The Reutlinger Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, California.
- Location
- 4000 Camino Tassajara, Danville, California 94506
- CMS Provider Number
- 055534
- Inspections on file
- 15
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Reutlinger Community during CMS and state inspections, most recent first.
A resident with severely impaired cognition and total-assist feeding needs experienced emotional distress when a family representative repeatedly yelled at the resident during a meal, expressing frustration about the resident’s inability to self-feed and then leaving the room angrily. Documentation of an acute change in mental status noted the emotional distress and verbal abuse but indicated that the care plan was not reviewed. The DON reported that no care plan was initiated after the incident because the abuse did not involve staff or another resident, despite facility policy requiring the IDT to develop and revise comprehensive care plans based on identified problems and changes in condition. A psychosocial care plan was only initiated later and addressed psychosocial issues in general terms, without specifically addressing the incident of verbal abuse and the resident’s psychosocial needs related to that event.
A resident who required continuous IV antibiotic therapy following recent spinal surgery was admitted after the DON assured the Admissions Coordinator that the facility could meet the care needs. However, no RN was scheduled for the night shift, leaving only an LVN on duty, who was not permitted to administer IV antibiotics. This resulted in the resident experiencing discomfort and an unplanned discharge back to the hospital after three days, contrary to the facility's assessment tool and admission policy.
The facility failed to complete and maintain competency records for all 17 Licensed Nurses, including LVNs and RNs, as required by their policy. Only wound care competencies were documented, leaving other areas unchecked. The DSD and DON confirmed the absence of comprehensive competency assessments, which are crucial for ensuring safe and competent care for residents.
The facility failed to act on the Consultant Pharmacist's monthly Drug Regimen Reviews for two residents, leading to unaddressed medication safety issues. One resident received Doxycycline without a stop date, and another was given Protonix without a "Do Not Crush" note, contrary to recommendations. The DON did not receive or follow up on the DRR documents from June to October 2024.
A resident's Lantus insulin was found in the medication cart beyond the 28-day usage period, making it expired. The insulin, which was also discontinued, was not destroyed as per facility policy. The resident had multiple diagnoses, including diabetes, and the expired medication posed a risk due to potential reduced effectiveness.
A resident experienced frustration and discomfort due to ill-fitting dentures that were not addressed by the facility for over a month. Despite being at high risk for nutrition and hydration issues, the resident's dental needs were not properly assessed or followed up on by staff, leading to ongoing discomfort and potential health risks.
Two residents on mechanical soft diets received incorrect meal textures, risking choking. A resident received a whole piece of meat instead of ground meat, and another received regular snap peas instead of finely chopped vegetables. Staff failed to check meal trays for accuracy before serving, contrary to facility policy.
The facility failed to maintain sanitary conditions in food storage and preparation. Plant-based patties in the freezer were defrosted and past their use-by date, and a can opener had brownish matter. Additionally, the ice machine used for residents had black matter, potentially contaminating the ice. The Director of Dietary Services acknowledged these issues, which violated the facility's policies and FDA guidelines.
A resident with severe cognitive impairment and nutritional risks was not promptly assisted during a meal, despite facility policies requiring such assistance. Staff interviews revealed a lack of awareness of the resident's needs, leading to a delay in providing necessary help, which could have impacted the resident's nutrition and dignity.
A resident with essential hypertension experienced an eight-hour delay in the completion of a stat blood draw ordered by a physician. The order was placed for a complete blood count, basic metabolic panel, urinalysis, and culture & sensitivity. Despite contacting the lab, no technician was available, and the order was canceled as the resident was taken to the hospital. Interviews revealed that stat labs should be completed within four to six hours, but the facility failed to ensure this timely completion.
A resident was transferred to a hospital with incorrect medical records, as the Unit Manager failed to verify the transfer packet contents. The resident, admitted with a UTI and atrial fibrillation, was lethargic and had low blood pressure when transferred for Covid evaluation. The facility's policy requires accurate information for continuity of care, which was not followed.
A facility failed to notify a resident's family member of a COVID-19 outbreak due to missing email contact information. The resident, with a history of UTI and atrial fibrillation, tested positive for COVID-19 and was hospitalized. Notifications were sent via email, but the family member was not informed as their email was not on file.
Failure to Care Plan Psychosocial Needs After Verbal Abuse by Family Representative
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan to assess and maintain the psychosocial well-being of a resident following an incident of verbal abuse by the resident’s family representative. The resident had a severely impaired cognitive status, with a BIMS score of 3/15, and required total assistance with food and fluid intake, with encouragement to self-feed with the left hand. The resident’s physician orders included a pureed diet with mildly thick liquids and 1:1 feeding. On the date of the incident, an acute change in mental status event record documented that the resident was seen tearing up around 6 p.m. while the family representative repeatedly yelled at the resident, expressing frustration that the resident could not feed herself, insisting she use her arms, and stating he was tired of helping her, before storming out of the room visibly angered. The acute change in mental status documentation indicated that the care plan was not reviewed. The DON stated that no care plan was initiated after the verbal abuse was observed because the abuse was not committed by staff or another resident, and acknowledged that there should have been a care plan initiated after the incident to serve as a blueprint for the resident’s care. Although the facility’s policy on the Interdisciplinary Team/Care Plan Process requires that an IDT develop and maintain a comprehensive care plan incorporating identified problem areas, risk factors, and changes in medical condition, the resident’s care plan addressing psychosocial well-being did not start until a later date and only generally stated that the resident had potential for psychosocial issues due to living in the facility. The record review and interviews showed that, despite documented emotional distress and verbal abuse, the facility did not review or revise the care plan at the time of the incident to address the resident’s psychosocial needs related to the event.
Failure to Ensure RN Staffing for Resident Requiring Continuous IV Antibiotic Therapy
Penalty
Summary
The facility failed to follow its Facility Assessment Tool and did not ensure the necessary resources were available to care for a resident requiring continuous intravenous antibiotic therapy (IV ATB) prior to admission. The Admissions Coordinator, after consulting with the Director of Nursing (DON), accepted the resident for admission based on the DON's assurance that the facility could manage the resident's need for continuous IV ATB therapy. However, the facility did not have a Registered Nurse (RN) scheduled to cover the night shift, which was required for the administration and monitoring of IV ATB therapy, as Licensed Vocational Nurses (LVNs) were not permitted to perform this task according to facility policy and scope of practice. The resident, who had recently undergone a third elective spinal surgery with hardware revision and was ordered to receive 12 grams of Ampicillin Sodium Injection intravenously every shift, was admitted to the facility. Despite the resident's complex care needs, the facility's staffing records showed that no RN was present during the night shift, and the DON had approved the staffing schedule. The LVN on duty expressed discomfort with the situation and ultimately requested the resident's physician to transfer the resident back to the hospital due to the inability to provide the required IV therapy. The resident experienced discomfort and frustration as a result of the facility's inability to provide the necessary care, leading to an unplanned and avoidable discharge back to the hospital after only three days. The family was initially assured that the facility could meet the resident's care needs, but was later informed otherwise, causing additional distress. The facility's own policies and assessment tool required that only residents who could be adequately cared for should be admitted, and that an RN should be available each shift to assist with IV therapy, but these requirements were not met in this case.
Failure to Maintain Competency Records for Licensed Nurses
Penalty
Summary
The facility failed to complete annual performance reviews and maintain competency/skills records for all 17 sampled Licensed Nurses (LNs), which included nine Licensed Vocational Nurses (LVNs) and eight Registered Nurses (RNs). During an interview and record review with the Director of Staff Development (DSD), it was revealed that the facility only had competency checks completed for skin and wound care, dated 7/11/24. The DSD was unable to locate any other competency checks for the LNs, despite searching the facility's storage and her office. The facility's policy required competency checks to be conducted upon hiring, after 90 days, and annually, to ensure LNs possess the necessary skills and knowledge to provide competent care. The Director of Nursing (DON) confirmed that no competency/skills assessments had been completed for any LNs in the past year. The facility's policy, titled 'Competency of Nursing Staff,' emphasized the importance of ensuring all nursing staff possess the competencies and skill sets necessary to meet resident needs safely and promote their well-being. The lack of completed competency checks placed residents at risk of receiving care from potentially incompetent LNs, as acknowledged by the DSD.
Failure to Implement Consultant Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that Drug Regimen Reviews (DRR) by the Consultant Pharmacist (CP) were acted upon on a monthly basis for two residents. The DRR binder did not include the CP's monthly recommendations for several months, from June through October 2024. The Director of Nursing (DON) stated she did not receive these documents from the CP, although the CP claimed they were emailed to both the DON and the Administrator. The CP noted that some recommendations were not addressed, requiring repeated reminders. For Resident 4, the DRR for August and September 2024 indicated that the resident was receiving Doxycycline for a chronic right arm infection without a specified stop date, which is necessary under the Antibiotic Stewardship program guidelines. The order summary for Resident 4 showed an active status for the medication without an end date, which could lead to continuous administration and potential side effects. The DON acknowledged the importance of reviewing the DRR monthly to ensure correct medication indications and special instructions. For Resident 34, the DRR for the same months highlighted that the resident was receiving Protonix, a long-acting medication that should not be crushed due to its protective enteric coating. However, the order summary did not include a "Do Not Crush" note as recommended by the CP. The DON admitted to an oversight in not following up with the CP when the DRR documents were not received, which led to the failure to implement the CP's recommendations and ensure medication safety for the residents.
Improper Storage of Medications for a Resident
Penalty
Summary
The facility failed to properly store medications for one resident, identified as Resident 18, which had the potential to lead to the administration of expired, less effective, and discontinued medication. During an observation and interview, it was found that the medication cart contained Resident 18's Lantus insulin, which was opened beyond the 28-day period recommended for use, rendering it expired. The Registered Nurse acknowledged that the insulin was expired and should have been destroyed. Resident 18 was admitted to the facility with multiple diagnoses, including pneumonitis and Type 2 diabetes mellitus with diabetic chronic kidney disease. The facility's policy required the destruction of insulin 28 days after opening, and the Assistant Director of Nursing confirmed that expired insulin posed a risk to the resident due to its potential reduced effectiveness. Additionally, a review of Resident 18's doctor's orders revealed that the Lantus insulin had been discontinued, yet it remained in the medication cart, contrary to the facility's policy of not using discontinued or outdated drugs.
Failure to Address Ill-Fitting Dentures
Penalty
Summary
The facility failed to address the issue of ill-fitting dentures for Resident 34, who had been without properly fitting dentures for over a month. Despite being aware of the problem, the facility did not take timely action to resolve it. Resident 34, who was edentulous and on a mechanical soft diet, expressed frustration and discomfort due to the lack of properly fitting dentures. The resident's Minimum Data Set (MDS) assessment indicated a high risk for nutrition and hydration issues related to the ill-fitting dentures, yet the MDS Coordinator did not physically assess the resident's oral cavity or ensure the dentures were fitted correctly. Interviews with staff revealed a lack of communication and follow-up regarding the resident's dental needs. The Social Services Director acknowledged contacting the dentist about the issue but found no documentation of follow-up actions until over a month later. The Director of Nursing stated that staff should address denture-related issues within 72 hours, but this was not done. The facility's policy required timely referrals for dental services, which were not adhered to in this case, leading to the resident's ongoing discomfort and risk for further health issues.
Failure to Follow Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure that therapeutic diets ordered by the physician were followed for two residents during dining observations. Resident 35, who was on a mechanical soft diet with ground meats, received a piece of meat that was not in bite size as indicated on the meal ticket. The Certified Nurse Assistant (CNA) serving the meal acknowledged that the meat was not prepared according to the diet order and removed the tray for replacement. The Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed that the meal tray was not checked for accuracy before being served, which placed Resident 35 at risk for choking. Resident 7, who was also on a mechanical soft diet, received regular texture snap peas instead of finely chopped vegetables as required by the diet order. The CNA feeding Resident 7 was unaware of the need for finely chopped vegetables, despite the meal ticket indicating this requirement. The Director of Dietary Services (DDS) admitted that the meal tickets should have been checked accurately before the trays were placed in the meal delivery cart, and the nursing staff should have verified the meal tickets before serving. The facility's policy and procedure for therapeutic diets and texture alterations require that nursing personnel ensure residents are served the correct diet by checking the diet card before serving. The policy also states that any errors should be reported to the dietary supervisor for correction. However, in these instances, the policies were not followed, leading to the potential risk of choking or aspiration for the residents involved.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during a survey. The kitchen freezer contained a bag of plant-based patties that were soft to touch and had a label indicating they were defrosting with a use-by date that had already passed. The Director of Dietary Services (DDS) confirmed that the patties were completely defrosted, which was against the facility's policy that required frozen foods to be held solidly frozen. Additionally, a tabletop can opener was found with an accumulation of brownish matter, which the DDS acknowledged should have been kept clean. Furthermore, the ice machine used to provide ice for residents had black matter on the ice sweep part, which could potentially contaminate the ice. The DDS admitted that the ice machine should not have had black matter inside, as it could have made the residents sick. The facility's policy and procedure for food and supply storage emphasized the importance of preventing contamination and maintaining the safety and wholesomeness of food for human consumption. The Food and Drug Administration (FDA) Federal Food Code also requires that equipment and utensils be clean to sight and touch.
Failure to Assist Resident During Meal
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 7, was treated with respect and dignity by not providing prompt assistance during a meal. Resident 7, who was admitted in October 2024 with diagnoses including sepsis and metabolic encephalopathy, had a severely impaired mental status as indicated by a BIMS score of 3 out of 15. The resident's care plan noted a risk for nutrition and hydration issues due to chewing and swallowing difficulties, requiring occasional to frequent assistance with feeding. On the day of the incident, Resident 7 was observed sitting with a meal tray but not eating, and it was noted that no staff were assisting her, despite her need for supervision or touching assistance during meals. Interviews with staff revealed that there was a lack of awareness regarding Resident 7's need for assistance. CNA 1, who eventually assisted the resident, was unaware of her requirements, while CNA 6 and the ADON confirmed that Resident 7 needed cueing and prompting to eat. The facility's policy on supervision of resident nutrition emphasized the need for prompt assistance for residents requiring help with eating, which was not adhered to in this case. The Director of Nursing acknowledged that the CNAs should have engaged with Resident 7 to encourage her to eat, as per the facility's policies on necessary care and services for activities of daily living.
Delay in Stat Lab Draw for Resident
Penalty
Summary
The facility failed to ensure the timely completion of a physician's order for a stat blood draw for a resident, resulting in an eight-hour delay. The resident, who was admitted in November 2022 with a diagnosis of essential hypertension, had a physician's order placed on November 16, 2022, at 3:00 p.m. for a stat blood draw to conduct a complete blood count, basic metabolic panel, urinalysis, and culture & sensitivity. However, the laboratory was contacted at 4:18 p.m., and by 11:45 p.m., it was noted that no lab technician was available to perform the draw. The order was eventually canceled at 12:44 a.m. on November 17, 2022, as the resident was taken to the hospital. Interviews with the Director of Nursing and a Licensed Vocational Nurse revealed that stat labs are expected to be completed within four to six hours, and if not done within three hours, the lab should be contacted again to expedite the process. The facility's policy and procedure for diagnostic services, dated May 24, 2013, states that all diagnostic service requests must be ordered by a physician and completed timely. Despite these guidelines, the facility did not ensure the timely completion of the stat lab order, potentially impacting the resident's treatment and well-being.
Failure to Provide Accurate Transfer Records
Penalty
Summary
The facility failed to provide accurate patient records during the transfer of a resident to a hospital. The resident, who was admitted in August 2024 with diagnoses of a urinary tract infection and unspecified atrial fibrillation, was transported to the hospital for further evaluation after testing positive for Covid. At the time of transfer, the resident was lethargic, had poor oral intake, and low blood pressure. However, the transfer packet accompanying the resident contained incorrect information, which was not verified by the Unit Manager before the transfer. The Unit Manager admitted to not checking the contents of the envelope containing the transfer documents, which included an incorrect face sheet. This oversight was discovered when the hospital notified the facility about the incorrect transfer packet. The facility's policy and procedure for transfers, dated October 1999, requires that all pertinent medical and other information be provided to the receiving community to ensure continuity of care. The failure to adhere to this policy resulted in the resident not having the correct records at the hospital, potentially delaying identification and treatment.
Failure to Notify Family of COVID-19 Outbreak
Penalty
Summary
The facility failed to notify a resident's emergency contact family member of a COVID-19 outbreak, resulting in a deficiency. The resident, admitted in August 2024 with a urinary tract infection and unspecified atrial fibrillation, tested positive for COVID-19 and was subsequently hospitalized. During interviews, the Infection Preventionist stated that family notifications were made via mass email, and the Administrator confirmed that the facility used face sheets to obtain email contact information. However, the resident's family member was not notified due to the absence of an email address on file, as the Administrator assumed all family members had email addresses.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
