Redding Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 1836 Gold Street, Redding, California 96001
- CMS Provider Number
- 055510
- Inspections on file
- 22
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Redding Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a clean, sanitary kitchen environment and to keep food service equipment and surfaces in good repair. Kitchen perimeter walls, pipes, drains, electrical coverings, and flooring were coated with food particles and grime, with chipped and peeling paint on walls, the sink, and around flooring. The exterior of the stove/oven had cooked-on grime, and rolling dollies holding kitchen supplies were covered in black filth. The walk-in refrigerator floor was buckled and uneven, with an open seam showing rust that oozed and puddled when cleaned. Review of facility policies showed requirements for clean, well-maintained floors, walls, ceilings, and equipment, and both the FNM and RD confirmed the kitchen’s lack of cleanliness and sanitation, which the report stated had the potential to cause foodborne illness and disease among residents consuming food prepared there.
Surveyors found that spray bottles of bleach cleaner solution were stored in unlocked cabinets above toilets in two wing three shower rooms, with the bottles placed among toiletry items. The ADON confirmed that one of these rooms is used as a resident shower/tub room and that both rooms are set up the same way, despite cabinets usually being locked. The DON, Adm, and Housekeeping/Laundry Supervisor each acknowledged that chemicals such as bleach, which are used by CNAs and nursing staff for cleaning, should be kept in locked cabinets for resident safety.
A resident with muscle weakness, difficulty walking, and moderate cognitive impairment, who wore glasses per the MDS, was observed with eyeglasses covered in smears. The resident stated she had told staff her glasses needed cleaning, but they were not cleaned, making it hard for her to see. The facility’s Resident Rights policy guaranteed a dignified existence, and the DON reported an expectation that staff clean residents’ eyeglasses daily, but this did not occur for this resident.
A resident with pulmonary edema, irregular heart rate, and muscle weakness had physician orders for CNAs to apply below-the-knee TED hose each morning and remove them in the evening, but the current care plan did not include this intervention after it had been resolved on a prior plan. Facility policy required care plans to be reviewed and revised upon readmission and to specify needed services, yet the TED hose order was omitted. CNAs reported not knowing the resident required TED hose, and on multiple occasions the resident stated the TED hose were not applied, while LNs documented on the MAR that they were in place without verifying, later admitting they had assumed CNAs applied them. The DON confirmed the TED hose were not applied despite MAR documentation and that the resident had documented pitting edema on most days reviewed.
Surveyors found that the facility failed to follow its own medication storage and handling policies for two residents. One resident’s home medications were discovered in stapled store pharmacy bags inside a cabinet in the medication room, despite a policy that ordinarily does not permit residents or families to bring medications into the facility. Another resident’s refused medications were found loose in a medication cup in a medication cart drawer, contrary to the facility’s policy requiring drugs to be stored in their original packaging or dispensing systems. Staff, including an LPN and the DON, acknowledged during interviews that these practices were not consistent with facility policy.
A resident's admission MDS inaccurately documented no hearing difficulty, despite multiple assessments and documentation indicating the resident was hard of hearing. Staff interviews and record reviews confirmed the error, and the MDS Coordinator acknowledged the admission MDS should have reflected the resident's hearing impairment.
A resident with hearing impairment did not have an individualized care plan addressing their hearing loss, despite documentation and assessments indicating this need. Staff were unaware of the resident's hearing difficulties, and the required care plan was not developed, potentially impacting the resident's communication and social engagement.
A resident with respiratory failure and chronic lung conditions received supplemental oxygen outside the prescribed saturation range on multiple occasions, with staff failing to notify the physician as required by the order. The DON confirmed that the facility did not follow the prescribed oxygen administration parameters.
A resident with a history of stroke, aphasia, and transgender identity was subjected to verbal abuse and discriminatory remarks by a CNA, who failed to use the resident's preferred pronouns and made derogatory comments about her gender identity. The incident caused the resident visible emotional distress, and interviews confirmed ongoing fear and upset. Facility policies prohibiting such discrimination were not followed.
The facility did not consistently serve food at appropriate temperatures, as reported by two residents and a family member, and failed to properly document food temperatures before meal service. Staff interviews and record reviews confirmed missing temperature logs and post-hoc documentation, resulting in noncompliance with food safety and quality standards.
A consultant pharmacist did not identify or report a missing indication for cyclobenzaprine administration in a resident's medication order. The MAR lacked documentation specifying whether the drug was given for pain or muscle spasms, and this irregularity was not caught during the monthly medication review as required by facility policy.
A resident with a history of stroke-related speech difficulties and transgender identity was subjected to witnessed verbal abuse by a CNA, who made derogatory comments and used profane language. Although the incident was reported to a charge nurse and administrator, the administrator and DON stated they were never informed, resulting in the required notifications to CDPH, the Ombudsman, and police not being made, and delaying investigation.
A resident's medical records, including the "Inventory of Personal Possessions" and "History and Physical," were not accessible when requested, with key documents missing from both electronic and paper charts. The DON later found the "History and Physical" in the Admissions office, but could not explain the location of the other document. Additionally, a physician took the resident's medical records home without authorization, causing further delays in record retrieval.
A resident admitted with a hip replacement and on supplemental O2 did not have the required admission H&P present in their medical record during review. The DON and MR staff confirmed the document was missing from both electronic and paper records, and it was later found in the Admissions office after the physician had taken it offsite.
A resident with a history of hip replacement and oxygen dependence had inconsistent nursing documentation regarding hearing status, with daily notes indicating adequate hearing and weekly notes indicating hearing impairment. The DON confirmed these inconsistencies during record review.
A resident's inventory list for personal effects and valuables was not properly completed, as it lacked signatures from both the responsible party and facility staff. The responsible party confirmed they were not given or asked to review the inventory at admission or discharge, and the staff member's signature was illegible and unidentifiable. This failure meant the resident's belongings were not accurately accounted for, as required by facility policy and regulation.
A resident with cognitive impairment and other medical conditions fell and injured her knee, leading to a physician ordering an x-ray. The facility failed to follow up on the x-ray results for two days, resulting in a delay in treatment for a broken bone and causing the resident to experience severe pain. The DON confirmed the oversight in not obtaining the x-ray report promptly.
A resident was moved to a new room without receiving the required written notice, causing distress and frustration. The move was decided by the Admission and Social Service Departments to accommodate new residents, and the resident was informed she had no choice. The facility's staff admitted they were unaware of the requirement for written notice, leading to a deficiency in protecting the resident's rights.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in care plans. One resident's MDS inaccurately omitted a serious mental illness diagnosis despite a PASRR evaluation recommending specialized services. Another resident's MDS incorrectly reported non-smoking status, despite evidence to the contrary. The MDS Coordinator acknowledged these errors, and both the DON and Administrator emphasized the importance of MDS accuracy.
A facility failed to complete a Level I PASRR for a resident readmitted with a new psychiatric diagnosis of unspecified psychosis. Despite the facility's policy requiring PASRR completion for all admissions, no new screening was conducted after the resident's return from a psychiatric stay. Interviews revealed a lack of training and clarity regarding the PASRR process, contributing to the oversight.
A facility failed to accurately complete a Level I PASRR for a resident with schizophrenia, as the initial screening done at the hospital omitted this diagnosis. The resident was admitted with a history of schizophrenia and major depressive disorder, but the PASRR only listed depression. The DON was responsible for ensuring the accuracy of these screenings, but the error was not corrected before admission.
A resident admitted for comfort care in an LTC facility was neglected, left in a soiled state, and not assisted with meals. Despite being continent and having an indwelling catheter, the resident was placed in a brief against his wishes. The loud television and lack of response to his requests for a bedpan and earplugs contributed to his distress, leading to his return to the hospital.
Unsanitary Kitchen Environment and Damaged Walk-In Refrigerator Flooring
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment for food preparation for all residents consuming food prepared by the kitchen. Surveyors observed that the perimeter walls of the kitchen at counter height and below, including pipes, drains, electrical coverings, and flooring, were covered with a buildup of food particles and adhered grime. Paint was chipped, peeling, and worn on the walls, sink, and around the flooring. The exterior sides of the stove/oven were unclean with cooked-on grime, and rolling dollies holding buckets of kitchen supplies were dirty with black filth. In the walk-in refrigerator, the flooring was buckled and uneven, with an open, unjoined seam down the middle that revealed a vein of rust; when the area was cleaned, rust material puddled from under and between the seam and spread across the floor. Review of the facility’s policies titled “General Cleaning of Food & Nutrition Services Department” and “Sanitation,” both dated 2023, showed that floors were required to be maintained in good condition, walls and ceilings washed thoroughly, heavily soiled surfaces cleaned as necessary, and all equipment kept clean and in good repair. During concurrent observation and interview, the Food and Nutrition Manager confirmed that the kitchen’s perimeter walls, pipes, drains, electrical coverings, flooring, rolling dollies, and exterior of the stove were dirty, that paint was chipped, peeling, and worn on walls, sink, and around flooring, and that the walk-in refrigerator flooring was buckled, uneven, and had a rust vein that oozed and puddled when cleaned. In a separate interview, the RD confirmed the kitchen was dirty and reported that she had written reports documenting the lack of general cleanliness and sanitation. The report stated these failures had the potential to incite harmful growth of unhealthy microorganisms resulting in foodborne illness among residents consuming food from the kitchen, which could lead to sickness and disease.
Unsecured Bleach Cleaner Stored in Shower Room Cabinets
Penalty
Summary
Surveyors identified a deficiency related to environmental safety in wing three shower rooms, where spray bottles of bleach cleaner solution were stored in unlocked cabinets above the toilets among toiletry items. Observations on 2/17/26 at 2:00 pm showed that both shower room one and shower room two had spray bleach bottles in these unsecured cabinets, with no locks visually present or available. The facility’s policies titled "Homelike Environment" (dated February 2021) and "Safety and Supervision of Residents" (revised July 2017) state that residents are to be provided with a safe environment and that resident safety and accident prevention are facility-wide priorities. During a concurrent observation and interview with the ADON on 2/17/26 at 2:05 pm in shower room two, the ADON confirmed that shower room one is used as a shower/tub room for residents and shower room two is used by staff for equipment storage, but both rooms were set up in the same manner with unlocked cabinets containing bleach. The ADON acknowledged that only shower room one directly affects residents as a safety concern and stated that cabinets are usually locked, though neither cabinet was locked at the time and no locks were visible. In subsequent interviews, the DON and Administrator each confirmed that cabinets containing chemicals such as bleach should be locked for resident safety, and the Housekeeping/Laundry Supervisor stated that the spray bleach is used by CNAs and nursing staff, is kept in the shower room cupboards for cleaning, and should be stored in locked cabinets.
Failure to Maintain Clean Eyeglasses Compromising Resident Dignity
Penalty
Summary
The facility failed to protect a resident’s right to a dignified existence when staff did not ensure her eyeglasses were kept clean. The resident was admitted with muscle weakness and difficulty walking, and her MDS indicated she wore glasses and had a BIMS score of 10/15, reflecting moderate cognitive impairment. During an observation and interview, the resident’s eyeglasses were noted to be covered in smears, and she reported that she had informed staff that her glasses needed to be cleaned but no one had done so, making it hard for her to see. The facility’s Resident Rights policy, revised October 2025, stated that residents are guaranteed a dignified existence, and the DON stated that her expectation was that staff clean residents’ eyeglasses daily. This failure could have resulted in a decrease in the resident’s vision and emotional well-being.
Failure to Revise Care Plan and Accurately Implement TED Hose Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise and implement a comprehensive care plan to include the ordered use of TED hose for one cognitively intact resident with diagnoses including pulmonary edema, irregular heart rate, and muscle weakness. Facility policies required goals and objectives to be reviewed and/or revised upon readmission and for the care plan to specify services needed to attain or maintain the resident’s highest practicable well-being. The resident was originally admitted and later readmitted with physician orders dated 3/6/24 and 2/8/26 directing that CNAs apply below-the-knee TED hose on in the morning and off in the evening. However, during review of the resident’s care plan dated 11/17/26, the DON confirmed that the application of TED hose had been resolved on a previous care plan and was not included on the current care plan, despite the ongoing physician orders. Surveyor observations and interviews showed that the TED hose were not being consistently applied as ordered and that documentation was inaccurate. On one observation, the resident stated she was supposed to have TED hose on every morning when getting out of bed, but CNA 1, who had been working with the resident for two months, reported not knowing the resident was supposed to receive TED hose in the mornings. On another day, the resident again reported that TED hose were not applied that morning. Review of the MAR for February 2026 showed that LNs 1 and 2 documented that TED hose were applied when they were not; LN 1 admitted charting that the TED hose were on when they were not, and LN 2 stated she assumed the CNA had put them on without actually seeing them on the resident. The DON confirmed that the TED hose were not applied despite MAR entries indicating otherwise, and the MAR also documented that the resident had pitting edema in her legs for 11 out of 17 days in February.
Improper Storage and Handling of Resident Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe storage and proper handling of medications for two residents. For one resident with a lower leg fracture and diabetes, who had a BIMS score of 15 indicating good decision-making ability, medications brought from home were found stored in stapled store pharmacy paper bags on the top right-hand side of a locked cabinet in the medication room. The facility’s policy titled “Medications Brought to the Facility by the Resident/Family” stated that the facility ordinarily does not permit residents and families to bring medications into the facility. During observation and interview, LN 3 confirmed that the bags contained this resident’s medications, acknowledged that the facility did not usually store outside medications in store pharmacy bags or inside a cabinet in the medication room, and did not know how they came to be stored there. The DON later stated that when family brings in medications from home, the facility asks them to take the medications back home and that these medications should not have been stored in the medication room cabinet. The second deficiency involved another resident with depression and high blood pressure, who had a BIMS score of 13 indicating good decision-making ability. During observation of medication cart 1 with LN 2, a medication cup containing pills was found loose in the top right-hand drawer of the cart. LN 2 stated that the medications were for this resident, who had refused to take them earlier in the day. The facility’s “Storage of Medications” policy indicated that drugs and biologicals are to be stored in the packaging, containers, or other dispensing systems in which they are received. In a subsequent interview, the DON stated that no medications should be kept in a medication cup inside the medication cart and that when a resident will not take medications, the medications should be disposed of.
Inaccurate MDS Assessment of Resident's Hearing Status
Penalty
Summary
The facility failed to ensure the accuracy of the admission Minimum Data Set (MDS) for one resident when the MDS indicated the resident had no hearing difficulty, despite multiple sources indicating otherwise. Documentation in the resident's referral packet, discharge summary, and initial assessments by the activities director and speech therapist all noted that the resident was hard of hearing or had trouble hearing out of the right ear. The MDS Coordinator confirmed that the admission MDS inaccurately reflected the resident's hearing status as having no difficulty, despite evidence from the speech therapy evaluation and activities assessment indicating otherwise. Interviews with the resident's family member and facility staff revealed that there was no visible indication in the resident's room about the hearing impairment, and staff did not appear to be aware of the resident's hearing difficulties. The MDS Coordinator acknowledged that the information used to complete the MDS should have included input from various assessments and documentation, which would have shown the resident was hard of hearing. The failure to accurately assess and document the resident's hearing status on the admission MDS was confirmed through record review and staff interviews.
Failure to Develop Care Plan for Resident with Hearing Loss
Penalty
Summary
The facility failed to develop an individual, written care plan addressing hearing loss for one resident with documented hearing impairment. The resident was admitted with a history of left hip replacement and dependence on supplemental oxygen, and was not their own responsible party. Despite information in the referral packet and assessments by the Activities Director and Speech Therapist indicating the resident was hard of hearing, no care plan was created to address this need. The Registered Nurse job description assigned responsibility for care plan development, but this was not carried out for the resident's hearing loss. Interviews with the resident's family member revealed that staff were unaware of the resident's hearing impairment, and the communication board in the room was left blank. The Director of Nursing confirmed the absence of a hearing loss care plan after reviewing the resident's records. The lack of a care plan for hearing loss had the potential to place the resident at risk for social isolation and mood or behavior disorders, as staff were not informed or guided on how to address the resident's communication needs.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
Facility staff failed to administer supplemental oxygen as prescribed for one resident with acute and chronic respiratory failure, chronic obstructive pulmonary disease, and chronic pulmonary edema. The resident's care plan and physician's orders specified that oxygen saturation should be maintained between 88% and 94%. However, review of the Medication Administration Records (MAR) revealed that on 66 out of 84 documented occasions, the resident's oxygen saturation was above 94% and the physician was not notified as required by the order. The Director of Nursing confirmed that staff did not follow the prescribed parameters for oxygen administration and failed to notify the physician when the resident's oxygen saturation exceeded the ordered range. The facility's policy required staff to verify and review physician orders for safe oxygen administration, but this was not adhered to in this case.
Failure to Protect Resident from Verbal Abuse and Discrimination
Penalty
Summary
The facility failed to protect the rights and dignity of a resident who identified as female and had a history of dysarthria following a stroke, transsexualism (transgender), and aphasia. The resident was her own responsible party and had a care plan indicating her female gender identity. Despite facility policies and training requiring staff to treat residents with respect and use their preferred gender identity and pronouns, a Certified Nurse Assistant (CNA) was witnessed verbally abusing the resident. Specifically, CNA B told the resident to "shut the [F word] up" and made derogatory remarks about the resident's gender identity, referencing her transition from male to female. This incident was reported by another CNA who intervened to stop the abuse. Observations and interviews with the resident revealed significant emotional distress following the incident. The resident, who had a low BIMS score indicating poor memory, became visibly upset, fearful, and unable to discuss the event in detail. She displayed signs of fear, such as trembling hands, watery eyes, and avoidance of eye contact, and confirmed through nonverbal cues and limited verbal responses that the incident had occurred and continued to affect her. Further interviews with CNA B showed a continued lack of respect for the resident's gender identity, as evidenced by the repeated use of incorrect pronouns and an aggressive tone during questioning. Facility policies explicitly prohibit discrimination against LGBT residents and require the use of preferred pronouns, but these were not followed in this case, resulting in a violation of the resident's rights and dignity.
Failure to Serve Food at Appropriate Temperatures and Incomplete Temperature Documentation
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, as required by their own policies and regulatory standards. Multiple interviews revealed that a resident and a family member both reported that food was often served cold, with the family member confirming they personally witnessed cold food being served. Another resident, who was cognitively intact according to her BIMS score, stated that her food was always cold and expressed disappointment during a meal observation, pushing her tray away and referencing ongoing complaints about food temperature at Resident Council meetings. Record reviews and staff interviews further substantiated the deficiency. The Certified Dietary Manager (CDM) acknowledged missing temperature documentation on several days and was observed writing temperatures on logs after being asked for them, rather than at the time food was served. The CDM and cook both described procedures for taking and documenting food temperatures, but logs reviewed showed missing entries for multiple meals. The Registered Dietician confirmed that temperatures were supposed to be taken and documented prior to tray line assembly, but this was not consistently done. These actions and inactions led to the failure to serve food at safe and appetizing temperatures.
Pharmacist Failed to Identify and Report Medication Order Irregularity
Penalty
Summary
The facility's consultant pharmacist (CP) failed to identify and report an irregularity in a physician's order for cyclobenzaprine, a muscle relaxant, for a resident who was admitted with a left hip replacement and chronic pulmonary edema. The physician's order specified cyclobenzaprine 5 mg by mouth every eight hours as needed for pain and muscle spasms in both legs, but the medication administration record (MAR) did not document the specific indication—whether it was given for pain or muscle spasms—each time the medication was administered. The facility's policy required the CP to review medication orders monthly and report any irregularities, including medications without adequate monitoring, to the physician for review. During the monthly medication regimen review, the CP did not identify or report the lack of documentation regarding the indication for cyclobenzaprine administration. In an interview, the CP acknowledged that there was no documentation indicating the reason for each administration of cyclobenzaprine and admitted this was a missed opportunity to catch the irregularity during the review. The deficiency was identified for one resident, and no irregularities were reported for cyclobenzaprine prior to the resident's discharge.
Failure to Report Witnessed Verbal Abuse to Required Agencies
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of witnessed verbal abuse toward a resident was not reported to the California Department of Public Health (CDPH), the local Ombudsman, or the police department. According to the facility's policies and procedures, all suspected allegations of abuse are required to be reported to these entities. The incident involved a Certified Nurse Assistant (CNA) overhearing another CNA verbally abusing a resident by making derogatory and inappropriate comments about the resident's gender identity and using profane language. The witnessing CNA reported the incident to the charge nurse and the administrator, but the administrator and Director of Nursing (DON) later stated that the allegation was never reported to them, and thus, no report was made to the required agencies. The resident involved had a history of dysarthria following a cerebral infarction, transsexualism (transgender identity), and aphasia, and was her own responsible party. The resident's care plan identified her as female. The failure to report the witnessed verbal abuse as required by policy resulted in a delay in investigation and did not ensure the resident's protection from further harm during the investigation process, as outlined in the facility's procedures.
Failure to Maintain Accessible and Secure Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were filed in an accessible manner, as required by regulation. During a review of the resident's electronic and paper medical records, key documents such as the "Inventory of Personal Possessions" and the admission "History and Physical" were missing and could not be located when requested. The Director of Nursing (DON) indicated these documents should have been in the paper chart in the medical records department, but they were not present. Later, the "History and Physical" was found in the Admissions office, and the location of the "Inventory of Personal Possessions" was not explained. Additionally, the facility was unable to provide a policy and procedure regarding the completeness, accuracy, and presence of medical records when requested. The facility also failed to ensure that medical records did not leave the premises without proper authorization. It was observed and confirmed that a physician had taken a resident's medical records home, which is not permitted unless expressly authorized by the Department. This action resulted in a delay in locating the resident's "History and Physical" and had the potential for the medical records to become lost. The lack of accessible and properly stored medical records caused delays in medical record accessibility for the resident, who had a history of left hip replacement and required supplemental oxygen.
Missing Admission History and Physical in Resident Medical Record
Penalty
Summary
A resident was admitted with a left hip replacement and required supplemental oxygen. Upon review of the resident's electronic medical record, the admission History and Physical (H&P) was not present. The Director of Nursing (DON) indicated that the H&P should be in the paper medical record, but it was not found during an initial review of the paper chart. The Medical Records (MR) staff also confirmed the absence of the H&P in the paper chart. Later, the DON located the H&P in the Admissions office and explained that the physician sometimes took H&Ps home and returned them later. The absence of the required admission H&P in the resident's medical record at the time of review constituted the deficiency.
Inconsistent Nursing Documentation of Resident's Hearing Status
Penalty
Summary
The facility failed to ensure that nurses' notes were meaningful, informative, and consistent for one resident. Specifically, the daily skilled charting notes documented the resident's hearing as adequate, while the weekly progress notes indicated the resident was hearing impaired and hard of hearing. This inconsistency in documentation was confirmed by the Director of Nursing during a review of the resident's records. The resident involved had a history of left hip replacement and required supplemental oxygen. The facility's policy required accurate and thorough assessment of residents' health status, but a policy specifically addressing the accuracy of medical records was requested and not provided. The inconsistent documentation of the resident's hearing status had the potential for the resident's specific care needs to go unmet.
Incomplete Inventory Documentation for Resident Personal Effects
Penalty
Summary
The facility failed to ensure that the inventory list for a resident's personal effects and valuables was complete, as required by regulation. Upon review, the inventory list for one resident was found to be missing signatures from both the responsible party and the facility staff who completed it. The Director of Nursing confirmed that the responsible party had not signed the inventory list at either admission or discharge, and the staff member's signature on the discharge section was illegible and could not be identified. Additionally, the responsible party stated that the inventory list was never reviewed or provided at either admission or discharge. Further review of the resident's records revealed that the resident was not their own responsible party and had been admitted with a left artificial hip joint and dependence on supplemental oxygen. The responsible party was present during the discharge process, as documented in the general notes, yet the required signatures were still missing from the inventory list. The facility's policy indicated that Certified Nurse Assistants were responsible for completing the form, but the specific staff member involved could not be identified. This deficiency was identified through interviews and record reviews, which demonstrated that the facility did not follow its own policy or regulatory requirements for documenting and verifying residents' personal property inventories. The lack of proper documentation and signatures had the potential for personal belongings not to be accurately accounted for, as directly stated in the report.
Plan Of Correction
1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A 100% audit of all current residents' most recent MDS assessments was initiated to ensure accuracy of sensory and communication sections (hearing and vision). Any discrepancies identified were corrected, and care plans were updated accordingly. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. All MDS staff and licensed nurses involved in assessment and data collection were re-educated on: - Accurate completion of the MDS per RAI (Resident Assessment Instrument) guidelines. - Verifying resident sensory status through observation, resident/family interview, and review of medical records prior to submission. The MDS Coordinator and DON will ensure that each admission and significant change MDS is reviewed for accuracy before final submission. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator or designee will conduct weekly audits for four (4) weeks, then monthly for two (2) months, of at least three (3) randomly selected MDS assessments to verify accuracy in the sensory section. Audit results will be presented during QAPI (Quality Assurance and Performance Improvement) meetings. Any errors identified will be corrected immediately, and staff involved will receive retraining as needed. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A facility-wide audit was conducted of all residents identified with hearing deficits to ensure that appropriate, individualized care plan interventions are in place. Any missing or incomplete care plan items were immediately corrected by the IDT. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. Licensed nurses and members of the IDT were re-educated on the requirement to develop and update individualized care plans that address all assessed resident needs, including sensory impairments such as hearing or vision loss. The MDS Coordinator and DON will ensure that any sensory deficits identified on the MDS trigger an appropriate care plan intervention. Newly admitted residents with hearing or vision concerns will have their care plans initiated within 48 hours of admission. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will conduct weekly audits for four (4) weeks, then monthly for two (2) months, to verify that residents with hearing deficits have active, individualized care plan interventions addressing communication and social engagement needs. Audit findings will be reported and reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Any identified deficiencies will be corrected immediately, and additional education provided as necessary. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. Prior to discharge, the resident's condition was stable, and no adverse effects were noted related to the oxygen administration. The attending physician was notified of the incident and made aware of the resident's discharge status. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents receiving supplemental oxygen were reviewed to ensure oxygen is being administered per the current physician's order. Any discrepancies were immediately corrected, and physicians were notified as needed. No other residents were identified as affected. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. A facility-wide in-service training was provided to all licensed nurses regarding proper administration and titration of supplemental oxygen according to physician orders, documentation of oxygen saturation readings, and the notification protocol for oxygen levels outside the ordered range. The Nursing Supervisor or designee will verify that all oxygen therapy orders clearly specify flow rate and target oxygen saturation range. All new and readmitted residents with oxygen orders will have those orders reviewed by the Director of Nursing (DON) or designee to ensure clarity and completeness. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will perform weekly audits for four (4) weeks, then monthly for two (2) months, to ensure residents receiving oxygen are administered therapy per physician orders. Audit results will be reviewed during the Quality Assurance and Performance Improvement. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #3 was immediately assessed by the licensed nurse for physical and emotional well-being following the incident. The resident denied injury or distress related to the event. Emotional support was offered if needed, and the attending physician was notified. The alleged perpetrator (CNA A) was immediately suspended pending investigation, and the allegation was reported to the California Department of Public Health (CDPH) and the Long-Term Care Ombudsman as required. The facility completed an internal investigation, and appropriate disciplinary action was taken based on the findings. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents were interviewed and observed for signs of distress, fear, or mistreatment. No additional residents reported or displayed evidence of abuse or neglect. Staff were reminded to immediately report any allegations, suspicions, or observations of abuse to the charge nurse and administration per facility policy. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. All facility staff will receive re-education on the Abuse Prevention Policy, including definitions, examples of verbal abuse, resident rights, and mandatory reporting procedures. Education emphasized that any form of disrespectful, degrading, or threatening language toward residents is strictly prohibited. The facility reinforced a zero-tolerance policy for abuse. New hires will receive abuse reporting training during orientation and annually thereafter. The DON and Administrator will ensure that all allegations are promptly investigated, and corrective actions are implemented as required by regulation. The DON or designee will conduct random staff and resident interviews weekly for four (4) weeks, then monthly for two (2) months, to ensure that residents feel safe and that staff adhere to the facility's Abuse Prevention Policy. All findings will be reported and reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Any identified issues will result in immediate corrective action and retraining. --- 5. Element #5: Completion Date. Date of full compliance: November 21, 2025 --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A review of the previous seven (7) days of temperature logs was conducted to identify any inconsistencies. No additional adverse findings were noted. The kitchen staff were instructed to verify and document meal temperatures before every tray line service to ensure food is served within the safe and acceptable temperature range. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. A comprehensive re-education was provided to all dietary staff regarding proper food holding, monitoring, and serving temperatures in accordance with state and federal food safety standards. Staff were re-trained on the requirement to record and document hot and cold food temperatures before each meal service. The Food Service Director or designee will conduct temperature audits before each meal service daily for two (2) weeks, then three times per week for the following four (4) weeks, and weekly for two (2) months thereafter. Audit results will be reviewed with the Director of Nursing (DON) and Administrator. Test trays will go out at least twice a week to varied staff with test tray slip to document temperature, presentation, and taste. CDM will make corrections based off test tray notes. Findings will be presented during QAPI (Quality Assurance and Performance Improvement) meetings. Any deviations will result in immediate staff retraining or disciplinary action, as appropriate. --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since been discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. A comprehensive audit of all current medication orders was completed by the Director of Nursing (DON) and Consultant Pharmacist to identify any potential irregularities or incomplete medication indications. Any identified discrepancies were clarified with the attending physician, and orders were corrected as needed. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Consultant Pharmacist was re-educated on their regulatory responsibility to review all monthly medication orders for accuracy, appropriate indications, and potential irregularities. - The Consultant Pharmacist has changed the protocol at the Pharmacy for any muscle relaxant medication to only be approved for a diagnosis of muscle spasms. - Licensed nurses were re-educated on the requirement to ensure all PRN (as-needed) medication orders specify the indication for use (e.g., pain, spasm, anxiety) and to clarify any vague or incomplete orders with the prescribing provider. - All new orders will be reviewed daily (Monday-Friday) using an order listing report at our IDT meeting. Any discrepancies will be corrected and/or clarified at that time. - The DON will ensure new medication orders are reviewed upon admission and during monthly medication regimen reviews for accuracy and completeness. - A process was implemented for the Consultant Pharmacist to document any identified irregularities and corresponding physician responses in the monthly review reports. 4. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. The DON or designee will conduct monthly medication order audits for three (3) months to ensure orders are complete, accurate, and free from irregularities. Audit results will be reviewed during Pharmacy & Therapeutics and QAPI (Quality Assurance and Performance Improvement) meetings. Any deviations will result in immediate correction and re-education. Continued compliance will be monitored through ongoing monthly pharmacist reviews. 5. Element #5: Completion Date. Date of full compliance: November 21, 2025 --- 1. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. 2. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. A review of all abuse allegation reports from the past 60 days was conducted to ensure proper and timely notification to CDPH, the Ombudsman, and law enforcement. No additional discrepancies were identified. The facility confirmed that all other incidents were appropriately reported in accordance with regulatory requirements. 3. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - All licensed nurses, department heads, and supervisors were re-educated on the facility's Abuse Prevention, Reporting, and Investigation Policy, emphasizing immediate reporting requirements to CDPH, the Ombudsman, and law enforcement within mandated timeframes. - The Abuse Reporting Checklist was updated to include verification boxes for required notifications. --- 4. Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1's medical record was located and properly filed in the designated medical records storage area on the same day the issue was identified. The record was reviewed for completeness and accuracy, and no missing documentation was found. The resident experienced no negative outcomes related to this deficiency. 5. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. A facility-wide audit of all residents' medical records was completed to ensure that all records were filed accurately and were easily accessible. No additional misplaced or inaccessible records were found. 6. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Health Information Manager (HIM) and Medical Records Clerk were re-educated on the facility's policy and procedure for medical record management, including filing, accessibility, and secure storage. - A Medical Record Location Log has been implemented for tracking temporary removal of charts (e.g., for audits, MD review, or IDT meetings). - A sign-out system will be maintained to ensure all records are returned promptly to their designated storage area. - The Administrator and DON will ensure that any new or updated records are filed daily. Education was provided to department heads on how to properly request and return resident charts through the HIM department. 7. Element #4: How the center plans to monitor its performance to make sure that solutions are sustained. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1's medical record was promptly retrieved and returned to the facility upon discovery. The record was reviewed for completeness and accuracy, and no missing documentation was identified. Resident #1 experienced no adverse outcomes because of this deficient practice. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this deficient practice. A complete audit of all current resident medical records was conducted to ensure that all records were on site and properly secured. No additional records were found to be missing or removed from the facility. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The facility's policy and procedure for medical record management was reviewed and revised to clearly state that resident medical records must always remain on facility grounds. - The Medical Director and attending physicians were re-educated on this policy, with emphasis that no original records are to leave the facility under any circumstances. - If a physician requires information for off-site review, photocopies or secure electronic copies will be provided by the Health Information Manager (HIM). - The Health Information Manager and Administrator will monitor compliance by verifying that all records remain on-site. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current residents' "Daily Skilled Charting" to ensure that assessments accurately reflected residents' actual functional and sensory statuses. Any discrepancies identified were immediately corrected, and nurses responsible were re-educated on accurate documentation practices. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - All licensed nurses were re-educated by the Director of Nursing (DON) on the importance of completing accurate and meaningful daily skilled charting that reflects each resident's current condition, including hearing, vision, and communication abilities. - The facility Daily Skilled Nursing Documentation Policy was reviewed and updated to include specific guidance on validating sensory documentation against current care plans and assessments. - The MDS Coordinator will ensure consistency between MDS assessments, care plans, and daily skilled documentation. - Any identified inaccuracies during documentation reviews will result in immediate correction and staff retraining. --- Element #1: How the corrective action will be implemented for residents affected by the deficient practice. Resident #1 has since discharged from the facility. Element #2: How the center will identify other residents having the potential to be affected by the same deficient practice. All current residents have the potential to be affected by this deficient practice. The facility conducted an audit of all current residents' personal inventory forms to ensure each form was complete, current, and signed by both facility staff and the responsible party. Any missing signatures or incomplete forms were corrected immediately. Element #3: What measure will be put into place or what systemic changes the center will make to ensure that the deficient practice does not recur. - The Charge Nurses were re-educated on the facility's Resident Personal Property and Inventory Policy, emphasizing that both the staff member completing the inventory and the responsible party (or resident, if applicable) must sign and date the inventory form upon admission and discharge. - The facility updated the Admission Checklist to include a verification step ensuring the inventory form is signed by both parties before completion of the admission process. - The Social Services Director and Admissions Coordinator will ensure that any changes to resident belongings during the stay are documented and signed accordingly. - The Director of Nursing (DON) will review the process quarterly to ensure compliance. Element #5: Completion Date. November 21, 2025
Delay in X-ray Follow-up Leads to Resident's Untreated Pain
Penalty
Summary
The facility failed to promptly follow up and report the results of an x-ray for a resident who experienced a fall and subsequent knee injury. The resident, who had a history of cognitive impairment and other medical conditions, fell and injured her left knee, prompting a physician to order an x-ray. Despite the x-ray being completed, the facility did not receive or follow up on the results for two days, during which the resident experienced severe pain due to a broken bone. The delay in obtaining and reporting the x-ray results led to a delay in treatment, causing the resident to endure unnecessary pain. The Director of Nursing confirmed that the facility had not received the x-ray report and had not taken steps to follow up with the imaging company within the expected timeframe. This oversight resulted in the resident's physician not being notified of the x-ray results until two days after the x-ray was performed, highlighting a deficiency in the facility's process for managing and communicating critical diagnostic information.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to protect the rights of Resident 1 by not providing a written notice of a proposed room change, as required by their policy. Resident 1, who was cognitively intact and capable of making her own decisions, was moved from her room without receiving a written notice or explanation for the change. The move was decided by the Admission Department and the Social Service Department to accommodate new residents, specifically males, and Resident 1 was informed that she had no choice in the matter. This lack of communication and disregard for Resident 1's preferences led to her experiencing distress and frustration. During interviews, Resident 1 expressed her dissatisfaction and emotional distress over the move, stating that she did not want to relocate and felt like she had no control over her life. The Social Service Director (SSD) and Director of Nursing (DON) admitted that they did not provide a written notice to Resident 1 and were unaware of the requirement until reviewing the Federal Regulations. The situation was further complicated by the presence of Resident 1's Personal Therapist, who confirmed that Resident 1 was upset and did not agree to the move. The facility's failure to adhere to their policy and federal regulations resulted in a deficiency in protecting Resident 1's rights.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. Resident #72 was admitted with a history of serious mental health conditions, including bipolar disorder and major depressive disorder. Despite a Level II Preadmission Screening and Resident Review (PASRR) evaluation recommending specialized services, the MDS inaccurately indicated that the resident did not have a serious mental illness. This oversight was acknowledged by the MDS Coordinator, who admitted that the PASRR Level II was missed in the admission MDS. Resident #65 was admitted with a history of chronic obstructive pulmonary disease and hypertension. The admission MDS inaccurately reported that the resident did not use tobacco, despite progress notes and the resident's own admission indicating they were a smoker. The MDS Coordinator acknowledged the error, stating that she misunderstood the resident's smoking status during the initial interview. Both the Director of Nursing and the Administrator expressed expectations for MDS accuracy to ensure appropriate care, but the inaccuracies in these assessments were not aligned with those expectations.
Failure to Complete PASRR for Readmitted Resident with New Psychiatric Diagnosis
Penalty
Summary
The facility failed to initiate a Level I Preadmission Screening and Resident Review (PASRR) for a resident who had received a new psychiatric diagnosis prior to readmission. The resident, who had a history of dementia with behavioral disturbance, was readmitted to the facility after a psychiatric stay with a new diagnosis of unspecified psychosis. Despite this new diagnosis, the facility did not complete a new PASRR upon the resident's return. The facility's policy required that all admissions have the appropriate PASRR completed, but this was not adhered to in the case of the resident. The resident's medical record showed no evidence of a new PASRR being completed after readmission, nor was there a referral made to the appropriate state-designated authority following the new psychiatric diagnosis. Interviews with facility staff, including the Director of Nursing (DON) and the Social Services Director (SSD), revealed a lack of clarity and training regarding the PASRR process, contributing to the oversight. The DON acknowledged that a new PASRR should have been completed when the resident was readmitted with a diagnosed mental illness of psychosis. The facility's process involved reviewing admissions for medications and diagnoses that would trigger a positive Level I PASRR, but this was not effectively executed in this instance. The DON admitted to a lack of training and understanding of the PASRR requirements, which led to the deficiency in the resident's care.
Failure to Accurately Complete PASRR for Resident with Schizophrenia
Penalty
Summary
The facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with schizophrenia. The resident was admitted to the facility with a medical history that included schizophrenia and major depressive disorder, both with onset dates matching the admission date. However, the Level I PASRR completed at the hospital prior to admission only listed depression as a serious diagnosed mental disorder, omitting schizophrenia. This omission led to the state being unable to complete a Level II evaluation, as the resident was not considered to have a serious mental illness according to the PASRR. Interviews with facility staff revealed that the hospital was responsible for completing the initial Level I PASRR, and the Director of Nursing (DON) was tasked with ensuring its accuracy before admission. Despite this, the schizophrenia diagnosis was not captured, and the PASRR was accepted as completed by the hospital. The DON acknowledged the need to redo and resubmit the PASRR to include the schizophrenia diagnosis. The facility's policy indicated that all admissions should have the appropriate PASRR completed, but this was not adhered to in this case.
Resident Neglect in Comfort Care
Penalty
Summary
The facility failed to provide appropriate care for a resident admitted for comfort care, resulting in a distressing experience for the resident. The resident, who was terminally ill and admitted for end-of-life care, was left in a soiled state with a loud television and was not assisted with eating. Despite the resident's request not to be placed in a brief, he was found in a soiled brief and hospital gown, with dried brown rings on his bed sheets, indicating prolonged neglect. The resident was admitted with conditions such as thrombocytopenia and an infected pacemaker and was aware of his surroundings, as noted in his admission assessment. He had an indwelling urinary catheter and was continent of bowel and bladder. However, during the night shift, the resident was not provided with the requested bedpan and was left in a diaper, contrary to his expressed wishes. The resident also reported that the television was excessively loud, and his requests for it to be turned down were ignored, contributing to his discomfort and inability to rest. Interviews with staff and family members revealed that the resident's needs were not adequately addressed. The resident's family found him in a distressing state the following morning, leading to his decision to leave the facility and return to the hospital. The facility's failure to adhere to the resident's preferences and provide necessary care, such as assistance with meals and maintaining a comfortable environment, resulted in a significant deficiency in the quality of care provided.
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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 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.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
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.
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 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.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
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.
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