Veterans Home Of California - Redding
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 3400 Knighton Road, Redding, California 96002
- CMS Provider Number
- 555891
- Inspections on file
- 32
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Veterans Home Of California - Redding during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents.
A resident with multiple serious diagnoses received Oxycodone for pain indications not specified in the physician's order, such as generalized and neck pain, rather than only for lower back pain as prescribed. Nursing staff administered the medication for these other pain complaints without obtaining a new physician order, contrary to facility policy, and the DON confirmed that an updated order should have been secured.
Surveyors found that staff did not consistently monitor the cooldown of potentially hazardous foods, such as cooked entrees and tuna salad, and failed to document required temperature checks. Additionally, a food service worker was observed chewing gum during food preparation, contrary to facility policy. These actions were confirmed through observation, staff interviews, and review of facility records.
Surveyors found that internal and external medications were stored together without separation in two medication storage areas, contrary to facility policy. Oral medications were placed next to external-use products such as eye drops and enemas, and staff acknowledged this improper practice had likely been ongoing and unrecognized.
A nurse was observed making three medication administration errors involving insulin and nasal spray for a resident with dysphagia and muscle weakness. The nurse did not follow manufacturer instructions for holding the insulin pen needle in the skin and failed to instruct the resident to blow their nose before nasal spray administration, resulting in a medication error rate above 5%.
The facility did not employ a full-time qualified supervisor dedicated to managing the day-to-day operations of dietetic services in the SNF. Leadership positions were vacant or shared between the SNF and RCFE, and the staff responsible for food and nutrition services did not meet regulatory requirements for full-time supervision, resulting in insufficient oversight of dietetic services.
A resident with heart failure and atrial fibrillation was administered psychotropic medications without documented informed consent in the medical record. Physician orders and the MAR confirmed administration of Temazepam and Trazodone, but neither the DON nor nursing staff could provide evidence of a signed consent form, as required by facility policy.
A resident's right to privacy was violated when a staff member opened and viewed the resident's bank statement without proper authorization. The resident's son, who held the Durable Power of Attorney, denied giving consent for this action. The facility's policy required mail to be opened only at the resident's request or forwarded to their representative, which was not adhered to in this case.
The facility's kitchen failed to maintain safe and sanitary conditions, with equipment like a chipped can opener and scratched cutting boards not replaced, and foods found uncovered in storage. Labeling issues were noted, with some items difficult to read or lacking labels, and expired food not discarded promptly. These deficiencies were confirmed by staff and violated facility policies and FDA guidelines.
The facility failed to cover two out of eight dumpsters in the main and satellite kitchens, potentially attracting pests and spreading bacteria, risking food contamination for forty-one residents. Observations revealed uncovered dumpsters, confirmed by the Assistant Administrator and Dietetics Assistant Director, who emphasized the need for dumpsters to be closed when not in use. The facility's Waste Management Program policy requires bins to have tightfitting covers and be closed when not being loaded.
A LTC facility exceeded the acceptable medication error rate, reaching 11.11%, due to improper administration of medications to two residents. A resident received crushed pantoprazole and finasteride, despite guidelines against crushing these medications. Another resident was not instructed to rinse his mouth after using an inhaler, contrary to the medication's instructions. The errors were attributed to staff not following medication administration guidelines.
The facility failed to implement care plans for two residents, leading to potential fall risks. One resident's assistive devices were not within reach, and 'Call don't fall' signs were missing. Another resident had outdated assistive devices and signage in their room, contrary to their care plan. These deficiencies were confirmed through observations and staff interviews.
Expired filter needles were found in the Emergency Drug Kit at an LTC facility, with staff unaware of their expiration. The facility's policy required regular review and cycling out of expired items, but the needles remained, posing a risk of using ineffective supplies.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment or supervision in the specified area was insufficient to prevent potential accidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or supervision lapses are provided in the report.
Pain Medication Administered Outside Prescribed Indication
Penalty
Summary
The facility failed to ensure that pain medication was administered as prescribed for a resident with diagnoses including heart failure, metastatic prostate cancer, and muscle weakness. The physician's order specified that Oxycodone 5 mg immediate release should be given by mouth every four hours as needed for lower back pain. However, review of the medication administration record revealed that the medication was given on ten occasions for indications other than lower back pain, such as generalized pain, body pain, facial pain, and neck pain. Multiple nurses administered the medication for these unapproved indications without obtaining a new physician order to cover the broader pain complaints. Interviews with nursing staff confirmed that the medication was not administered strictly according to the prescriber's order, and the Director of Nursing acknowledged that a physician order should have been obtained for the resident's general pain. Although the physician and pharmacist later stated it was acceptable to administer the medication for other pain indications, the facility's policy required medications to be administered only as ordered by the prescriber. This deviation from the prescribed order resulted in a failure to provide safe and appropriate pain management as required by facility policy.
Failure to Monitor Food Cooldown and Prohibit Gum Chewing in Food Preparation Areas
Penalty
Summary
The facility failed to consistently follow food safety standards in the handling and preparation of potentially hazardous foods (PHFs). Surveyors observed that multiple cooked and frozen food items, such as macaroni and cheese, corned beef, vegetarian meatloaf, and lentil loaf, were stored without proper cooldown temperature monitoring. Additionally, prepared tuna salad made from ingredients stored at room temperature was not monitored for temperature during storage, with staff only checking temperatures shortly before use. Review of the facility's cooldown logs confirmed that these items were not tracked during the cooling process, and the facility's policy did not provide guidance for documenting or monitoring the cooldown of PHFs prepared from room temperature ingredients. During food production observations, a food service worker was seen chewing gum while preparing mechanically altered food items, in direct violation of the facility's policy prohibiting gum chewing in kitchen or serving areas. The worker confirmed having gum in her mouth when questioned. These lapses in food handling and staff conduct were identified through direct observation, staff interviews, and review of departmental documentation.
Failure to Separate Internal and External Medications in Storage Areas
Penalty
Summary
Surveyors observed that internal-use medications, such as oral tablets and capsules, were stored directly adjacent to external-use products, including eye drops and enemas, in two medication storage areas within the facility. There was no physical barrier, labeled bin, or designated shelving to separate medications intended for internal administration from those for external use. This storage practice was noted during a tour of the Clamath and another nursing station, where items like Loperamide tablets, Glucosamine Sulfate capsules, and Calcium Citrate tablets were intermixed with Fleet Saline Enema, GenTeal Tears Lubricant Eye Drops, Refresh Plus Eye Drops, and Major Ear Drops. During an interview at the time of observation, the facility's Quality Assessment Nurse acknowledged the improper storage and indicated that this practice had likely been ongoing and unrecognized by staff. The facility's own policy on medication storage specifically requires that internally administered medications be kept separate from externally used medications, but this policy was not being followed as evidenced by the observed storage conditions.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of twenty-eight opportunities during a medication pass, resulting in a 10% error rate. Specifically, a Licensed Vocational Nurse (LVN) administered two types of insulin to a resident with dysphagia and muscle weakness but did not follow the manufacturer's instructions for holding the insulin pen needle in the skin for the required duration after pressing the dose button. The LVN admitted to routinely removing the pen immediately after pressing the button, rather than adhering to the specified holding time. Additionally, the same LVN administered a nasal spray to the same resident without instructing the resident to blow their nose beforehand, contrary to standard manufacturer instructions for intranasal sprays. The LVN stated that she was unaware of the need for the resident to clear their nasal passages prior to administration. These observed actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Lack of Full-Time Qualified Supervisor for Dietetic Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to manage the food and nutrition service, specifically lacking a full-time qualified position dedicated to supervising and managing the day-to-day operations of the skilled nursing dietetic services. During the survey, it was observed that the Food Manager (FM) was responsible for both the skilled nursing facility (SNF) and a separately licensed residential care facility for the elderly (RCFE), and his position was not dedicated full-time to the SNF. The Dietetics Assistant Director (DAD), a Registered Dietitian, also had responsibilities split between the SNF and RCFE, and her role was not solely dedicated to the SNF. The organizational chart review confirmed that the Director of Dietetics and a Food Service Supervisor (FSS) II positions were vacant, and there was no full-time qualified Food Service Director dedicated to the SNF. Interviews with facility leadership and staff further revealed that the current structure did not provide a full-time qualified supervisor for the SNF dietetic services. The DAD confirmed that all dietetic services leadership positions were shared between the RCFE and SNF, and the Registered Dietitian assigned to the SNF focused on clinical nutrition care rather than day-to-day management of dietetic services. The FM had not completed the necessary training to become a Certified Dietary Manager, and the facility had not attempted to modify position descriptions or minimum qualifications to address the deficiency. Facility policy and regulatory requirements were reviewed, indicating that if a dietitian is not employed full-time, a full-time Food & Nutrition Services supervisor must be responsible for the operation of the food service. The facility's failure to meet these requirements resulted in a lack of dedicated, qualified supervision for the SNF dietetic services, as evidenced by vacant leadership positions and shared responsibilities among existing staff.
Lack of Documented Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a complete and accurate medical record was maintained for a resident who was prescribed psychotropic medications. Specifically, there was no documentation in the resident's medical record indicating that informed consent was obtained for the administration of Temazepam and Trazodone, both psychotropic medications. The resident's face sheet showed admission with diagnoses including heart failure and unspecified atrial fibrillation. Physician orders for Temazepam and Trazodone were present, and the Medication Administration Record confirmed that these medications were administered on multiple occasions. Interviews with the DON and an RN revealed that the physician was responsible for discussing the treatment and obtaining written consent, and that nursing staff should verify the presence of a signed consent form before administering psychotropic medications. Review of facility policy confirmed that written informed consent must be documented and filed in the resident's health record prior to initiating psychotropic drug therapy. Despite these requirements, no such documentation was found in the resident's record at the time of review.
Unauthorized Access to Resident's Personal Information
Penalty
Summary
The facility failed to respect a resident's right to personal privacy when a staff member opened and viewed the resident's bank account statement without proper authorization. The resident, who was oriented to person and place, had her finances managed by her son and daughter. The resident's son held the Durable Power of Attorney, as indicated in the resident's Face Sheet and the durable power of attorney document dated March 1, 2023. During an interview, the Medical Social Worker (MSW) admitted to opening and viewing the resident's bank account statement for June 2024, claiming that consent was given by the resident's son via telephone. However, the MSW could not provide documented evidence of this consent, and the resident's son later denied giving such consent. The facility's policy stated that mail could only be opened at the resident's request or forwarded to their representative if they had a conservator, power of attorney, or other representative. This policy was not followed, leading to unauthorized access to the resident's personal information.
Food Safety and Sanitation Deficiencies in Facility's Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the food service department, as observed during a survey. Equipment such as a can opener with metal chipped off the cutting tip and discolored cutting boards with deep scratches were not replaced, posing a risk of contamination. Foods were found uncovered in storage areas, including frozen burritos, chicken breasts, and vegetable patties with ice build-up, as well as a bag of pork and uncooked ravioli left open to the air. These conditions were confirmed by the Food Manager and Dietetics Assistant Director, who acknowledged the potential for cross-contamination and food quality degradation. Additionally, the facility did not appropriately label food items, with black pepper and bay leaves having labels that were difficult to read, and ice cream bowls lacking labels entirely. This oversight was confirmed by the Dietetics Assistant Director, who stated that staff were expected to label food items with a use-by date to ensure safety. Furthermore, expired food items, such as apple juice boxes, were not discarded in a timely manner, leading to confusion about product safety. These deficiencies were in violation of the facility's policies and procedures, as well as the 2022 FDA Food Code.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two out of eight dumpsters were covered for the main and satellite kitchens, which had the potential to attract pests, rodents, and spread bacteria, leading to food contamination for a population of forty-one residents. During an observation and interview with the Assistant Administrator, it was noted that one out of four trash dumpsters for the main kitchen was not covered, exposing trash. The Assistant Administrator confirmed that the dumpster should be closed and proceeded to close the two lids. Similarly, an observation in the satellite kitchen revealed that one out of four trash dumpsters was not covered, exposing trash. The Dietetics Assistant Director stated that trash dumpsters need to be closed at all times when not in use to prevent attracting rodents or pests to the facility. A review of the facility's Waste Management Program policy indicated that movable bins used for storing or transporting solid wastes should have tightfitting covers and be closed when not being loaded.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11.11% error rate. This was due to the improper administration of medications to two residents. Resident 26 was given pantoprazole and finasteride in a crushed form, contrary to guidelines. Pantoprazole, a delayed-release medication, was crushed and mixed with applesauce, despite the manufacturer's instructions against crushing. Similarly, finasteride, which requires special handling, was also crushed and administered in the same manner. The Licensed Vocational Nurse (LVN) involved did not notice the 'Do Not Crush' and 'Caution Special Handling' labels on the medication packaging and was unaware of the implications of these labels. Additionally, Resident 21 was not instructed to rinse his mouth after using an inhaler containing fluticasone furoate, umeclidinium, and vilanterol. This step is crucial to prevent potential side effects such as hoarseness and oropharyngeal candidiasis, as indicated by the medication's packaging and prescribing information. The Registered Nurse (RN) administering the medication failed to provide this instruction, and the resident did not have a history of refusing to rinse his mouth after inhalation. The facility's policies and procedures for medication administration were not adhered to in these instances. The Director of Nursing acknowledged that the medications should not have been crushed and that proper instructions should have been given to Resident 21. The facility's guidelines require that altering the form of a medication, such as crushing, should only be done with a physician's order and that special handling instructions should be followed for certain medications.
Failure to Implement Care Plans for Fall Prevention
Penalty
Summary
The facility failed to implement the care plans for two residents, leading to potential safety risks. For one resident, who had a left below-knee amputation and a right transmetatarsal amputation, the care plan required that assistive devices such as a wheelchair and prosthetic leg be within reach. However, during an observation, these items were found across the room and in the bathroom, respectively, making them inaccessible. Additionally, the care plan included the posting of 'Call don't fall' signs, which were not present in the resident's room. Interviews with the Quality Assurance Registered Nurse and the Occupational Therapist confirmed these oversights. For another resident diagnosed with Alzheimer's Disease and ataxic gait, the care plan specified the use of a manual wheelchair, yet a walker and corresponding signage were still present in the room, contrary to the updated care plan. Furthermore, 'Call don't fall' signs, which were part of the fall prevention strategy, were missing from the resident's room. The Assistant Director of Nursing and a Physical Therapist confirmed that the walker had been discontinued and should have been removed, along with the signage. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to adhere to the established care plans.
Expired Filter Needles Found in Emergency Drug Kit
Penalty
Summary
The facility failed to ensure the safe monitoring of pharmaceutical medical supplies when four expired filter needles were found in the injectable Emergency Drug Kit (E-Kit). These filter needles, which are designed to remove particles that might contaminate medication, were found without expiration dates in the Klamath Unit medication room. The Pharmacy Technician initially stated that some filter needles did not have expiration dates, and the most recent expiration date was posted on the E-kit lid for staff to alert the main pharmacy for replacements. However, upon further investigation, it was confirmed by the Manufacturer Representative that the filter needles had expired on January 24, 2022. Interviews with the Director of Nursing and a Registered Nurse revealed uncertainty and lack of awareness regarding the expiration dates of the filter needles. The facility's policy and procedure for the Emergency Drug Kit indicated that the contents should be reviewed by the pharmacy services committee and cycled out before expiration. Despite this policy, the expired filter needles remained in the E-kit, posing a potential risk of using ineffective medical supplies and contaminated medications for residents.
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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