The Avenues Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 2043 19th Avenue, San Francisco, California 94116
- CMS Provider Number
- 055963
- Inspections on file
- 21
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Avenues Transitional Care Center during CMS and state inspections, most recent first.
A resident with quadriplegia, dementia, and high fall risk was left unsupervised in a high bed with side rails down during incontinent care. The staff member left the room to get supplies, leaving the resident on their side, and the ordered low air loss mattress was not in use. The resident fell from the bed, sustained serious injuries, and later died. Facility records showed lack of staff training on fall safety and failure to follow care plan interventions.
The facility failed to meet food safety standards when a dirty frying pan was found among clean ones, wet trays were improperly stored, and a dented can was found in dry storage. The DM acknowledged these issues, which could lead to contamination and foodborne illnesses among 133 residents.
The facility failed to follow physician orders for two residents by not obtaining monthly MUAC measurements as an alternative to weights, which were refused. Additionally, the facility did not monitor or document bruising at injection sites for a resident self-administering insulin, potentially affecting insulin absorption and well-being.
The facility failed to ensure proper accountability and administration of medications for several residents. Controlled Drug Records did not reconcile with Medication Administration Records, leading to unaccounted medications. An LVN administered the wrong medication to a resident and left another resident's medication at the bedside without ensuring it was ingested. Additionally, a shared pill cutter was not cleaned between uses, risking drug interactions. These actions violated facility policies and raised concerns about medication management.
The facility failed to properly store and label medications, with one storage room exceeding recommended temperatures, an undated multi-dose vial in the refrigerator, and expired lidocaine patches found in a medication cart. The DON and RNS acknowledged these issues, which contravened facility policies.
The facility failed to implement its infection control program, with deficiencies including improper storage of a urinal, lack of hand hygiene by a janitor handling soiled linens, and nursing staff not performing hand hygiene during medication administration. Additionally, an RN administered medication without gloves, posing infection risks.
Two residents with severe cognitive impairments were not treated with dignity during meal assistance, as CNAs stood over them while feeding, contrary to facility policy. Despite knowing the requirement to sit at eye level, the CNAs did not follow this procedure, impacting the residents' dignity and respect.
A facility failed to ensure safe self-administration of medications for a resident who was observed with multiple prescription medications left on their overbed table. The resident, with no cognitive impairment, had a care plan specifying self-administration of insulin but not other medications. An LVN admitted to leaving the medications at the bedside, contrary to facility policy, and the interdisciplinary team did not determine if the medications could be self-administered.
A resident on heparin for DVT prophylaxis was not monitored for bleeding, despite the facility's policy requiring such monitoring. The resident, readmitted with a femur fracture and rectal hemorrhage, had no documented evidence of bleeding monitoring in their medical record. The ADON confirmed the lack of monitoring, which contradicted the facility's anticoagulation protocol.
The facility failed to ensure two residents were free from unnecessary antipsychotic medications. One resident continued PRN Seroquel beyond 14 days without reevaluation, and another resident lacked behavioral monitoring for Seroquel use. The facility's policy requires non-pharmacological interventions and behavioral monitoring for residents on psychotropic medications, which were not followed.
The facility failed to honor the food preferences of two residents, leading to a deficiency in dietary services. One resident, requiring a mechanical soft diet, was served hard carrots, while another was served a regular menu despite a preference for chow mein or potstickers. These incidents highlight a failure to adhere to the facility's policy on respecting residents' food preferences.
The facility did not meet the required minimum room size of 80 square feet per resident for 47 out of 48 rooms. Observations showed rooms occupied by two or three residents, with only one room meeting the standard. Interviews with residents indicated no major concerns about room size. The Administrator requested a waiver for room size variance from the California Department of Public Health.
A resident's comprehensive MDS assessment was completed 23 days after admission, exceeding the required 14-day period. The resident had multiple diagnoses, including osteoarthritis and schizoaffective disorder. The MDS Coordinator acknowledged the delay, which contravened both facility policy and regulatory requirements.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple health issues, including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury. The baseline care plan, which is crucial for addressing immediate health and safety needs, was completed several days late, as confirmed by the MDS Coordinator.
Failure to Prevent Avoidable Fall Resulting in Resident Injury and Death
Penalty
Summary
A resident with quadriplegia, dementia, and a history of physical injury was admitted to the facility and assessed as being at high risk for falls, with severe cognitive impairment and total dependence on staff for mobility and toileting. The care plan specified that the resident's bed should be kept in a low position and that two or more staff were required for toileting hygiene and repositioning. Despite these interventions, the resident was left alone in a high bed position with both side rails down while a CNA left the room to obtain additional supplies during incontinent care. During this period of unsupervised time, the resident rolled from the bed and fell to the floor, sustaining multiple injuries including a head injury, abrasions, and skin tears. The CNA reported leaving the resident on their side and did not return the resident to a supine position before leaving. The resident's low air loss mattress, which was ordered to prevent skin breakdown, had been removed at the time of the incident. The facility's documentation and staff interviews confirmed that the CNA had not received specific training on the use of low air loss mattresses or fall safety, and competency validation for peri-care was not documented in the employee file. The facility's policies required a hazard-free environment and adequate supervision to prevent accidents, but these were not followed in this case. The resident's fall resulted in a traumatic brain injury, hospitalization, and subsequent death. The facility's investigation identified the resident's positioning and the absence of the low air loss mattress as contributing factors to the fall.
Food Safety Violations in Kitchen Practices
Penalty
Summary
The facility failed to adhere to food safety requirements as observed during a survey. A dirty frying pan with dried food debris was found stacked among clean frying pans under the food preparation counter. The dietary manager (DM) acknowledged that these were supposed to be clean pans, but one was visibly dirty with dried scrambled egg remains and scratches, indicating improper cleaning and storage practices. Additionally, large metal serving trays were found stacked wet under the food preparation counter, with some trays still moist and dripping. The DM confirmed that the trays were indeed wet, which contradicts the 2022 Federal Food Code that requires equipment and utensils to be air-dried before storage. Furthermore, a dented can of mushrooms was found among undented canned products in the dry storage room, which the DM admitted should not have been there. This is contrary to FDA guidelines that consider dented cans as potentially hazardous. These deficiencies have the potential to contaminate clean cooking utensils and promote the growth of foodborne illnesses among the 133 residents.
Failure to Monitor Nutritional Status and Injection Sites
Penalty
Summary
The facility failed to adhere to physician orders for two residents, Resident 32 and Resident 78, by not obtaining monthly measurements of mid upper arm circumference (MUAC) as an alternative to monthly weights, which both residents refused. Resident 32, who has severe cognitive impairment and a history of refusing care, had no recorded weights since May 2024 and no documentation of MUAC measurements, despite a physician's order from September 2023 to obtain these monthly. Similarly, Resident 78, who has no cognitive impairment but a history of refusing weights, also had no recorded weights or MUAC measurements for the year 2024, despite a similar physician's order. The lack of documentation and adherence to these orders had the potential to result in unplanned and undesirable weight loss for both residents. Additionally, the facility failed to monitor and document the condition of Resident 78's injection sites for bruising, as required by a physician's order. Resident 78, who self-administers insulin, showed signs of bruising on the right lower abdomen, which was not documented in the resident's medical records. The Assistant Director of Nursing acknowledged the oversight and stated that the nurses should have checked for bruising, notified the physician, and updated the care plan accordingly. The failure to monitor and document the injection sites could lead to uneven insulin absorption and negatively affect Resident 78's physical and psychosocial well-being. The facility's policy on weight assessment and intervention, as well as the policy on changes in a resident's condition or status, were not followed in these cases. The multidisciplinary team is expected to prevent, monitor, and intervene for undesirable weight loss, and the nursing staff is required to notify the physician of any significant changes in a resident's condition. However, these protocols were not adhered to, resulting in deficiencies in the care provided to Residents 32 and 78.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for five residents, as the Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR). For Resident 105, a tablet of oxycodone was signed out but not documented on the MAR. Similarly, Resident 119's lorazepam was signed out but not recorded on the MAR. Resident 81 had two instances where oxycodone was signed out but not documented. Resident 30's oxycodone was documented on the MAR but not signed out on the CDR. Lastly, Resident 36 had four instances of oxycodone signed out but not documented on the MAR. These discrepancies resulted in unaccounted medications, raising concerns about potential abuse and diversion. The facility also failed to administer the correct prescribed medication to Resident 28. During a medication pass, an LVN administered Geri-Tussin DM instead of the prescribed guaifenesin. This error was acknowledged by the DON, who stated that medication errors should not occur. Additionally, the facility failed to ensure that Resident 432 ingested the full dose of prescribed medication. The LVN left a cup of ClearLax water on the resident's bedside table, and the resident did not finish the medication while the LVN was present. The DON confirmed that medications should not be left at the bedside and that residents should be observed to ensure they ingest the full dose. Furthermore, the facility did not adhere to proper cleaning protocols for shared medical equipment. An LVN used a shared pill cutter to split medications for Resident 432 without cleaning it between uses. This practice was acknowledged by the LVN and the DON, who noted that it could lead to potential drug interactions and expose residents to medication residue. The facility's policy requires that shared items be cleaned and disinfected between uses, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, leading to potential ineffectiveness and safety concerns. In one of the medication storage rooms, the temperature consistently exceeded the manufacturer's recommended range of 68 to 77 degrees Fahrenheit, reaching up to 81 degrees. This was observed over a period of several months, with the temperature exceeding the limit on numerous occasions. The Director of Nursing (DON) acknowledged that the elevated temperature could render medications ineffective, as evidenced by the storage of vancomycin, which requires specific temperature conditions. Additionally, the facility did not properly label a multi-dose vial of Tuberculin Purified Protein Derivative (TPPD) in the medication storage room refrigerator. The vial was opened and undated, contrary to the facility's policy that requires labeling with the date of opening. The DON confirmed awareness of the issue and stated that the vial should have been labeled to ensure timely disposal, as vials in use for more than 30 days should be discarded. Furthermore, expired medications were found in the facility's medication cart. Three lidocaine 5% patches with an expiration date of October 2020 were discovered in a bag labeled with a resident's name. The Registered Nurse Supervisor (RNS) acknowledged the presence of these expired patches and confirmed they were available for use, which is against the facility's policy that mandates the removal and disposal of expired medications. The DON also confirmed awareness of the expired patches and reiterated the expectation for staff to discard such medications.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program in several instances. In one case, a urinal used by a resident was improperly stored inside a trash bin at the bedside, rather than in the designated holder. The resident confirmed using the urinal in this manner, and staff interviews revealed that this practice was against infection control protocols, which require urinals to be stored in a holder to prevent contamination. Another deficiency was observed during the collection of soiled linen on the second floor. A janitor failed to perform hand hygiene before and after glove use while handling soiled linens. The janitor admitted to not performing hand hygiene due to a lack of gloves in the hallway and limited English proficiency. Interviews with the housekeeping supervisor and infection preventionist confirmed that hand hygiene is required before donning and after doffing gloves, especially when handling potentially infectious materials like soiled linens. Additionally, nursing staff did not adhere to hand hygiene protocols during medication preparation and administration. An LVN was observed not performing hand hygiene before preparing and administering medications to two residents and failed to disinfect a blood pressure cuff before and after use. Furthermore, an RN administered medication without wearing gloves, even when handling oral secretions. These actions were acknowledged by the staff involved and were identified as risks for cross-contamination and infection by the Director of Nursing.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect during meal assistance. Resident 92, who was admitted with severe cognitive impairment and required total assistance with eating, was observed being fed by CNA 1 while the CNA stood over the resident. This was contrary to the facility's policy, which requires CNAs to sit at eye level with residents during feeding to maintain dignity and respect. Interviews with the CNA, Assistant Director of Nursing, and Director of Staff Development confirmed that the proper procedure was not followed. Similarly, Resident 7, who also had severe cognitive impairment and required assistance with eating, was fed by CNA 2 while the CNA stood at the bedside. Despite acknowledging the requirement to sit while feeding, CNA 2 did not retrieve a chair and continued to stand throughout the meal. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for a resident, identified as Resident 78, who was observed with multiple prescription medications left on their overbed table. The medications included hydralazine, amlodipine, Eliquis, valsartan, and amiodarone, which were left by an LVN who acknowledged that the resident preferred to take medications after breakfast. The LVN admitted that they should have stayed to encourage the resident to take the medications immediately and should not have left them at the bedside. Resident 78 was admitted with diagnoses including type 1 diabetes mellitus, end-stage kidney disease, and dependence on renal dialysis. The resident's Minimum Data Set assessment indicated no cognitive impairment and no impairment in the range of motion, requiring only setup or clean-up assistance with daily activities. Despite this, the interdisciplinary team did not determine if the medications left on the overbed table could be self-administered by the resident, and there was no active order for self-administration of medication. The facility's policy on self-administration of medications requires an assessment of the resident's mental and physical abilities and documentation of findings. However, the resident's care plan only specified self-administration of insulin Lispro and Glargine, with no mention of other medications. The Assistant Director of Nursing confirmed that there was no order for self-administration and that medications should not be left at the bedside, highlighting a lack of adherence to the facility's policy and procedure.
Failure to Monitor Resident on Heparin for Bleeding
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication, specifically in the case of a resident who was not monitored for bleeding while on heparin, an anticoagulant. The resident was readmitted to the facility with a fracture of the left femur and a hemorrhage of the anus and rectum. The physician's order prescribed heparin injections twice daily for 30 days as a prophylactic measure against deep vein thrombosis (DVT). However, there was no evidence in the resident's medical record of monitoring for bleeding, a known adverse effect of heparin. During an interview and record review, the Assistant Director of Nursing confirmed that the resident was on heparin and had not been monitored for signs and symptoms of bleeding. The facility's policy on anticoagulation required staff and physicians to monitor for possible complications in individuals receiving anticoagulation therapy. The prescribing information for heparin also indicated that hemorrhage is a common adverse reaction, underscoring the necessity for monitoring. This oversight had the potential to result in undetected adverse effects from the medication.
Failure to Monitor and Discontinue Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary antipsychotic medications. For one resident, there was no evidence of non-pharmacological interventions being attempted before the use of PRN Seroquel, and the medication was ordered for more than 14 days without discontinuation or reevaluation by a physician. The resident was readmitted with diagnoses including vascular dementia, psychotic disorder with delusion, and mood disorder. The Assistant Director of Nursing (ADON) confirmed that the PRN Seroquel should have been discontinued after 14 days, but it remained active for 23 days. For another resident, there was no evidence of specific behavioral monitoring for the use of Seroquel. The resident was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance. The ADON acknowledged that the resident's behaviors were not monitored for the effectiveness of the medication, which is necessary to determine if the medication is working and to note any changes in the resident's episodes. The facility's policy requires staff to monitor and document residents' behaviors when receiving psychotropic medication, but this was not done for the resident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to a deficiency in dietary services. Resident 36, who required a mechanical soft diet with soft vegetables, was served a regular menu that included hard carrots. This was observed during a kitchen tray line inspection, where the dietary manager confirmed the hardness of the carrots using a metal ladle. The cook subsequently replaced the hard vegetables with diced, soft carrots from the substitute menu. Resident 68 was also affected, as he was served a regular menu of fried rice, mixed vegetables, and pork slices, despite his meal ticket indicating a preference for chow mein with chicken or potstickers. Initially, the cook stated that the resident did not want chow mein, but after further inquiry, it was confirmed by the registered dietitian that the resident still wanted potstickers. These incidents demonstrate a failure to adhere to the facility's policy on respecting residents' food preferences, as outlined in their procedures.
Facility Fails to Meet Room Size Requirements for Residents
Penalty
Summary
The facility failed to ensure that 47 out of 48 resident rooms met the required minimum of 80 square feet per resident. During an observation conducted on March 18, 2025, it was noted that rooms on the first, second, and third floors were occupied by two or three residents, with curtains used to divide each bed. The Administrator confirmed that all rooms were equipped for three residents except for rooms 8, 25, and 41, which were for two residents. However, only one room met the required size standard. Interviews with residents revealed that some did not express concerns about the room size. Resident 1 in Room 10 stated that the space was "okay," and Resident 28, through an AI translator device, denied any issues with her room size. A review of facility-submitted documents, including a Client Accommodations Analysis and a Room Size Waiver Request, listed the rooms with less than 80 square feet per resident. The Administrator had requested a waiver for variance in room size from the California Department of Public Health.
Delayed MDS Assessment Completion
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident within the required 14-day period following admission. The resident, who was admitted with multiple diagnoses including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury, had their MDS assessment completed 23 days after admission, which is 9 days late. This delay was acknowledged by the MDS Coordinator during an interview. The facility's policy, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, mandates that the admission assessment be completed by the end of the 14th day, counting the admission day as day one. The failure to adhere to this requirement could potentially delay the identification of the resident's needs and significant issues affecting their well-being.
Failure to Timely Develop Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by their policy. The baseline care plan is essential to address the resident's immediate health and safety needs, including specific health concerns and risks such as elopement or falls. The resident in question was admitted with multiple diagnoses, including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury. Despite these significant health issues, the baseline care plan was not completed until several days after the admission. The review of the resident's records showed that the baseline care plan was completed and signed by both the resident and an LVN on a date that was beyond the 48-hour requirement. During an interview, the MDS Coordinator confirmed that the baseline care plan was completed late, acknowledging that it should have been done by the eighth day of admission. This delay in completing the baseline care plan could potentially lead to delayed identification of the resident's needs and significant issues affecting their well-being.
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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