The Sequoias
Inspection history, citations, penalties and survey trends for this long-term care facility in Portola Valley, California.
- Location
- 501 Portola Road, Portola Valley, California 94028
- CMS Provider Number
- 055466
- Inspections on file
- 15
- Latest survey
- August 11, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at The Sequoias during CMS and state inspections, most recent first.
Surveyors found that a carton of orange juice, four cartons of apple juice, and a paper cup wrapped in plastic were stored in a refrigerator without expiration dates, use by dates, or labels. The Registered Dietitian confirmed that all refrigerated food should be labeled and dated, in accordance with facility policy and CMS guidance.
A resident transitioning from Medicare Part A to LTC did not receive the required Skilled Nursing Facility Beneficiary Notice of Non-Coverage (SNFABN), despite the issuance of a Notice of Medicare Non-Coverage (NOMNOC) to the family. The Social Worker confirmed the SNFABN was not completed, resulting in the resident not being properly informed of potential financial liability for non-covered services.
A resident with advanced dementia and high fall risk experienced 10 unwitnessed falls, yet the care plan was not reviewed or revised by the interdisciplinary team as required. Despite interventions like floor mats and a private caregiver, the care plan lacked input from the resident's representative and was not updated after repeated incidents, contrary to facility policy.
During a review of controlled medication records, surveyors found that nursing staff signed out narcotics from the CDR for two residents but failed to document administration on the eMAR as required. Interviews with the DON and an LVN confirmed that the facility's process and policy require documentation on both records, but this was not completed for several doses of Oxycodone and Tramadol given as PRN for pain management.
The facility did not ensure proper implementation of its antibiotic stewardship program, as the IP failed to notify physicians when two residents did not meet McGeer criteria for antibiotic use and did not track antibiotic use for another resident. Antibiotics were administered without qualifying symptoms or appropriate monitoring, contrary to facility protocols.
The facility failed to ensure safe food storage by keeping a garlic oil container beyond its use-by date in the refrigerator. During an observation, both the Director of Dining Services and the Executive Chef acknowledged the expired product should have been discarded, as per facility policy and CMS and FDA guidelines, to prevent potential foodborne illnesses.
A facility failed to communicate a physician's recommendation to avoid using a Hoyer lift for a resident with a fracture, leading to a delay in informing direct caregivers. The recommendation was not documented in the endorsement report book until nearly 48 hours later, and a CNA was only informed that the resident was on bedrest. The facility also lacked a policy on shift-to-shift endorsement.
The facility failed to ensure a clean and homelike environment by improperly storing washbasins on bathroom floors and having gaps in window screens. Washbasins used for personal hygiene were found on the floor in four rooms, and window screens in two rooms had gaps, potentially allowing pests inside. The facility's policies did not adequately address these issues.
The facility failed to transmit the MDS for a resident in a timely manner and did not complete and transmit the MDS for another resident, violating contractual agreements with the State and CMS. The MDS Nurse confirmed these issues during an interview and record review. Additionally, the facility lacked a policy for tracking and timely transmission of MDSs, submitting an incomplete document from a CMS manual instead.
A facility failed to accurately code a resident's MDS assessment regarding restraints, as the resident was incorrectly marked as restrained. The MDS Nurse was unsure why the assessments were coded this way and planned to correct and resubmit them. Additionally, the facility lacked a proper policy for accurate MDS coding, providing only pages from a CMS manual without essential policy elements.
A resident in a LTC facility was observed with her leg bent under her wheelchair due to refusing footrests, believing they would tip her chair. An LVN confirmed this behavior was not documented in her care plan, violating the facility's policy requiring comprehensive care plans for all residents.
A facility failed to monitor a resident for adverse side effects or behavioral changes while on Ambien, a hypnotic medication for insomnia. Despite the care plan requiring monitoring every shift, no evidence of such monitoring was found. Interviews with staff confirmed the absence of documentation regarding sleeping patterns or behaviors, contrary to the facility's policy on psychotherapeutic medication management.
A medication labeling discrepancy was identified in an LTC facility when an LVN dispensed Prednisone for a resident. The medication labels did not match the physician's order in the EMR, indicating a different dosage. The LVN acknowledged the discrepancy and noted the absence of a dosage change sticker. The DON and pharmacist confirmed the need for labels to match the EMR and for a change of direction sticker to prevent medication errors.
The facility failed to transmit PBJ data to CMS on time due to the MDS Nurse lacking access to the CMS website, which delayed submission past the deadline. Additionally, the facility's PBJ data transmission policy was incomplete, missing key elements like objectives, responsibilities, and purpose.
Failure to Label and Date Food Items in Refrigerator
Penalty
Summary
Surveyors observed that a carton of orange juice, four cartons of apple juice, and a paper cup wrapped in plastic were stored inside the pantry refrigerator without expiration dates, use by dates, or labels. During an interview conducted at the time of observation, the Registered Dietitian confirmed that all food stored in the refrigerator should be labeled with expiration or use by dates. Review of the facility's policy indicated that all food items must be covered, labeled, and dated, and that foods past their use by, sell by, or best by dates should be discarded. Additionally, CMS guidance requires staff to inspect, properly store, and label all food and beverages upon receipt and during storage. The lack of labeling and dating on these items constituted a failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Failure to Provide Required Beneficiary Notice Upon Change in Medicare Coverage
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident who was discharged from Medicare Part A coverage to long-term custodial care. During a review of records and an interview with the Social Worker, it was found that although a Notice of Medicare Non-Coverage (NOMNOC) was issued and signed by the resident's family member, the required Skilled Nursing Facility Beneficiary Notice of Non-Coverage (SNFABN) was not completed for the resident. The Social Worker acknowledged that the SNFABN was not used and stated awareness that it is required for long-term residents. This omission occurred when the resident transitioned from Medicare-covered services to custodial care, and the facility did not inform the resident of potential financial liability for services not covered under Medicare/Medicaid or the facility's per diem rate, as required by CMS guidance.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident after 10 incidents of unwitnessed falls, despite the resident being identified as high risk for falls. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, pain in the left leg, cognitive communication deficit, and generalized anxiety disorder, had a history of moderate to advanced dementia and required total care. The care plan for falls was initiated, and interventions such as floor mats and a private caregiver during the day were in place. However, the care plan did not reflect input from the resident's representative, and there was no evidence that the plan was updated or revised after repeated falls, as required by facility policy and procedure. Observations and interviews revealed that staff were aware of the resident's frequent falls, particularly at night, and that the resident exhibited anxiety and confusion. The facility's fall risk assessments consistently indicated a high risk, and the resident's cognitive assessment was incomplete, with no BIMS summary score documented. Despite these findings and the facility's policy requiring the interdisciplinary team to update the care plan after falls, the care plan remained unchanged after multiple incidents, and the required comprehensive assessment and team review were not documented.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure that controlled medications were fully accounted for, as evidenced by discrepancies found during a random audit of controlled medication use for two out of four sampled residents. In both cases, nursing staff signed out controlled medications from the Controlled Drugs Records (CDR) but did not document the administration of these medications on the Electronic Medication Administration Record (eMAR). Specifically, for one resident with an order for Oxycodone 5 mg as needed for pain, the CDR indicated that doses were signed out on two occasions, but there was no corresponding documentation on the eMAR or in the nursing progress notes to confirm administration. For another resident with orders for Tramadol 25 mg and 50 mg as needed for pain, the CDR showed that doses were signed out on four occasions, but again, there was no documentation on the eMAR to indicate administration. Interviews with the Director of Nursing (DON) and a Licensed Nurse (LVN1) confirmed that the facility's process requires documentation of controlled medication administration on both the CDR and the eMAR. The DON and LVN1 verified that the required documentation was missing for the identified instances. Review of the facility's policy indicated that the licensed nurse is responsible for charting the date and time of each administered medication, including PRN medications, on the eMAR. The lack of documentation resulted in inaccurate accountability of controlled medications for the affected residents.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the Infection Preventionist (IP) not consistently following established protocols for antibiotic use and monitoring. Specifically, the IP did not communicate or provide notification to the primary medical doctor when residents' symptoms did not meet the McGeer criteria for antibiotic use. For two residents, antibiotics were prescribed and administered despite the absence of qualifying symptoms, and there was no documentation of physician notification or further guidance sought. In one case, a resident received a full course of antibiotics for a urinary tract infection (UTI) without presenting any UTI symptoms, and in another, a resident was given antibiotics for pneumonia despite lacking respiratory symptoms, with only weakness, lethargy, and a change in level of consciousness noted. Additionally, the IP failed to track antibiotic use for one resident who was prescribed Methenamine for UTI prevention, omitting this information from the antibiotic use monitoring spreadsheet. The facility's policy required the IP to review antibiotic utilization and notify providers of findings inconsistent with appropriate use, but this process was not followed. These actions and omissions resulted in antibiotics being prescribed and administered without proper indication or monitoring, as required by the facility's antibiotic stewardship protocols.
Expired Garlic Oil in Kitchen Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary conditions for food storage in the kitchen, as evidenced by the presence of a garlic oil container in the refrigerator that was beyond its use-by date. During an observation and interview with the Director of Dining Services (DoDS) and the Executive Chef (EC), it was confirmed that the garlic oil was expired and should have been discarded. Both the DoDS and EC acknowledged the oversight and agreed that the expired product should have been removed from storage. The facility's policy and procedure on food storage, as well as guidance from the Centers for Medicare and Medicaid Services (CMS) and the U.S. Food and Drug Administration (FDA), emphasize the importance of discarding food past its expiration date to prevent contamination and ensure food safety. The failure to adhere to these guidelines and procedures posed a potential risk for foodborne illnesses among residents, as unsafe food handling practices can expose them to pathogens.
Failure to Communicate Physician's Recommendation
Penalty
Summary
The facility failed to ensure timely communication of a physician's recommendation regarding the care of a resident who had a fracture of unknown origin. The physician assessed the resident and recommended that staff refrain from using a Hoyer lift, as it was likely the cause of the fracture. However, this recommendation was not documented in the endorsement report book until almost 48 hours later, leading to a delay in communication to all direct caregivers. During an interview, a CNA assigned to the resident stated that they were only informed that the resident was on bedrest and were not told about the specific recommendation to avoid using the Hoyer lift. Additionally, the facility was unable to provide a policy regarding shift-to-shift endorsement, and the policy they did provide did not contain any guidance on reading and passing on physician's notes and recommendations to the next shift.
Deficiencies in Environmental Maintenance and Hygiene Practices
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by two specific issues. Firstly, during observations on two separate days, washbasins were found stored on the bathroom floors in four different rooms. These washbasins are used for personal hygiene, including cleaning residents' bodies and private areas. The Staff Development Nurse acknowledged that staff were trained to use these washbasins for such purposes and confirmed that they should not be stored on the floor. The facility's policy on cleaning and disinfecting non-critical resident-care items did not address the proper storage of washbasins. Secondly, window screens in two rooms were observed to have gaps between the window opening and the outer frame, which could potentially allow flying pests into the residents' living spaces. The facility's policy on scheduled maintenance, which includes a checklist for external grounds inspections, indicated that window screens should be checked during weekly inspections. However, the gaps in the window screens suggest that this aspect of the maintenance policy was not adequately followed.
Failure to Transmit and Complete MDS Timely
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) for one resident in a timely manner and did not complete and transmit the MDS for another resident. This failure violated the facility's contractual agreement with the State and the Centers for Medicare & Medicaid Services (CMS). During an interview and record review, the MDS Nurse confirmed that the MDS for one resident was transmitted late and the MDS for another resident was incomplete. Additionally, the facility was unable to provide a policy that governs the tracking and timely transmission of MDSs. The document submitted by the facility was an excerpt from a Resident Assessment Instrument (RAI) manual and lacked essential policy elements such as general information, purpose, policy, and procedure, and did not address the system for tracking MDS due dates and submissions.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to accurately code a resident's Minimum Data Set (MDS) assessment, specifically regarding the use of restraints. This deficiency was identified for one of the twelve sampled residents, referred to as Resident 10. The MDS assessments dated November 14, 2023, and February 14, 2024, incorrectly indicated that Resident 10 was restrained. However, during an observation and interview on May 22, 2024, Resident 10 stated he was never restrained, and there were no signs of restraints in his room or on his wheelchair or bed. The MDS Nurse acknowledged the error and expressed uncertainty about why the assessments were coded as such, indicating a need for correction and resubmission. Additionally, the facility was unable to provide a policy regarding the accurate coding of MDS data. Instead, they submitted pages from a Resident Assessment Instrument (RAI) manual published by CMS, which lacked essential policy elements such as general information, purpose, policy, and procedure. The document also did not address how the MDS nurse should gather and verify data through observation, record reviews, or staff/resident interviews before coding a resident's MDS.
Failure to Develop Individualized Care Plan for Wheelchair Footrest Refusal
Penalty
Summary
The facility failed to develop an individualized care plan for a resident who refused to use footrests on her wheelchair. During an observation, the resident was seen with her left leg bent under the seat of her wheelchair and dragging it as she moved down the hallway. An interview with an LVN revealed that the resident had a history of refusing footrests due to a belief that they would tip her wheelchair. However, this behavior was not documented in the resident's care plan. The facility's policy requires that all residents have a comprehensive care plan that is periodically reviewed and revised, but this was not adhered to in the case of this resident.
Failure to Monitor Adverse Effects of Ambien
Penalty
Summary
The facility failed to ensure proper monitoring for adverse side effects or behavioral changes in a resident receiving Ambien, a hypnotic medication used to treat insomnia. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, generalized muscle weakness, and insomnia, was prescribed Ambien 5mg to be taken at bedtime. However, during interviews and record reviews, it was found that there was no evidence of monitoring for adverse side effects or behaviors associated with the use of Ambien, despite it being part of the resident's care plan. The care plan for the resident indicated that there should be monitoring for adverse side effects of the medication every shift, but this was not implemented. Interviews with the Licensed Vocational Nurse and the Infection Preventionist revealed that there was no documentation of monitoring sleeping patterns, sleeping hours, or any related behaviors since the initiation of the care plan. The facility's policy on psychotherapeutic medication management, which requires consistent monitoring for effectiveness and adverse consequences, was not followed in this case.
Medication Labeling Discrepancy in LTC Facility
Penalty
Summary
The facility failed to ensure that all medications were properly labeled, as observed with a medication cart used for a resident. The issue was identified when a Licensed Vocational Nurse (LVN) was dispensing Prednisone for a resident, and the medication label did not match the physician's order in the electronic medical record (EMR). The LVN was administering a total of 7 mg of Prednisone, which was consistent with the physician's order, but the medication labels indicated a different dosage. The Prednisone 5 mg tablet label incorrectly stated that the resident should receive 6 mg daily, and the 1 mg tablet label also indicated a dosage of 6 mg daily, which did not align with the EMR order. The LVN acknowledged the discrepancy and noted that the medication should have had a sticker indicating a dosage change, which was missing. The Director of Nursing (DON) confirmed that medication labels should match the physician's written order and that a dosage change sticker should be applied if the order changes but the medication is still usable. The pharmacist also stated that a change of direction sticker is necessary to ensure nurses follow the new order in the EMR, highlighting the potential for medication errors if labels and EMR orders are inconsistent.
Failure to Timely Transmit PBJ Data and Incomplete Policy
Penalty
Summary
The facility failed to transmit their Payroll Based Journal (PBJ) data to the Center for Medicare Services (CMS) in a timely manner, which is a requirement to ensure compliance with their contract agreement with the State and CMS. The Minimum Data Set Nurse (MDS Nurse), who was responsible for transmitting the PBJ data, did not have access to the CMS website and had to contact IT at CMS to gain access. This process took 48 hours, resulting in a missed deadline for PBJ data submission. Additionally, the facility provided an incomplete PBJ data transmission policy. The document, titled PBJ Reporting Export & Conversion Process Guide, was undated and lacked key elements of a standard policy, such as clearly stated objectives, outlined responsibilities, and a defined purpose.
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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