization, the RN's hands would not be considered clean enough to touch the lip-surface of the cups, which could lead to cross-contamination and infection risk. The Administrator expected nurses to hold water cups below the lip-surface to prevent contamination.
Failure to Post Daily Nurse Staffing Data in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily at the beginning of each shift in a prominent location accessible to residents. The facility's policy required that the number of licensed nurses and unlicensed nursing personnel responsible for direct care be posted within two hours of each shift's start. However, observations revealed that the staffing data was only posted in the first-floor lobby, which was not accessible to residents whose rooms were located on the second through fifth floors. The posted data was outdated, with the same document from several days prior being displayed over multiple days. Interviews with facility staff, including the Staffing Coordinator, RN, and Director of Nursing Services (DNS), confirmed the failure to update and appropriately post the staffing data. The Staffing Coordinator, who was responsible for posting the data, was on vacation, and in her absence, the DNS or a morning nurse manager was supposed to handle the task. However, the DNS admitted to not completing the postings, and the data remained outdated and inaccessible to residents. The Administrator acknowledged that the data was only posted in the lobby and should have been updated by 9:00 AM each day.
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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