The Redwoods, A Community Of Seniors
Inspection history, citations, penalties and survey trends for this long-term care facility in Mill Valley, California.
- Location
- 40 Camino Alto, Mill Valley, California 94941
- CMS Provider Number
- 555826
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Redwoods, A Community Of Seniors during CMS and state inspections, most recent first.
A resident with a medically complex condition had conflicting information between their signed POLST form and the MDS assessment, with the MDS indicating full treatment and artificial nutrition while the POLST specified DNR, selective treatment, and no artificial nutrition. The MDS coordinator and DON confirmed the inaccuracy, and it was noted that the facility lacked a policy for MDS assessment completion.
The facility did not establish or maintain an infection prevention and control program, as required, resulting in a lack of systematic measures to prevent, identify, and control infections among residents and staff.
The facility did not provide written notice to the LTC Ombudsman when two residents were transferred to the hospital, as required by policy and regulation. Multiple staff members, including the DSD, Admin, LNs, and SSD, were unaware of the requirement and confirmed that no notifications were made for these transfers.
Two residents at risk for falls in an LTC facility experienced multiple falls due to inadequate supervision and ineffective care plans. One resident suffered two hip fractures, while the other fell seven times in four months. The facility failed to update care plans with appropriate interventions and did not increase supervision, despite the residents' high fall risk.
The facility failed to track mandatory training compliance, resulting in overdue trainings for a licensed nurse and a CNA. Additionally, an unlicensed staff member worked with an expired BLS certification for 4.5 months, and was observed not following infection control protocols. The DSD admitted to not having a system to track certifications, contrary to facility policy.
The facility did not post daily nursing staffing information as required, with the posting from the previous Friday still displayed on Monday. The Staffing Coordinator was responsible for weekday postings, but on weekends, charge nurses were tasked with this duty, which was not consistently fulfilled. This failure contradicted federal regulations requiring daily postings at the beginning of each shift.
The facility did not ensure timely responses to the Pharmacist's Drug Regimen Review reports, affecting all residents receiving medications. Reviews for May and June lacked follow-up, and earlier months showed incomplete documentation. The Consulting Pharmacist had to seek physician responses, and the DON admitted to not following through on recommendations, despite policy requiring action within 30 days.
A resident with dementia and no documented aggression was prescribed Seroquel without proper justification or monitoring. The facility failed to document aggression or attempt non-pharmacological interventions before administering the medication. The prescribing physician did not respond to the pharmacist's recommendation to discontinue Seroquel, and the facility did not adhere to its policy on psychotropic medication use.
The facility failed to maintain proper medication storage conditions, with a refrigerator consistently at 28°F instead of the required 36-46°F, affecting medications for two residents. The medication room door was found propped open, risking unauthorized access, and an expired medication was stored with active ones in a cart. The DSD confirmed these issues, indicating a need for staff education on proper procedures.
A resident with a history of falls and Alzheimer's Disease suffered multiple falls resulting in major injuries due to inaccurate fall risk assessments. The assessments failed to accurately reflect the resident's condition, including her fall history, need for supervision, incontinence, and the number of medications increasing fall risk. This led to inadequate care planning and interventions.
The facility failed to follow its Infection Control and QAPI policies by not tracking chronic UTIs among residents. Licensed Staff A admitted to not maintaining surveillance data, leaving the chronic infections section blank for several months. Specific cases included residents with multiple UTIs, yet no data was captured for root cause analysis, contrary to the facility's policies.
A staff member failed to follow Enhanced Barrier Precautions and Hand Hygiene policies while providing care to a resident who was incontinent of stool. The staff member did not wear an isolation gown or perform hand hygiene after care, despite facility policies requiring these measures for high-contact activities. This lapse was acknowledged by the staff member and confirmed by a licensed staff member, highlighting the risk of infection spread.
The facility failed to provide adequate annual training in abuse and dementia care for three CNAs. Unlicensed Staff N received only one hour of abuse training and no dementia training, while Unlicensed Staff O and P received one hour each of abuse and dementia training. The facility's assessment required at least 12 hours of training annually, but only about 5 hours were provided, as confirmed by the DSD.
A facility failed to document a resident's advance directives and POLST, despite the resident's serious medical conditions. Staff interviews revealed reliance on verbal communication and manual chart checks, which led to the oversight. The facility's policies required documentation of these directives, but they were not followed.
A facility failed to create a resident-centered care plan for a resident with a stage 4 pressure ulcer. The care plan lacked specific treatments ordered by the physician and included only generalized interventions. This deficiency was confirmed by the DSD, highlighting a failure to meet the facility's policy for comprehensive care plans.
Inaccurate MDS Assessment Due to POLST Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a medically complex condition. The resident's MDS assessment, specifically section S which documents Physician Orders for Life-Sustaining Treatment (POLST), indicated that the resident had chosen to receive full treatment, including resuscitation and a trial period of artificial nutrition via feeding tube. However, a review of the resident's signed POLST form revealed that the resident had actually chosen Do Not Resuscitate (DNR), selective treatment, and no artificial means of nutrition, including feeding tubes. This discrepancy was confirmed during interviews with the MDS coordinator and the Director of Nursing (DON), both of whom acknowledged that the MDS assessment did not accurately reflect the resident's documented wishes as indicated on the POLST form. Further investigation revealed that the facility did not have a policy or procedure in place regarding the completion of MDS assessments. The DON confirmed that the information in section S of the MDS should be transcribed directly from the signed POLST form, and that any mismatch would render the MDS assessment inaccurate. The lack of an accurate MDS assessment could result in care and treatment that does not align with the resident's documented preferences. The findings were supported by a review of relevant professional guidance, which emphasized the importance of accurate documentation for MDS accuracy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as required by regulations. The report specifically notes the absence of a comprehensive program designed to prevent, identify, report, investigate, and control infections and communicable diseases among residents and staff.
Failure to Notify Ombudsman of Resident Transfers to Hospital
Penalty
Summary
The facility failed to provide written notice of transfer to the Long-Term Care Ombudsman for two residents who were transferred to the hospital. Interviews with staff, including the Director of Staff Development, Administrator, Licensed Nurses, and Social Services Director, revealed that none were aware of the requirement to notify the Ombudsman when residents were transferred to the hospital. Staff members confirmed that they had not completed notices of transfer nor notified the Ombudsman in such cases. The Director of Nursing verified that no notice was completed and the Ombudsman was not notified for the two residents transferred to the hospital at the end of March 2025. A review of the facility's policy and procedure indicated that the Ombudsman should be notified in all cases of transfer or discharge, in accordance with regulatory requirements. Additionally, an All Facilities Letter specified that notice must be sent to the local LTC Ombudsman for any transfer or discharge initiated by the facility. Despite these requirements, the facility did not notify the Ombudsman for the two residents transferred to the hospital, as confirmed by staff interviews and record review.
Inadequate Supervision and Care Plan Implementation for Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective care plans for two residents at risk for falls, leading to multiple incidents. Resident 190, with a history of falls and severe cognitive impairment, suffered three falls within a short period, resulting in two hip fractures. The facility did not create a care plan before the first fall and failed to update the care plan with appropriate interventions after subsequent falls. Despite being at high risk for falls, the supervision for Resident 190 was not increased, and the documentation of staff checks was inconsistent. Resident 34, who was completely dependent on staff for daily activities, experienced seven falls over four months. The facility's care plans for Resident 34 lacked specific interventions to prevent falls and did not increase supervision despite the repeated incidents. Documentation of neurological checks and fall risk assessments was incomplete or missing, and the facility did not revise care plans promptly after each fall. The facility's policies on fall prevention and management were not followed, as evidenced by the lack of adequate supervision and failure to update care plans with effective interventions. The Director of Nursing acknowledged the need for improvement in managing falls, including accurate fall risk assessments and documentation of visual checks. The facility's failure to implement and monitor appropriate interventions contributed to the residents' repeated falls and injuries.
Deficiencies in Staff Training and Competency Tracking
Penalty
Summary
The facility was found to lack a system for tracking staff compliance with mandatory training requirements, leading to overdue trainings for two out of four sampled employees. Specifically, one licensed nurse and one certified nursing assistant (CNA) had not completed their annual mandatory trainings on time. The Director of Staff Development (DSD) confirmed that there was no tracking system in place to ensure these trainings were completed annually, which is a requirement according to the facility's Employee Benefits document and the DSD's job description. Additionally, the facility failed to ensure that a competent Director of Staff Development was in place to enforce training and verify competencies for nursing staff. This was evidenced by the fact that an unlicensed staff member's Basic Life Support (BLS) certification had been expired for 4.5 months while they were working at the facility. The DSD was unaware of this expiration and admitted that it was her responsibility to track current competencies and certifications, not the payroll department as she initially stated. Furthermore, during an observation, the unlicensed staff member was seen providing care without following proper infection control protocols, such as wearing a gown or washing hands after providing care to a resident. This incident, along with the expired BLS certification, highlighted the facility's failure to maintain sufficient and competent staffing as per their policy and procedure, which requires all staff to be appropriately trained and certified to perform their duties.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nursing staffing information was posted in a conspicuous place, as required, on one of the five days surveyed. On 7/08/24, it was observed that the staffing information posted was from the previous Friday, 7/05/24, indicating that the information had not been updated over the weekend. The Director of Staff Development confirmed this finding during an observation and interview, noting that the unit clerk was typically responsible for posting the information daily around 10:00 a.m. Further interviews revealed that the Staffing Coordinator was responsible for creating and posting the daily staffing information on weekdays, usually by 8:30 a.m. However, on weekends, this task was delegated to charge nurses, who did not always post the information if they were busy. The facility's policy required posting within three hours of each shift's start, but this contradicted federal regulations, which mandated daily posting at the beginning of each shift. This discrepancy led to the failure to post updated staffing information on 7/06/24 and 7/07/24, potentially impacting the ability of residents, visitors, and staff to review and advocate for appropriate staffing levels.
Failure to Act on Pharmacist's Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely responses from physicians and the Medical Director to the Pharmacist's Drug Regimen Review (DRR) reports, which are monthly summaries of each resident's medication irregularities. This deficiency was identified during a review of the monthly Drug Regimen Review binder, which revealed that for the months of May and June, there were no follow-up responses to the recommendations made by the Consulting Pharmacist. Additionally, previous months' reports from February, March, and April also showed incomplete documentation of physician responses or follow-through on the pharmacist's recommendations. Interviews conducted with the Consulting Pharmacist and the Director of Nursing (DON) highlighted the lack of timely follow-up and documentation. The Consulting Pharmacist noted that she had to actively seek out physicians for responses, although there had been some improvement with a new Medical Director. The DON acknowledged her oversight responsibility and admitted to not following through with the pharmacist's recommendations. The facility's policy, dated September 2018, requires that recommendations be acted upon within 30 days, but this was not adhered to, placing all residents receiving medications at risk for negative clinical outcomes.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that Resident 16 was free from unnecessary psychotropic drugs, specifically Seroquel, which was prescribed without proper justification or monitoring for aggression. Resident 16 was admitted with dementia without behavioral disturbance and a history of repeated falls. Despite this, she was prescribed Seroquel for aggression, although there was no documentation or evidence of aggressive behavior in her care plans or medical records. The Director of Staff Development (DSD) confirmed the absence of monitoring for aggression and the lack of evidence for other interventions prior to the administration of Seroquel. During observations, Resident 16 was noted to be pleasant and polite, with no signs of aggression. The prescribing physician, Physician R, was unavailable for an interview but indicated via text that Resident 16 had behavioral issues upon admission and suggested a gradual dose reduction. However, the facility's records did not support the presence of aggression, and the pharmacist had recommended discontinuing Seroquel due to the lack of aggression issues, but received no response from the physician. The facility's policy on psychotropic medications requires that such medications be used only when necessary and with proper documentation of the condition being treated. The policy also mandates that physicians respond to feedback from staff regarding medication use. In this case, the facility did not adhere to its policy, as there was no documented need for Seroquel, and the physician did not respond to the pharmacist's recommendation to discontinue the medication.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain the appropriate temperature for a medication refrigerator, which was consistently recorded at around 28 degrees Fahrenheit, below the required range of 36 to 46 degrees Fahrenheit. This issue persisted for several months, as indicated by the temperature logs dating back to December 2023. Medications stored in this refrigerator, including Lorazepam oral liquid for two residents and an emergency medication kit, were potentially compromised due to improper storage conditions. The Director of Staff Development (DSD) confirmed the findings and acknowledged the need for staff education on maintaining correct refrigerator temperatures. Additionally, the medication room door was found propped open and unattended, contrary to the facility's policy requiring it to be locked at all times. This lapse in security could have allowed unauthorized access to medications. Furthermore, an expired medication was discovered in a medication cart used for the south hall, stored alongside active medications. Licensed Staff I confirmed the presence of the expired medication, which was intended for resident use but was rarely utilized. The facility's policy mandates that outdated medications be returned to the pharmacy or destroyed, highlighting a failure to adhere to established procedures.
Inaccurate Fall Risk Assessments Lead to Resident Injuries
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who suffered multiple falls, resulting in major injuries. The resident, who had a history of falling, Alzheimer's Disease, restlessness, and agitation, was inaccurately assessed as being at low risk for falls after a significant fall that resulted in a hip fracture. The fall risk assessment did not reflect the resident's true condition, including her history of falls, need for supervision with ambulation, incontinence, and the number of medications that increased her fall risk. This inaccurate assessment potentially contributed to inadequate care planning and interventions to prevent further falls. The resident experienced a second fall, resulting in another hip fracture. Although the subsequent fall risk assessment correctly identified the resident as high risk, it still inaccurately documented the number of medications increasing fall risk. The facility's policy on medical record documentation emphasizes the need for factual, complete, and accurate entries, which was not adhered to in this case. The Director of Nursing confirmed the inaccuracies in the fall risk assessments during a review of the resident's records.
Failure to Track and Surveil Chronic UTIs
Penalty
Summary
The facility failed to adhere to its Infection Control and QAPI policies by not tracking and surveilling data for residents with chronic urinary tract infections (UTIs). This deficiency was identified through interviews, observations, and record reviews. Licensed Staff A admitted to not tracking chronic UTIs, which is a critical component of the facility's infection control and QAPI processes. The lack of tracking and surveillance was confirmed during a review of the Infection Control Surveillance Report Tool, where the section for chronic infections was left blank for several months. This oversight was further highlighted by the absence of data for root cause analysis during QAPI and IDT conferences. Specific cases of residents with multiple UTIs were noted, including a resident who experienced three UTIs within three months and another resident with two UTIs in two months. Despite these occurrences, the facility did not capture or analyze data to investigate the root causes of these chronic infections. The facility's policies, including the Infection Control Plan and the QAPI program, emphasize the importance of systematic surveillance and data-driven quality improvement efforts, which were not followed in this instance.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Policies
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions and Hand Hygiene policies, as observed during a survey. A staff member, identified as Unlicensed Staff F, was seen providing hygiene care to a resident who was incontinent of stool without wearing the required isolation gown. This occurred despite the presence of an Enhanced Barrier Isolation Cart outside the resident's room, which contained the necessary personal protective equipment (PPE) such as gloves, masks, and gowns. Furthermore, Unlicensed Staff F exited the resident's room without performing hand hygiene, either by washing hands or using hand sanitizer, after completing the care. During an interview, Unlicensed Staff F admitted to forgetting to wear a gown and to perform hand hygiene after providing care to the resident. Licensed Staff A confirmed that the care provided to the resident was considered a high-contact activity under the facility's Enhanced Barrier Precautions policy, which mandates the use of gowns and gloves, as well as hand hygiene before and after resident care. Licensed Staff A acknowledged the risk of a serious infection outbreak in the facility if such precautions are not followed. The facility's policies on Enhanced Barrier Precautions and Hand Hygiene emphasize the importance of using PPE and practicing hand hygiene to prevent the transmission of infections, including multiple drug-resistant organisms. The Infection Preventionist's role includes ensuring compliance with these procedures. The facility's policies also highlight the importance of treating residents with respect and dignity, and ensuring a safe and sanitary environment to prevent communicable diseases and infections.
Inadequate Training for CNAs in Abuse and Dementia Care
Penalty
Summary
The facility failed to provide adequate annual training in abuse and dementia care for three out of four unlicensed staff members, specifically Certified Nursing Assistants (CNAs) identified as Unlicensed Staff N, O, and P. During an interview and record review with the Director of Staff Development (DSD), it was revealed that Unlicensed Staff N received only one hour of abuse training and no dementia training. Unlicensed Staff O received one hour each of abuse and dementia training, while Unlicensed Staff P also received one hour each of abuse and dementia training. This was confirmed by the DSD during the interview. The facility's document titled 'Facility Assessment' from 2023 indicated that nurse aides are required to receive no less than 12 hours of in-service training annually, which must include dementia management and resident abuse prevention training. However, the DSD stated that the CNAs were provided with only about 5 hours of such training per year. This discrepancy highlights the facility's failure to meet the required training standards, potentially impacting the competency of the staff in providing quality care to residents.
Failure to Document Advance Directives and POLST
Penalty
Summary
The facility failed to ensure that a resident's medical records were updated to reflect discussions and documentation regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST). The resident, who was admitted with serious medical conditions including pyonephrosis, kidney stones, sepsis, hypokalemia, and dysphagia, did not have an advance directive or executed POLST documented in their medical record. This oversight was identified during a record review, which revealed the absence of these critical documents. Interviews with facility staff, including the Social Services Director and Licensed Staff, highlighted gaps in the process of obtaining and documenting advance directives and POLST forms. The Social Services Director admitted that the process relied on verbal communication and manual checks of resident charts, which failed in this instance. Additionally, Licensed Staff confirmed that the resident's code status was not listed in the electronic medical administrative record, and a manual chart review showed an unexecuted POLST. The facility's policies required that residents be provided with information about their rights to make medical decisions and that POLST forms be completed and signed, but these procedures were not followed for the resident in question.
Deficient Care Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to develop a resident-centered, comprehensive care plan for a resident with a stage 4 pressure ulcer. The resident, who was admitted with a pressure ulcer on the left heel and a history of repeated falls, was observed using a special boot on the left lower leg. A document titled 'Skin Only Evaluation' indicated that the resident had a stage 4 pressure ulcer on the left heel, with specific treatment orders including washing with normal saline, applying Medihoney, and covering with Mepilex dressing. However, the care plan initiated for the resident's pressure wound did not include these specific treatments and instead contained generalized interventions that were not resident-specific or measurable. During a review with the Director of Staff Development, it was confirmed that the care plan lacked specific information tailored to the resident's needs. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans with measurable objectives, but this was not reflected in the care plan for the resident. The interventions listed were basic and did not address the specific treatments ordered by the physician, leading to a deficiency in providing adequate care for the resident's pressure ulcer.
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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