Palm Village Retirement Comm.
Inspection history, citations, penalties and survey trends for this long-term care facility in Reedley, California.
- Location
- 703 W Herbert Ave, Reedley, California 93654
- CMS Provider Number
- 555513
- Inspections on file
- 17
- Latest survey
- July 29, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Palm Village Retirement Comm. during CMS and state inspections, most recent first.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A staff member was observed using a regular metal teaspoon instead of a standardized portioning utensil to serve cottage cheese for a resident with specific dietary orders, despite the availability of proper measuring tools and facility policies requiring their use. This resulted in the resident not receiving the ordered portion size as specified in their care plan.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
Three residents had inaccurate MDS assessments, including one whose history of fall and surgery was not documented, and two whose use of restraints or bed alarms was incorrectly coded. Staff interviews and record reviews confirmed these errors, and facility leadership acknowledged the responsibility for ensuring accurate resident assessments.
A resident admitted with multiple diagnoses, including dementia and a recent respiratory issue, was prescribed an antibiotic, but staff did not develop a baseline care plan within 48 hours to address the new medication. Nursing staff and the DON confirmed that a care plan should have been initiated to monitor for side effects and effectiveness, as required by facility policy.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Multiple residents did not receive care in accordance with professional standards, including failures to assess and document a skin injury, administer oxygen therapy as ordered, and carry out a prescribed medication order. Nursing staff did not complete required assessments or follow physician orders for oxygen and medication administration, as confirmed by staff interviews and record reviews.
Surveyors identified that the facility's medication error rate was 5 percent or greater, indicating a failure to maintain medication administration accuracy within regulatory limits.
Surveyors identified infection control deficiencies when an LVN failed to perform hand hygiene after disposing of a soiled wound dressing, and when two residents' nasal cannulas were not properly stored in designated bags, leaving the equipment exposed to contamination. Staff interviews and facility policies confirmed that these actions did not meet infection prevention standards.
A resident with a Foley catheter had their drainage bag left uncovered and visible to others, despite being cognitively intact and having multiple medical conditions. Staff and the DON confirmed that the catheter bag should have been covered with a dignity bag at all times, in accordance with facility policy to protect resident privacy and dignity.
A resident was admitted with diagnoses of anxiety, dementia, and Alzheimer's disease, and was prescribed psychotropic medications. The facility did not complete a new PASARR Level I screening after the initial assessment from the hospital failed to include the anxiety diagnosis and medication use. Staff interviews confirmed that the PASARR was not reviewed for accuracy upon admission, contrary to facility policy requiring such review for all new admissions.
The facility did not notify the appropriate authorities when a resident with MD or ID services experienced a significant change in condition, as required.
Two residents received pain medications that were not administered according to physician orders or facility protocols. One resident was given an opioid combination medication for moderate or no pain instead of only for severe pain as prescribed, while another was given acetaminophen for pain when it was only ordered for elevated temperature. These actions were confirmed through record review and staff interviews, showing a failure to follow medication administration instructions.
A resident with dementia, psychosis, and osteoporosis, identified as a fall risk and requiring substantial assistance with transfers, did not have a non-skid mat on her wheelchair as required by her care plan. An LPN confirmed during observation and interview that the mat was not in place, despite facility policy and the intervention being documented.
A facility failed to provide a written transfer notice to a resident and their representative when the resident was transferred to the hospital. The facility's policy requires that such notices be given in writing and in a language and manner understood by the resident and their representative. The Social Worker confirmed that the notice was not provided to the resident or their representative, although it was sent to the ombudsman.
A facility failed to provide a written bed hold notice to a resident or their representative when the resident was transferred to the hospital, as required by their policy. The facility's policy mandates written notification of the bed hold provision and state policy at the time of admission and transfer. Interviews revealed that the facility was unaware of the requirement to issue written notices, and had only been providing verbal notices.
The facility did not ensure RN coverage for eight consecutive hours daily, as required by policy. Nursing schedules revealed multiple dates without documented RN coverage, confirmed by the Administrator. Despite efforts to hire RNs and support LPNs transitioning to RNs, the facility struggled to maintain consistent RN staffing.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Failure to Use Standardized Portioning Utensils During Food Service
Penalty
Summary
Kitchen staff failed to use appropriate portioning utensils during meal preparation, as observed when a staff member used a regular metal teaspoon instead of a standardized portioning utensil to serve cottage cheese for a resident. The staff member was preparing cottage cheese and strawberry salads to accommodate special requests, and used a small, regular metal spoon to scoop and portion two scoops of cottage cheese into each container. The resident's dietary order specified an exact amount—8 ounces of cottage cheese and fruit for a morning snack—to support stable weight trends. The kitchen had measuring cups, scoops, and spoodles available, and staff interviews confirmed that regular spoons should not be used for portioning food. The resident involved had diagnoses including dementia and hypertension, but was assessed as having no cognitive impairment. Interviews with other kitchen staff, the Registered Dietitian, and the Certified Dietary Manager confirmed that recipes and dietary orders require the use of standardized portioning tools to ensure accurate and consistent meal portions. Facility policies also required the use of standard tools for portion control. The failure to use the correct utensil resulted in the resident not being served the specified portion as ordered.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident complaints in a timely and non-retaliatory manner.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the health and functional status of three residents. For one resident, the MDS assessment did not document a history of fall and surgery, despite the resident being admitted with a hip fracture following a fall and subsequent surgery. The MDS nurse acknowledged that the fall and surgery were not coded in the assessment, and both the Director of Nursing (DON) and the Administrator confirmed that their expectation was for MDS assessments to be completed accurately, with staff responsible for ensuring the accuracy of the information. Another resident's quarterly MDS assessment inaccurately indicated the use of restraints and alarms, although observations and staff interviews confirmed that the resident did not use any restraints or alarms. The MDS nurse and other staff members recognized this as an error, and the DON emphasized the importance of accurate documentation, as it reflects the resident's condition and ensures appropriate care is provided. The facility's job description for the MDS Coordinator and professional references reviewed also highlighted the requirement for assessments to accurately reflect the resident's status in accordance with state and federal guidelines. A third resident's MDS assessment failed to document the use of a bed sensor alarm, even though the alarm was observed in use and was included in the resident's care plan and provider's orders. The MDS nurse confirmed that the assessment did not accurately reflect the resident's current care needs and acknowledged the responsibility to review care plans and provider orders during assessments. The DON reiterated the expectation that the MDS should reflect the resident's current care needs and that assessments should be conducted in a timely and accurate manner.
Failure to Initiate Baseline Care Plan for Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was prescribed an antibiotic for a respiratory problem. Upon review, it was found that the resident, who had diagnoses including dementia, a history of falls, and hypertension, was admitted and started on an antibiotic regimen for a cough. However, no care plan was created to address the use of the antibiotic, including monitoring for side effects or the effectiveness of the therapy, during the period the medication was administered. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of licensed nurses to initiate a care plan immediately upon starting new medications, and that this was not done in this case. Facility policy and job descriptions reviewed also indicated that baseline care plans should be completed within 48 hours to address immediate health and safety concerns. The absence of a care plan for the antibiotic was acknowledged by staff and leadership during the survey.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on the absence of a comprehensive approach to care planning, as required, and was observed through review of the resident's records and care documentation.
Failure to Meet Professional Standards in Assessment, Documentation, and Adherence to Physician Orders
Penalty
Summary
The facility failed to meet professional standards of quality for five residents due to multiple deficiencies in assessment, documentation, and adherence to physician orders. For one resident with a history of femur fracture, muscle weakness, and severe cognitive impairment, the licensed nurse did not accurately assess or document a change in skin condition, specifically a deep tissue injury, during the weekly assessment. Interviews with nursing staff confirmed that the required comprehensive skin assessment was not completed, and the injury was not documented as per facility policy and professional standards. Another deficiency involved residents with orders for oxygen therapy. One resident with diagnoses including congestive heart failure and acute respiratory failure did not receive oxygen therapy as ordered by the physician. Observations revealed the absence of an oxygen concentrator and nasal cannula, and staff confirmed that the resident was not receiving oxygen despite an active order. Similarly, two other residents received oxygen at incorrect flow rates, with one receiving a higher flow than ordered and another not receiving oxygen as prescribed. Staff interviews and record reviews confirmed that oxygen, considered a medication, was not administered in accordance with provider orders, contrary to facility policy and professional standards. Additionally, a resident with heart failure and Alzheimer's disease did not receive a prescribed medication (Trazodone hydrochloride) as ordered by hospice. The order was filed in the resident's chart but was not carried out, and the required notifications and documentation were not completed. Staff interviews confirmed that the process for verifying and implementing medication orders was not followed, resulting in the resident not receiving the intended medication. These deficiencies were corroborated by facility policies, job descriptions, and professional references reviewed during the survey.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on the surveyors' findings that the facility did not maintain medication error rates below the regulatory threshold.
Infection Control Failures in Hand Hygiene and Oxygen Equipment Storage
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices involving two residents. In one instance, a Licensed Vocational Nurse (LVN) was seen exiting a resident's room after performing a wound dressing change, carrying the soiled dressing in her bare hands. The LVN disposed of the dressing in a trash can outside the room and then moved the wound cart without performing hand hygiene. Interviews with the LVN, Director of Nursing (DON), Director of Staff Development (DSD), and Infection Preventionist (IP) confirmed that this action did not follow facility policy or infection control protocols, as hand hygiene should have been performed after handling soiled dressings to prevent cross contamination. Additionally, the same resident did not have a storage bag available for their nasal cannula (NC) in the room. Observations and interviews with the DON, DSD, and IP confirmed that a storage bag should have been present and used to store the NC when not in use, as per facility policy and manufacturer recommendations. The absence of a storage bag meant the NC could have been exposed to unclean surfaces, increasing the risk of contamination. A separate observation found another resident's oxygen NC tubing lying unbagged on a bedside table next to used tissues and a trash can. Staff interviews confirmed that the NC should have been stored in a designated bag when not in use, and that the tubing is changed weekly and should be labeled. The IP and DON both validated that the observed practice did not align with facility policy, and that the NC was at risk of contamination due to improper storage. Facility policies and professional references reviewed by surveyors supported the expectation for proper storage and handling of respiratory equipment to prevent infection.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
A deficiency occurred when a resident's urinary catheter drainage bag was left uncovered and visible to other residents and visitors, contrary to facility policy and expectations. The resident, who was cognitively intact and had diagnoses including Parkinson's disease, diabetes mellitus, obstructive and reflux uropathy, and malignant neoplasm of the prostate, had a physician's order for a Foley catheter to gravity drainage. During an observation, the catheter bag was not covered by a dignity bag as required. Staff interviews confirmed that the catheter bag should have been covered at all times to maintain the resident's dignity and privacy. Both a Licensed Vocational Nurse and the Director of Nursing acknowledged that the lack of a dignity bag violated the resident's right to privacy and dignity, as outlined in the facility's policy. The facility's policy specifically states that staff must help residents keep urinary catheter bags covered to promote dignity and respect.
Failure to Complete Accurate PASARR Assessment for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) Level I screening for a resident when the initial PASARR, completed prior to admission in a general acute care hospital, did not include the resident's diagnosis of anxiety or the use of psychotropic medications. Upon admission, the resident's records indicated diagnoses of anxiety, dementia, and Alzheimer's disease, and the resident was prescribed medications such as lorazepam and quetiapine fumarate. Despite these findings, the PASARR Level I assessment was not updated or reviewed for accuracy by the Admission Coordinator/Minimum Data Set Nurse (AC/MDSN), who acknowledged responsibility for ensuring accurate PASARR assessments for new admissions. Interviews with facility staff, including the AC/MDSN and the Director of Nursing (DON), confirmed that the PASARR assessment was not reviewed for accuracy upon admission, and a new assessment was not completed despite discrepancies in the resident's diagnoses and medication use. Facility policy requires a PASARR Level I screening for each resident upon admission and mandates review for accuracy, especially when there are significant changes in a resident's physical or mental condition. The failure to complete an accurate PASARR assessment had the potential to impact the resident's receipt of appropriate services related to their mental health diagnosis and medication regimen.
Failure to Notify Authorities of Significant Change for MD/ID Residents
Penalty
Summary
The facility failed to notify the appropriate authorities when residents receiving services for mental disorders (MD) or intellectual disabilities (ID) experienced a significant change in condition. This deficiency was identified based on the observation that required notifications were not made as mandated when such changes occurred for these residents.
Failure to Administer Pain Medications According to Physician Orders and Protocols
Penalty
Summary
Two residents experienced deficiencies related to the administration of medications that were not in accordance with physician orders and facility protocols. One resident, who was cognitively intact and had a history of chronic back pain and related diagnoses, was prescribed acetaminophen-codeine to be administered for severe pain. However, nursing staff administered this medication 21 times over several days for pain levels documented as 0-6 out of 10, which corresponded to no pain, mild, or moderate pain, rather than severe pain as specified in the order. The medication administration records and interviews with nursing staff, the pharmacy consultant, and the Director of Nursing confirmed that the medication was repeatedly given outside the prescribed parameters, and the pain scale was not properly used to guide administration. Another resident, who had a history of a recent fall and was described as alert but confused, was administered acetaminophen for complaints of pain and headache. The physician's order for this medication specified it was to be given only for temperatures above 101 degrees Fahrenheit, not for pain. Despite this, nursing staff administered the medication for pain on at least two occasions. Both the pharmacy consultant and the Director of Nursing confirmed that the medication was not administered according to the physician's order, and that staff should have contacted the physician for an appropriate pain management order instead of using the medication off-label. Facility policies and procedures reviewed during the investigation emphasized the importance of assessing pain accurately, following medication administration instructions, and adhering strictly to prescriber orders. The failures identified in both cases were confirmed through interviews, record reviews, and direct observation, demonstrating that staff did not follow established protocols or physician instructions in the administration of pain medications for these residents.
Failure to Provide Non-Skid Mat as Fall Prevention Intervention
Penalty
Summary
A deficiency was identified when a resident with dementia, psychosis, and osteoporosis, who required substantial assistance with transfers and was assessed as a fall risk, did not have a non-skid mat on her wheelchair as specified in her care plan. The care plan, dated 4/5/23, included an intervention to provide a non-skid mat under the wheelchair seat cushion to reduce the risk of falls, but during observation and record review, it was found that this intervention was not implemented. A Licensed Vocational Nurse confirmed during an interview and observation that the non-skid mat, which was available in the facility, was not present under the resident's wheelchair seat cushion as required. The facility's policy on fall precautions states that assistive devices and equipment should be used appropriately to maximize resident safety, but this was not followed in the resident's case.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident, identified as R118, and their representative when the resident was transferred to the hospital. This deficiency was identified during a review of the facility's policy on transfer and discharge notices, which mandates that residents and their representatives be notified in writing and in a language and manner they understand before a transfer or discharge occurs. The review of R118's electronic medical record revealed that the resident was transferred to the hospital on 05/09/24, but there was no evidence of a signed transfer notice by R118 or their representative. During an interview, the Social Worker confirmed that the facility did not provide the written notice of transfer/discharge to R118 or their representative at the time of the transfer. Although the facility generated the form and sent it to the ombudsman, the residents and their representatives were not given the written notice, which is a requirement according to the facility's policy.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident, identified as R118, or their representative when the resident was transferred to the hospital. According to the facility's policy titled Bed-Hold Notification, dated January 2017, residents or their representatives should be informed in writing of their right to exercise the bed hold provision and the state bed-hold policy of seven days. This policy mandates that written information be provided at the time of admission and transfer to a general acute care hospital or for therapeutic leave. However, a review of R118's electronic medical record revealed no documented evidence that such a notice was provided at the time of transfer. Interviews conducted during the investigation revealed that the Admission Director confirmed the facility's failure to provide the bed hold notices to R118 upon transfer to the hospital. The Admission Director also admitted that the facility was unaware of the requirement to issue bed hold notices upon a resident's transfer to the hospital. Furthermore, the Administrator stated that it was their expectation for bed holds to be done upon admission and upon a resident's transfer or discharge from the facility. However, the Administrator confirmed that the facility had only been providing verbal notices, not written ones, as required by their policy.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours within a 24-hour period, seven days a week, as required by their policy. This deficiency was identified through interviews, record reviews, and a review of the facility's policy titled 'Departmental Supervision, Nursing,' which was revised in August 2022. The policy mandates that an RN provides services for at least eight consecutive hours every 24 hours, seven days a week. However, the facility's nursing schedules from December 24, 2023, to August 2, 2024, showed no documented evidence of RN coverage for the specified hours on multiple dates. During an interview, the Administrator confirmed the lack of RN coverage on the listed dates and mentioned that the facility was actively searching for RNs to hire. Additionally, the Administrator noted that although the facility supported several LPNs in transitioning to RNs, they did not remain with the company.
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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