University Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 5602 University Ave, San Diego, California 92105
- CMS Provider Number
- 055328
- Inspections on file
- 37
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at University Care Center during CMS and state inspections, most recent first.
A resident with hypothyroidism and acid reflux did not receive morning medications on time due to multiple LNs splitting the tasks of preparing, administering, and documenting the medications, with one LN signing the MAR before the medications were actually given. This practice was not in accordance with facility policy, which requires the same licensed individual to prepare, administer, and document medication administration, creating the potential for medication errors.
A cook was observed placing a used mixing spoon with clean utensils during the preparation of pureed meals for multiple residents. Both the registered dietician and DON confirmed that this practice was inappropriate and contrary to facility policy, which requires measures to prevent cross-contamination during food preparation.
Three residents with complex medical conditions had incomplete POLST forms, missing key information such as effective dates and the relationship of the signer to the resident. This incomplete documentation was confirmed by a nurse and could lead to confusion among care providers.
Surveyors identified infection control lapses, including clean linens stored in contact with outside packages, trash cans and debris in clean linen closets, and a nurse administering medications to a resident with a gastrostomy tube under Enhanced Barrier Precautions without wearing a required gown. Facility staff acknowledged these practices did not meet infection control standards.
Two residents did not receive care in accordance with professional standards: one with a PICC line did not have required catheter length measurements performed or documented during dressing changes, and another with a gastrostomy tube had medications administered without verification of tube placement. Nursing staff and the DON confirmed these omissions, which were contrary to facility policy and physician orders.
A resident with severe cognitive impairment, total dependence for ADLs, and high risk for pressure ulcers was not consistently turned and repositioned every two hours as required by their care plan and facility policy. Multiple observations and staff interviews confirmed the lack of regular repositioning, despite the resident's significant risk factors for skin breakdown.
A resident with dysphagia and aphasia who was receiving enteral nutrition via a gastrostomy tube had their tube feeding formula administered without a required label. Observation and interviews with a per diem nurse and the DON confirmed the formula was not labeled, contrary to facility policy, which mandates labeling for safety and accuracy.
Nine rooms housing three residents each did not meet the required minimum of 80 sq ft per resident, with each room measuring between 206 and 211 sq ft. No residents expressed concerns, and no negative impacts on quality of care or quality of life were observed.
A resident with hypothyroidism did not receive Levothyroxine as per the prescribed schedule, with doses administered later than the ordered 6 AM time. The facility's care plan policy, which requires timely and person-centered interventions, was not followed, as confirmed by the LN and DON.
A resident with hypothyroidism did not receive Levothyroxine at the prescribed time of 6 AM, as documented in the MAR. The medication was administered later than ordered on multiple occasions, potentially affecting its absorption and effectiveness. The LN was unaware of the specific reasons for the timing, and the DON emphasized the importance of timely administration. The facility's policy supports timely medication administration to enhance therapeutic effects.
A facility failed to ensure that agency staff had the necessary competency to document care, resulting in a CNA not documenting care for a resident who died, and an LN administering medications late. The resident had multiple diagnoses, including congestive heart failure and diabetes. The facility did not review the agency's skills checklists, and there was no documentation of a change in condition or physician notification regarding abnormal lab results.
A resident with multiple health issues, including open sores, was found in a room with old food and numerous insects, posing infection risks. The resident had not received regular showers or clean clothing, contrary to facility policy. Staff interviews revealed a lack of awareness about the risks, and pest control issues were noted.
The facility failed to document proactive maintenance checks for room temperatures during extreme temperature changes. An unannounced visit revealed malfunctioning air conditioning in the east hallway, with residents reporting discomfort. The Director of Maintenance admitted to not documenting temperature checks for over a year, and the Administrator was unaware of the lack of temperature monitoring during the outage.
A resident with hemiplegia had a stage 1 pressure injury that was not documented weekly as required by the facility's policy. The Treatment Nurse confirmed the oversight, and the DON acknowledged the lapse in following the protocol for weekly monitoring and documentation of pressure injuries.
Failure to Follow Medication Administration Policy
Penalty
Summary
Licensed Nurses (LNs) at the facility failed to follow established policy and procedure regarding medication administration for a resident diagnosed with hypothyroidism and acid reflux. The resident, who was alert and oriented and had decision-making capacity, reported not receiving his morning medications on time. Upon inquiry, it was discovered that one LN had prepared the medications, another LN administered them, and a third LN had already signed the Medication Administration Record (MAR) as if the medications had been given, even though the resident had not yet received them. This process was confirmed through interviews with the involved LNs and review of the resident's clinical record. The facility's policy requires that the same licensed individual who prepares the medication must administer it and document the administration in the MAR. The Director of Nursing and Administrator confirmed that this expectation was not met in this instance, as the tasks were divided among three different LNs, contrary to policy. This deviation from professional standards of practice created the potential for medication errors, as the MAR did not accurately reflect the actual administration of medications.
Failure to Separate Clean and Used Utensils During Meal Preparation
Penalty
Summary
During the preparation of pureed meals for nine residents, a cook (CK) was observed placing used utensils, specifically a large mixing spoon that had been used to mix tortillas and turkey meat in a blender, into a tray containing clean mixing spoons and colored scoops. This action occurred in the presence of the registered dietician (RD) and was directly observed by surveyors. The CK acknowledged during an interview that it was important not to mix used and clean utensils to prevent possible contamination, and admitted to being nervous as it was her first time being observed during a survey. The RD confirmed witnessing the incident and stated that mixing clean and used utensils was not appropriate due to the risk of contamination. The Director of Nursing (DON) also stated in an interview that separating clean and used utensils is important to prevent cross-contamination and protect residents' health. A review of the facility's policy on food preparation and service indicated that appropriate measures must be used to prevent cross-contamination, which was not followed in this instance.
Incomplete POLST Documentation for Multiple Residents
Penalty
Summary
The facility failed to maintain complete Physician Orders for Life Sustaining Treatment (POLST) forms for three residents. During a review, it was found that the POLST forms for these residents were incomplete, lacking necessary information such as the date the form became effective and the relationship of the person signing the form to the resident. These omissions were confirmed during interviews with a licensed nurse, who acknowledged that the forms should have been fully completed to accurately reflect the residents' wishes regarding life-sustaining treatment. The residents involved had significant medical conditions, including dementia, muscle weakness, adult failure to thrive, hemiplegia, hemiparesis following a stroke, bacteremia, diabetes type 2, endocarditis, autistic disorder, and cognitive communication deficits. The incomplete documentation did not provide an accurate representation of the care provided and had the potential to cause confusion among care providers, as noted in the findings.
Infection Control Lapses in Linen Handling and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed multiple infection control deficiencies within the facility. Clean linens were found stored in direct contact with packages transported from an outside laundry service, with the Director of Environmental Services (DES) and Infection Preventionist Nurse (IP) confirming that packaging should be removed before linens are placed in closets. Additionally, trash cans, including one containing used gloves, were present inside clean linen closets, which both the DES and IP acknowledged should not occur. The clean linen closets also had visible dust and debris on the floor, contrary to facility policy and staff statements that these areas should be kept clean and free from trash and dust. A licensed nurse was observed administering medications to a resident with a gastrostomy tube (GT) who was under Enhanced Barrier Precautions (EBP) without wearing the required isolation gown. The nurse performed hand hygiene and wore a face mask but did not don a gown, later stating she was unaware of the requirement. EBP signage posted outside the resident's room clearly indicated that gown and gloves were required for high-contact activities such as device care, including feeding tubes. The Director of Nursing (DON) confirmed that all staff are expected to adhere to infection control procedures.
Failure to Follow Professional Standards for PICC and GT Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For one resident with a peripherally inserted central catheter (PICC line), physician orders and facility policy required that the external catheter length be measured with each dressing change and documented. However, review of the Medication Administration Record (MAR) and interviews with nursing staff and the Director of Nursing (DON) confirmed that these measurements were not performed or documented during April. The DON acknowledged that measuring and documenting the PICC line length was a standard of practice and should have been completed as ordered. In a separate incident, a resident with a gastrostomy tube (GT) did not have tube placement checked prior to medication administration. Observation of a licensed nurse administering medications revealed that the nurse flushed the GT and administered medications without verifying tube placement, as required by facility policy. The nurse admitted to not checking placement, and the DON confirmed that verifying GT placement before administering medications was necessary to prevent complications.
Failure to Consistently Reposition Resident at Risk for Pressure Ulcers
Penalty
Summary
A deficiency was identified when a resident, admitted with acute respiratory failure with hypoxia and dysphagia, was not consistently turned and repositioned every two hours as required by their care plan and facility policy. Multiple observations over two days showed the resident lying on their back for extended periods, with only minor adjustments such as a pillow under the left arm, and no evidence of repositioning. A family member also reported not seeing the resident turned or repositioned during their visit. Interviews with nursing staff confirmed the importance of regular turning and repositioning to prevent skin breakdown, especially given the resident's severe cognitive impairment, total dependence on activities of daily living, and high risk for pressure ulcers as indicated by their Braden score and care plan. Record reviews further confirmed that the resident was dependent for all ADLs, had a severely impaired mental status, and was at risk for skin breakdown due to immobility and contractures. Despite these risk factors and clear care plan interventions, the required two-hourly turning and repositioning was not consistently implemented. The facility's own policy also emphasized individualized repositioning schedules for residents at risk of pressure injuries, which was not followed in this case.
Failure to Label Tube Feeding Formula for Resident Receiving Enteral Nutrition
Penalty
Summary
A resident with diagnoses of dysphagia and aphasia was admitted to the facility and required a gastrostomy feeding tube. During an observation, it was noted that the resident's tube feeding formula, Fiber source HN, was being administered at a specified rate but was not labeled as required. The lack of labeling was confirmed during interviews with a per diem licensed nurse and the Director of Nursing, both of whom acknowledged the importance of labeling for safety, accuracy, and adherence to physician orders. A review of the facility's policy on enteral feedings indicated that the formula label should include the resident's name, ID, room number, type of formula, date and time prepared, and initials of the person who hung the formula. The policy also requires verification of the label against the order before administration. The failure to label the tube feeding formula was identified through observation, interview, and record review, and was found to be inconsistent with facility policy and standard safety practices.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in nine out of 39 resident rooms, as determined through review of the Client Accommodations Analysis form. Specifically, rooms 31, 33, 35, 36, 37, 38, 39, 40, and 41 each housed three residents but did not meet the square footage requirement, with each room measuring slightly above 206 to 211 square feet, resulting in less than 80 square feet per resident. Observations and a confidential resident group interview were conducted, and no residents expressed concerns about their rooms. Additionally, no quality of care or quality of life concerns were observed during the survey period for residents in these rooms.
Failure to Implement Care Plan for Medication Administration
Penalty
Summary
The facility failed to implement a care plan related to medication administration for a resident diagnosed with hypothyroidism. The resident was admitted with a physician's order to receive Levothyroxine at 6 AM, which should be administered on an empty stomach or before breakfast. However, a review of the medication administration record (MAR) revealed that the medication was administered at various times between 8:24 AM and 8:37 AM on multiple occasions, deviating from the prescribed schedule. During interviews, the Licensed Nurse (LN) confirmed that the medication was ordered to be given at 6 AM, and the Director of Nursing (DON) acknowledged that the medication should be administered within one hour before or after the scheduled time. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans with measurable objectives and timetables, which were not adhered to in this case, leading to the deficiency.
Failure to Administer Levothyroxine on Time
Penalty
Summary
The Licensed Nurses (LNs) at the facility failed to administer Levothyroxine to Resident 1 within the time frame ordered by the physician. Resident 1, who was admitted with a diagnosis of hypothyroidism, had a physician's order for Levothyroxine to be administered at 6 AM. However, the Medication Administration Record (MAR) showed that the medication was consistently given later than ordered, with times recorded at 8:24 AM, 8:31 AM, 8:37 AM, and 8:29 AM on various dates. This deviation from the prescribed schedule had the potential to affect the absorption and effectiveness of the medication. During interviews, LN 1 acknowledged the medication should be administered on an empty stomach or before breakfast, as per the physician's order, but was unaware of the specific reasons for this requirement. The Director of Nursing (DON) confirmed that medications should be administered on time, emphasizing the importance of adhering to the prescribed schedule due to potential medical reasons. The facility's policy on administering medications, revised in April 2019, also highlighted the need for timely administration to enhance therapeutic effects and prevent interactions. Despite these guidelines, the failure to administer Levothyroxine as ordered was identified as a deficiency during the survey.
Deficiency in Staff Competency and Documentation
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN) provided by an agency had the necessary competency to document care during their shift. As a result, the CNA did not document any care provided for a resident who was sampled for death, and the LN documented medications were given late. Additionally, there was no documentation of a change in condition or physician notification regarding abnormal laboratory results. Furthermore, no follow-up social services notes were documented for the resident's roommate who was present at the time of the resident's death. The facility was unable to provide requested evidence of the events prior to the resident's death. The resident involved had multiple diagnoses, including congestive heart failure, diabetes mellitus type two with chronic kidney disease stage three, acute respiratory failure with hypoxia, and pulmonary hypertension. The Director of Nursing (DON) acknowledged that the agency staff did not participate in facility training and that the facility did not review the agency's skills checklists before allowing them to work. The DON also noted that the insulin administration was documented late, and there was no documentation to clarify if two doses of Lispro were given within one hour of each other. The facility's policy indicated that medications should be administered within one hour of their prescribed time, but this was not adhered to in this case.
Inadequate Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by the conditions observed in the room of a resident with multiple health issues, including severe protein-calorie malnutrition and open sores. During an unannounced visit, it was noted that the resident's room contained an accumulation of old food and beverage items, which attracted numerous small flying insects. These insects were observed landing on the resident's skin, food, and beverages, posing a risk of foodborne illness and infection to the resident's open wounds. The resident was also found wearing soiled clothing, with disheveled hair, and the surrounding area was notably dirty. Interviews with staff, including a CNA and the Infection Preventionist, revealed a lack of awareness and understanding of the risks associated with the presence of insects and old food in the resident's environment. Further investigation revealed that the resident had not received regular showers or bed baths, as required by the facility's policy, which mandates bathing twice per week. The resident's shower log indicated only one shower was provided over a period of several weeks, and nail care was not performed weekly as required. The Director of Nursing acknowledged the failure to provide adequate hygiene care, which is essential to prevent bacterial growth and potential infection. Additionally, the facility's pest control report indicated ongoing issues with fruit fly activity, which had not been adequately addressed. The facility's policies on infection prevention and control, as well as bathing procedures, were not effectively implemented, contributing to the observed deficiencies.
Failure to Document Temperature Checks During HVAC Malfunction
Penalty
Summary
The facility failed to provide documented evidence of proactive maintenance checks for room and facility temperatures during extreme temperature changes. An unannounced visit was conducted following a complaint about the air conditioner malfunctioning in the east hallway. Observations revealed that resident rooms in the east hallway had one or more fans, and a small air conditioner unit was present in one room. Ceiling fans were operational along the hallway. Resident 3 reported that her room had been hot for several days due to the broken air conditioner, and she was informed that a part was needed for repairs. The Director of Maintenance (DM) acknowledged that the air conditioner in the east hallway stopped working on a Sunday night and informed the Administrator (ADM) the following morning. A repair company was contacted, and the blower part was replaced, but another issue arose with the air conditioner in the north hallway. The DM admitted to routinely checking room temperatures weekly but had not documented these checks for at least a year. During the visit, room temperatures were measured, with some rooms exceeding the recommended range of 72-80 degrees Fahrenheit. The DM was unable to locate the binder where temperatures were previously recorded. The ADM, who started at the facility recently, was aware of the air conditioner issue but was not informed that temperature checks were not being performed during the outage.
Failure to Document Weekly Pressure Injury Assessments
Penalty
Summary
The facility failed to ensure that pressure injuries were documented in the medical record every week as per the facility's policy for one of the sampled residents. Resident 1, who was admitted with hemiplegia, had a stage 1 pressure injury to the sacral area documented in the progress notes. However, the required weekly wound assessments were not conducted, as confirmed by the Treatment Nurse during an interview. The Director of Nursing acknowledged that pressure injuries should be monitored weekly and documented in medical records, in accordance with the facility's policy and procedure. The policy, dated 2001, specifies that skin assessments should be repeated weekly and any skin issues should be described and documented. The failure to perform these assessments resulted in the inability to accurately assess the progression or deterioration of Resident 1's pressure injury.
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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