Topanga Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Canoga Park, California.
- Location
- 22125 Roscoe Blvd, Canoga Park, California 91304
- CMS Provider Number
- 056092
- Inspections on file
- 38
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Topanga Terrace during CMS and state inspections, most recent first.
The facility failed to provide non-pharmacological interventions before administering opioid pain medication to two residents. Despite care plans and physician orders requiring such interventions, the MAR showed multiple instances where Hydrocodone-acetaminophen was given without prior non-drug methods. The DON confirmed the lack of adherence to the facility's pain assessment policy, resulting in a deficiency.
The facility failed to administer medications as prescribed for two residents, leading to potential health risks. One resident did not receive lorazepam at the prescribed time for anxiety management, and another resident was given metoprolol on dialysis days when it should have been withheld. These errors were confirmed by the nursing staff and were contrary to the facility's medication administration policies.
A facility failed to ensure non-pharmacological interventions were attempted before administering lorazepam to a resident with severe cognitive impairment and respiratory failure. Despite a care plan outlining interventions like repositioning and music therapy, documentation showed lorazepam was given without these attempts. Interviews with staff confirmed the importance of such interventions to avoid unnecessary medication and adverse effects, but the facility's policy lacked guidance on this practice.
The facility failed to develop comprehensive care plans for two residents, one with vision impairment and another using insulin for diabetes management. The first resident's visual impairment was not addressed in a care plan, despite being noted in assessments. The second resident's care plan did not reflect changes after the resident and family requested to discontinue blood sugar checks and insulin. The facility's policy on care planning was not followed, leading to deficiencies in person-centered care.
Two residents with limited English proficiency were not provided with communication boards at their bedsides, hindering their ability to communicate needs to staff. Despite facility policies ensuring access to communication aids, these residents faced challenges in expressing their needs, such as assistance when soiled, due to the absence of these aids.
A resident with visual impairment was not properly communicated to the nursing staff, resulting in a lack of care planning and increased risk of falls. Despite the resident's condition being noted in the Social Services-Admission-Evaluation, it was not shared with the Interdisciplinary Team, leading to a deficiency in care.
A resident with a history of diabetes, traumatic brain injury, and hypertension was administered Metoprolol despite a physician's order to hold the medication if the heart rate was below 60 bpm. On two occasions, the resident's heart rate was below this threshold, yet the medication was given, placing the resident at risk for bradycardia. This action was against the facility's medication administration policy.
A facility failed to follow its policy on storing and discarding leftover food brought by family for a resident. An observation revealed a resident had flan and a partially eaten enchilada on an overbed table, which were not labeled or refrigerated as required. The RN confirmed the food was unsafe and could cause foodborne illness, highlighting a lapse in adhering to food safety procedures.
The facility failed to follow infection control protocols in two cases: an LVN did not wear a gown while administering medication via a gastrostomy tube to a resident on enhanced barrier precautions, and another resident's oxygen tubing was found on the floor. These actions were contrary to the facility's policies, increasing infection risk.
A resident in an LTC facility did not receive the influenza vaccine as required by the facility's policies. The resident was admitted with several diagnoses and was dependent on staff for certain activities. The Infection Preventionist Nurse mistakenly documented the vaccine administration without obtaining informed consent from the resident or their Responsible Party. The Director of Nursing confirmed the oversight, which was contrary to the facility's policy requiring documentation and informed consent during the admission process.
A resident with chronic respiratory failure was not properly offered or documented as having received the COVID-19 vaccine, leading to uncertainty about its administration. The facility's records showed discrepancies, with the IP and DON unable to confirm the vaccine's administration. Additionally, no care plan was initiated to monitor adverse effects post-vaccination, contrary to the facility's policy.
The facility failed to report an injury of unknown source within the required two-hour timeframe to the SSA for a resident with severe cognitive impairment and an acute fracture. The DON stated the injury was considered pathological, but the resident could not describe the incident, and no witnesses were present. The facility's policy mandates immediate reporting, which was not followed.
Failure to Provide Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering as-needed opioid pain medication to two residents, Resident 204 and Resident 26. For Resident 204, the care plan initiated on 10/15/2024, indicated the use of non-pharmacological pain-relieving remedies such as positioning, relaxation therapy, and heat and cold application. However, the Medication Administration Record (MAR) showed that Hydrocodone-acetaminophen was administered multiple times without any documented attempts of non-pharmacological interventions. Licensed Vocational Nurse 1 confirmed that these interventions were not attempted, acknowledging the importance of such measures to prevent unnecessary medication and potential adverse side effects. Resident 26, who had diagnoses including chronic respiratory failure and pain in the leg, also did not receive non-pharmacological interventions prior to the administration of PRN pain medication. The care plan for Resident 26 included similar non-drug interventions, and the physician's orders required documentation of these attempts before administering medication. Despite this, the MAR indicated that Hydrocodone-acetaminophen was administered numerous times in September and October 2024 without prior non-pharmacological interventions. The Director of Nursing confirmed that the licensed staff did not offer any non-drug methods to reduce pain as ordered by the physician. The facility's policy and procedure on pain assessment, last reviewed in January 2024, emphasized the importance of assessing residents for pain and providing adequate management, including non-pharmacological interventions. The policy required documentation of the effectiveness of any interventions, whether medication or non-drug methods. The failure to adhere to these policies and procedures resulted in a deficiency, as the facility did not ensure that non-pharmacological interventions were attempted and documented before administering opioid pain medication to the residents.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to administer medications as prescribed for two residents, leading to potential health risks. For Resident 24, who was admitted with acute and chronic respiratory failure and had severely impaired cognition, the facility did not follow the physician's orders for administering lorazepam. The medication was prescribed to be given at midnight to manage anxiety, but it was administered at various other times without notifying the physician. This deviation from the prescribed schedule was acknowledged by the Licensed Vocational Nurse and the Director of Nursing, who confirmed that the nurses did not follow the physician's orders. For Resident 70, who was admitted with end-stage renal disease and other serious health conditions, the facility failed to hold doses of metoprolol as ordered on dialysis days. The medication was supposed to be withheld at 2:00 p.m. on days when the resident received dialysis, but it was administered on three occasions. This oversight was confirmed by the Licensed Vocational Nurse and the Director of Nursing, who acknowledged that administering metoprolol on dialysis days could lead to low blood pressure. The facility's policies and procedures for medication administration and care of dialysis residents were not adhered to in these cases. The policies clearly stated that medications should be administered according to the prescriber's written orders and that medications on dialysis days should only be held by physician's order. The failure to follow these guidelines resulted in the administration of medications contrary to the physician's orders, potentially compromising the residents' health.
Failure to Attempt Non-Pharmacological Interventions Before Administering Lorazepam
Penalty
Summary
The facility failed to ensure that licensed nurses attempted non-pharmacological interventions before administering as-needed lorazepam to a resident. The resident, who was admitted with acute and chronic respiratory failure and had severely impaired cognition, was dependent on staff for activities of daily living. The care plan for the resident included non-pharmacological interventions such as repositioning, deep breathing exercises, and music therapy to alleviate anxiety. However, the facility did not document attempts of these interventions before administering lorazepam on multiple occasions. During interviews, both the Licensed Vocational Nurse and the Director of Nursing acknowledged the importance of attempting non-pharmacological interventions prior to medication administration to prevent unnecessary use and potential adverse side effects. The facility's policy on psychoactive medications did not include guidance on non-pharmacological interventions, which contributed to the deficiency. This oversight had the potential to place the resident at increased risk of experiencing adverse side effects from lorazepam.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with vision impairment. The resident, admitted with diagnoses including depression and chronic respiratory failure, was found to have intact cognitive skills but was dependent on staff for various daily activities. Despite the resident's visual impairment being noted in the Social Services-Admission-Evaluation, there was no care plan initiated to address this condition. Licensed Vocational Nurse 1 confirmed the resident's inability to see clearly during an assessment, and it was acknowledged that a Change of Condition should have been triggered to assess the resident's needs and risks. The Social Services Director admitted to not discussing the resident's vision issues with the Interdisciplinary Team, resulting in a lack of a care plan to meet the resident's needs. The facility also failed to create an individualized care plan for a resident using insulin for diabetes management. The resident, admitted with type 2 diabetes and other conditions, was receiving insulin injections as per a sliding scale. However, after the resident and a family member requested to discontinue blood sugar checks and insulin administration, the facility did not update the care plan to reflect these changes. The Director of Nursing acknowledged that a care plan should have been developed to include goals and interventions for insulin use and to document the resident's refusal of blood sugar checks and insulin injections. This oversight resulted in a lack of monitoring and necessary services for the resident. The facility's policy on Interdisciplinary Team Guidelines and Care Planning, which emphasizes the inclusion of appropriate team members in the care planning process, was not followed in these cases. The policy requires that care plans include the resident's strengths, goals, life history, and preferences, and that residents and their representatives participate in establishing care goals and outcomes. The failure to adhere to these guidelines led to deficiencies in providing person-centered care for the residents involved.
Failure to Provide Communication Aids for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide communication devices or boards at the bedsides of two residents, Resident 22 and Resident 350, who had limited English proficiency. This deficiency was identified through observations, interviews, and record reviews. Resident 22, who was diagnosed with dementia and dysphagia, was noted to have a preferred language other than English and required an interpreter to communicate with healthcare staff. Despite this, no communication board was available at the resident's bedside, as confirmed by a registered nurse. The resident's care plan indicated a communication problem and the need for a communication board to maintain the current level of communication function. Similarly, Resident 350, who was admitted with type two diabetes mellitus, difficulty in walking, and spinal stenosis, also faced communication barriers due to language differences. The resident's care plan highlighted a communication problem and the need for a translator and communication board. However, during an observation, it was found that no communication board was present at the resident's bedside. The resident expressed difficulty in communicating with staff due to the language barrier, which led to unmet needs, such as being unable to verbalize the need for assistance when soiled. The facility's policy on Limited English Proficiency, last reviewed in January 2024, stated that reasonable steps would be taken to ensure meaningful access for individuals with limited English proficiency, including providing interpreters and communication aids at no cost. Despite this policy, the lack of communication boards for the two residents prevented effective communication with staff, potentially delaying necessary care and treatment.
Failure to Communicate Resident's Visual Impairment
Penalty
Summary
The facility's Interdisciplinary Care Team failed to effectively communicate and collaborate regarding a resident's visual impairment, leading to a deficiency in care. Resident 93, who was admitted with diagnoses including depression and chronic respiratory failure, was found to be visually impaired during an assessment. Despite this, the nursing staff was not informed of the resident's condition, and no care plan was developed to address the resident's visual impairment. This lack of communication and care planning was confirmed through interviews with the nursing staff and the Social Services Director, who acknowledged that the resident's visual impairment was not communicated to the Interdisciplinary Team or included in the care conference. The deficiency was further highlighted by the fact that the resident's visual impairment was noted in the Social Services-Admission-Evaluation but not communicated to the nursing staff, resulting in a lack of awareness and appropriate care planning. The facility's policies on care planning and fall/accident mitigation were not followed, as the resident's risk factors, such as potential falls due to visual impairment, were not addressed. This oversight had the potential to lead to serious injury for the resident due to the inability to see.
Failure to Adhere to Physician's Order for Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the physician's order regarding the administration of Metoprolol. The resident, who was comatose and had a history of type 2 diabetes mellitus, traumatic brain injury, and hypertensive chronic disease, had a physician's order to hold Metoprolol if the heart rate was less than 60 beats per minute. However, on two occasions, the medication was administered despite the resident's heart rate being below the specified threshold. During a review of the Medication Administration Record for October 2024, it was found that the resident's heart rate was 50 bpm in the morning and 59 bpm in the evening on the same day, yet Metoprolol was administered both times. This action was contrary to the physician's order and placed the resident at risk for bradycardia, which could lead to serious health complications. The facility's policy on medication administration, which requires medications to be administered as prescribed, was not followed in this instance.
Failure to Follow Food Safety Procedures for Resident's Outside Food
Penalty
Summary
The facility failed to adhere to its policy regarding the storage and disposal of leftover food brought in by family members for a resident. During an observation and interview, it was noted that a resident had an overbed table with a clear cup containing flan and a container with a partially eaten enchilada, which were brought by the family the previous day. The Certified Nursing Assistant confirmed the presence of these food items, and the Registered Nurse verified that the food belonged to the resident. The facility's policy, last reviewed on January 17, 2024, mandates that prepared food brought in for residents must be consumed within one hour to prevent foodborne illness, with any unused food to be disposed of immediately. However, the food items in question were not labeled with a date or time, making it impossible to determine how long they had been in the resident's room. The Registered Nurse acknowledged that the food was not safe for consumption and could potentially cause foodborne illnesses, indicating a failure to follow the facility's food safety procedures.
Infection Control Lapses in Medication Administration and Oxygen Tubing Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed in two instances. In the first instance, a Licensed Vocational Nurse (LVN 3) did not don a gown before administering medications via a gastrostomy tube to a resident on enhanced barrier precautions (EBP). This resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was readmitted with conditions including chronic respiratory failure and dependence on a ventilator. Despite a sign indicating EBP requirements and the facility's policy mandating gown use for high-contact activities, LVN 3 administered the medication without wearing a gown, acknowledging the oversight during an interview. In the second instance, the facility did not maintain proper infection control regarding a resident's oxygen tubing. The resident, admitted with atrial fibrillation and pneumonitis, was observed with their nasal cannula oxygen tubing on the floor. A Licensed Vocational Nurse (LVN 4) confirmed the observation and stated the need to replace the tubing. The Director of Nursing (DON) later affirmed that oxygen tubing should be kept off the floor to prevent infection, aligning with the facility's standard precautions policy. These deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in adherence to infection control protocols. The facility's policies on enhanced barrier precautions and standard precautions were not followed, increasing the risk of infection for the residents involved.
Failure to Administer and Document Influenza Vaccine
Penalty
Summary
The facility failed to implement its policies and procedures related to the influenza vaccine for one of the sampled residents, identified as Resident 93. The deficiency was identified during an interview and record review, which revealed that Resident 93 was admitted to the facility with diagnoses including encephalopathy, abnormal posture, and depression. The Minimum Data Set (MDS) indicated that Resident 93 had intact cognitive skills for daily decision-making but was dependent on staff for certain activities. Despite this, the resident was not in the facility during the influenza vaccination season, and there was no documentation of the influenza vaccine being administered to Resident 93 on the Medication Administration Record (MAR) for the specified date. The Infection Preventionist Nurse (IP) acknowledged that there was no informed consent obtained from Resident 93 or her Responsible Party (RP) regarding the administration of the influenza vaccine. The IP admitted to mistakenly documenting that the vaccine was administered. The Director of Nursing (DON) confirmed that licensed staff are required to offer the influenza vaccination to all residents upon admission, but Resident 93 did not receive it. The facility's policy indicated that residents or their responsible parties should be informed about the vaccinations during the admission process, and documentation should be promptly recorded in the MAR, which was not adhered to in this case.
Failure to Administer and Document COVID-19 Vaccine
Penalty
Summary
The facility failed to offer the COVID-19 vaccination to a resident, identified as Resident 43, which placed the resident at a higher risk of acquiring and transmitting the virus. Resident 43 had been admitted to the facility with chronic respiratory failure and was dependent on a respirator. The resident's cognitive skills were intact, and they were dependent on staff for daily activities. The facility's records indicated that a verbal consent for the COVID-19 vaccine was obtained from the resident's family member, and the vaccine was reportedly administered on a specific date. However, discrepancies were found in the documentation regarding the administration of the vaccine. The Immunization Record suggested that the Infection Preventionist Nurse (IP) administered the vaccine, but the Medication Administration Record (MAR) did not reflect this, and the progress notes indicated that another nurse administered the vaccine. Both the IP and the Director of Nursing (DON) were unable to confirm who administered the vaccine or if it was administered at all. The responsible party for Resident 43 also expressed uncertainty about whether the vaccine was given. Additionally, the facility failed to initiate a care plan to monitor potential adverse effects following the administration of the COVID-19 vaccine to Resident 43. The IP acknowledged that normally a care plan would be developed post-vaccine administration, but this was not done for Resident 43. The facility's policy required efforts to vaccinate unvaccinated residents within a week of admission, but it appears this was not effectively implemented for Resident 43.
Failure to Report Injury of Unknown Source Within Required Timeframe
Penalty
Summary
The facility failed to implement its policy and procedures for reporting a reasonable suspicion of a crime in accordance with Section 1150B of the Act. Specifically, the facility did not report an injury of unknown source within two hours to the State Survey Agency (SSA) for a resident who was observed with left hand swelling, purplish discoloration, and pain. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was found to have an acute fracture of the 4th metacarpal. Despite the injury being identified on 4/10/2024, the facility did not report it to the SSA until 4/16/2024, well beyond the required two-hour window. The Director of Nursing (DON) stated that the facility did not report the injury within the required timeframe because they determined it was a pathological fracture rather than a result of abuse or mistreatment. However, the resident was unable to describe what happened, and no staff or other residents witnessed the incident. The facility's policy mandates immediate reporting of any injury of unknown source to local law enforcement and the SSA within two hours, which was not followed in this case.
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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