Rialto Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rialto, California.
- Location
- 1471 S Riverside Ave, Rialto, California 92376
- CMS Provider Number
- 055213
- Inspections on file
- 34
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Rialto Post Acute Center during CMS and state inspections, most recent first.
A resident with quadriplegia, multiple sclerosis, acute respiratory failure, and lymphocytosis developed a new stage 3 pressure injury on the right hip that was identified only after a CNA reported it to the WTN. The WTN documented the wound’s size and characteristics and noted that the hip area had previously been clear of skin breakdown. CNA staff and the DON stated that daily skin checks during care and repositioning every two hours are expected practices, and facility policy requires daily skin inspection and identification of early signs of pressure injuries, such as non-blanchable erythema. The DON acknowledged that, consistent with this policy, staff should have provided care and identified the developing pressure injury sooner.
A nurse failed to reconcile discharge medications, resulting in two medications prescribed for one resident being given to the caregiver of another resident who was not prescribed them. The resident who should have received the medications had heart failure, while the resident who received them had encephalopathy and cirrhosis with moderate cognitive impairment. The error was discovered after the family reported receiving the wrong medications, and records confirmed the mistake.
Two CNAs assisted a resident with Alzheimer's dementia in bed while the resident's abdomen and diaper were exposed, as the privacy curtain was not drawn and the door was left open. Both CNAs acknowledged the lapse in privacy, and the DON confirmed this violated facility guidelines for resident dignity.
A resident with dementia and a history of elopement was admitted with orders for a wander guard and one-on-one supervision, but neither was implemented due to equipment unavailability and lack of staff assignment. The resident left the facility unnoticed and was later found deceased offsite. Required risk assessments and supervision protocols were not followed.
The facility failed to report allegations of abuse involving two residents to the appropriate authorities as required by policy. In one case, a resident alleged that an LVN twisted her wrist, and in another, a resident reported that a CNA forcibly pushed her leg during a transfer, resulting in pain. Despite being informed of these allegations, facility leadership did not notify the California Department of Public Health or other mandated agencies, citing disbelief in the allegations and unfamiliarity with reporting requirements.
A resident's right to access medical records was violated when a law firm requested records for a legal matter, but the facility failed to deliver them within the required timeframe. The request was delayed due to a fax being sent to the wrong number and awaiting legal team approval, contrary to the facility's policy of providing access within 48 hours.
A resident with moderate cognitive impairment hit another resident with a water pitcher after a verbal disagreement, leading to a physical altercation. The affected resident, who had a recent hip surgery, experienced increased pain and required hospital evaluation. The facility's failure to prevent the altercation highlights a deficiency in their abuse prevention measures.
The facility failed to ensure accurate MDS assessments for three residents, leading to deficiencies in documenting their medical conditions. A resident with schizophrenia did not have a Level II PASRR reflected in their MDS, another resident's diabetes mellitus was not indicated despite receiving insulin, and a third resident's serious mental illness was not captured in the MDS despite a completed Level II PASRR. Interviews with staff confirmed these omissions.
The facility failed to secure medications for two residents, leading to potential accident hazards. A resident with severe cognitive impairment was found with unsecured medications at their bedside, despite not being assessed for self-administration. Another resident with intact cognition had over-the-counter medication at their bedside without proper authorization or assessment. Staff interviews revealed a lack of adherence to the facility's policy on medication storage and administration, resulting in a deficiency.
A resident with severe cognitive impairment and an indwelling urinary catheter received improper catheter care from a CNA, who failed to follow clean technique and did not rinse soap from the skin. The CNA also positioned the catheter drainage bag incorrectly, lying flat on the floor, which could hinder proper drainage. The facility's policy was not adhered to, as confirmed by the DON and Administrator.
Failure to Timely Identify Developing Pressure Ulcer on Resident’s Hip
Penalty
Summary
The deficiency involves the facility’s failure to identify signs of a developing pressure ulcer in a timely manner for one resident. The resident was admitted with significant medical conditions including quadriplegia, multiple sclerosis, acute respiratory failure, and lymphocytosis. On a documented change in condition evaluation dated March 3, 2026, the Wound Treatment Nurse (WTN) recorded that a CNA reported a pressure injury on the resident’s right hip. Upon assessment, the WTN identified a stage 3 pressure injury on the right hip, measuring 3.7 x 3 x 0.3 cm, with 90% granulation tissue and 10% slough, and obtained treatment orders from the MD. The WTN stated that the resident’s right hip area had been clear with no prior skin breakdown before this finding. CNA 1 reported that staff perform daily skin checks during care and report any skin changes to charge nurses, and that residents are repositioned every two hours to prevent skin breakdown and pressure ulcers. The DON stated that staff are supposed to conduct daily skin inspections during personal care to identify and report any skin changes, and acknowledged being informed of the new stage 3 pressure injury on the resident’s right hip on March 3, 2026. Review of the facility’s “Prevention of Pressure Injuries” policy, revised April 2020, showed that staff are required to inspect the skin daily during personal care or ADLs and identify any signs of developing pressure injuries, such as non-blanchable erythema. The DON acknowledged the policy and stated she expected staff to have provided care sooner.
Failure to Reconcile Discharge Medications Results in Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to properly cross-check and reconcile discharge medications according to facility policy, resulting in the transfer of two medications—Atorvastatin and Eliquis—prescribed for one resident to the caregiver of another resident who was not prescribed these medications. The error occurred during the discharge process, when the LVN inadvertently provided two medication carts belonging to the first resident to the caregiver of the second resident. The facility’s policy required nurses to reconcile all pre-discharge medications with the resident’s post-discharge medications and document the reconciliation, but this step was not completed. The resident who was supposed to receive the medications had a history of hypertensive heart disease with heart failure and no mental impairment, while the resident who mistakenly received the medications had diagnoses of encephalopathy and cirrhosis of the liver, with moderate cognitive impairment. The error was discovered after the family of the second resident reported receiving medications not prescribed to their family member, prompting notification of facility leadership. Review of medical records confirmed that the medications in question were not prescribed to the second resident, but were prescribed to the first.
Failure to Maintain Resident Dignity and Privacy During Transfer
Penalty
Summary
Two Certified Nursing Assistants (CNAs) failed to maintain the dignity and privacy of a resident diagnosed with Alzheimer's dementia during a transfer in bed. The surveyor observed that the resident's abdomen and diaper were exposed because the privacy curtain was not drawn and the door to the room was left open, allowing potential exposure to anyone passing by. Both CNAs acknowledged during interviews that the resident's privacy was not upheld and that the situation was inappropriate. The Director of Nursing confirmed that this was a violation of facility guidelines regarding resident privacy and dignity. Facility policy reviewed indicated that residents are to be treated with dignity and respect at all times.
Failure to Provide Supervision and Wanderguard Results in Resident Elopement and Death
Penalty
Summary
A deficiency occurred when the facility failed to provide required one-on-one supervision and did not apply a wander guard for a newly admitted resident with dementia and a history of elopement. The resident, who had recently been released from jail and was on parole, was admitted with diagnoses including dementia with agitation and a major cognitive disorder. Documentation from the hospital and admission records indicated the need for a wander guard to prevent the resident from leaving the facility unassisted, and active orders were in place for its application and monitoring every shift. Despite these orders, the wander guard was not available at the time of admission, and the facility did not provide documented evidence that one-on-one supervision was implemented as required. Nursing notes indicated that the wander guard was not applied, and interviews with the DON revealed that no staff member was assigned to monitor the resident at the time he left the facility. The elopement risk assessment for the resident was completed only after the resident had already eloped, and it incorrectly indicated that the resident was not at risk for elopement or wandering. The resident was last seen in the facility in the morning and was later found to be missing. Police were notified, and the resident was subsequently found deceased at a bus stop several miles from the facility. The facility's policies required supervision based on assessed needs and completion of elopement risk assessments upon admission, but these procedures were not followed for this resident, resulting in the resident's elopement and death.
Removal Plan
- The DON provided a 1:1 in service to RN regarding 1:1 monitoring intervention to ensure it is followed.
- The DON/ADON provided in service to the nursing staff regarding 1:1 monitoring intervention to ensure it is followed.
- Ensure all new admissions have a completed elopement risk assessment.
- The NHA/CEO conducted an inspection of current residents with wander guard to check for placement and function.
- The NHA/CEO provided in service training to Maintenance Staff regarding wander guard alarm.
- Return demonstration of Maintenance by Nursing Home Administrator/CEO was conducted and performed well.
- Licensed Nursing staff along with the Maintenance, checked all residents with wander guard with the alarm door, all functioning well.
- Wander guard will be checked by the licensed nurses for placement attached to the resident every shift and for wander guard to be functioning daily.
- The licensed nurses re-evaluated the Wander/Elopement Risk of the residents at high risk for Wandering/Elopement.
- Licensed Nurses will conduct visual check of high-risk resident for wandering/elopement every 2 hours indicating location of the resident.
- A designated RN conducted inspection of current residents on 1:1 monitoring to ensure proper implementation.
- Resident started on 1:1 monitoring every hour by assigned CNA to determine resident's activity and provide supervision.
- RN Supervisor conducting actual physical head count of residents during shift to shift endorsements.
- RN Supervisor prints the facility census indicating resident's name, room number and bed assignment.
- Outgoing RN Supervisor together with the incoming RN Supervisor will conduct actual physical head count during room rounds.
- Both RN Supervisors will confirm number of actual physical head count by writing the final count in the census print out. Both RNs will sign to confirm actual head count.
- Completed census with actual head count will be filed in the RN Supervisor binder.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report allegations of abuse involving two residents in accordance with its own policy and regulatory requirements. In the first incident, a resident with a history of hemiplegia, hypertensive heart disease, COPD, and depression alleged that a Licensed Vocational Nurse (LVN) twisted her right wrist while attempting to turn off her phone, which had inadvertently connected to the facility's overhead speaker. The resident reported the incident to the Charge Nurse and complained of a burning sensation in her wrist. The LVN denied any physical contact, stating he was only trying to help with the phone, and the incident was reported to the Administrator and Director of Nursing (DON). However, the facility did not report the allegation to the California Department of Public Health (CDPH) or other required authorities as outlined in their policy. In the second incident, another resident with diagnoses including COPD, peptic ulcer, esophagitis, and type 2 diabetes alleged that a Certified Nurse Assistant (CNA) pushed her left leg forcibly while using a mechanical lift, resulting in ongoing pain and the need for continuous pain medication. The CNA stated she only lightly touched the resident's leg to reposition it and stopped when the resident expressed pain. The incident was brought to the attention of the LVN and DON, but again, the facility did not report the allegation to CDPH or other mandated agencies. Interviews with facility leadership revealed a lack of familiarity with the reporting policy and a failure to recognize the obligation to report all allegations of abuse, regardless of staff denial or the resident's history. The Administrator acknowledged that neither incident was reported as required, citing disbelief in the allegations and lack of awareness of one of the incidents. Review of the facility's abuse investigation and reporting policy confirmed that all alleged violations must be reported immediately to appropriate authorities, which was not done in these cases.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to ensure a resident's right to access personal and medical records was upheld when a law firm requested medical records for a legal matter. The request was made for a resident who was admitted with multiple sclerosis and had a BIMS score indicating cognitive intactness. The request for records was sent via fax on January 16, 2025, but was not received by the Director of Health Information (DHI) until January 24, 2025, due to it being sent to the Business office fax number. The records were not delivered within the facility's policy timeframe of two working days, as the DHI was awaiting approval from the facility's legal team and had not contacted the law office representing the resident. The facility's Policy and Procedure for the release of information, dated November 2009, states that residents may access their records within 48 hours of a request, excluding weekends and holidays. However, the DHI acknowledged a delay in dispatching the documents, which was not in compliance with the policy. During a review and interview, the Director of Nursing and the administrator agreed with the acknowledgment of the delay, confirming the failure to meet the specified timeframe for providing the requested records.
Resident-to-Resident Altercation Due to Inadequate Abuse Prevention
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in an altercation between two residents. Resident #88, who had moderate cognitive impairment, hit Resident #216 with a plastic water pitcher after a verbal disagreement. Resident #216, who had intact cognition and a recent hip surgery, was admitted to the facility just two days prior to the incident. The altercation occurred after Resident #88 complained about Resident #216's coughing, leading to a physical confrontation where Resident #88 hit Resident #216, and Resident #216 bit Resident #88's thumb during the struggle. The facility's policy on abuse prevention was not effectively implemented, as Resident #88 had a history of changing rooms due to noise issues but no documented history of physical abuse. The staff did not anticipate or prevent the altercation, despite Resident #88's known behavioral issues. The incident resulted in Resident #216 experiencing increased pain and requiring hospital evaluation for potential complications related to their recent hip surgery. Interviews with staff and residents revealed that the facility did not adequately assess the compatibility of roommates, leading to the altercation. The staff's response to the incident included separating the residents and notifying the appropriate authorities, but the initial failure to prevent the altercation highlights a deficiency in the facility's abuse prevention measures.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their medical conditions. Resident #22, who was admitted with a diagnosis of schizophrenia, had a significant change MDS that did not reflect a completed Level II Preadmission Screening and Resident Review (PASRR), despite a letter confirming its completion. Interviews with the MDS Assistant, Director of Nursing (DON), and Administrator confirmed that the Level II PASRR should have been included in the MDS. Resident #119, admitted with hemiplegia, had a quarterly MDS that failed to indicate a diagnosis of diabetes mellitus, despite receiving insulin injections and having a care plan that acknowledged the condition. Similarly, Resident #97, admitted with multiple psychiatric diagnoses, had an MDS that did not reflect a Level II PASRR evaluation indicating a serious mental illness, despite documentation confirming its completion. Interviews with facility staff, including the MDS Assistant, DON, and Administrator, revealed that the MDS should have accurately captured the PASRR information and the residents' medical conditions.
Failure to Secure Medications and Prevent Potential Accidents
Penalty
Summary
The facility failed to ensure that potentially hazardous medications were secured to prevent potential accidents for two residents. Resident #104, who had severe cognitive impairment and was not assessed for self-administration of medications, was found with a cup of pills on their over-bed table. The medications were within reach, and the resident stated they had forgotten to take them. Despite multiple staff members, including LVNs and CNAs, being involved in the resident's care, none could confirm who left the medications at the bedside. The facility's policy clearly stated that medications should not be left at the bedside unless the resident was assessed and authorized for self-administration, which was not the case for Resident #104. Resident #75, who had intact cognition, was found with a roll-on applicator and a pump bottle of Pain Wizard Natural Relief at their bedside. The resident stated that the nurses were aware of the medication's presence. However, there was no order for the resident to self-administer this over-the-counter medication, nor was there an assessment completed for self-administration. Staff members, including CNAs and LVNs, were unaware of the medication's presence or mistook it for deodorant, indicating a lack of awareness and adherence to the facility's policy regarding medication storage and administration. Interviews with the facility's nursing staff, including the ADON and DON, revealed a lack of compliance with the facility's policy on medication administration and storage. The staff acknowledged that medications should not be left at the bedside without proper assessment and orders. The DON and Administrator confirmed that neither resident was appropriate for self-administration of medications, and the presence of medications at the bedside posed a risk, especially for residents with cognitive impairments or those who wander. The facility's failure to adhere to its policies resulted in a deficiency in ensuring a safe environment free from accident hazards.
Improper Urinary Catheter Care and Positioning
Penalty
Summary
The facility failed to provide proper urinary catheter care for a resident, leading to a potential risk of urinary tract infection or other complications. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, had an indwelling urinary catheter due to a neurogenic bladder. During an observation, a CNA was seen performing catheter care without following the facility's policy. The CNA used a single towel to clean multiple areas without changing to a clean section, did not rinse the soap from the resident's skin, and failed to dry the skin before applying a clean brief. Additionally, the CNA improperly positioned the urinary catheter drainage bag by allowing it to lie flat inside a basin on the floor, which could prevent proper drainage. The CNA admitted to forgetting the correct procedure due to nervousness. The Director of Nursing and the Administrator both confirmed that the facility's policy was not followed, which included using a clean area of the cloth for each stroke, rinsing off soap, and ensuring the drainage bag was positioned correctly to facilitate gravity drainage.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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