Valley Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Bernardino, California.
- Location
- 1680 N Waterman Ave, San Bernardino, California 92404
- CMS Provider Number
- 056183
- Inspections on file
- 23
- Latest survey
- April 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Valley Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a history of falls and stroke, was allowed to leave the facility on an overnight pass with family, as permitted by physician orders. However, staff could not produce the required sign-out documentation, and interviews confirmed the facility's protocol was not followed, resulting in a failure to ensure proper tracking of the resident's departure and return.
The facility failed to assess and identify residents for smoking upon admission, did not complete required quarterly smoking assessments, and allowed multiple residents to smoke unsupervised and possess lighters, including those with supplemental oxygen orders. Care plans were not updated to address safe storage, supervision, or use of smoking materials, and staff interviews confirmed a lack of consistent supervision and inventory of lighters, resulting in significant safety hazards.
Surveyors found that food items past their best buy dates were not discarded, food debris was present under kitchen equipment, a scoop was improperly stored on top of a grains container, and wet trays were stacked without air drying. These actions were not in accordance with the facility's food safety and sanitation policies, as confirmed by the Dietary Services Supervisor.
Surveyors observed that two dumpsters were overflowing with trash and had lids that were not completely closed. The Maintenance Supervisor and Administrator confirmed that this did not comply with facility policy, which requires dumpsters to be kept closed and free of litter. Review of the FDA Food Code also indicated that outside receptacles must have tight-fitting lids.
Nine residents did not receive documented written information about their right to formulate an Advance Directive. Although the Social Services Designee stated that written materials were offered and explained at admission, the required documentation was incomplete, and there was no evidence in the records that the information was provided, as required by facility policy.
The facility did not complete and submit comprehensive admission MDS assessments on time for two residents, as required by federal regulations. Review of records and staff interviews confirmed that the assessments were incomplete and lacked the necessary RN Assessment Coordinator verification, potentially delaying individualized care planning.
Two residents did not have individualized care plans developed to address their psychiatric diagnoses and the use of specific psychotropic medications. One resident was administered divalproex and quetiapine without corresponding care plan interventions, and another resident with schizoaffective disorder lacked a care plan problem for this diagnosis. The absence of these care plans was confirmed by the MDS nurse assistant, contrary to facility policy.
Two residents did not receive appropriate respiratory care when staff failed to follow a physician's order for oxygen administration for one resident and provided oxygen to another resident without a physician's order. Both residents were cognitively intact and had respiratory diagnoses requiring oxygen therapy, but staff did not adhere to facility policy or provider directives regarding oxygen flow rates and order verification.
A resident with end-stage renal disease on hemodialysis did not receive prescribed Sevelamer on multiple dialysis days because staff failed to send the medication or coordinate with the dialysis center, resulting in missed doses as documented in the MAR.
A resident with advanced age, acute kidney failure, morbid obesity, and weight fluctuations did not receive a required quarterly nutritional assessment from the RD, despite facility policy mandating such reviews at least quarterly. The RD was present in the facility but did not assess the resident, and staff confirmed this omission was not in line with established procedures.
A resident with a history of CVA and hemiplegia was admitted on hospice and required substantial assistance for mobility, but did not receive an initial therapy screening for rehabilitative services as required by facility policy. Staff interviews revealed that hospice residents were not being screened for rehab needs, despite policy stating all residents should be screened upon admission.
Staff failed to follow infection control protocols, including hand hygiene during medication administration for multiple residents, proper use of PPE when entering a resident's isolation room, and timely replacement of overfilled sharps containers on medication carts. These actions were not in accordance with facility policies and were acknowledged by staff during interviews.
The facility failed to respond promptly to call lights, affecting four residents with no mental impairments. Despite their conditions, including metabolic encephalopathy, anemia, multiple sclerosis, and Parkinson's disease, residents reported significant delays in assistance, ranging from 30 minutes to an hour. The facility's policy for timely response was not followed, as acknowledged by the administrator.
The facility failed to follow its garbage disposal policy when two outdoor dumpsters were left open, as observed during an inspection. The policy requires dumpsters to be closed to prevent attracting pests, which could pose a health risk to the 100 clinically compromised residents.
A facility failed to notify a resident's responsible party about blisters on the resident's hand, as required by policy. The resident, diagnosed with Alzheimer's and dementia, lacked decision-making capacity, necessitating family involvement. An LVN admitted forgetting to inform the resident's wife, and the DON confirmed the oversight, acknowledging the policy requirement for prompt notification of significant condition changes.
Failure to Document Resident Sign-Out for Overnight Pass
Penalty
Summary
The facility failed to follow its policy and procedure for signing residents out when a resident left the premises on an overnight pass. According to the facility's policy, all residents leaving the premises must be signed out and signed back in upon return. Record review and staff interviews revealed that there was no documentation or log available to confirm that the resident was properly signed out or signed back in, despite staff statements that this is standard protocol. The administrator acknowledged that the sign-out sheet could not be located, and the Director of Nursing could not recall if the resident had been signed out at the time of the incident. The resident involved had multiple medical diagnoses, including gout, hypertension, muscle contracture, a history of falls, major depressive disorder, anxiety, and a previous stroke with aphasia. Physician orders permitted the resident to go out on a therapeutic pass with family, and departmental notes indicated the resident left with family via wheelchair. However, the absence of the required sign-out documentation meant the facility did not ensure compliance with its own procedures for tracking residents leaving and returning to the facility.
Failure to Assess, Supervise, and Safely Manage Resident Smoking Activities
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents, specifically related to resident smoking practices. Multiple residents were not assessed for smoking upon admission, and quarterly smoking assessments were not completed as required by facility policy. Several residents who smoked were not identified on the facility's Smoker Worksheet, and their smoking status was not properly documented or evaluated. In addition, care plans for residents who smoked were not updated to reflect current assessments or to address safe storage, supervision, and use of smoking materials. Residents were observed smoking unsupervised in designated areas and in proximity to others using supplemental oxygen, despite facility policies prohibiting such practices. Several residents in possession of lighters also had active physician orders for supplemental oxygen, significantly increasing the risk of fire. Staff interviews confirmed that residents were allowed to keep their own cigarettes and lighters, and that supervision during smoking activities was not consistently provided. Some staff expressed concerns about the safety of allowing residents to possess lighters, especially near those using oxygen, but these concerns were not addressed in practice. Record reviews revealed that the facility did not inventory or document the presence of lighters upon admission, and that the care plans for residents who smoked were outdated or incomplete. The facility's policies required smoking assessments on admission and quarterly, as well as individualized care plans for smoking residents, but these were not followed. The lack of proper assessment, supervision, and safe storage of smoking materials placed residents at risk of serious harm, including fire hazards and burns, as directly observed and documented by surveyors.
Removal Plan
- Conduct a thorough and complete smoking assessment for all residents who smoke in the facility.
- Implement a new smoking screening assessment which screens the resident for safety and capability to participate in smoking activities.
- Secure all lighters from smoking residents and ensure lighters are kept in a locked box located in the medication room.
- Monitor and supervise the residents during smoking activities, with staff responsible for securing and distributing lighters.
- Update the admission process to include admitting nurse to interview and assess the resident for smoking and complete the smoking assessment.
- Update the Medication Administration Record for residents who are identified smokers so licensed nurses can monitor and observe residents who smoke.
- Update the care plans for all smoking residents.
- In-service all staff on the facility's smoking policy and procedures and safety measures related to smoking.
- Meet with all residents who are identified as smokers to inform them regarding the new protocol with disposable lighters. The disposable lighters will be in possession of the facility instead of residents who smoke.
- Continuously monitor the designated smoking area by staff to ensure that any residents who are smoking are smoking in a safe manner and no changes of condition are taking place. A monitoring log will be filled out by the staff member and kept on file for further evaluation and review.
Failure to Follow Food Safety and Sanitation Standards in Dietary Services
Penalty
Summary
Surveyors observed multiple failures to adhere to food safety and sanitation standards in the facility's kitchen. A container of parsley flakes and two unopened bags of bread were found to be past their best buy dates, and the Dietary Services Supervisor (DSS) confirmed these items should have been discarded according to facility policy. Additionally, food debris was found on the floor under the stove and the large food mixer, which was acknowledged by the DSS as not meeting cleanliness expectations. A scoop was also found improperly stored on top of a grains and cereal container, rather than in its designated clean container, contrary to facility policy. Further, wet trays were observed stacked together without being air dried, which the DSS stated was not in compliance with facility procedures. Review of the facility's policies and the 2022 FDA Food Code confirmed that equipment and utensils are required to be air dried after cleaning and sanitizing. These deficiencies were identified through direct observation, interviews with the DSS, and review of facility policies, indicating lapses in following established food safety and sanitation protocols.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey when two dumpsters located across the parking lot had lids that were not completely closed and were overflowing with multiple bags of trash. The Maintenance Supervisor acknowledged that the trash should not be overflowing and that the lids should be fully closed. During a review of the facility's policy and procedure on food-related garbage and refuse disposal, it was confirmed that the policy requires outside dumpsters to be kept closed and free of surrounding litter. The Administrator also confirmed that the facility was not in compliance with this policy, as the dumpster lids were not closed all the way. Additionally, the 2022 FDA Food Code was reviewed, which requires outside receptacles to have tight-fitting lids or covers.
Failure to Provide and Document Written Information on Advance Directives
Penalty
Summary
The facility failed to provide written information regarding the right to formulate an Advance Directive to nine out of ten sampled residents. Record reviews for these residents showed that while each had an Advance Directive Acknowledgement form indicating they understood they were not required to have an Advance Directive to receive care, the forms were incomplete and lacked documentation that written information about Advance Directives was actually provided. Additionally, reviews of the residents' POLST forms confirmed that these residents did not have Advance Directives on file. During interviews and record reviews, the Social Services Designee (SSD) stated that she explained the purpose of Advance Directives and POLST forms to residents or their responsible parties at admission and offered written materials about Advance Directives. However, the SSD acknowledged that she only documented this process on the Advance Directive Acknowledgement form and did not document elsewhere. Upon review, the SSD verified that the forms for the affected residents were incomplete and did not show evidence that written information had been provided. The facility's policy required that upon admission, residents be given written information about their right to accept or refuse medical treatment and to formulate an Advance Directive. The policy also required staff to document the offer of assistance and the resident's decision regarding Advance Directives in the medical record. The lack of complete documentation and evidence that written information was provided constituted the deficiency identified in the report.
Failure to Complete Admission MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely completion of the comprehensive admission Minimum Data Set (MDS) assessments for two residents. For both residents, review of their admission records and MDS documentation revealed that the required comprehensive admission MDS assessments were not completed and submitted by the federally mandated deadline. Specifically, the MDS Section Z - Assessment Administration for each resident was incomplete, and the RN Assessment Coordinator's signature verifying assessment completion was missing. The MDS Nurse Assistant confirmed during interviews that the assessments were not submitted by their respective due dates. This deficiency was identified through interviews and record reviews, which showed that the assessments for both residents were overdue. The lack of timely completion of these assessments had the potential to delay the care planning process necessary to meet the residents' comprehensive and individualized care needs, as required by federal regulations.
Failure to Develop Individualized Care Plans for Residents with Psychiatric Diagnoses and Medications
Penalty
Summary
The facility failed to develop individualized care plans for two residents, resulting in deficiencies related to the management of their medical and psychiatric needs. For one resident, there was no care plan addressing the use of divalproex, prescribed for poor impulse control, and quetiapine, prescribed for schizoaffective disorder with visual hallucinations. Despite these medications being administered as ordered, the care plan did not include problems, goals, or interventions related to their use, nor did it address necessary monitoring for side effects and behaviors. The Minimum Data Set Nurse Assistant (MDSNA) confirmed that care plans should have been developed for these medications and that their absence meant staff lacked guidance on monitoring the resident appropriately. Another resident with an active diagnosis of schizoaffective disorder did not have a care plan problem developed for this condition. The MDSNA verified that each diagnosis should be addressed in the care plan to ensure staff are informed on how to care for and monitor the resident's individualized needs. The facility's policy requires care plans to incorporate goals and objectives for each resident's highest level of independence, but this was not followed in these cases.
Failure to Follow Physician Orders and Obtain Orders for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to two residents by not adhering to physician orders and established procedures for oxygen administration. For one resident with a diagnosis of chronic obstructive pulmonary disease (COPD), staff were observed administering oxygen at 1 liter per minute (LPM) via nasal cannula, despite an active physician's order specifying 2 LPM. This discrepancy was confirmed by both nursing and medical records staff, and the facility's policy indicated that oxygen should be administered at the ordered rate. The resident was cognitively intact and had a care plan directing staff to provide oxygen as indicated by provider orders. For a second resident with a history of acute respiratory failure with hypoxia, staff were observed administering oxygen at 5 LPM via nasal cannula without a physician's order in place at the time of observation. The absence of a physician's order for oxygen administration was confirmed by medical records staff, and the facility's policy required verification of a physician's order prior to oxygen administration. The resident was also cognitively intact and independent, with a care plan later reflecting the need for oxygen as needed for shortness of breath and low oxygen saturation.
Failure to Administer Dialysis-Related Medication as Ordered
Penalty
Summary
The facility failed to provide necessary dialysis-related care for a resident with end-stage renal disease who required hemodialysis three times per week. The resident had a physician's order for Sevelamer, a medication to control phosphorus levels, to be administered with meals on dialysis days. Review of the Medication Administration Record (MAR) showed that the medication was not given on multiple dialysis days, with staff documenting the resident as 'absent from home without meds.' Both a registered nurse and a licensed vocational nurse confirmed that the medication was not administered as ordered when the resident left for dialysis. Facility policy required staff education on medication timing for dialysis patients and agreements with the dialysis provider to ensure proper care coordination, including medication administration. However, staff interviews revealed that the facility did not send the medication with the resident or communicate with the dialysis center to ensure the medication was given, resulting in missed doses on several occasions.
Missed Quarterly Dietitian Assessment for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that a resident's nutritional and dietary needs were met when the Registered Dietitian (RD) did not complete the required quarterly assessment. A resident with a history of weight fluctuations, advanced age, acute kidney failure, and morbid obesity was receiving Lasix for fluid retention. The last nutritional assessment for this resident was completed on November 27, 2024, and the next quarterly assessment was due before the end of February 2025. However, the RD did not assess the resident during this period, despite being present in the facility in early March. Interviews with facility staff, including the Dietary Services Supervisor and the Quality Assurance Nurse, confirmed that the facility's policy requires the RD to assess residents on admission, quarterly, annually, and as needed. Review of the facility's policies further supported this expectation, stating that the RD is responsible for assessing nutritional needs and reviewing care plans at least quarterly. The failure to complete the quarterly assessment for this resident was acknowledged by staff as not following facility policy.
Failure to Screen Hospice Resident for Rehabilitative Services Upon Admission
Penalty
Summary
The facility failed to obtain an initial screening for rehabilitative services for one resident upon admission. The resident, who had a history of cerebrovascular accidents (CVA) and hemiplegia, was admitted with significant mobility limitations and required substantial to maximal assistance for mobility, as documented in the MDS. The resident expressed a desire to regain strength and function in the affected limbs and reported performing exercises several times a week. Despite these needs and the presence of orders for the use of an omni cycle, there were no orders for rehabilitative therapy, and no therapy screening was completed upon admission. Interviews with facility staff revealed that residents admitted on hospice were not being assessed or screened for rehabilitative services, with the Director of Rehab stating that such services for hospice residents were provided by the hospice facility. However, a review of the facility's policy indicated that a therapy screen should be completed upon admission for all residents, regardless of hospice status. The Director of Rehab confirmed that the required screening was not performed for this resident, in violation of facility policy.
Failure to Implement Infection Control and Prevention Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in several observed instances. During medication administration, a nurse did not perform hand hygiene at multiple required points, including after sanitizing equipment, before and after touching residents, and before and after administering medications. This occurred with three different residents, including one who required blood glucose monitoring and insulin administration. The nurse acknowledged awareness of the facility's infection control policies but did not adhere to them during these procedures. In another instance, a certified nurse assistant entered the room of a resident on Contact Isolation Precautions without donning gloves or a gown and did not perform hand hygiene after assisting the resident with personal items. The resident had an active physician's order for contact isolation due to bacteremia. The CNA confirmed knowledge of the policy requiring PPE and hand hygiene but did not follow these protocols during the observed interaction. Other staff interviews confirmed the expectation for PPE use and hand hygiene when entering and exiting isolation rooms and after contact with residents or their belongings. Additionally, two medication carts were found with sharps containers filled past the full line indicator, contrary to facility policy, which requires containers to be replaced when 75% to 80% full. Staff responsible for the carts acknowledged that the containers should have been replaced. The facility's policy and procedures for sharps disposal were not followed, as confirmed by the quality assurance nurse.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to adhere to its policy and procedure for timely response to call lights, affecting four residents. Each resident, despite having no mental impairment as indicated by their Brief Interview for Mental Status (BIMS) scores, reported significant delays in receiving assistance. Resident 1, diagnosed with metabolic encephalopathy, experienced instances where staff mistakenly assumed he was asleep and turned off the call light without checking his needs. Resident 2, with anemia, reported waiting at least 30 minutes for assistance, occurring at least once daily. Resident 3, diagnosed with multiple sclerosis, experienced wait times of 45 minutes to an hour. Resident 4, with Parkinson's disease, also reported delays of up to an hour. The facility's policy, titled 'Answering the Call Light' and dated March 2021, was not followed, as acknowledged by the facility administrator. The policy's purpose is to ensure timely responses to residents' requests and needs, which was not met in these cases. The administrator admitted that staff needed to respond more promptly to call lights, indicating a systemic issue in the facility's response protocol that jeopardized the health and safety of the residents involved.
Improper Garbage Disposal
Penalty
Summary
The facility failed to adhere to its food-related garbage disposal policy when two outdoor dumpsters were left open. This was observed during an inspection on November 23, 2024, at 1:20 p.m., when the surveyor, accompanied by the Director of Staff Developer, noted that the dumpsters were not closed. The facility's policy, dated October 2017, requires that outside dumpsters be kept closed and free of surrounding litter. Additionally, the FDA Federal Food Code, 2022, emphasizes the importance of proper storage and disposal of garbage to prevent attracting pests. This oversight had the potential to attract vermin, posing a significant health risk to the 100 clinically compromised residents residing in the facility.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to adhere to its policy regarding the notification of changes in a resident's condition. Specifically, a Licensed Vocational Nurse (LVN) did not inform the responsible party of blisters observed on the right hand of a resident diagnosed with Alzheimer's and dementia. The resident's medical records indicated that they lacked the capacity to understand and make decisions due to dementia, necessitating the involvement of a responsible party in their care decisions. Despite this requirement, the LVN admitted to forgetting to notify the resident's wife, who was listed as the responsible party. The Director of Nursing (DON) acknowledged the oversight and confirmed that the facility's policy mandates prompt notification of the resident's representative in the event of significant changes in the resident's physical condition. The facility's policy, dated February 2021, clearly states that a nurse should notify the resident's representative of any significant changes in the resident's condition. This failure to communicate the change in the resident's condition had the potential to exclude the family from participating in the resident's care plan.
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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