Summerfield Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 1280 Summerfield Rd, Santa Rosa, California 95405
- CMS Provider Number
- 056364
- Inspections on file
- 27
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Summerfield Health Care Center during CMS and state inspections, most recent first.
A resident with a high fall risk and cognitive impairment fell and sustained injuries within 24 hours of admission due to inadequate supervision. Despite being aware of the resident's impulsive behaviors and previous need for a 1:1 sitter during hospitalization, the facility did not provide the necessary supervision, relying instead on a tab alarm and positioning near the nursing station. The resident's family had to hire a private sitter after the fall occurred.
A resident with a fractured wrist was not wearing a required wrist brace for two days due to a lack of communication among staff and private sitters. The physician had ordered the brace to be worn 24/7 to ensure proper healing, but staff were unaware of this requirement. The facility admitted responsibility for the oversight during a care conference with the family.
Two residents were transferred from a facility to other skilled nursing facilities without proper consent or documentation. One resident was moved to a lower-rated facility without being informed, causing emotional distress. The other resident was transferred while in poor health, and the family was not informed. The facility failed to provide valid reasons or documentation for these transfers.
The facility failed to ensure that the nursing care plans for managing pain for two residents were comprehensive and resident-centered. Despite pain management reviews indicating specific pharmacological and non-pharmacological interventions, these were not incorporated into the care plans, resulting in generalized and ineffective pain management strategies.
The pharmacy consultant failed to identify instances where Polycarbophil was administered alongside other medications, contrary to the manufacturer's guidelines. This error was observed in three residents, with nurses administering Polycarbophil concurrently with other medications. The Pharmacy Consultant reports for January and February 2024 did not document these irregularities, and the consultant admitted to being unaware of the required two-hour interval between Polycarbophil and other medications.
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 21%. Errors included improper administration of Polycarbophil, Potassium Chloride, and Metformin, as well as the substitution of over-the-counter fish oil for the prescribed Lovaza. Staff admitted to being unaware of proper administration guidelines.
The facility failed to maintain proper temperature controls for medication storage from December 2023 through February 2024. Despite multiple temperature deviations in the medication refrigerator, no corrective actions were taken, compromising the safety and effectiveness of the stored medications.
The facility failed to ensure safe food storage and staff knowledge of sanitizing practices. A dietary aid could not describe the three-compartment dishwashing method or find relevant policies. Additionally, temperatures in storage areas were not regularly checked or recorded, risking food safety.
The facility failed to provide necessary respiratory care consistent with a resident's care plan and physician's orders. A resident with COPD and Chronic Respiratory Failure was observed receiving oxygen at 3.5 LPM, contrary to the physician's order of up to 2 LPM as needed. This discrepancy was confirmed by an LVN and the Director of Nursing, highlighting a failure to verify and adhere to prescribed oxygen therapy.
The facility failed to provide appropriate pain management for a resident with chronic pain, administering medication intended for moderate pain even when the resident reported severe pain. Nurses did not consult the physician for a stronger pain medication, leading to inadequate pain relief.
A resident with Iron Deficiency Anemia was not served the alternate meal he ordered, causing frustration and repeated issues with meal preferences. The facility's policy to provide suitable alternate meals was not followed, as confirmed by multiple staff interviews.
The facility failed to ensure that two of four trash cans in the kitchen were completely covered when not in use. These trash cans had large circular holes in their lids, allowing trash to be exposed to air. One trash can was found overflowing with garbage, with soiled gloves sitting on top. A kitchen staff member confirmed these trash cans had been in use for a year and found them convenient for discarding trash without opening the lid each time.
A facility failed to ensure complete and accurate clinical documentation for a resident with Diabetes Mellitus. A physician's order to recheck the resident's blood glucose level was not documented as completed, and the recheck was done at an incorrect time, questioning the credibility of the documentation.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident who was assessed as a high fall risk due to a history of falls, decreased mobility, generalized weakness, restlessness, and cognitive impairment. Despite being aware of the resident's impulsive and unsafe behaviors, the facility did not provide the necessary 1:1 supervision that was required during the resident's recent hospitalization. Instead, the facility relied on interventions such as a tab alarm and positioning the resident near the nursing station, which proved inadequate as the resident fell within the first 24 hours of admission, resulting in a head injury, seizures, skin tears, and a fractured right wrist. Interviews with facility staff revealed that the resident was placed in a wheelchair with a tab alarm at the nursing station, and staff were able to prevent falls during the resident's first two attempts to stand. However, during the third attempt, staff were not positioned close enough to prevent the fall. The Director of Admissions acknowledged that the resident required significant care and informed the family that a private sitter might be necessary. Despite this, the facility did not provide a 1:1 sitter upon admission, and the resident's family had to hire a private caregiver after the fall occurred. The facility's Director of Nursing and other staff members indicated that various interventions were attempted before considering a 1:1 sitter, citing staffing expenses as a concern. The facility's policies and procedures emphasized the importance of identifying interventions to prevent falls, yet the care plan for the resident only included basic safety measures. The facility's failure to provide adequate supervision and the necessary 1:1 sitter, despite the resident's known high fall risk and impulsive behavior, directly contributed to the resident's fall and subsequent injuries.
Failure to Ensure Resident Wore Wrist Brace as Ordered
Penalty
Summary
Facility staff failed to follow physician orders for a resident to wear a wrist brace on her right wrist at all times, from February 10 to February 11. This oversight was discovered when a family member visited the resident and noticed the absence of the brace. The family member inquired with both licensed and unlicensed staff, none of whom were aware of the brace's location or the requirement for the resident to wear it continuously. The physician had ordered the brace to be worn 24/7 to ensure proper healing of the resident's fractured wrist. Interviews with various staff members revealed a lack of communication regarding the resident's need for the wrist brace. A private sitter and unlicensed staff were unaware of the requirement, and licensed staff not assigned to the resident were also uninformed about the wrist fracture and the necessity of the brace. The Director of Rehabilitation Services confirmed that the resident was supposed to wear a cervical collar and a right-hand splint, as per the physician's orders, and acknowledged the risk of further injury if the orders were not followed. The Assistant Director of Nursing and the Director of Nursing both acknowledged the physician's orders and the need for staff to communicate about the brace. However, the private sitter's manager stated that no communication had been made to ensure the placement of the wrist brace. The facility admitted responsibility for the oversight during a care conference with the family, acknowledging that the resident's wrist brace was not on during the specified dates. Medical records indicated that the resident had a history of trying to remove the splint, and staff were supposed to monitor the wrist for circulation and swelling every shift.
Improper Resident Transfers Without Consent or Documentation
Penalty
Summary
The facility failed to permit two residents to remain in the facility when they were transferred to other skilled nursing facilities without adequate reason or proper documentation. Resident 1 was transferred to a lower-rated facility without being informed or consenting to the move, causing her emotional distress. The Social Services Director (SSD) had informed Resident 1's family member that the resident would stay for at least three weeks, but the transfer occurred on the sixth day without Resident 1's knowledge or consent. The SSD documented verbal consent from a family member, but Resident 1 was the only authorized decision-maker. Resident 2 was also transferred without proper documentation or consent. The resident was in poor health at the time of transfer, suffering from malnutrition, dehydration, and a urinary tract infection. The family member of Resident 2 was surprised by the transfer and had not requested it. The SSD documented verbal consent from the family member, but there was no evidence that Resident 2 initiated the transfer. The SSD admitted that the reasons for transfer listed on the documents were not valid for either resident. The facility's policy required documentation for transfers, but the SSD failed to provide any rationale or documentation for the transfers. The SSD stated that the initial care conference triggered discussions about transfers, but there was no documentation of these conversations. The facility's policy did not include an option for SNF-to-SNF transfers, leading the SSD to incorrectly mark the reason for transfer as the residents' health improvement, which was not the case.
Failure to Develop Comprehensive Pain Management Care Plans
Penalty
Summary
The facility failed to ensure that the nursing care plans for managing pain for two residents were comprehensive, resident-centered, and included specific pharmacological and non-pharmacological interventions based on the residents' pain assessments. Resident 11, who was admitted with diagnoses including Diabetes Mellitus with Diabetic Neuropathy, reported severe pain due to neuropathy. Despite a pain management review indicating the use of Acetaminophen and Oxycodone, and non-pharmacological interventions like cold packs, hot packs, rest, and repositioning, these specifics were not incorporated into Resident 11's care plan. The care plan only contained standard interventions without addressing the individualized needs identified in the pain assessment. Similarly, Resident 109, who had a left artificial shoulder joint and experienced constant pain, also had a care plan that lacked specific interventions. Despite a pain management review indicating the use of Tylenol and Oxycodone, and non-pharmacological interventions like warm packs, breathing and relaxation, and repositioning, these were not included in the care plan. Both the Licensed Vocational Nurse and the Registered Nurse acknowledged that the care plans were too generalized and not comprehensive. The facility's policy required the interdisciplinary team to develop a comprehensive care plan for each resident, which was not adhered to in these cases.
Pharmacy Consultant Fails to Identify Polycarbophil Administration Errors
Penalty
Summary
The pharmacy consultant failed to identify instances where patients received Polycarbophil in conjunction with other oral medications, contrary to the manufacturer's guidelines. These guidelines stipulate that Polycarbophil should be taken at least two hours before or after other medications. This error was observed in three patients who received Polycarbophil alongside other medications. During observations, it was noted that Licensed Vocational Nurse (LVN) A, Registered Nurse (RN) B, and LVN C administered Polycarbophil along with other medications to Residents 28, 153, and 106, respectively. The Medication Administration Records (MAR) for these residents indicated that Polycarbophil was scheduled to be administered at the same time as other medications, which is against the manufacturer's guidelines. A review of the Pharmacy Consultant reports for January and February 2024 revealed no documented irregularities related to the administration of Polycarbophil and the required spacing between it and other medications. During an interview, the Pharmacy Consultant E admitted to being unaware of the guideline requiring a two-hour interval between the administration of Polycarbophil and other medications. This oversight led to the concurrent administration of Polycarbophil with other medications, potentially diminishing their effectiveness.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 21%. During a medication pass, six medication errors were observed out of twenty-eight opportunities for three residents. Licensed Vocational Nurse (LVN) A administered Polycarbophil to Resident 28 with only 30 milliliters of water instead of the required 8 ounces and did not separate the administration of Polycarbophil from other medications by at least two hours. Additionally, LVN A administered Potassium Chloride to Resident 28 without food, contrary to the recommended guidelines. LVN A admitted to being unaware of these administration guidelines. Registered Nurse (RN) B administered Polycarbophil to Resident 153 with only 50-60 milliliters of water and did not separate it from other medications. RN B also administered Metformin to Resident 153 without food, despite the requirement for the medication to be taken with food. RN B acknowledged her lack of awareness regarding the proper administration guidelines for these medications. LVN C administered Polycarbophil to Resident 106 with only 100 milliliters of water and did not separate it from other medications. Additionally, LVN C administered over-the-counter fish oil instead of the prescribed Lovaza to Resident 106, mistakenly believing the two were interchangeable. LVN C admitted her confusion was due to a lack of knowledge about the differences between the two medications.
Improper Temperature Control for Medication Storage
Penalty
Summary
The facility did not maintain proper temperature controls for medication storage from December 2023 through February 2024. The medication refrigerator temperatures were found to be outside the acceptable range of 36 F to 46 F on multiple occasions, with temperatures recorded as low as 30 F. Despite the facility's policy requiring immediate notification of the Director of Nursing (DON) when temperatures fall outside the acceptable range, no direct actions were taken to address these deviations. The DON acknowledged the temperature excursions but could not provide documentation of any corrective actions taken during this period. Interviews with the Pharmacy Consultant and Infection Preventionist revealed that staff were educated on the importance of maintaining proper temperature controls, yet failed to document or act on the temperature deviations. The Infection Preventionist admitted to not reviewing the temperature logs and confirmed that no adjustments were made to the medication refrigerator during the three months in question. This inaction compromised the safety and effectiveness of the stored medications, as freezing and thawing cycles can diminish their efficacy.
Deficiencies in Food Storage and Sanitizing Practices
Penalty
Summary
The facility failed to ensure resident food was stored safely and that staff were knowledgeable of sanitizing practices. A dietary aid was unable to describe the three-compartment method for washing and sanitizing dishes during emergencies and could not find the facility policy or procedure that explained the process. The dietary aid also had difficulty understanding the English-written policies. Additionally, the temperature in the dry storage room and emergency food storage room, where food and drinks for residents were stored, was not checked regularly, and there were no records to verify that food was being stored at safe temperatures. This was confirmed through observations and interviews with the dietary manager and administrative assistant, who were unable to provide evidence of regular temperature checks or a policy requiring such documentation. During an observation, it was noted that there was no thermometer or recording log in the dry storage area to check and record the temperature. The emergency food and water storage room had a thermometer, but no log was available to check if the temperature was being recorded. The dietary manager admitted to checking the temperature occasionally but not daily and could not provide evidence of these checks. The facility's policy required food to be stored within a specific temperature range but did not mandate documentation of these temperatures. The maintenance director also confirmed that while he checked the temperature in residents' rooms, he did not check the temperature of the kitchen storage areas.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility did not provide the necessary respiratory care consistent with the resident's care plan and current physician's orders for oxygen therapy. Resident 41, who had medical diagnoses including COPD and Chronic Respiratory Failure with Hypoxia, was observed receiving oxygen therapy via nasal cannula at 3.5 LPM. However, the physician's order specified that oxygen should be titrated up to 2 LPM as needed for O2 saturation less than 90% or shortness of breath. During an observation and interview, LVN J confirmed that Resident 41 was on 3.5 LPM of oxygen, which was inconsistent with the physician's order and the resident's care plan. The Director of Nursing stated that licensed nurses are expected to verify the physician's order for oxygen therapy. A review of the resident's MAR and care plan confirmed the discrepancy between the observed oxygen administration and the physician's order. The facility's policy and procedure for oxygen administration also emphasized the need to verify the physician's order and review the resident's care plan. This failure to adhere to the prescribed oxygen therapy had the potential to result in respiratory acidosis and affect the health and well-being of Resident 41.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 151, who had a history of chronic low back pain, compression fractures, kidney stones, and a possible urinary tract infection. Despite having a physician's order for Hydrocodone-Acetaminophen to be administered for moderate pain (pain level 4-6), the medication was repeatedly given to Resident 151 when he reported severe pain (pain level 7-9). This discrepancy was observed on multiple occasions, with the medication being administered 32 times for severe pain out of 44 total administrations from 3/3/24 to 3/14/24. During interviews, both Licensed Vocational Nurse K and Registered Nurse L acknowledged that it was inappropriate to administer the medication for severe pain and admitted that they should have contacted the physician for a stronger pain medication. However, they failed to do so. Resident 151 consistently reported that the medication did not relieve his severe pain, indicating that his pain management needs were not being adequately addressed. The Director of Nursing confirmed that there should have been communication between the nurses and the physician regarding the inadequacy of the current pain management plan. The facility's policies and procedures for pain management and medication administration were not followed, as they clearly state that the physician should be consulted if the current pain management orders are ineffective. This failure to adhere to professional standards of practice and the resident's comprehensive care plan resulted in inadequate pain management for Resident 151.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident 107, who had ordered an alternate meal but was served the regular meal of the day. Resident 107, who has a medical diagnosis of Iron Deficiency Anemia, expressed frustration and stated that this was not the first time such an incident had occurred. The Dietary Manager and Assistant Administrator confirmed that Resident 107 had ordered the alternate meal earlier that day, but the request was missed during trayline service. The Meal Change Request Form, which indicated the resident's preference for soup and a tuna wrap, was not provided to the surveyor in printed form, and the Dietary Manager could not recall when the form was received by the kitchen. Interviews with various staff members, including Cook H and Occupational Therapist I, revealed that the Meal Change Request Form was submitted at least one hour before trayline service began. However, the form was not processed in time, resulting in Resident 107 receiving the incorrect meal. The facility's policy states that residents will be provided a suitable nourishing alternate meal if the planned meal is refused, but this policy was not followed in the case of Resident 107. Multiple interviews confirmed that this was not an isolated incident, as Resident 107 had previously reported receiving incorrect meals on several occasions.
Improper Disposal of Garbage in Kitchen
Penalty
Summary
The facility failed to ensure that two of four trash cans in the kitchen were completely covered when not in use. These trash cans had large circular holes measuring approximately 12 inches in diameter cut out in their lids, which allowed staff to discard garbage without removing the lid. This resulted in the trash being exposed to air at all times. During an observation, one of the trash cans was found overflowing with garbage, with soiled gloves sitting on top of the trash due to the overflow. The trash cans were not in continuous use, with lapses of five to ten minutes when nobody disposed of garbage. A kitchen staff member confirmed that these trash cans had been in use since he was hired a year ago and found them convenient for discarding trash without opening the lid each time. The facility's policy required all food waste to be placed in sealed, leak-proof, non-absorbent, tightly closed containers, and for garbage and trash cans to be inspected daily to ensure no debris was on the ground or surrounding area, and that the lids were closed. The FDA Food Code 2022 also indicated that receptacles for refuse should be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent, and should be kept covered. The facility's failure to comply with these standards had the potential to result in the development and growth of pests, foul odors, and the spread of pathogenic microorganisms.
Failure to Document Blood Glucose Recheck
Penalty
Summary
The facility failed to ensure clinical documentation for one resident was complete and accurate. Specifically, a physician's order to recheck a resident's blood glucose (BG) level was not documented in the medical record as completed. The resident, who had a medical history including Diabetes Mellitus with Diabetic Neuropathy, had a BG level recorded as 384 mg/dl, but there was no documentation of a recheck in three hours as required by the physician's order. The Director of Nursing (DON) claimed the recheck was done based on information from the glucometer and an interview with the Licensed Vocational Nurse (LVN) responsible, but the glucometer did not indicate the identity of the resident, and the recheck was done at an incorrect time, further questioning the credibility of the documentation. Interviews with the DON and the Director of Staff Development (DSD) revealed that while it was considered best practice to document BG rechecks, it was not confirmed as a requirement. The facility's policy on charting and documentation indicated that all services provided to the resident should be documented to facilitate communication among the interdisciplinary team. However, the failure to document the BG recheck as per the physician's order resulted in incomplete and inaccurate clinical documentation, which could have serious implications for the resident's care.
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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