The Pavilion At Sunny Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Fullerton, California.
- Location
- 2222 N. Harbor Blvd., Fullerton, California 92835
- CMS Provider Number
- 555733
- Inspections on file
- 35
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Pavilion At Sunny Hills during CMS and state inspections, most recent first.
A resident admitted from acute care with atrial fibrillation, a Zio cardiac monitor, urinary retention, and rectal bleeding did not have these conditions reflected in the comprehensive care plan. Although transfer documents and physician orders directed cardiac monitoring, PVR checks with I/O catheterization parameters, and monitoring for rectal bleeding, the January care plan contained no problems or interventions for the Zio patch, urinary retention, or rectal bleeding. Nursing leadership and an RN later confirmed these issues were present and should have been included in the care plan.
A resident with physician orders for PVR checks every six hours over several days had a documented PVR of 337 cc, above the ordered threshold for I/O catheterization. The record showed no evidence that an I/O catheterization was performed, that the MD was notified of the continued urine retention, or that further reassessment and monitoring occurred, and the resident’s care plan did not include a urinary retention problem. An RN later confirmed that facility expectations included MD notification, reassessment, monitoring, and care plan development in such circumstances.
A resident experienced a rapid, unplanned weight loss of 12 lbs. (about 6%) within less than a month, triggering thresholds outlined in the facility’s weight management P&P for closer monitoring and intervention. Despite weekly weights showing a 7 lb. loss in nine days and an additional 5 lb. loss shortly thereafter, the nutritional assessment initially documented no weight change, and the RD did not conduct follow-up until weeks after the weight decline began, even though she acknowledged such a loss would be concerning and required follow-up. An IDT note later summarized the ongoing weight loss, and leadership staff were informed of these findings.
A resident’s daughter reported to nursing staff that a CNA was unable to meet the resident’s needs and was harassing the resident, and this was documented as a change of condition using an SBAR tool. Despite facility policy requiring person-centered, comprehensive care plans to be developed and revised by the IDT, review of the medical record showed no care plan problem or interventions were added to address the reported unmet needs or alleged harassment. Two LVNs confirmed during interviews that no care plan was developed in response to this change of condition and acknowledged that care plans are intended to ensure goals and interventions are created and updated as needed.
Two residents receiving respiratory treatments did not have their nebulizer and oxygen equipment stored and labeled according to facility policy, and required oxygen in use signage was missing from their room entrances. For one resident, surveyors found a nebulizer mask and tubing left on a nightstand without a bag, name, or date, while the resident was also using an oxygen concentrator and had portable oxygen tanks in the room with no oxygen in use sign posted. For another resident with asthma using oxygen via concentrator and nasal cannula, oxygen tubing wrapped around a portable tank on the wheelchair was not bagged or labeled, and no oxygen in use sign was posted outside the room. Staff, including an OT, a CNA, an LVN, and the IP, confirmed these observations and acknowledged that facility policies required the equipment to be bagged, dated, and labeled, and signage to be posted when oxygen was in use.
A resident with severe cognitive impairment was placed in a wheelchair with a lap buddy and pressure pad alarm without a physician's order, informed consent, or a care plan. Staff confirmed the use of these devices to prevent unassisted movement, but medical record review and interviews revealed that required assessments and documentation were not completed prior to their application.
Two residents did not receive required care and monitoring after significant events. One resident with severe cognitive impairment had abnormal neurological findings documented after returning from the hospital, but the physician was not notified as required. Another resident was not monitored or documented for required periods following an unwitnessed fall. These failures were confirmed by facility leadership and were not in accordance with facility policy.
A resident with impaired decision-making capacity reported alleged abuse and mistreatment to an acute care hospital RN, who then informed facility staff. The LVN on duty failed to immediately notify the Administrator or report the allegation to required authorities, resulting in an eight-hour delay before the Administrator became aware and submitted the necessary reports. This delay did not comply with the facility's policy for immediate reporting of abuse allegations.
A resident received PRN acetaminophen and baclofen, but the administration was not documented in the MAR or progress notes. An LVN confirmed giving the medications but failed to record them, and this was later verified by an RN. The DON acknowledged that documentation should occur immediately after administration.
A resident did not receive necessary care and services, including suctioning, daily weight monitoring, and medication administration, as per physician orders. The facility failed to document and implement these orders, notify the physician of medication refusals, and provide required catheter and wound care. These deficiencies were confirmed through interviews and medical record reviews.
The facility was found non-compliant with State laws and its own policy as an LVN and a CNA were observed not wearing their name badges, which are required for staff identification. The CNA stated her badge had fallen off, while the LVN admitted her badge was on the cart. The ADON confirmed that name badges should be worn at all times.
A resident in hospice care did not receive prescribed latanoprost eye drops for glaucoma due to a failure in communication and documentation by the facility staff. The medication was received, but the order was not documented or administered until days later, causing the resident to experience eye discomfort. Interviews with staff confirmed the oversight, with the LVN admitting to forgetting to verify and carry out the order.
A resident with Type 2 Diabetes Mellitus did not receive proper insulin administration due to a failure by nursing staff to prime the Tresiba insulin pen as per manufacturer's instructions. The LVN and RN involved were unaware of the priming requirement, which was confirmed by the ADON. This oversight risked incorrect medication dosing.
Failure to Revise Care Plan for Cardiac Monitor, Urinary Retention, and Rectal Bleeding
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised to reflect specific care needs for one sampled resident following admission from an acute care hospital. Facility policy titled “Comprehensive Care Plans-Timing” (revised 1/2025) required that each resident have a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, with involvement of the resident and/or representative. For this resident, admitted in January 2026 and discharged in February 2026, review of the January 2026 plan of care showed no care plan problem addressing the presence of a Zio patch, a wearable cardiac monitor that was documented as present on admission in a Wound Weekly Monitoring Assessment dated 1/15/16 and referenced in the Discharge to SNF Summary and Transfer Order dated 1/14/26 as a cardiac monitor requiring follow-up for atrial fibrillation. The same resident’s January 2026 plan of care also lacked care plan problems for urinary retention and rectal bleeding, despite these conditions being identified and ordered for monitoring and intervention. The Discharge to SNF Summary and Transfer Order dated 1/14/26 documented urinary retention as a reason for the acute care hospitalization, and an Order Summary Report dated 1/15/26 included a physician’s order for PVR checks every six hours for three days with in-and-out catheterization if PVR exceeded 250 cc and MD notification if two or more consecutive catheterizations were required. Additionally, an Order Summary Report dated 1/17/26 contained a physician’s order to monitor signs and symptoms of rectal bleeding, yet no corresponding care plan problem was initiated. During interviews, RN 1 confirmed the Zio patch was present on admission and agreed it should have been care planned, and the ADON verified that care plans for urinary retention and rectal bleeding were absent and should have been revised to reflect these problems.
Failure to Follow Physician Orders and Monitor Urinary Retention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services related to urinary retention and bladder management for one resident. The facility’s policies required licensed nurses to document and implement physician orders and outlined expectations for bowel and bladder retraining, including assessment of continence status and voiding patterns. For this resident, the January care plan did not include a problem for urinary retention. A physician’s order dated mid-January directed staff to check post-void residual (PVR) every six hours for three days, to perform an in-and-out (I/O) catheterization if the PVR was greater than 250 cc, and to notify the physician if there were two or more consecutive catheterizations every six hours for three days. On a specific date in January at 1200 hours, the Medication Administration Record documented a PVR of 337 cc, which exceeded the ordered threshold for I/O catheterization. There was no documentation in the progress notes or closed medical record that an I/O catheterization was performed in response to this elevated PVR, that the physician was notified of the continued urine retention, or that the resident was reassessed or further monitored after the 337 cc residual was identified. The 337 cc PVR entry was the last documented PVR in the ordered sequence. During interview and concurrent record review, an RN confirmed that if a resident continued to retain urine after three days, the physician should be notified, reassessment and monitoring should occur, and a care plan problem should be created, and verified that these steps were not documented for this resident. These failures had the potential to negatively impact the resident’s well-being.
Failure to Timely Address Significant Resident Weight Loss
Penalty
Summary
The facility failed to ensure timely nutritional intervention for a resident who experienced significant, rapid weight loss. The facility’s Weight Management policy, revised in 12/2024, required monitoring and intervention for residents with sudden changes in nutritional intake, a loss or gain of 5 lbs. since the last recorded weight, or weight changes greater than 5% in one month, among other thresholds. The resident was admitted in mid-January 2026 with a goal weight of 185–190 lbs., and the nutritional assessment dated 1/21/26 documented “no weight change” despite subsequent weight records showing a decline. The Weight and Vitals Summary showed the resident’s weight decreased from 187 lbs. on 1/15/26 to 180 lbs. on 1/24/26 (a 7 lb. loss in nine days), and then to 175 lbs. on 2/1/26, totaling a 12 lb. loss (approximately 6.4%) in less than a month. Despite these documented changes, the facility did not address the resident’s significant weight loss in a timely manner. The resident’s weight remained 175 lbs. on 2/8/26, and an IDT Progress Note dated 2/9/26 recorded no change for one week, a 5 lb. loss over two weeks, and a 12 lb. (6%) loss over three weeks since admission. During interview, the RD stated she received copies of the weekly weights and acknowledged that a 7 lb. weight loss in nine days would be concerning and require follow-up, and that the resident had experienced significant weight loss of 6% from admission. The RD reported that she did not follow up with the resident until 2/9/26 and stated that, ideally, she should have followed up earlier. The Administrator, Administrator Assistant, ADON, and DON were informed of and acknowledged these findings.
Failure to Update Care Plan After Reported Staff Inability to Meet Needs and Harassment
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a reported change of condition and allegation of staff misconduct for one resident. The facility’s policy on Comprehensive Care Plans requires that each resident have a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, including the resident and representative when applicable. For this resident, an SBAR: Change of Condition dated 1/31/26 documented that the resident’s daughter reported a CNA was unable to meet the resident’s needs and was harassing the resident. Despite this documented change of condition and allegation, review of the resident’s plan of care showed no care plan problem was developed to address the daughter’s report that staff were not meeting the resident’s needs and the allegation of harassment. During interviews and concurrent medical record reviews, LVN 2 and LVN 3 each verified that no care plan problem had been developed following the reported change of condition on 1/31/26. LVN 2 stated that the purpose of developing a care plan related to a change of condition is to ensure goals and interventions are being met or revised as needed, and LVN 3 stated that the importance of a care plan is to create and update resident goals and interventions as needed. The Administrator was later informed of and acknowledged these findings. The facility’s inaction in updating the care plan after the documented report from the resident’s daughter constituted a failure to develop a comprehensive care plan that reflected the resident’s individual care needs and the reported concerns.
Failure to Properly Store Respiratory Equipment and Post Oxygen in Use Signage
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and procedures for nebulizer and oxygen therapy for two residents. For one resident with a physician’s order for albuterol-ipratropium via nebulizer every six hours, surveyors observed the nebulizer mask lying face down and the nebulizer tubing connected to the machine on the nightstand, not stored in a plastic bag, and not labeled with the resident’s name or date, contrary to the facility’s nebulizer therapy policy. This resident was also using an oxygen concentrator at the bedside with two portable oxygen tanks present, but there was no “oxygen in use” signage posted outside the room as required by the facility’s oxygen therapy policy. The OT and an LVN both confirmed the mask and tubing were not bagged, dated, or labeled, and verified the absence of the required oxygen signage. For another resident with asthma and an order to use oxygen via nasal cannula as needed to maintain oxygen saturation above 92%, surveyors observed oxygen tubing curled around a portable oxygen tank in an oxygen holder on the back of the resident’s wheelchair. The tubing was not stored in a plastic bag and was not labeled, despite the facility’s oxygen therapy policy requiring oxygen delivery equipment to be changed weekly, stored in a plastic bag at the bedside when not in use, and used for a single resident only. This resident was on oxygen therapy via concentrator and nasal cannula at the time of observation, yet there was no “oxygen in use” signage posted outside the room entrance. A CNA and an LVN both verified that the tubing was not bagged or labeled and that the required oxygen signage was not present. The Infection Preventionist later acknowledged that oxygen and nebulizer tubing should be changed, bagged, and dated weekly and as needed, and that oxygen in use signage should be posted for all rooms with residents using oxygen.
Failure to Obtain Physician Order and Consent for Restraint Devices
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary restraints by not obtaining a physician's order or informed consent for the use of a lap buddy and pressure pad alarm on the resident's wheelchair. Observations and interviews confirmed that the resident was using these devices, but a review of the medical record showed no documentation of a physician's order, informed consent, or a care plan addressing their use. The facility's policies require a physician's order, informed consent, and a resident-centered care plan for any physical restraint, including devices such as lap buddies and alarms that the resident cannot remove easily. The resident in question had severe cognitive impairment, as indicated by a BIMS score of 00 and documentation that the resident lacked capacity to make decisions. Staff interviews revealed that the devices were used to alert staff if the resident attempted to get up unassisted, due to episodes of leaning forward. Despite this, there was no evidence that the required assessments, orders, or consents were completed prior to the application of these devices. Further interviews with nursing staff and facility administration confirmed the absence of a physician's order, informed consent, and a care plan for the use of the lap buddy and pad alarm. The facility's own policies, as reviewed, clearly outline the steps required before applying such devices, including assessment by the interdisciplinary team and ongoing documentation, none of which were present in this case.
Failure to Report Abnormal Neuro Findings and Monitor Post-Fall Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for two residents. For one resident with severe cognitive impairment, after returning from the hospital following a fall with a forehead laceration, neurological assessments documented fixed pupil reactions on multiple occasions. Despite these abnormal findings, there was no evidence that the physician was notified as required by facility policy. The Assistant Director of Nursing (ADON) confirmed that these findings were abnormal and should have been reported and documented. For another resident with intact cognition, following an unwitnessed fall, the medical record did not contain documentation of post-fall monitoring during the morning and night shifts. Facility policy requires 72-hour monitoring and documentation after a fall, including assessments and physician notification. The ADON verified that there was no documentation to show the resident was monitored as required during these shifts. Facility policies reviewed included requirements for neurological assessments, documentation after significant events, and post-fall management, all of which were not followed in these cases. The failures were confirmed through observation, interviews, and medical record review, and were acknowledged by facility leadership.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one of four sampled residents. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, a resident who lacked capacity to make decisions was transferred to an acute care hospital, where she informed the hospital RN that she did not want to return to the facility due to alleged abuse and mistreatment. The hospital RN relayed this information to the facility staff around midnight. However, the LVN who received the information only reported it to the RN supervisor on duty and did not notify the Administrator, CDPH L&C Program, Long-Term Care Ombudsman, or local law enforcement as required by policy. The Administrator, who serves as the facility's Abuse Coordinator, was not informed of the allegation until approximately eight hours after it was made. Only after being notified did the Administrator report the incident to the appropriate authorities. Both the LVN and the Administrator acknowledged that the allegation should have been reported immediately according to facility policy. The delay in reporting had the potential to delay the investigation and prevent prompt corrective actions.
Failure to Document PRN Medication Administration in Medical Record
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for one resident. According to the facility's policy, medications must be administered and documented in accordance with physician orders and professional standards. A review of the resident's medical record and Medication Administration Record (MAR) revealed that two tablets of acetaminophen 325 mg and one tablet of baclofen 5 mg, which were ordered to be given as needed, were not documented as administered on a specific date and time. The progress notes also lacked documentation of these medications being given. Interviews with the resident's family member and the LVN confirmed that the medications were administered between 1200-1300 hours, but the LVN acknowledged failing to document the administration in the MAR. The RN corroborated that the LVN had verified the administration verbally but was unable to document it. The Director of Nursing was informed of these findings and acknowledged the expectation that licensed nurses document medication administration immediately after giving medications.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for a resident, identified as Resident 2. The facility did not ensure that Resident 2 had a physician's order for suctioning as per the discharge order from the acute care hospital. Despite the resident's care plan indicating the need for suctioning to maintain a clear airway, the order was not documented or implemented by the nursing staff upon admission. This oversight was confirmed during an interview with an LVN, who acknowledged that the suctioning order was missing and should have been entered by the nurse receiving the physician's orders. Additionally, the facility did not adhere to the physician's instructions to weigh Resident 2 daily and administer Lasix medication as needed based on weight changes. The resident's medical records lacked documentation of daily weight monitoring, which was a critical component of managing the resident's heart failure and COPD. Interviews with the LVN and ADON confirmed the absence of a physician's order for daily weight monitoring, which was a deviation from the prescribed care plan. The facility also failed to notify the physician and responsible party of Resident 2's repeated refusals of medications and supplements. The resident's MAR indicated multiple instances of medication refusal, yet there was no documentation of physician notification or a COC/SBAR being completed. Furthermore, the facility did not provide the necessary indwelling urinary catheter care and wound care treatments as ordered by the physician. The TAR showed blank entries for several dates, indicating that these treatments were not performed. The ADON confirmed that blank entries meant the care was not provided, and the Administrator and DON were made aware of these findings.
Non-Compliance with Name Badge Policy
Penalty
Summary
The facility failed to comply with State laws and its own policies and procedures regarding employee identification, as evidenced by two staff members, an LVN and a CNA, not wearing their name badges. During an observation and interview, the CNA was found without her name badge and stated it had fallen off, but she intended to put it back on. Similarly, the LVN was observed without her name badge and acknowledged that the purpose of the badges was for residents and families to identify staff members. The LVN admitted that the badge was on the cart instead of being worn. The Assistant Director of Nursing (ADON) confirmed that name badges are expected to be worn at all times as part of the staff uniform.
Failure to Administer Prescribed Eye Drops for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident by not following up with the hospice for an order of latanoprost eye drops, which are used to treat glaucoma. The resident was admitted for hospice care, and an order for the eye drops was issued by the hospice physician. The medication was received by the facility nurse, but the order was not documented in the resident's medical records or administered until several days later. This oversight resulted in the resident experiencing eye discomfort for weeks before receiving the prescribed treatment. The facility's policies and procedures require that nursing home staff obtain and communicate orders from hospice physicians to the resident's attending physician in a timely manner. However, the order for the eye drops was not communicated or documented, leading to a delay in treatment. Interviews with facility staff, including the MDS nurse, hospice case manager, and DON, confirmed the lapse in following up on the order. The LVN who received the medication admitted to forgetting to verify and carry out the order, resulting in the resident not receiving the necessary eye drops until a later date.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident by not following the manufacturer's instructions for administering insulin using a Tresiba insulin pen. During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen preparing and administering the Tresiba insulin pen without priming it as required. The manufacturer's instructions specify that the pen should be primed by selecting two units, holding the pen with the needle pointing up, and ensuring a drop of insulin is visible at the needle tip before selecting the prescribed dose. This step was omitted by the LVN, who directly selected the prescribed dose and administered it to the resident. The resident involved had a diagnosis of Type 2 Diabetes Mellitus and was prescribed a daily dose of 12 units of Tresiba insulin. The LVN, along with a Registered Nurse (RN), admitted to being unaware of the priming requirement. The Assistant Director of Nursing (ADON) confirmed the findings and acknowledged that the insulin pen should be primed before selecting the dose. This oversight in following the correct procedure for insulin administration posed a risk of the resident not receiving the correct amount of medication.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
A resident with HTN and heart failure experienced a significant increase in BP from a prior normal reading, but the LVN who obtained the elevated value did not perform a reassessment, repeat the BP, document a change in condition, or notify the physician. Review of the vital signs record and progress notes confirmed the lack of follow-up assessment or provider notification, despite facility policy requiring hypertensive readings to be reported and documented. The ADON verified that the expected practice of assessing and documenting changes in BP was not followed in this instance.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
Failure to Assess and Report Elevated Blood Pressure
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and facility policy after an elevated blood pressure reading for one resident. The resident was admitted with diagnoses including hypertension and heart failure and had intact cognitive skills and decision-making capacity. The resident was dependent on staff for several ADLs, including toileting, bathing, and lower body dressing. On review of the Vital Signs Record, the resident’s blood pressure increased from a prior reading of 128/75 mmHg to 168/77 mmHg on 2/27/2026. There was no documentation of any reassessment, repeat blood pressure measurement, or physician notification following this elevated reading. Progress notes contained no change in condition documentation related to the elevated blood pressure. During interview, the LVN who obtained the 168/77 mmHg reading confirmed that the physician was not notified and that no reassessment, repeat blood pressure, or change in condition documentation was completed. The ADON, upon review of the records, confirmed the absence of reassessment, change of condition documentation, and physician notification, and stated that staff were expected to assess residents, monitor vital signs, and notify the physician for changes in condition, and that a change from 128/75 mmHg to 168/77 mmHg required assessment and documentation even if the resident denied symptoms. The facility’s blood pressure policy indicated hypertensive readings should be reported to the physician and that staff should document and evaluate findings, which was not followed in this case.
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
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