Santa Clara Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Clara, California.
- Location
- 991 Clyde Avenue, Santa Clara, California 95054
- CMS Provider Number
- 056069
- Inspections on file
- 52
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Santa Clara Post Acute during CMS and state inspections, most recent first.
A resident with a history of leukemia and transplant received 12 doses of Tacrolimus at 10 times the prescribed amount after an RN misread and incorrectly transcribed the physician's order. The error went undetected until a pharmacy consultant's review, during which time the resident developed symptoms and required hospitalization. Facility policy requiring medications to be administered as prescribed was not followed.
The facility failed to follow masking guidelines during the designated winter respiratory virus period. Multiple staff members, including a licensed nurse, CNAs, and an administrator in training, were observed with masks down below their mouths in patient care areas. Despite being aware of the requirement, staff members only adjusted their masks upon noticing the surveyor, indicating inconsistent compliance with the guidelines.
A resident with mobility issues did not receive ordered RNA services due to staffing shortages, as RNAs were often reassigned to other duties. The resident required two-person assistance for sit-to-stand exercises, but these were inconsistently provided, with documentation errors and lack of communication about service refusals.
The facility failed to ensure staff performed their job functions competently when a cook did not properly verbalize the cool down process for cooking hot foods. The cook stated incorrect temperatures and times, which were later clarified by the Dietary Services Supervisor as being in violation of the 2022 Federal FDA Food Code.
The facility failed to develop comprehensive care plans for three residents, including addressing mental health conditions, diabetes, depression, and specific activity interventions, as confirmed by staff and record reviews.
The facility failed to monitor and address significant weight loss for a resident, leading to unmonitored weight losses of 8.8 lbs in March and 20.8 lbs in April. The resident was not weighed weekly as required, and no interdisciplinary team meetings were held to discuss the weight losses. Additionally, there was no documentation indicating that the physician or responsible party were informed.
The facility failed to accurately complete the MDS for two residents, leading to misclassification of bed rails as restraints for one resident and omission of dialysis treatments for another. These inaccuracies compromised the development of appropriate care plans and interventions.
The facility failed to ensure complete monitoring and documentation of a resident's change of condition while taking an antibiotic for a UTI. Nurses did not document every shift as required, and the last dose of the antibiotic was not recorded. The DON confirmed the lapse in documentation and monitoring.
The facility failed to ensure proper respiratory care for a resident who was receiving oxygen therapy without a physician's order. The resident, with chronic respiratory failure, COPD, and type 2 diabetes, was observed using oxygen at different rates during two separate observations. Despite the need for oxygen therapy, there was no physician order for its administration, as confirmed by a review of the resident's physician orders and an interview with the DON.
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Records (MAR). The Director of Nursing (DON) confirmed the discrepancies, which led to unaccounted tablets and potential misuse or diversion.
The facility failed to follow an approved menu for three residents on CCD Renal and Renal diets, serving a fruit cup instead of a snickerdoodle cookie without proper approval and logging, potentially compromising the residents' nutritional status.
A hospice aide transferred a resident using a Hoyer lift without the required assistance from another person, contrary to the resident's care plan and facility policy. The resident had significant medical conditions requiring two-person assistance for safe transfers.
The facility failed to implement proper infection prevention and control practices. CNAs were observed feeding two residents without performing hand hygiene between assisting each resident. Additionally, urine drainage bags for three residents were found on the floor, contrary to facility policy.
The facility failed to protect residents from physical abuse when one resident hit another, causing injury. Despite the incident being reported and first aid administered, the facility administrator did not consider it abuse, contrary to the facility's policies.
The facility failed to maintain a sanitary environment as four of seven shower stalls were found to have mold. The Environmental Services Director confirmed the issue, and two residents reported improper cleaning and cracked tiles. The facility's policy requires a clean and orderly environment, which was not met.
Resident Received 10x Prescribed Dose of Tacrolimus Due to Transcription Error
Penalty
Summary
A medication error occurred when a resident with a history of chronic myeloid leukemia, graft versus host disease, and bone marrow transplant was admitted to the facility with physician orders for Tacrolimus 0.5 mg daily. However, the medication was transcribed incorrectly by a registered nurse as Tacrolimus 5 mg daily, resulting in the resident receiving 12 doses at ten times the prescribed amount over a 12-day period. The error was not identified until the facility's pharmacy consultant discovered the discrepancy during a monthly medication regimen review. The resident's medication administration records confirmed that Tacrolimus 5 mg was administered daily from 3/31/25 to 4/11/25. Interviews with the Director of Nursing and the registered nurse responsible for the transcription confirmed the misreading and inaccurate transcription of the dosage. The resident reported feeling very sick and was subsequently hospitalized after experiencing symptoms including fatigue, headache, shortness of breath, and diarrhea. Laboratory results showed a Tacrolimus level at the threshold of toxicity during this period. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance. The error was only identified after the pharmacy consultant's review, and the resident's condition required transfer to the hospital for further care. The incident was reported to the California Department of Public Health, which confirmed the administration of the incorrect medication dosage.
Failure to Adhere to Masking Guidelines During Respiratory Virus Season
Penalty
Summary
The facility failed to adhere to guidelines for masking during the designated winter respiratory virus period, as observed by surveyors. Multiple staff members, including a licensed nurse, certified nursing assistants, and an administrator in training, were seen with their masks down below their mouths in various patient care areas. These observations occurred at different times and locations within the facility, such as nursing stations and patient rooms. Each staff member adjusted their mask upon noticing the presence of the surveyor, indicating a lack of consistent compliance with the masking requirement. Interviews with the staff members confirmed their awareness of the requirement to wear masks properly in patient care areas. The County guidelines mandate that all individuals in patient care areas of health care delivery facilities must wear a face mask during the designated winter respiratory virus period, which spans from November 1 to March 31. The failure to comply with these guidelines had the potential to spread infection throughout the facility, as noted in the report.
Inadequate Restorative Nursing Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide appropriate restorative nursing assistant (RNA) services to a resident as ordered by the physician, which had the potential to result in a decline in the resident's range of motion. The resident was admitted with diagnoses including spondylosis and post-laminectomy in the lumbar region, and difficulty in walking. The physician's order required sit-to-stand exercises with two-person assistance three times a week. However, the facility's documentation indicated that these services were inconsistently provided, with several instances marked as not applicable or resident refused, despite the resident stating she never refused the services. Interviews with the case manager and RNA staff revealed that the facility did not have enough RNAs to provide the required two-person assistance, as RNAs were often reassigned to work on the floor as CNAs. The case manager was not informed of any refusals by the resident, and there was no care plan addressing any RNA service refusals. The facility's policy stated that residents should receive restorative nursing care as needed, but the lack of sufficient staff and communication led to the deficiency in providing the ordered RNA services.
Improper Cool Down Process for Cooked Foods
Penalty
Summary
The facility failed to ensure that staff performed their job functions competently according to standards of practice when a cook did not properly verbalize the cool down process for cooking hot foods such as meat dishes. During an observation, Cook J was seen attending to pots and pans on the stove and, when asked about the proper cool down process, stated incorrect temperatures and times. Specifically, Cook J mentioned cooling food to 145 degrees Fahrenheit in one hour but did not know the subsequent required temperatures. The Dietary Services Supervisor later clarified that hot foods should be cooled to 140 degrees Fahrenheit in one hour, then to 70 degrees Fahrenheit in two hours, and finally to 41 degrees Fahrenheit in four hours. This discrepancy was found to be in violation of the 2022 Federal FDA Food Code, which mandates cooling cooked time/temperature control for safety food within specific time frames and temperatures.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for three residents. For Resident 162, who was admitted with diagnoses of Bipolar disorder and PTSD, there were no care plans developed to address these mental health conditions. This was confirmed by the Minimum Data Set Coordinator (MDSC A), who stated that care plans should be completed within 14 days from the date of admission and should include all diagnoses and interventions to ensure the resident's mental health needs are addressed. Resident 55, who was admitted with diagnoses of diabetes and depression, also did not have care plans to address these conditions. The resident had physician's orders for insulin and venlafaxine, but these were not included in the care plan. Both MDSC A and MDSC B confirmed that there were no care plans for Resident 55's diabetes, use of insulin, depression, or use of antidepressant medication, despite the requirement that care plans be completed within 14 days of admission. For Resident 26, who was non-ambulatory and mostly stayed in her room, the activity care plan did not include interventions for room visits and the activities provided during these visits. The Activity Director (AD) and the Director of Nursing (DON) confirmed that the care plan was not comprehensive and did not specify the room visits and activities, despite the resident's need for individualized care. The facility's policy mandates that each resident's care plan should be comprehensive and include measurable outcomes to maintain the resident's highest practicable well-being.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure significant weight loss was monitored and assessed for Resident 165. The resident experienced significant weight losses in March and April, but the facility did not initiate weekly weights, nor did they convene an interdisciplinary team (IDT) meeting to address these losses. The Registered Dietitian (RD) confirmed that Resident 165 should have been weighed weekly and that IDT meetings should have been held to discuss the weight losses and identify interventions to prevent further weight loss. Resident 165 had multiple diagnoses, including type 2 diabetes, congestive heart failure, and anemia, which put her at nutritional risk. Despite this, the facility only recorded her weight once a month, leading to unmonitored significant weight losses of 8.8 lbs in March and 20.8 lbs in April. The care plan for Resident 165 indicated that she should have been weighed weekly for one month following her readmission, but this was not followed. Interviews with the RD and the Director of Nursing (DON) revealed that the facility's protocol for significant weight loss was not followed. The RD and DON both confirmed that there were no IDT meetings or change of condition (COC) documentation when Resident 165 experienced significant weight losses. Additionally, there was no documentation indicating that the physician or the responsible party were informed of these significant weight losses, which was against the facility's policy on weight management.
Inaccurate MDS Completion for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for two residents, which compromised the ability to develop appropriate care plans and interventions. For Resident 68, who had diagnoses including cerebral infarction, hemiplegia, paraplegia, and weakness, the MDS incorrectly coded bed rails as restraints. The Minimum Data Set Coordinator (MDSC) confirmed that the bed rails were used as a mobility enabler and did not meet the definition of restraints, yet they were still coded as such in the MDS. This misclassification was acknowledged by the MDSC during interviews and record reviews, indicating a misunderstanding of the coding instructions provided in the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) Manual. For Resident 50, who had end-stage renal disease and was dependent on renal dialysis, the MDS failed to indicate that the resident received dialysis treatments. Despite the resident attending dialysis sessions three times a week, this information was left blank in Section O0110J1 of the MDS. The MDSC confirmed the omission during an interview and acknowledged that the dialysis treatments should have been recorded. This failure to accurately document the resident's treatments was contrary to the coding instructions in the RAI Manual, which require the inclusion of all special treatments, procedures, and programs received by the resident within the specified time periods.
Incomplete Monitoring and Documentation of Change of Condition
Penalty
Summary
The facility failed to ensure complete monitoring and documentation of a change of condition for one resident, identified as Resident 179. This deficiency was observed when nurses did not fully document and monitor Resident 179's condition while he was taking Keflex, an antibiotic prescribed for a urinary tract infection (UTI). The review of Resident 179's medication administration record (MAR) and progress notes revealed that nurses did not document every shift, as required, and failed to record the administration of the last dose of Keflex. Interviews with Registered Nurses M and N confirmed the incomplete documentation and monitoring, which should have included 72 hours of monitoring and documentation during and after the antibiotic treatment. Resident 179 was readmitted with diagnoses including a UTI, generalized muscle weakness, and other cerebral infarction due to occlusion or stenosis of a small artery. Despite the care plan's directive to monitor and document for probable causes of pain episodes, the nurses did not adhere to the facility's policy and procedure for change of condition documentation. The Director of Nursing (DON) verified the lapse in documentation and monitoring, acknowledging that nurses should have documented every shift for 72 hours and continued documentation post-antibiotic treatment.
Failure to Ensure Proper Respiratory Care for Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for Resident 48, who was receiving oxygen therapy without a physician's order. Resident 48, who has chronic respiratory failure with hypoxia, COPD, and type 2 diabetes, was observed using oxygen at different rates during two separate observations. Despite the resident's need for oxygen therapy, there was no physician order for its administration, as confirmed by a review of the resident's physician orders and an interview with the Director of Nursing (DON). The DON acknowledged that a physician's order is required for oxygen administration and explained that the order was discontinued when Resident 48 was admitted to the hospital and was not reordered upon her return to the facility. The facility's policy on oxygen administration, dated 1/31/23, mandates that a physician's order must be verified for oxygen administration. However, this protocol was not followed for Resident 48, leading to the deficiency. The observations and record reviews clearly indicate that the resident was receiving oxygen therapy without the necessary physician's order, which could potentially compromise her health and well-being.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the Controlled Drug Record (CDR) and the Medication Administration Records (MAR). For Resident 64, the CDR indicated that two tablets of Norco were signed out, but the MAR documented the administration of only one tablet. Similarly, for Resident 173, the CDR showed that two tablets of oxycodone were signed out at 5 a.m. and another two tablets at 6 a.m., but the MAR indicated the administration of only one tablet at 5 a.m. and no documentation for the 6 a.m. dose. For Resident 183, the CDR indicated that one tablet of oxycodone was signed out on two separate occasions, but there was no documentation on the MAR for either administration. During a concurrent interview and record review, the Director of Nursing (DON) confirmed the discrepancies between the CDR and the MAR for all three residents. The facility's policy requires that the licensed nurse administering the controlled medication immediately document the administration details on both the CDR and the MAR. The failure to accurately document the administration of controlled medications resulted in unaccounted tablets, raising concerns about potential misuse or diversion of these medications.
Unapproved Menu Substitution for Therapeutic Diets
Penalty
Summary
The facility failed to follow a menu approved by the registered dietitian (RD) for three residents on a consistent carbohydrate (CCD) renal diet and renal diet. During an observation, these residents were served a fruit cup instead of the prescribed snickerdoodle cookie. The Regional Registered Dietitian (RRD) confirmed that any menu substitutions need to be signed off by the facility's RD and recorded on a log, which was not done for the dessert substitution. The Regional Dietary Manager (RDM) explained that the snickerdoodle cookies did not turn out well, leading to the unapproved substitution. The facility's RD stated that if any food runs out, the Dietary Services Supervisor (DSS) should alert her to sign off on a menu substitution log, which did not happen in this case. The facility's policy requires that menus be served as written unless a substitution is approved and logged. The facility document indicated that the CCD Renal and Renal therapeutic diets were to receive a snickerdoodle cookie for dessert, which was not provided, leading to a potential compromise in the residents' nutritional status.
Failure to Follow Two-Person Assistance Policy for Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure hospice services were provided in accordance with professional standards of practice for one resident when a hospice aide transferred the resident using a Hoyer lift without the required assistance from another person. The resident, who had diagnoses including cerebral infarction, hemiplegia, paraplegia, and weakness, was admitted to hospice services with a physician's order indicating the need for Hoyer lift assistance with transfers. The resident's care plan also specified the requirement for two-person assistance during Hoyer lift transfers. During an observation, the hospice aide was seen transferring the resident from bed to wheelchair using the Hoyer lift without any assistance. The hospice aide confirmed that no other person was assisting during the transfer. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that facility policy mandates two-person assistance for Hoyer lift transfers. The facility's policy and the hospice services contract both stipulated that services should be provided in accordance with applicable policies and procedures, which were not followed in this instance.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for five residents. Certified Nurse Aides (CNAs) were observed feeding two residents without performing hand hygiene between assisting each resident. Specifically, CNA H and CNA I did not perform hand hygiene while feeding and assisting Residents 5 and 82 on multiple occasions. Both CNAs acknowledged the lapse in hand hygiene, and the Assistant Director of Nursing (ADON) confirmed that hand hygiene should be performed between assisting residents. The facility's policy on feeding also indicated that hand hygiene must be performed, which was not adhered to in these instances. Additionally, the facility failed to maintain proper infection control practices for residents with urine drainage bags. Observations revealed that the urine drainage bags of Residents 37, 47, and 166 were on the floor, either directly or enclosed in dignity bags. Both the ADON and Licensed Vocational Nurses (LVNs) confirmed that urine drainage bags should not touch the floor, even when enclosed in dignity bags. The facility's policy on urinary catheter infection control also indicated that catheter tubing and drainage bags should be kept off the floor, which was not followed in these cases.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical abuse when one resident hit another resident in the face, causing injury. The incident occurred when Resident 2 hit Resident 1 in the face, resulting in a skin tear above Resident 1's eyebrow. This act was deemed deliberate and considered abuse. The facility reported the incident to the California Department of Public Health, and first aid was administered to Resident 1's injury. Resident 1, who has diagnoses including dementia, paranoid personality disorder, and anxiety disorder, was found with a skin tear on the right side of his face. Resident 1's care plan included interventions for assessing and promptly rendering care for injuries. Resident 2, who has diagnoses including mild cognitive impairment, depression, and alcohol dependence, admitted to hitting Resident 1 because he was annoyed by him. Resident 2's care plan included monitoring for episodes of hitting others and initiating room changes. The facility's investigation confirmed the physical altercation based on staff and resident interviews and the injury sustained by Resident 1. Despite this, the facility administrator considered the incident an altercation rather than abuse, as they believed Resident 2's act was not intentional to harm Resident 1. The facility's policies on abuse prevention and prohibition clearly state that residents have the right to be free from abuse, including abuse by other residents.
Mold Found in Shower Stalls
Penalty
Summary
The facility failed to provide a safe and sanitary environment for residents when four of seven shower stalls were found to have molds. During an environmental tour, the Environmental Services Director (EVS) confirmed the presence of mold on the tiles in shower stalls located in Stations A, B, and C. The EVS admitted that the floor machine used for cleaning does not reach the corners of the shower stalls and acknowledged the oversight. Interviews with two residents revealed that the shower stalls were not cleaned properly, with one resident also noting cracked tiles. A review of the facility's policy and procedure titled 'Homelike Environment' indicated that residents are to be provided with a clean, sanitary, and orderly environment, which was not upheld in this instance.
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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