Smith Ranch Skilled Nursing & Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 1550 Silveira Parkway, San Rafael, California 94903
- CMS Provider Number
- 555595
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Smith Ranch Skilled Nursing & Rehabilitation Cente during CMS and state inspections, most recent first.
The facility did not post required contact information for the California Department of Public Health (CDPH), making it difficult for residents to file complaints. Interviews with residents and staff confirmed that CDPH contact information was not available in public areas, and residents were unaware of how to contact the agency.
Multiple failures in food storage and preparation were observed, including unwashed produce, dirty food transport carts, expired food items not discarded, contaminated rice not removed, improperly sealed food containers, and lack of proper labeling on opened food. These issues were confirmed by dietary staff and were not in accordance with facility policies, affecting a population of 73 residents.
The QAPI committee did not identify or address missed treatments in the RNA program, resulting in multiple residents not receiving restorative nursing services as ordered by physicians. Audits showed numerous missed visits, and interviews with the DON and DOR revealed a lack of awareness and oversight regarding the issue.
Licensed nurses documented the administration of Budesonide to a resident with COPD and asthma, even though the medication was never dispensed by the pharmacy and was not available in the medication cart. Multiple nurses confirmed they had recorded giving the medication on several occasions, and the DON verified the inaccuracy. Facility policies and professional standards requiring accurate documentation and verification of medication availability were not followed.
Several residents with significant mobility limitations did not receive restorative nursing care as ordered, including range of motion exercises and necessary equipment such as splints. In multiple cases, staff were unaware of or did not follow physician orders, and residents were not evaluated for restorative programs after discharge from physical therapy. This resulted in missed therapy sessions and lack of interventions to maintain or improve residents' functional abilities.
A resident with multiple mental health diagnoses was administered Lamotrigine, a psychotropic medication, without documented informed consent. Review of the medical record and interviews with staff confirmed that the required consent was not obtained or present, despite facility policy mandating written informed consent prior to starting such medications.
Two residents with significant mobility impairments were found unable to access their call lights, as observed by staff and confirmed by interviews. One resident with hemiplegia, paraplegia, and contractures could not reach the call light placed above her right hand, while another with hemiplegia and aphasia had her call light dangling off the bed. Staff, including a CNA, LVN, and the DON, acknowledged that call lights should always be within reach, consistent with facility policy.
Surveyors observed a visibly soiled privacy curtain, dirty clothing piled on a nightstand, and an air conditioner in disrepair with missing vents and food particles in a resident room. Staff confirmed these conditions did not meet facility policies for cleanliness and maintenance.
A resident's MDS assessment inaccurately indicated an active diagnosis of viral hepatitis, even though the resident was not receiving treatment for the condition. Both the MDSC and MDS RN confirmed that the diagnosis should not have been marked as active according to RAI guidelines, leading to the submission of incorrect data to CMS.
A resident with dementia and mobility limitations, identified as at risk for pressure ulcers, was found with her pressure reducing mattress machine turned off for an unknown period. Despite physician orders and care plan interventions requiring the mattress to be on and checked every shift, staff failed to ensure its use until an LVN eventually turned it on after observation.
A resident with dysphagia and severe protein-calorie malnutrition was not weighed daily as ordered by the physician, resulting in 69 missing daily weights over several months. The RD confirmed the missing weights and noted significant weight loss, despite facility policy requiring regular monitoring and documentation of resident weights.
A resident receiving continuous tube feeding for dysphagia and severe malnutrition had their Jevity 1.5 formula, feeding pump bag, and syringe left unlabeled and undated. Both the LVN and DON confirmed that all enteral feeding materials should be labeled and dated per facility policy and manufacturer guidelines, but this was not done, creating the potential for expired formula and equipment to be used.
Surveyors identified a medication error rate of 19.23% after observing five errors among 26 opportunities, including missed and incorrectly administered medications for two residents with complex medical needs. Errors included omitted doses, improper timing, failure to follow administration instructions, and not flushing a G-Tube after medication delivery, all in violation of facility policy.
Medications and supplements, including prescription cream, powdered magnesium, sleep aids, and multivitamins, were found unsecured at the bedside of three residents. Staff, including a CNA and the DON, confirmed that medications should not be accessible at bedside and must be stored in locked compartments, in accordance with facility policy.
A resident with multiple mental health diagnoses, but no memory impairment, gave her credit card to a front desk staff member to purchase personal items. The staff member used the card for personal purchases without proper authorization, despite facility policies and staff training prohibiting such actions. The resident later discovered unapproved charges, leading to feelings of embarrassment and distrust.
Failure to Post State Agency Contact Information for Resident Complaints
Penalty
Summary
The facility failed to publicly post the contact information for the California Department of Public Health (CDPH), as required, which prevented residents from being able to file complaints regarding their care or the facility. During interviews, all eight Resident Council members reported not knowing how or where to file complaints with CDPH and could not recall seeing any posted information. Observations conducted with the Activities Director and the Administrator confirmed that CDPH contact information was not posted on either the first or second floor of the facility. The Director of Nursing also confirmed that the facility did not have CDPH contact information posted for residents. A review of the facility's policy on Resident Rights indicated that residents have the right to communicate with outside agencies, but this right was not supported by the required postings.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store and prepare food in a safe and sanitary manner, as evidenced by multiple observations and staff interviews. Dietary staff did not rinse romaine lettuce as instructed on the packaging before chopping and plating it for resident meals. The Dietary Aide stated the lettuce was not rinsed because it was believed to be pre-cleaned, but both the packaging and facility policy required rinsing before use. The Kitchen Manager confirmed this was not in accordance with facility procedures. Additionally, two food transport carts used to move food from the Main Kitchen to the Nourishment Room were found to be dirty, with visible hair, residue, and substances on their surfaces. These carts were present in clean areas of the kitchen and were not cleaned prior to use, contrary to facility policy requiring all food service equipment to be cleaned and sanitized after each use. Multiple food items in the walk-in refrigerator and freezer were observed to be past their use-by dates and had not been discarded as required. The Registered Dietician confirmed these items should have been removed before or on their expiration dates. Further deficiencies included a bin of uncooked rice contaminated with a green leafy substance, which was not discarded, and several food items in both the freezer and dry storage that were left open to the air and not stored in sealed containers. Many opened food items were also not properly labeled with open or use-by dates. These failures were confirmed by staff and were not in compliance with the facility's policies and procedures for food storage, preparation, and handling. The kitchen served a population of 73 residents.
QAPI Oversight Failure Leads to Missed Restorative Nursing Treatments
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to provide adequate oversight of the Restorative Nursing Assistance (RNA) program, resulting in residents not receiving treatments as ordered by physicians. A review of the Restorative Program Monthly Audit for April 2025 revealed 84 missed RNA visits among 13 residents. Additionally, the Order Listing Report indicated that 22 residents were currently receiving RNA services. Despite these missed treatments, neither the Director of Nursing (DON) nor the Director of Rehabilitation (DOR) were aware of any issues with the RNA program. The DOR stated that her responsibilities were limited to staff training and entering RNA orders, while the DON only performed a cursory review of weekly progress notes without verifying that treatments matched physician orders. Further review of QAPI meeting minutes from October 2024 to April 2025 showed no discussion or identification of concerns related to the RNA program. The facility's QAPI plan referenced monitoring clinical care through consultant evaluations, MDS-QI scores, and surveys, but there was no evidence that these tools were used to identify or address the missed RNA treatments. The lack of oversight and failure to audit the RNA program led to residents not receiving the prescribed restorative nursing services.
Inaccurate Medication Documentation Due to Undispensed Medication
Penalty
Summary
Licensed nurses failed to follow professional standards of practice by documenting the administration of Budesonide, a respiratory medication, to a resident with COPD and asthma, despite the medication never being dispensed by the pharmacy. Observations showed that the medication was not present in the medication cart, and multiple nurses confirmed through interviews and record reviews that they had documented giving the medication on several occasions in April and May, even though it was not available. The pharmacy had requested clarification regarding the resident's respiratory medications due to concerns about duplicate therapy, but the facility did not respond, resulting in the medication not being delivered. Further review of the resident's Medication Administration Record (MAR) revealed repeated entries indicating the administration of Budesonide, which was confirmed by the Director of Nursing to be inaccurate since the medication was never dispensed. Facility policies and professional guidelines reviewed during the investigation emphasized the need for accurate, truthful, and comprehensive documentation, as well as verification of medication availability prior to administration. The failure to adhere to these standards resulted in inaccurate documentation for the resident.
Failure to Provide Ordered Restorative Nursing Care to Residents with Mobility Impairments
Penalty
Summary
The facility failed to provide restorative nursing care (RNA) as ordered for four residents with significant mobility and functional impairments. For one resident with a right leg amputation and artificial hip, the care plan and physician orders required active range of motion (AROM) exercises three times a week to prevent decline in muscle strength and contractures. However, the resident did not receive any RNA therapy since January, despite no documented medical reason to withhold therapy. The restorative nursing assistant was unaware of the order, and the Director of Rehabilitation did not follow up with the physician or ensure the therapy was provided. Another resident with hemiplegia, paraplegia, and multiple contractures was ordered to receive passive range of motion (PROM) exercises for both upper and lower extremities three times a week. The resident only received RNA for upper extremities once a week and did not have a brace or splint for contracted hands, despite expressing a goal to regain self-feeding and oral care abilities. The restorative nursing assistant and occupational therapist confirmed the lack of appropriate therapy and equipment, and the Director of Rehabilitation was unaware of the incomplete RNA provision. A third resident with gait abnormalities, right knee contracture, and hemiplegia was ordered to receive RNA for bilateral upper extremities twice a week and PROM three times a week. The resident only received RNA for lower extremities, as the restorative nursing assistant did not review the orders for upper extremity therapy. The Director of Rehabilitation and DON were not aware of the missed therapy. Additionally, a fourth resident with cellulitis and mobility issues was discharged from physical therapy due to insurance coverage ending and was not evaluated for or provided RNA, despite expressing a desire to regain strength and being instructed to use a wheelchair instead of a walker. The Director of Rehabilitation confirmed that the resident should have been encouraged to ambulate with a walker and that no RNA eligibility assessment was performed.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of a psychotropic medication, Lamotrigine, for one resident. The resident was admitted with diagnoses of Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. A review of the resident's medical record and order summary showed that Lamotrigine had been prescribed and administered without a corresponding informed consent form present in the record. The Social Services Assistant confirmed that no informed consent had been obtained for this medication. Further confirmation was provided by the Consultant Pharmacist, who stated that informed consent was required prior to administering Lamotrigine. The facility's own policy and procedure on informed consent, dated February 2025, specifies that written informed consent must be obtained by the prescribing physician or licensed healthcare practitioner and recorded in the resident's medical record before initiating treatment with psychotherapeutic drugs. This policy was not followed in the case of this resident.
Failure to Ensure Call Light Accessibility for Residents with Physical Limitations
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents with significant physical limitations. One resident, admitted with hemiplegia, paraplegia, and multiple contractures, was observed lying in bed with both hands and neck contracted. The call light was placed by her collar bone, above her right hand, but she stated she was unable to move her hands or call for assistance because the call light was not within her reach. Her roommate confirmed that she often had to press her own call light for this resident, as the call light was frequently not placed within reach. A CNA confirmed the call light was not within reach and acknowledged it should have been. Another resident, admitted with hemiplegia of the left side, need for assistance with care, and aphasia, was observed lying in bed with her call light dangling off the bed, out of reach. An LVN confirmed the resident was unable to reach her call light and stated it should always be within reach. The Director of Nursing also confirmed that call lights should always be accessible to residents. The facility's policy and procedure on answering call lights indicated that staff should ensure the call light is accessible to the resident.
Failure to Maintain Cleanliness and Repair in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents as evidenced by several observed deficiencies. In one room, the privacy curtain between beds was visibly soiled with a brown substance in multiple spots. A CNA confirmed the curtain needed immediate replacement, and the DON stated that curtains are to be changed when soiled, as per facility policy. Additionally, in the same room, approximately eight pieces of dirty clothing were found unfolded and piled on a resident's nightstand. The CNA confirmed the clothing was dirty and should have been placed in a blue mesh bag for laundry, which was also supported by the DON's statement regarding proper handling of soiled clothing. Further, the air conditioner in the same room was found to be in disrepair, with missing and broken vents and visible food particles present. The DON confirmed the air conditioner was dirty and not functioning properly, indicating that maintenance should have been contacted immediately. The Maintenance Supervisor later stated that air conditioners should not have broken or missing vents and that a work order should have been placed right away. Facility policy requires all interior surfaces, fixtures, and equipment to be maintained in good repair to ensure a safe and clean environment.
Inaccurate MDS Assessment for Active Diagnosis
Penalty
Summary
The facility failed to accurately assess and submit data for one resident when the Minimum Data Set (MDS) did not reflect the resident's current status. Specifically, the MDS 3.0 Section I- Active Diagnoses for this resident indicated an active diagnosis of viral hepatitis, despite the resident not receiving any treatment for this condition at the time of assessment. Review of the resident's order summary confirmed there was no treatment for viral hepatitis, and both the MDS Coordinator and MDS Registered Nurse acknowledged that the MDS should not have indicated an active diagnosis, as per the Resident Assessment Instrument (RAI) guidelines, which require active treatment within the past 7 days for such coding. The inaccurate MDS data was transmitted to CMS, resulting in a deficiency related to assessment accuracy.
Failure to Ensure Pressure Reducing Mattress Was Used as Ordered
Penalty
Summary
A deficiency occurred when staff failed to implement physician-ordered interventions to prevent skin breakdown for a resident at risk for pressure ulcers. The resident, who had diagnoses including dementia and mobility issues, was observed in bed with the pressure reducing mattress machine turned off. The resident confirmed the machine was off and could not recall when it was last on or when staff last assisted her out of bed. A CNA also observed the machine was off and acknowledged it should be on but did not turn it on. Later, an LVN entered the room, plugged in the machine, and turned it on, stating it should always be on to prevent the mattress from deflating. Review of the resident's Braden Scale Assessment indicated she was at risk for developing pressure sores, and her care plan included the use of a physician-prescribed pressure reduction mattress. Physician orders specified the mattress should be set to alternating mode, with settings checked for functionality every shift. Despite these orders and care plan interventions, the pressure reducing mattress was not in use for an unknown period, as confirmed by multiple staff and the resident, resulting in a failure to follow prescribed interventions for pressure ulcer prevention.
Failure to Perform Daily Weights for Resident with Malnutrition
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of dysphagia and severe protein-calorie malnutrition was weighed daily as ordered by the physician. The resident's order summary specified daily weights with instructions to notify the physician of significant weight changes. However, a review of the resident's weight records revealed that 69 daily weights were missing over a period of several months. The registered dietician confirmed the missing weights and noted that the resident had significant weight loss and should have been weighed every day. The facility's policy required resident weights to be monitored and recorded at intervals established by the interdisciplinary team, but this was not followed in this case.
Failure to Label and Date Enteral Feeding Equipment and Formula
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of dysphagia and severe protein-calorie malnutrition, who was receiving continuous enteral feeding via a g-tube, had their feeding equipment and formula improperly managed. During an observation, it was found that the bottle of Jevity 1.5 formula, the enteral feeding pump bag containing the formula, and a syringe used for enteral feeding were all hanging on a pole in the resident's room without any labels or dates. The items were not marked with the resident's name, room number, formula type, date, or infusion rate as required. Interviews with the LVN and the DON confirmed that all enteral feeding materials should be labeled and dated according to facility policy and manufacturer instructions, which specify that the formula should hang for no more than 24 hours. Review of the resident's orders and facility policy further supported the requirement for proper labeling and dating of enteral feeding equipment and formula. The failure to label and date these items created the potential for expired enteral feeding supplement and equipment to be used for the resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by five medication errors out of 26 observed opportunities, resulting in a 19.23% error rate. One resident with diagnoses including COPD, asthma, and orthostatic hypotension did not receive Budesonide and Midodrine as ordered during the morning medication pass. The nurse responsible stated she forgot the respiratory medications and later discovered Budesonide was not available in the medication cart. The nurse also did not administer Midodrine due to its absence from the cart and did not follow the facility's protocol to check the emergency supply or contact the pharmacy for a stat delivery. Additionally, the same resident did not receive Ipratropium nasal spray at the correct time and the administration did not follow manufacturer instructions, such as priming the spray, instructing the resident to blow their nose, or using the correct head positioning. Trelegy, another respiratory medication, was also administered outside the prescribed time frame. The nurse admitted to being unsure of the correct administration technique for the nasal spray and confirmed that medications should be given within one hour of the scheduled time, as per facility policy. Another resident with dysphagia received Midodrine via G-Tube, but the nurse failed to flush the tube with water after administration, contrary to facility policy. The nurse acknowledged that an additional flush was necessary to ensure the medication cleared the tubing and to prevent clogs. These observed failures were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policies and procedures.
Failure to Secure Medications in Locked Storage
Penalty
Summary
The facility failed to implement safe medication storage practices for three residents. For one resident with dementia, a jar of triamcinolone acetonide cream with a pharmacy label was found on the bedside table. A CNA mistook the medication for a non-prescription ointment and returned it to the bedside. The LVN confirmed that the resident was forgetful and should not have unsupervised access to medications. The DON and Consultant Pharmacist both stated that medications should not be kept at the bedside and must be stored in locked compartments, as per facility policy. In two other cases, one resident had a large container of powdered magnesium, a bottle of sleep aid, and a bottle of PM leg cramp medication on the dresser at bedside, while another resident had a bottle of multivitamins on the bedside table. Both the DON and Consultant Pharmacist confirmed that these medications should not be accessible at bedside and should be dispensed from the pharmacy or kept in the medication cart. The facility's policy requires all medications and biologicals to be stored in locked compartments, which was not followed in these instances.
Misappropriation of Resident Property by Staff
Penalty
Summary
A facility failed to protect a resident from misappropriation of property when a front desk staff member used the resident's credit card for personal purchases. The resident, who had diagnoses including bipolar disorder, depressive disorder with psychotic symptoms, and anxiety disorder, but no memory impairment, had given her credit card to the staff member to buy personal items for herself and for the staff member. However, upon reviewing her bank statements, the resident discovered multiple unapproved transactions. The staff member admitted to using the resident's card several times for fuel and also receiving cash from the resident. Documentation and interviews confirmed that the staff member had used the card for personal benefit and had an agreement with the resident not to inform management. The staff member later apologized in writing for the situation and acknowledged the misuse of the resident's funds. Interviews with facility staff, including the DON, DSD, DSS, and licensed nurses, revealed that staff were trained and expected not to accept credit cards or cash from residents, nor to make purchases for them. The facility's employee handbook and abuse policy also prohibited staff from accepting gifts, tips, or resident property, and emphasized the resident's right to be free from misappropriation and exploitation. Despite these policies and training, the staff member's actions resulted in the resident feeling taken advantage of, distrustful, and embarrassed.
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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