Rosewood Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasant Hill, California.
- Location
- 1911 Oak Park Boulevard, Pleasant Hill, California 94523
- CMS Provider Number
- 056476
- Inspections on file
- 26
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Rosewood Post Acute during CMS and state inspections, most recent first.
A resident’s responsible party, who is the resident’s son and a full-time physician, was notified by phone on the morning of a scheduled interdisciplinary care conference that was held later that same day, leaving him unable to attend due to short notice. The SSA documented a single morning call with a voicemail left and later recorded that the responsible party had been invited but did not attend, while also acknowledging that returned calls were typically not documented and that the responsible party’s work schedule was known. The responsible party reported ongoing difficulty getting calls returned, trouble arranging conferences at times he could attend, and not being kept informed or included in treatment decisions, despite facility policy stating that resident representatives are encouraged to participate in care planning and that meetings should be scheduled at the best time for the family.
A resident’s responsible party (RP), who works full time as a physician, was notified by voicemail on the morning of a scheduled interdisciplinary care conference that the meeting would occur later that same day, leaving him unable to attend. The SSA documented only that a message was left and acknowledged typically not charting returned calls, while the care conference proceeded with staff present and the RP noted as invited but not attending. The RP reported ongoing difficulty having calls returned, trouble getting conferences scheduled at times he could attend, and not being kept informed of the resident’s care and treatment, despite facility policy stating that residents and their representatives are encouraged to participate in care planning and that meetings should be scheduled at times suitable for the resident and family.
Two residents with severe cognitive impairment and behavioral/communication limitations were left without adequate supervision, allowing one to self-propel into another's room where the second resident struck him in the face while both were in wheelchairs. Staff later acknowledged that closer line-of-sight monitoring was needed, particularly for cognitively impaired residents, but at the time of the event the lack of effective supervision and protection led to the assaulted resident sustaining pain, redness, and swelling near the left eye despite an existing abuse prohibition policy.
A resident admitted with nonrheumatic tricuspid valve disorder did not have a completed Inventory of Personal Effects form at admission or discharge. The belongings section of the form was left blank, and required signatures from the resident or representative and facility staff were missing at both admission and discharge. This occurred despite a facility policy requiring staff to list all personal items on admission, update the list as needed, and obtain signatures to acknowledge receipt of personal property.
A resident, assessed as cognitively intact and admitted with muscle weakness, reported to a family member that an LVN hit his leg during care. The LVN denied the allegation but failed to report it to supervisors or the administrator, and no documentation or investigation was initiated as required by facility policy.
A resident with severe cognitive impairment and communication deficits developed a foul-smelling right big toe, which was documented by an RN and referred to podiatry. However, there was no documentation or recall that the responsible party was notified of this change in condition, leaving them uninformed, despite facility policy requiring such notification.
A resident with severe cognitive impairment and communication difficulties experienced a change of condition involving a foul-smelling toe, which was documented by an RN and referred to podiatry. However, there was no evidence that the responsible party was notified, as required by facility policy. Both the RN and DON confirmed the lack of documentation and notification.
The facility failed to follow physician's orders for two residents with Foley catheters, leading to unreported changes in urine character and unauthorized catheter flushes. This resulted in one resident being hospitalized for a urinary tract infection and potential risks for the other. The facility did not document or notify physicians of these changes, violating care standards.
A resident with hemiplegia, hemiparesis, and morbid obesity fell out of bed during ADL care due to inadequate supervision and lack of assistive devices. The resident required a two-person assist, but a CNA continued care alone after a student CNA left the room. The resident sustained a nasal bone fracture and facial bruising. The care plan did not specify the need for a two-person assist, despite documentation indicating this requirement.
A CNA verbally abused a resident during an altercation in an LTC facility. The resident, with a history of alcohol abuse and anxiety disorder, was concerned about another resident's distress and asked the CNA to leave the room. The CNA responded by yelling at the resident. The resident's care plan included strategies for managing verbal behaviors, which were not followed during the incident.
A facility failed to conduct reference checks for a CNA before hiring, contrary to its abuse prevention policy. This oversight was discovered after a verbal altercation between the CNA and a resident, who was admitted with alcohol abuse and anxiety disorder. The CNA, unable to hear a resident's roommate due to noise, inappropriately told the resident to 'shut the hell up.' The Director of Staff Development confirmed that while background checks were done, reference checks were not documented.
Insufficient Notice to Responsible Party for Care Planning Conference
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient notice of a care planning conference to the responsible party (RP) for one of three sampled residents, resulting in the RP not being able to participate in care planning. The resident’s son, who is the designated RP and a full-time working medical doctor, reported that the facility called him and left a message on the morning of 11/13/25 stating that a care planning conference was scheduled for later that same day. He stated he was unable to attend due to the short notice. He also reported having difficulty getting his calls returned by facility staff and being unsuccessful in the past in getting care conferences scheduled at times he could attend. He stated he was not kept informed of the resident’s care and treatment and was not included in making treatment decisions. Record review and staff interviews confirmed that Social Service Assistant (SSA) 1 attempted to contact the RP on the morning of 11/13/25, left a message requesting a return call, and documented this in a Social Service Progress Note at 9:02 a.m. The Interdisciplinary Care Conference Progress Note, entered at 2:47 p.m. the same day, listed the RP as having been invited by phone but not attending, and indicated that a copy of the care plan was refused by the resident/resident representative. SSA 1 acknowledged usually not documenting when calls were returned and knew the RP was a doctor who worked full time. The Social Services Director stated that calling the son on the same day as the care conference was short notice. The facility’s care planning policy states that residents and their representatives are encouraged to participate in care plan development and that every effort will be made to schedule care plan meetings at the best time for the resident and family, which did not occur in this instance.
Insufficient Notice to Responsible Party for Care Plan Conference
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient notice to a resident’s responsible party (RP) to allow participation in the development and implementation of a person-centered care plan. The resident’s son, who is the RP and a full-time working medical doctor, reported that he received a voicemail from the facility on the morning of 11/13/25 informing him that a care planning conference was scheduled for later that same day. Due to the short notice, he was unable to attend. He also stated he had ongoing difficulty getting his calls returned by facility staff and had been unsuccessful in the past in getting care conferences scheduled at times he could attend, and that he was not kept informed of the resident’s care and treatment. Interviews and record reviews showed that the Social Service Assistant (SSA) called the RP on the morning of 11/13/25, left a message, and documented in a Social Service Progress Note that there was no answer and a message was left requesting a return call. The SSA stated that returned calls were usually not documented in the chart. A Progress Note from later that same day documented that an Interdisciplinary Care Conference was held, listed the staff attendees, and indicated that the son/RP was invited by phone but did not attend, and that a copy of the care plan was refused by the resident/resident representative. The Social Services Director acknowledged that calling the RP on the same day as the care conference was short notice. The facility’s care planning policy stated that residents and their representatives are encouraged to participate in care plan development and that every effort will be made to schedule care plan meetings at the best time for the resident and family.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Facial Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him in the face. One resident with dementia, who was rarely/never understood, had memory problems, and never/rarely made decisions regarding daily tasks, was able to self-propel his wheelchair independently and was known by staff to be confused and to enter other residents' rooms. On the day of the incident, this resident wheeled himself along the hallway and into another resident's room without apparent staff intervention or monitoring to prevent unsafe interactions. A restorative nurse assistant, who was with another resident at the time, heard yelling, rushed to the room, and observed the second resident swinging his arm and hitting the first resident on the left side of his face while both were in their wheelchairs. The second resident had diagnoses including anxiety and aphasia and a BIMS score of 0/15, indicating severe impairment in memory and thinking. Progress notes documented that this resident physically struck the other resident in the left eye and was angry and refused to speak with staff about the incident. Progress notes for the injured resident documented mild pain to the left eye and surrounding area, with redness and mild swelling. A nurse later stated that the incident could have been avoided by ensuring the injured resident was kept in line of sight, and emphasized that residents with severe cognitive impairment are a vulnerable population requiring protection from abuse. The facility’s abuse prohibition policy defined physical abuse as including hitting, but the incident occurred despite this policy, resulting in the resident sustaining pain, swelling, and redness near the left eye after being hit by another resident.
Failure to Complete Resident Personal Belongings Inventory at Admission and Discharge
Penalty
Summary
The facility failed to complete a personal belongings inventory for one sampled resident, resulting in an inaccurate record of the resident's possessions. The resident was admitted with diagnoses including nonrheumatic tricuspid valve disorder and later discharged home. A review of the admission record showed that, at the time of admission, the Inventory of Personal Effects form for this resident was not filled out. During an interview and concurrent record review, the Administrator confirmed that the Inventory of Personal Effects form for this resident had not been completed. Further review of the Inventory of Personal Effects form showed that the section listing the resident's personal belongings was blank, and the Certification of Receipt sections for both admission and discharge contained no signatures from the resident or resident representative, nor from a facility staff representative. Review of the facility's policy and procedure titled "Resident's Personal Property" indicated that personnel are required to identify and record resident belongings upon admission, list all items on the Inventory of Personal Effects form, keep the form in the clinical chart, add any additional items brought in after admission, and obtain signatures from the resident or representative and an employee at admission and again at discharge. These required steps were not carried out for this resident.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
A resident, who was cognitively intact and admitted with muscle weakness, reported to a family member that a Licensed Vocational Nurse (LVN) hit his right leg while assisting him back to bed. The family member confronted the LVN, who denied the allegation, but the incident was not documented in the resident's departmental notes. The LVN later acknowledged being aware of the accusation but did not report the alleged abuse to her supervisor or the facility administrator, as required by the facility's abuse policy. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported within 24 hours and investigated within 2 hours, with thorough documentation. However, the LVN failed to follow these procedures, resulting in the incident not being reported or investigated in a timely manner. The administrator confirmed that the LVN should have reported the allegation, and a review of facility records showed no documentation or investigation of the alleged abuse.
Failure to Notify Responsible Party of Resident's Change of Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change of condition as required by policy. The resident, who had a cognitive communication deficit and aphasia, was admitted with severe cognitive impairment as indicated by a BIMS score of 0. On a specific date, a registered nurse documented that the resident's right big toe had a foul smell and planned to refer the resident to podiatry. However, during a subsequent review, both the Director of Nursing (DON) and the RN were unable to find documentation that the RP had been informed of this change in condition. The RN also could not recall notifying the RP about the issue with the resident's toe. Interviews with the DON confirmed that facility policy requires immediate notification of the physician and the RP in the event of a change of condition. Review of the facility's policy and procedure further supported this requirement, stating that residents, family, legal representatives, and physicians must be informed of significant changes in the resident's physical, mental, or psychosocial status. The lack of documentation and recall regarding notification resulted in the RP being uninformed and unaware of the resident's change of condition.
Failure to Notify Responsible Party of Resident's Change of Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's change of condition. The resident, who had a cognitive communication deficit and aphasia, was admitted with severe cognitive impairment as indicated by a BIMS score of 0. On a specific date, a registered nurse documented that the resident's right big toe had a foul smell and that a referral to podiatry would be made. However, there was no documentation that the RP was informed of this change in the resident's condition. During interviews and record reviews, both the RN and the Director of Nursing (DON) were unable to find evidence that the RP had been notified about the resident's condition. The RN could not recall informing the RP, and the DON confirmed that facility policy requires notification of the physician and RP in the event of a change of condition. The facility's policy also specifies that residents, family, legal representatives, and physicians must be informed of significant changes in condition or treatment needs.
Failure to Monitor and Report Changes in Foley Catheter Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for two residents, Resident 2 and Resident 3. For Resident 2, the facility did not follow physician's orders to monitor the Foley catheter urine output and failed to report changes in urine character to the physician. This oversight led to Resident 2 being transferred to the hospital with a urinary tract infection requiring intravenous antibiotics. The facility's records showed that there were multiple instances of missing documentation regarding urine character monitoring, and the attending physician was not notified of the observed changes. Similarly, for Resident 3, the facility did not adhere to physician's orders to monitor the Foley catheter urine output and failed to report changes in urine character to the physician. The records indicated that Resident 3's urine had sediment and cloudiness, and a foul smell was observed over several days, yet these changes were not communicated to the physician. Interviews with staff revealed that the presence of sediments and bloody urine should have prompted physician notification, but this was not done. Additionally, the facility performed Foley catheter flush/irrigation without a physician's order for both residents. This action was not documented in the treatment administration records, and there was no written order for the flush. The facility's policy required specific documentation for catheter irrigation, which was not followed. These failures in adhering to physician orders and facility policies had the potential to contribute to the development of urinary tract infections in the residents.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for a resident who required a two-person assist during Activities of Daily Living (ADLs). The resident, who was admitted with conditions including hemiplegia, hemiparesis, morbid obesity, and weakness, fell out of bed during ADL care, resulting in a nasal bone fracture and facial bruising. The resident's Minimum Data Set indicated an intact cognitive status, and the resident reported falling on her face due to the absence of a bed rail to hold onto during repositioning. During the incident, a Certified Nursing Assistant (CNA) was providing ADL care with a student CNA, who left the room at the resident's request. The CNA continued the care alone, despite knowing the resident required a two-person assist, and turned away to grab a towel when the resident rolled over and fell. The CNA admitted to not informing the Licensed Vocational Nurse (LVN) about the student CNA's departure and was unaware of the lack of side rails on the bed. The resident's care plan indicated the need for a positioning bar/rail in bed but did not specify the requirement for a two-person assist with bed mobility, as documented in the Weekly Summary Documentation. The facility had previously conducted in-service education for CNAs on providing two-person assistance for residents with similar needs, which the CNA involved in the incident had attended. The incident was documented in the resident's progress notes and reviewed by the Interdisciplinary Fall team, highlighting the need for maximum assistance for the resident's ADLs.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a Certified Nursing Assistant (CNA) yelled at a resident during a verbal altercation. The incident involved a resident who was admitted with diagnoses of alcohol abuse with intoxication and anxiety disorder. The resident had a Brief Interview for Mental Status (BIMS) score indicating intact cognitive status. During the incident, the CNA entered the room to assist another resident who was hollering and crying. The first resident, concerned about the situation, instructed the CNA to leave the room and get the charge nurse. In response, the CNA yelled at the resident, telling them to "shut the hell up." The resident's care plan included interventions for verbal behaviors toward staff, such as allowing time for expression of feelings and providing empathy, encouragement, and reassurance. The care plan also advised staff to postpone care activities if the resident became combative or resistive and to remove the resident from the environment if needed, while speaking in a calm, reassuring voice. Additionally, another care plan for the resident's history of verbal outbursts directed toward others recommended providing a calm, quiet, well-lit environment. These interventions were not followed during the incident, leading to the verbal altercation and the deficiency.
Failure to Conduct Reference Checks for CNA
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse by not conducting a reference check on a Certified Nursing Assistant (CNA) prior to hiring. This oversight was identified during a review of the CNA's employee files, which showed that although the CNA had listed two previous employers, no reference checks were conducted. The Director of Staff Development confirmed that while background screenings were performed, reference checks were not documented, which was contrary to the facility's policy titled 'Abuse Prohibition & Prevention and Reporting Reasonable Suspicion of a Crime in the Facility.' This policy, last revised in August 2022, required the facility to review prospective employees' employment history and check information from previous or current employers. The deficiency was highlighted during an incident involving a resident who was admitted with diagnoses including alcohol abuse with intoxication and anxiety disorder. The resident, while intoxicated, had a verbal altercation with the CNA, who responded inappropriately by telling the resident to 'shut the hell up.' This incident occurred when the CNA was attempting to assist the resident's roommate, who was hollering and crying. The CNA admitted to yelling at the resident due to the inability to hear the roommate over the noise. This situation underscored the potential risk of exposing residents to staff who may have a propensity for abusive behavior due to the lack of proper reference checks.
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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