Shields Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cerrito, California.
- Location
- 3230 Carlson Boulevard, El Cerrito, California 94530
- CMS Provider Number
- 555364
- Inspections on file
- 20
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shields Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple health issues continued to receive routine acetaminophen for pain management without reevaluation, despite ongoing assessments showing no pain. Physician-ordered lab tests were not completed, and required monitoring of fluid intake and output was not performed, even though the resident's intake was often below the recommended level. When a STAT urinalysis was ordered due to a change in condition, the nurse failed to notify the physician after unsuccessful attempts to obtain a specimen and did not document the actions taken, resulting in delayed care.
A resident's medical record was not accurately documented when an LVN failed to record a physician's STAT order for urinalysis and straight catheterization, including the date and time received. The LVN did not notify the physician of unsuccessful attempts to obtain a urine specimen or the resident's ongoing pain, and the order was not properly documented or communicated between shifts. The DON was unaware of the order's status, and the progress notes lacked critical timing information.
The facility did not report two residents who tested positive for COVID-19 to the health department, despite facility policy requiring such reporting. Interviews with the DON, Admin, and IP confirmed knowledge of the cases and the lack of reporting, with the IP later receiving instructions from public health to report all positive cases.
A resident council meeting was held in an empty resident room that could not accommodate all interested participants, with several residents in wheelchairs present. A resident reported discomfort with meetings being held in her room and noted that space was insufficient for group participation. The AD and Admin confirmed that meetings were held in empty rooms due to lack of a designated space, limiting resident involvement. Facility policy required provision of space and privacy for such meetings, which was not met.
The facility did not ensure that discussions about advance directives were documented in the medical records for several residents, including those with cognitive impairment and those who were cognitively intact. Review of records and staff interviews confirmed that required documentation and follow-up regarding advance directives were missing, contrary to facility policy.
The Consultant Pharmacist did not provide comprehensive onsite pharmacy services, as evidenced by loose pills found in a med cart, tube feeding formula stored under a hand washing sink, and a cabinet full of discontinued narcotics that had not been destroyed in a timely manner. The CP had not been physically present for medication reviews, drug destruction, or QA meetings, contrary to facility and pharmacy policy.
Surveyors found expired sour cream, a bag of soggy salad, and a dirty utensil holder in the kitchen, all of which were acknowledged by the Dietary Supervisor as not meeting facility policy and posing risks such as stomach upset and cross-contamination for residents receiving food from the kitchen.
A resident was unable to store perishable food brought by family due to the facility's lack of a refrigerator, despite facility policy requiring such storage. Both the ADON and DON confirmed that the refrigerator previously available for resident use had not been replaced after it broke, and families were told to only bring food for immediate consumption.
A resident receiving hospice care did not have a coordinated plan of care developed with participation from hospice representatives, the resident, or their representatives, as required by facility policy. Interviews with the SSD and DON confirmed that no care plan conference was scheduled and no collaboration occurred with hospice staff, resulting in the resident's hospice care plan lacking required input.
A resident with morbid obesity, hemiplegia, and hemiparesis, who required two-person assistance for bed mobility, was turned by a CNA without help, resulting in the resident falling from bed and sustaining a left femur fracture. Staff interviews confirmed the resident's need for extensive assistance, and the incident occurred when the bed was in a high position.
Two residents with a diagnosis of schizophrenia were not referred for a required PASRR Level II evaluation. Review of admission records and PASRR Level I screenings revealed that the necessary referrals were not made, and the DON and MDS coordinator were unaware of the requirement.
A resident's legal representative did not receive requested medical records within the required timeframe, as the facility delayed processing and mailing the documents for over forty days despite receiving a hand-delivered authorization request. The delay was due to miscommunication and lack of timely action by staff, in violation of facility policy.
A resident with dementia and a high risk for pressure ulcers developed a stage 3 sacral wound, but staff failed to consistently assess and document the wound as required. Facility records showed missing or incomplete weekly wound assessments, and interviews with the DON and an LVN confirmed that expected documentation practices were not always followed.
A facility failed to complete a comprehensive MDS assessment for a resident within the required timeframe. The MDSC acknowledged the delay was due to workload, and the assessment was still in progress at the time of the survey. Facility policy mandates timely assessments, which was not followed.
A facility failed to provide a resident with a 30-day notice of discharge and did not send a copy to the State Long-Term Care Ombudsman. The resident, with severe cognitive impairment and multiple diagnoses, was discharged home without proper notification and documentation procedures being followed.
A resident with severe cognitive impairment and multiple medical conditions was discharged without proper consideration of their needs, leading to re-admission to the hospital. The discharge plan did not account for the availability and capability of caregiver support, nor did it ensure the resident's diet requirements were met. The facility's policy and procedure for discharge planning were not followed, resulting in the resident falling multiple times and being sent back to the hospital.
Failure to Reevaluate Pain Medication, Complete Lab Orders, and Monitor Fluid Status
Penalty
Summary
The facility failed to provide necessary treatment and care services for a resident with severe cognitive impairment and multiple medical diagnoses, including non-Alzheimer's dementia and malnutrition. The resident was routinely administered acetaminophen twice daily for pain management, despite documentation over several months indicating no complaints of pain and regular pain assessments showing no pain. The care plan required reassessment of the need for pain medication, but this was not done, and the medication regimen continued without reevaluation, contrary to facility policy and professional standards. Additionally, the facility did not carry out physician-ordered diagnostic laboratory tests, including blood work, for the resident. The Director of Nursing confirmed that the laboratory tests ordered by the physician were not performed. The resident's care plan also required monitoring and documentation of fluid intake and output due to a risk for fluid deficit related to chronic urinary tract infection. However, daily fluid intake was not consistently tallied, output was not recorded, and the resident's intake was frequently below the minimum required amount, with no documentation to show that intake and output were monitored as required by the care plan and facility policy. When the resident experienced a change in condition, including abdominal pain and other symptoms, a STAT order for a urinalysis via straight catheterization was received. The nurse attempted to obtain the specimen twice without success but did not notify the physician of the failed attempts or document the order and actions taken. The STAT order was endorsed to the next shift without timely follow-up, and the Director of Nursing was unaware of the delay. The facility's policies required prompt communication with the physician and documentation of such events, which did not occur in this case.
Failure to Accurately Document and Communicate STAT Lab Orders
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurately documented and systematically organized according to accepted professional standards. Specifically, a Licensed Vocational Nurse (LVN) did not document a physician's order for a STAT urinalysis (UA) and straight catheterization, including the date and time the order was received. The LVN attempted to obtain a urine specimen by straight catheterization twice without success and endorsed the STAT order to the night shift nurse but did not notify the physician of the failed attempts or the resident's continued complaints of pain. The LVN also did not document the order for straight catheterization in the resident's medical record. Upon review of the resident's progress notes and laboratory reports, it was found that the documentation did not reflect the time the physician's order for STAT labs was received, and the Director of Nursing (DON) was unaware that the STAT lab order had been endorsed from shift to shift or that it was received a day before the resident was transferred to the hospital. The lack of proper documentation and communication regarding the physician's orders and the resident's condition contributed to the deficiency identified during the survey.
Failure to Report COVID-19 Outbreak to Health Department
Penalty
Summary
The facility failed to implement its policy and procedure for reporting an outbreak of communicable disease, specifically COVID-19. Two residents tested positive for COVID-19 in July 2025, with one resident being transferred to the hospital for shortness of breath and subsequently testing positive for COVID-19, and another resident's laboratory test confirming a positive result. Despite these cases, the facility did not report the outbreak to the local or state health department as required by their policy. Interviews with the Director of Nursing, Administrator, and Infection Preventionist confirmed awareness of the two positive cases but revealed that no report was made to the health department. The facility's policy, dated September 2022, defines an outbreak as even a single case of a highly communicable disease and assigns responsibility for reporting to the Administrator. The Infection Preventionist stated that the facility later received instructions from the county public health nurse to report all positive COVID-19 cases, but the initial cases were not reported as required.
Inadequate Space Provided for Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate space for resident council meetings, as evidenced by observations and interviews. During a resident council meeting, six residents in wheelchairs were seated in an empty resident room, which was reported to be insufficient to accommodate all interested participants. One resident, who was cognitively intact and able to express her needs, stated that meetings were sometimes held in her room or other empty resident rooms, but these spaces were not large enough for all residents wishing to attend. She also expressed discomfort with having meetings in her personal room. The Activity Director confirmed that space was limited and that more residents would participate if a larger area were available. As a result, some meetings were conducted one-on-one in residents' rooms instead of as group sessions. The Administrator acknowledged that there was no specific room assigned for resident council meetings and that meetings typically took place in empty resident rooms. Review of the facility's policy indicated that the resident council should be provided with space, privacy, and support to conduct meetings, which was not being met at the time of the survey.
Failure to Document Advance Directive Discussions in Resident Records
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with residents and/or their responsible parties. Specifically, for four out of fifteen sampled residents, there was no evidence in the medical records that advance directives were addressed as required. These residents included individuals with varying cognitive abilities, such as those who were cognitively intact and those with severe cognitive impairment due to conditions like dementia and Alzheimer's disease. In each case, reviews of admission records, Minimum Data Set (MDS) assessments, and Physician Orders for Life-Sustaining Treatment (POLST) forms showed either the absence of an advance directive or a lack of documentation regarding any discussion about advance directives. Interviews with facility staff, including the Social Service Director (SSD) and the Director of Nursing (DON), confirmed that there was no documentation of advance directive discussions or follow-up with the residents or their responsible parties. The facility's policy required that information about advance directives be provided and documented upon or prior to admission, and that the existence of such directives be prominently displayed in the medical record. However, this process was not followed for the identified residents, resulting in incomplete records regarding their wishes for medical treatment.
Consultant Pharmacist Failed to Provide Comprehensive Onsite Pharmacy Services
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) provided comprehensive consultation on all aspects of pharmacy services. During observations, loose pills were found in the medication cart, and multiple bottles of tube feeding formula were stored in a cabinet underneath a hand washing sink. The Registered Nurse (RN) present was unaware of the improper storage of both the loose pills and the formula. The Director of Nursing (DON) confirmed the improper storage and stated that there was a designated container for loose pills, expecting licensed nurses to dispose of medications properly. Additionally, a cabinet in the medication room was found to be full of discontinued narcotic medications, with the last destruction of these drugs by the CP occurring several months prior. The DON stated that the CP had been conducting medication reviews remotely and had not visited the facility to assist with the destruction of discontinued medications. The Administrator reported that the CP had been inconsistent with facility visits, continued remote reviews since the COVID-19 period, and had not attended quarterly Quality Assurance (QA) Committee meetings since 2022. The CP's Director of Clinical Operation was unaware of the lack of physical presence and stated that pharmacy policy required in-person visits for drug destruction and QA attendance.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
During an initial kitchen tour, surveyors observed two expired containers of sour cream stored in the kitchen refrigerator, one of which was opened and nearly empty. The Dietary Supervisor (DS) confirmed that the expired sour cream should have been disposed of and acknowledged the risk of stomach upset for residents if consumed. Additionally, an opened plastic bag of soggy salad was found in the refrigerator, which the DS also stated should have been discarded due to similar risks. Review of the facility's policy indicated that all perishable food items are to be stored properly, with open dates and use-by dates per manufacturer guidelines. Further observation revealed that the utensil holder used for storing kitchen utensils was not clean, with visible brownish stains and scattered brownish particles. The DS acknowledged the utensil holder was dirty and recognized the risk of cross-contamination from storing utensils in such a condition. Facility policy requires all kitchen equipment and surfaces that come in contact with food to be cleaned and sanitized after each use. The 2022 Federal Food Code also mandates that food-contact surfaces be clean to sight and touch, and free of food residue and debris.
Failure to Provide Refrigerator for Resident Food Storage
Penalty
Summary
The facility failed to provide a means for residents to store food brought in by family members, as evidenced by the experience of one resident who was unable to refrigerate food brought from home. During a resident council meeting, the resident reported that she had to consume the food immediately and share it with her caregiver because there was no refrigerator available for resident use. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed in interviews that the facility previously had a refrigerator for this purpose, but it had broken and was not replaced. Instead, families were instructed to only bring enough food for immediate consumption and to take any leftovers home. A review of the facility's policy and procedure on food brought by family or visitors indicated that perishable foods should be stored in resealable containers with tight-fitting lids in a refrigerator, labeled with the resident's name, item, and use-by date. However, the facility was not following this policy due to the lack of a refrigerator, resulting in the resident being unable to store perishable food items as intended. The resident involved was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS).
Failure to Collaborate with Hospice for Resident's Plan of Care
Penalty
Summary
The facility failed to follow its hospice policy and procedure by not collaborating, developing, and implementing a coordinated plan of care (POC) with hospice representatives for a resident who was admitted into the hospice program. The resident, who had a principal diagnosis of a disorder of the brain, was admitted to the facility and started on hospice services. However, the resident's hospice POC did not reflect the participation of hospice representatives, the resident, or the resident's representatives, as required by facility policy and applicable regulations. Interviews with the Social Services Designee (SSD) and the Director of Nursing (DON) confirmed that no care plan conference had been scheduled with the hospice provider, and there was no collaboration with hospice representatives in developing the resident's hospice care plan. The SSD acknowledged awareness of the requirement but stated that the care conference had not been scheduled. The DON confirmed that the facility had not met to collaborate with hospice representatives on the resident's POC, attributing the failure to an oversight. Review of the facility's policy indicated that such collaboration and coordination were required for residents receiving hospice services.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
Resident 14, who had diagnoses including morbid obesity, hemiplegia, and hemiparesis, required extensive assistance by two staff members for bed mobility and repositioning, as documented in the resident's care plan and Minimum Data Set (MDS). Despite these documented needs, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without requesting the required assistance. During this unsupervised care, the resident was rolled out of bed and fell to the floor, resulting in a left femur fracture. The resident's bed was also noted to be in a high position at the time of the fall. Interviews and record reviews confirmed that the CNA was aware of the need for a second person to assist but did not seek help. The resident was subsequently found screaming in pain and was transferred to the hospital, where the fracture was confirmed. Staff interviews further corroborated that the resident consistently required two to three persons for safe repositioning due to her condition, and the Director of Rehabilitation stated the fall was avoidable if proper assistance had been used.
Failure to Refer Residents with Schizophrenia for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that two residents with a diagnosis of schizophrenia were properly screened and referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation, as required for individuals with mental disorders or intellectual disabilities. Record reviews showed that both residents had a documented diagnosis of schizophrenia at the time of admission, but their PASRR Level I screenings did not result in a referral for Level II evaluation. During interviews, the Director of Nursing and the MDS coordinator confirmed they were not aware of the need to refer these residents for further PASRR assessment.
Failure to Timely Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's representative with copies of the resident's medical records within the required forty-eight-hour timeframe after receiving a written request. The representative hand-delivered an authorization request for the records, which was received by facility staff. Despite this, the medical records staff did not promptly process the request, stating uncertainty about when the request was received and indicating that the request may have been left in the administrator's office. The medical records staff later confirmed to the representative that the request was still being processed several weeks after the initial submission. Ultimately, the requested documents were not mailed until forty-two days after the initial request, as confirmed by a USPS receipt. The facility's own policy required that such requests be fulfilled within forty-eight hours, excluding weekends and holidays. The delay in providing the records was due to a lack of timely communication and follow-through by both the medical records staff and the administrator, resulting in the representative not receiving the necessary documents within the mandated period.
Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a coccyx pressure ulcer for one resident with a history of dementia and a urinary tract infection. The resident was admitted with a low pain score and later developed a stage 3 pressure ulcer in the sacral region. Review of facility records showed inconsistent and incomplete documentation of weekly wound assessments and skin evaluations, with several dates missing required wound descriptions and skin section entries. The Braden Scale assessment indicated the resident was at very high risk for pressure ulcers, yet the documentation did not consistently reflect thorough wound monitoring. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that weekly wound assessments, including staging and detailed wound descriptions, were expected but not always completed or documented as required. Facility policy specified that all wound assessment data should be recorded in the resident's medical record, but this was not consistently done. The lack of regular and complete wound assessment documentation had the potential to delay identification of infection or changes in the wound's condition.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident within the regulatory specified timeframes. The resident was admitted to the facility, and the Admission MDS was not completed within 14 calendar days as required. The MDS Coordinator (MDSC) acknowledged that the Admission Assessment should have been completed by the specified date but was delayed due to the MDSC's workload. During an interview and record review, the MDSC confirmed that the Admission MDS was still in progress and not yet completed at the time of the survey. The facility's policy requires that the Assessment Coordinator ensures timely resident assessments, which was not adhered to in this case.
Failure to Provide Timely Discharge Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a resident with a notice of proposed discharge within the required timeframe of at least 30 days prior to the actual discharge date. Additionally, the facility did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman as required. The resident, who was admitted with multiple diagnoses including cerebral palsy, dysphagia, repeated falls, rhabdomyolysis, syncope, and dorsalgia, had a BIMS score indicating severe cognitive impairment. Despite this, the resident was discharged home without the proper notification and documentation procedures being followed. The Notice of Proposed Transfer/Discharge was signed by the caregiver on the same day as the discharge, which was only five days after the notification date, far short of the required 30-day notice period. During interviews, the Physical Therapist indicated that the resident still needed 24-hour care at the time of discharge, and the Administrator admitted to not knowing if the discharge notice was sent to the Ombudsman office. Furthermore, the facility lacked a policy and procedure addressing discharge notices, and no proof was provided that the notice was sent to the Ombudsman office.
Failure to Implement Effective Discharge Planning
Penalty
Summary
The facility failed to implement effective discharge planning for a resident who required 24-hour care. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral palsy, dysphagia, and repeated falls, was discharged without proper consideration of their needs. The discharge plan did not account for the availability and capability of caregiver support, nor did it ensure the resident's diet requirements were met. This oversight led to the resident being re-admitted to the hospital shortly after discharge due to severe pain and repeated falls. Interviews and record reviews revealed that the resident's family had agreed to take the resident home only when they could use the bathroom independently. However, the resident still required significant assistance with activities of daily living (ADLs) and needed 24-hour care at the time of discharge. The Director of Nursing (DON) was unaware of the resident's need for 24-hour care, which would have altered the discharge plan to keep the resident in the facility for long-term care. Additionally, the caregiver did not attend training sessions, and the resident's discharge plan was not thoroughly reviewed by the interdisciplinary team. The facility's policy and procedure for discharge planning were not followed, as the discharge plan did not include a description of the resident's discharge goals, the degree of caregiver support, or factors that could make the resident vulnerable to readmission. The caregiver reported being unable to provide the necessary 24-hour care and stated that the resident fell multiple times after being discharged. The resident was eventually sent back to the hospital due to severe pain and repeated falls, highlighting the facility's failure to ensure a safe and effective discharge plan.
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 severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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