Valley Oaks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Maria, California.
- Location
- 830 East Chapel Street, Santa Maria, California 93454
- CMS Provider Number
- 055826
- Inspections on file
- 27
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Valley Oaks Post Acute during CMS and state inspections, most recent first.
A resident's Medication Administration Record (MAR) inaccurately showed that medication was administered within the facility on two occasions, when in fact the resident had left the facility and received the medication from an outside provider. The DON confirmed the discrepancy, resulting in inaccurate medical records.
A resident experiencing coffee ground emesis, indicative of upper GI bleeding, was transferred to the ED without a comprehensive nursing assessment being documented beforehand. Review of nursing progress notes and interview with the DON confirmed the absence of required assessment documentation prior to the transfer.
A resident with complex medical needs, including a stage 4 sacral pressure ulcer and deep tissue injury to the heel, did not receive or have documented daily wound care treatments as ordered by the physician for two consecutive days. The DON confirmed that the absence of documentation indicated the treatments were not performed, despite facility policy requiring assessment and documentation of pressure ulcers and their care.
A resident with multiple complex medical conditions experienced a fall and developed a bloodshot eye, but staff failed to complete required change in condition assessments, post-fall risk evaluations, and timely documentation. Family notification was not performed as per policy, and the IDT meeting to review the resident's status was delayed beyond the required timeframe. These actions resulted in incomplete records and communication regarding the resident's care.
A resident with Type 2 Diabetes and multiple other diagnoses was admitted to a facility without an insulin sliding scale order. Despite consistently high blood sugar levels, the facility failed to manage the resident's diabetes effectively. The resident's condition worsened, leading to hospitalization with diabetic ketoacidosis and subsequent death. The facility's inadequate response and lack of timely medical intervention contributed to the resident's critical condition.
The facility failed to ensure dishware was air-dried before stacking, as observed by surveyors. A dietary aide was seen stacking wet dishes, contrary to facility policy and FDA guidelines, potentially affecting all 51 residents. Interviews confirmed improper drying practices, posing a risk of bacterial growth and foodborne illness.
Two residents in an LTC facility experienced falls without proper evaluation or documentation, leading to deficiencies in fall prevention. One resident with severe cognitive impairment fell from bed, and another with Alzheimer's disease had multiple falls. The facility failed to update care plans or document incidents, resulting in a lack of communication and intervention.
The facility failed to ensure proper documentation and follow-up for falls experienced by two residents. One resident rolled off the bed during care, and another experienced multiple falls, but the incidents were not properly documented or discussed by the interdisciplinary team (IDT). The facility's processes for evaluating and addressing falls were not effectively implemented, leading to a lack of follow-up and intervention.
A facility failed to ensure staff adhered to contact isolation precautions for a resident with Clostridium difficile (C. diff). Observations revealed that staff, including a housekeeper and CNAs, entered the resident's room without wearing the required gown and gloves, despite the presence of a sign indicating contact precautions. The resident had severe cognitive impairment and a history of recurrent enterocolitis due to C. diff. Interviews with the Infection Preventionist and DON confirmed the expectations for PPE use and hand hygiene, which were not consistently followed, leading to the deficiency.
A resident was unable to access their personal funds on a weekend due to the facility's practice of limiting access to funds outside of weekday hours. Despite the facility's policy and regulatory requirements, the resident was told to wait until Monday unless it was an emergency. The resident had intact cognition and a medical history including type 2 diabetes mellitus.
The facility did not submit the findings of an alleged abuse investigation involving two residents to the State Survey Agency within the required timeframe. The incident involved a physical altercation between two residents, and although the investigation was completed, the results were not reported as per the facility's policy.
A resident with dementia and Alzheimer's exhibited aggressive behavior, which was documented in Nursing Progress Notes but inaccurately reflected in the MDS assessment. The facility's DON acknowledged the discrepancy, which could lead to unmet care needs.
A resident with dementia and Alzheimer's exhibited aggressive behavior, including kicking another resident, but their care plan was not revised as required by facility policy. The care plan had not been updated since a previous revision, despite documented changes in the resident's condition.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one resident when the Medication Administration Record (MAR) indicated that medication was administered on two specific dates, despite the resident having left the facility and receiving the medication from an outside provider. Review of the outside provider's Medication Dosing Log confirmed that the medication was administered at their facility on those dates. During an interview, the Director of Nursing confirmed that the resident did not receive the medication in the facility, but rather from the outside provider. This resulted in the MAR reflecting inaccurate documentation of prescribed medication, contrary to accepted professional standards for medication administration and recordkeeping.
Failure to Document Comprehensive Assessment Prior to Hospital Transfer
Penalty
Summary
The facility failed to document a comprehensive nursing assessment for one of two sampled residents who experienced a significant change in condition. Specifically, the nursing progress notes for the resident, who was sent to the Emergency Department for coffee ground emesis (a sign of upper gastrointestinal bleeding), did not contain evidence that a comprehensive assessment was completed prior to transfer. During an interview and record review, the Director of Nursing confirmed that no assessment was documented, despite the expectation that one should have been completed. This lack of documentation was identified through review of nursing progress notes covering the period before the resident's transfer.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
A resident was admitted to the facility with multiple complex medical conditions, including a stage 4 pressure ulcer on the sacral region and deep tissue damage to the left heel. Physician orders were in place for daily wound care treatments for both pressure ulcers, specifying cleansing, application of topical agents, and dressing changes. However, a review of the Treatment Administration Record (TAR) revealed missing documentation for the prescribed treatments on two consecutive days for both wounds. The Director of Nursing confirmed that blank entries on the TAR indicated the treatments were not performed, and acknowledged that the treatments should have been initiated as ordered, even though the resident was a new admission and it was the weekend. The facility's policy required full assessment and documentation of pressure ulcers, including current treatments, which was not reflected in the records for the days in question. The failure to provide and document the ordered wound care treatments constituted a lapse in ensuring that services met professional standards of quality for the resident's pressure ulcers.
Failure to Assess, Document, and Notify Changes in Resident Condition
Penalty
Summary
The facility failed to ensure proper assessment and notification procedures were followed for a resident who experienced multiple changes in condition. Specifically, when the resident was observed with a bloodshot right eye, there was no documentation of a change in condition (COC) assessment, such as an SBAR, in the medical record. The Director of Nursing (DON) confirmed that neither an assessment nor appropriate documentation was completed, despite facility policy requiring such documentation for changes in a resident's medical or mental condition. Additionally, the facility's policy on charting and documentation mandates that all changes in a resident's condition be recorded in the medical record, which was not done in this instance. Following a fall incident, the facility did not complete a post-fall risk assessment for the resident, as required by both the facility's orientation materials and its policy on assessing falls and their causes. The DON acknowledged that a post-fall assessment was not performed or documented, and that the facility's procedures require such an assessment after a fall. The lack of documentation and assessment meant that the resident's medical record did not accurately reflect the incident or the resident's subsequent risk status. Furthermore, the facility did not notify the resident's family of the changes in condition, including the fall and the bloodshot eye, as required by facility policy. The DON and a licensed nurse both stated that it is standard practice to notify family members after such incidents, but there was no evidence that this occurred. Additionally, the Interdisciplinary Team (IDT) meeting to review the resident's changes in condition was not conducted within the required 72-hour timeframe, with the DON confirming the delay. These failures resulted in incomplete communication and documentation regarding the resident's care and condition.
Failure to Manage Diabetes Leads to Resident's Hospitalization and Death
Penalty
Summary
The facility failed to provide quality care for a resident with Type 2 Diabetes (DM2) who was admitted with multiple diagnoses, including DM2 with neuropathy, COPD, pneumonia, atherosclerotic heart disease, chronic kidney disease, congestive heart failure, high blood pressure, transient ischemic attack, and cerebral infarct. Upon admission, the resident did not have an insulin sliding scale order, and the facility's protocol was to check blood sugar levels daily and notify a doctor if levels exceeded 400 mg/dl. Despite consistently high blood sugar readings, the facility did not adequately manage the resident's diabetes, leading to a critical situation. The resident's blood sugar levels were documented as consistently high, with readings such as 385 mg/dl, 390 mg/dl, and 498 mg/dl over several days. On one occasion, the night shift nurse notified the doctor when the blood sugar was 'HI,' and the doctor ordered 10 units of Lispro insulin, but there was no written or signed order for this. The resident's blood sugar continued to be high, and there was a lack of documentation and follow-up on the resident's glucose levels until the situation worsened. Ultimately, the resident was transferred to the hospital with a diagnosis of diabetic ketoacidosis with coma, acute kidney injury, and ventricular tachycardia. The resident's condition deteriorated, and he passed away the following morning. The facility's failure to manage the resident's diabetes effectively and provide timely medical intervention contributed to the resident's critical condition and subsequent death.
Improper Dish Drying Practices in Facility Kitchen
Penalty
Summary
The facility failed to ensure that dishware was allowed to air dry before being stacked in the kitchen, as observed by surveyors. This practice was contrary to both the facility's policy and the U.S. FDA 2022 Food Code, which require that dishes be air-dried before stacking to prevent microbial growth. During an observation, a dietary aide was seen stacking wet dessert bowls, plate holders, and plate covers without allowing them to air-dry. Interviews with the dietary aide, another staff member, the Food Service Supervisor, and the Administrator confirmed that the dishes were not being dried properly before stacking, which could lead to bacterial growth. The deficiency had the potential to affect all 51 residents who received meals from the facility's kitchen. The Director of Nursing was unaware of the dish drying and storing process, but expected the kitchen staff to follow proper procedures. The Administrator acknowledged the importance of allowing dishes to air-dry to prevent bacterial growth. The facility's failure to adhere to proper dish drying procedures posed a risk of foodborne illness to the residents.
Deficiencies in Fall Management and Documentation
Penalty
Summary
The facility failed to ensure proper evaluation and documentation of falls for two residents, leading to deficiencies in fall prevention and management. Resident #36, who had a history of severe cognitive impairment and was at high risk for falls, experienced a fall on 03/01/2024. The fall occurred when the resident rolled off the bed while receiving incontinence care. Despite the incident, no new interventions were added to the resident's care plan, and the fall was not documented in the facility's incident log. Interviews with staff revealed a lack of awareness and documentation regarding the fall, indicating a breakdown in communication and procedural adherence. Resident #25, who had Alzheimer's disease and was at risk for falls, experienced multiple falls between 06/19/2024 and 11/27/2024. Documentation for these falls was incomplete or initiated by staff who were not present at the time of the incidents. The facility's Director of Nursing (DON) and Director of Medical Records were unaware of these falls due to the absence of communication notes, which are necessary for initiating audits and discussions during clinical meetings. This lack of documentation and communication prevented the implementation of specific interventions to prevent further falls. The facility's policies on fall risk assessment and management were not effectively followed, as evidenced by the lack of documentation and failure to implement new interventions after falls occurred. The DON and Administrator expected nurses to complete all required documentation during the shift when incidents occurred, but this expectation was not met. The facility's failure to adhere to its policies and ensure proper communication and documentation contributed to the deficiencies in fall prevention and management for the residents involved.
Deficiency in Fall Documentation and Follow-Up
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to address and identify quality deficiencies related to the evaluation, tracking, and documentation of falls. This deficiency was identified during a survey conducted from December 16 to December 19, 2024, which revealed that the facility did not follow its established processes for discussing falls in morning meetings, conducting root-cause analyses, developing and implementing interventions, and evaluating the effectiveness of interventions for two residents who experienced falls. Resident #36 experienced a fall on March 1, 2024, when they rolled off the bed while receiving incontinence care. The resident was found on their knees beside the bed and complained of knee pain, with an abrasion noted on the right knee. However, there was no evidence in the resident's care plan of any new interventions added after the fall. Additionally, the incident was not included in the facility's Incidents by Incident Type log, and the Director of Nursing (DON) was unable to locate any documentation of an investigation or discussion by the interdisciplinary team (IDT) regarding the fall. Resident #25 experienced multiple falls on June 19, October 4, October 17, and November 27, 2024. Documentation for these falls was incomplete or missing, and the incidents were not captured in the facility's records. Interviews with staff revealed that communication notes and incident reports were not consistently completed, and the IDT did not discuss these falls in their meetings. The facility's processes for follow-up and audits related to falls were not effectively implemented, leading to a lack of documentation and follow-up on the residents' falls.
Failure to Adhere to Contact Isolation Precautions for C. diff Resident
Penalty
Summary
The facility failed to ensure staff adhered to contact isolation precautions and donned the appropriate personal protective equipment (PPE) while performing care or services in the room of a resident with a known communicable disease, Clostridium difficile (C. diff). This deficiency was identified during observations where staff members, including a housekeeper and certified nurse aides (CNAs), entered the resident's room without wearing the required gown and gloves, despite the presence of a sign indicating the need for contact precautions. The resident, who had severe cognitive impairment and a history of recurrent enterocolitis due to C. diff, was on contact precautions, and the failure to adhere to these precautions had the potential to affect other residents in the facility. During the observations, Housekeeper #3 entered the resident's room wearing gloves and a mask but no gown, acknowledging later that she forgot to don the gown. Similarly, CNA #4 entered the room without any PPE, moved the resident's wheelchair, and used hand sanitizer instead of washing hands with soap and water, which is necessary for C. diff. CNA #5 also failed to wear a gown while rearranging the resident's bed linens, which touched her clothing, and did not remove her gloves or wash her hands before exiting the room. These actions were contrary to the facility's policy and CDC guidelines, which require wearing gloves and gowns for all interactions that may involve contact with the resident or potentially contaminated areas. Interviews with the staff, including the Infection Preventionist (IP) and the Director of Nursing (DON), confirmed the expectations for PPE use and hand hygiene when dealing with residents on contact precautions. The IP and DON reiterated that staff should wear gowns and gloves when entering the resident's area, remove PPE before leaving the room, and wash hands with soap and water, especially in cases involving C. diff. Despite these protocols, the staff's failure to consistently follow the guidelines led to the deficiency noted in the report.
Failure to Provide Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide a resident with access to their personal funds on weekends, which is a violation of the resident's rights to manage their financial affairs. According to the facility's policy, residents should have access to funds of fifty dollars or less within twenty-four hours and access to larger amounts within three banking days. The State Operations Manual also requires that resident requests for access to their funds be honored as soon as possible, with specific timeframes for different amounts. However, Resident #20, who had intact cognition and a medical history including type 2 diabetes mellitus, hypothyroidism, and mixed hyperlipidemia, reported being unable to access their funds on a weekend because the Business Office employee was not available, and the Administrator encouraged waiting until Monday unless it was an emergency. Interviews with the Director of Nursing and the Administrator revealed that the facility managed residents' money and expected residents to have access to it after hours and on weekends. However, the Administrator indicated a preference to limit access to residents' funds on weekends, suggesting that non-emergency requests wait until the following Monday. This practice led to Resident #20 being unable to access their funds when needed, despite the facility's policy and regulatory requirements to provide timely access to personal funds.
Failure to Submit Abuse Investigation Findings
Penalty
Summary
The facility failed to submit the findings of an alleged abuse investigation to the State Survey Agency within five working days of the incident, as required by their policy. The incident involved two residents, where one resident was yelling because the other was in his bed, leading to a physical altercation where one resident kicked the other. The incident occurred on 9/29/24, and the facility's administrator confirmed the occurrence and the need for an investigation. However, despite completing the investigation, the results were not submitted to the Department, as confirmed by the administrator during an interview on 11/18/24. The facility's policy, revised in July 2017, mandates that a written report of the investigation findings be provided to the appropriate agencies within five working days, which was not adhered to in this case.
Inaccurate MDS Assessment of Resident's Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, leading to inaccurate documentation of the resident's behavior. The resident, who was admitted with diagnoses including dementia, Alzheimer's disease, depression, and hypertension, exhibited physical aggression towards others. Despite these behaviors being documented in the Nursing Progress Notes (NPN) on multiple occasions, the MDS assessment inaccurately reported that such behaviors were not exhibited. The discrepancy was acknowledged by the facility's Director of Nursing (DON) during a review of the resident's records. The DON confirmed that the MDS assessment did not accurately reflect the resident's aggressive behavior, as noted in the NPN. This inaccuracy in the MDS assessment had the potential for the resident's care needs to go unmet, as the assessment is a standardized tool used to measure health status and inform care planning.
Failure to Revise Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for reviewing and revising a person-centered comprehensive care plan for a resident who exhibited aggressive behavior. Resident 1, who was admitted with diagnoses including dementia, Alzheimer's disease, depression, and hypertension, showed physical and verbal aggression, posing a danger to themselves and others. Despite these changes in condition, the care plan, last revised on July 8, 2024, was not updated to reflect the resident's new behavioral symptoms. The deficiency was highlighted when Resident 1 became aggressive and kicked another resident in the leg. This incident was documented in the nursing progress notes, but the care plan was not revised accordingly. The facility's policy, which mandates ongoing assessments and care plan revisions as residents' conditions change, was not followed. The Director of Nursing confirmed that the care plan was not updated after the resident's change in status, leading to the deficiency noted in the report.
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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