White Blossom Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 1990 Fruitdale Avenue, San Jose, California 95128
- CMS Provider Number
- 555068
- Inspections on file
- 36
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at White Blossom Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia, hemiparesis, type II DM, and muscle wasting was left in a wheelchair unattended in a hallway after an OT session. The OT reported telling a nurse and a CNA that the resident was in the hallway. An LVN acknowledged being informed and stated the resident remained in the hallway for a short period while the LVN turned away to speak with another resident. A CNA heard a noise, found the resident on the floor with the wheelchair tipped on its side, and the DON reported that another resident had seen the resident’s backpack catch and cause the wheelchair to tip. The resident was later documented as having an abrasion to the left elbow, and facility policy stated residents have a right to a dignified existence.
Staff failed to provide timely assessment, physician notification, and complete documentation for two residents—one who was transferred to the hospital with symptoms of malaise and later diagnosed with sepsis, and another who experienced a fall without proper physician notification or thorough investigation. These actions did not follow facility protocols and were confirmed by staff interviews and record reviews.
Licensed nurses did not accurately complete an elopement and wandering risk assessment for a resident with severe cognitive impairment and multiple diagnoses affecting cognition. The assessment was incomplete and did not reflect the resident's conditions, and no care plan was developed to address elopement or wandering risks, despite facility policy requiring such interventions.
A facility failed to update a Level I PASRR for a resident with a new diagnosis of psychotic disorder. Despite the resident's history of major depressive and mood disorders, and a new diagnosis in June 2023, the PASRR was not updated since March 2022. Interviews with staff confirmed the need for an updated PASRR, as per facility policy.
The facility failed to ensure accurate PASRR Level I screenings for two residents with serious mental disorders. One resident was admitted with schizoaffective disorder and schizophrenia, but the initial screening did not reflect these diagnoses. Another resident had multiple mental health conditions, but only schizophrenia was noted in the screening. The facility did not submit new screenings after the residents stayed over 30 days, as required. Staff interviews revealed a lack of awareness and responsibility for ensuring screening accuracy.
The facility failed to implement proper infection control practices, including leaving bleach containers open, improper glove use by CNAs, and inadequate storage of clean and contaminated items. A resident's nasal cannula was improperly stored, and used meal trays were placed under a water dispenser, all confirmed by staff as against protocol.
A resident received quetiapine fumarate (Seroquel) without adequate indication and monitoring of target behaviors in an LTC facility. The medication was requested by a family member and ordered by a physician without specifying its use or monitoring requirements. The Pharmacy Consultant recommended monitoring, but this was not documented, violating the facility's policy on antipsychotic medication use.
A facility failed to follow infection prevention practices when the door of a Covid-19 isolation room was found open. A resident with acute pulmonary edema and respiratory failure was confirmed Covid-19 positive. Both an LVN and the Infection Preventionist acknowledged the door should have been closed, as per CDC guidelines.
The facility failed to implement proper infection control practices for emergency crash carts. Crash carts B and C contained oropharyngeal airway kits not stored in original packaging and lacked expiration dates. Crash cart A had OPAs with a yellowish substance and no expiration date. Additionally, crash carts B and C had a Yankauer suction tip and nasal cannula without expiration dates, violating facility policy.
The facility failed to conduct thorough investigations and report outcomes for several alleged altercations involving residents. Investigation summaries for altercations between residents did not indicate whether the facility determined if the incidents occurred. The administrator confirmed that the investigations were not thorough or clear, and did not follow the facility's policy for abuse reporting and investigation.
Three residents experienced constipation due to the facility's failure to follow physician orders for bowel management. Despite having orders for interventions like MOM, Bisacodyl suppository, and enemas, these were not administered as prescribed. Staff interviews revealed a lack of adherence to the bowel management protocol, with nurses failing to check and administer necessary medications. The facility's policy required daily review and medication administration, which was not followed.
A Social Service Director failed to document informing a resident's responsible party about a psychologist appointment, preventing the RP from attending. The resident had multiple medical conditions and was not self-responsible, requiring the RP's involvement in treatment decisions.
A resident reported that the rehabilitation staff used a space heater for several months due to a malfunctioning heating unit, while she was not allowed to have one. The space heater was observed in use during a facility tour, and the DON removed it, acknowledging that staff could not use space heaters. The Maintenance Supervisor confirmed the prohibition of space heaters and could not provide maintenance logs for the heating system.
Resident Left Unattended in Hallway Falls From Wheelchair
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment when a resident with significant physical impairments was left unattended in a hallway and subsequently fell from her wheelchair. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, type II diabetes mellitus, and muscle wasting and atrophy. After an occupational therapy session, the Occupational Therapist placed the resident in her wheelchair outside her room in the hallway and stated he informed a nurse and a CNA that the resident was in the hallway, but he did not recall whether they acknowledged this information. An IDT note documented that therapy had completed a session with the resident approximately three minutes before the incident and left her in the hallway, endorsed to a nurse who was passing medications at that time. According to interviews, LVN A reported being across the hallway when the OT placed the resident in the hallway and stated she acknowledged when the OT told her the resident was back and had been dropped off in the hallway. LVN A further stated the resident remained in the hallway for about two minutes, during which LVN A turned her back to the resident to speak to another resident in another room. CNA B reported being in another resident’s room when she heard a sound like something hitting the floor; upon checking, CNA B found the resident on the floor on her side facing away from the wheelchair, with the wheelchair tipped on its side. The DON stated that another resident, who was later discharged and unavailable for interview, had witnessed the incident and reported that the resident’s backpack hanging on the back of the wheelchair became caught, causing the wheelchair to tip. Nurse’s notes indicated the resident returned from Good Samaritan Hospital with an abrasion to the left elbow following the fall. The facility’s Resident Rights policy stated that residents are guaranteed certain basic rights, including the right to a dignified existence.
Failure to Ensure Timely Assessment, Physician Notification, and Documentation for Change in Condition and Fall Incident
Penalty
Summary
Facility staff failed to provide necessary care and services for two residents by not ensuring timely assessment, physician notification, or complete documentation during significant changes in condition and after an incident. For one resident with a history of hemiplegia, traumatic brain injury, diabetes, and memory deficits, staff did not perform a timely assessment or notify the physician when the resident complained of malaise and was subsequently transported to the hospital by his wife. Documentation was incomplete regarding the events leading up to the transfer, and the physician was not notified until several hours after the resident had already left the facility. The resident was later admitted to the hospital for suspected sepsis related to a complicated urinary tract infection, with symptoms of fever, chills, and malaise reported for several days prior to admission. For another resident with disseminated coccidioidomycosis and a thoracic spinal cord injury, staff did not notify the physician or conduct a thorough investigation after the resident experienced a fall. The clinical record and progress notes showed no evidence of physician notification following the fall, and the responsible nurse confirmed that neither the physician was notified nor the incident endorsed to the next shift. The interdisciplinary team note regarding the fall was created 11 days after the incident, and the investigation was incomplete, as not all involved staff were interviewed and there were discrepancies in the documentation of the circumstances surrounding the fall. Facility policies required prompt assessment, physician notification, and thorough documentation in the event of a change in condition or incident. However, in both cases, staff failed to follow these protocols, resulting in delayed notification and incomplete documentation. These failures were confirmed through interviews with staff and review of facility records and policies.
Failure to Accurately Assess and Care Plan for Elopement Risk
Penalty
Summary
Licensed nurses failed to accurately complete an elopement and wandering risk assessment for a resident with severe cognitive impairment and multiple diagnoses affecting cognition, including cerebral palsy, chromosomal abnormality, and developmental delay. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and there was a documented incident where the resident eloped from the facility during a shift change. However, the elopement and wandering risk assessment did not reflect the resident's diagnoses, with relevant sections left blank or incorrectly marked, and the assessment did not indicate the presence of cognitive-impacting diagnoses. Additionally, there was no care plan developed to address elopement or wandering risks for the resident, despite facility policy requiring care plans for residents identified as at risk. Both the assistant director of nursing and the licensed vocational nurse who completed the assessment confirmed that the documentation was inaccurate and incomplete. Facility policies reviewed stated that residents at risk for wandering or elopement should have care plans with strategies and interventions to maintain safety, which was not done in this case.
Failure to Update PASRR for Resident with New Mental Disorder
Penalty
Summary
The facility failed to update a Level I Preadmission Screening and Resident Review (PASRR) for a resident who was newly diagnosed with a serious mental disorder. The resident, who was admitted in 2007, had a medical history that included major depressive disorder and mood disorder, with a new diagnosis of psychotic disorder in June 2023. Despite this new diagnosis, the facility did not update the resident's PASRR Level I Screening, which was last completed in March 2022 and indicated a need for a Level II evaluation. Interviews with facility staff, including an MDS Licensed Vocational Nurse and the Director of Nursing, confirmed that an updated PASRR should have been completed following the new diagnosis. The facility's policy on admission criteria, updated in October 2024, also specified that a new PASRR should be completed for residents with new mental illness diagnoses. However, the resident's medical record showed no evidence of an updated PASRR after the diagnosis of psychotic disorder.
Failure to Ensure Accurate PASRR Screenings for Mental Disorders
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) Level I screenings accurately reflected the presence of diagnosed serious mental disorders for two residents. Resident #127 was admitted with a medical history of schizoaffective disorder and schizophrenia, and was discharged from the hospital with orders for risperidone, an antipsychotic medication. However, the initial PASRR Level I screening completed at the hospital did not indicate the presence of these serious mental disorders, despite the resident receiving psychotropic medication for schizoaffective disorder. The facility did not submit a new Level I screening after the resident remained in the facility for more than 30 days, as required. Similarly, Resident #25 was admitted with a history of multiple mental health diagnoses, including schizophrenia, major depressive disorder, bipolar disorder, anxiety disorder, and borderline personality disorder. The initial PASRR Level I screening completed at the hospital only reflected the diagnosis of schizophrenia and omitted the other mental health conditions. The facility also failed to submit a new Level I screening after the resident remained in the facility for more than 30 days, despite the initial screening's inaccuracies. Interviews with facility staff, including the Admissions Director, Medical Records Director, MDS RN, and the Director of Nursing, revealed a lack of awareness and responsibility for ensuring the accuracy of PASRR screenings. The staff acknowledged that new Level I screenings should have been completed for both residents due to the inaccuracies in the initial screenings and the residents' extended stays in the facility. The facility's policy required all new admissions and readmissions to be screened for mental disorders, but this was not effectively implemented in these cases.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey. Eight plastic containers of bleach were found with open lids, exposing their contents in various locations such as on top of garbage hampers and isolation bins outside residents' rooms. This was confirmed by the Director of Staff Development (DSD), who acknowledged that the lids should have been closed to prevent exposure. Additionally, two Certified Nursing Assistants (CNAs) were observed wearing the same gloves while moving from room to room without performing hand hygiene between tasks, which they admitted was against infection control protocols. Further observations revealed that a box of clean gloves and a bottle of hand sanitizer were placed too close to an open trash bin on a treatment cart, which was confirmed by a Licensed Vocational Nurse (LVN). Three laundry hampers with linens on top were improperly stored outside by the facility's patio, and a bin overflowing with housekeeping towels was found outside the laundry area hallway. The Environmental Director confirmed that these items should have been stored properly to prevent contamination. Additionally, a housekeeping cart contained a mix of clean and potentially contaminated items, such as empty drinking water bottles and opened gloves, which was acknowledged by the DSD as inappropriate storage. Resident 1's nasal cannula was found hanging and touching a wheelchair, which the DSD confirmed should have been stored in a mesh bag to prevent contamination. Lastly, a red pushcart with used meal trays and utensils was parked underneath a water and juice dispenser in the nursing station, which the DSD confirmed was an infection control issue. The facility's policies on hand hygiene, glove use, and standard precautions were reviewed, indicating expectations for proper infection control practices that were not adhered to in these instances.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who was admitted with diagnoses including dementia, type 2 diabetes mellitus, and essential hypertension, received quetiapine fumarate (Seroquel) without adequate indication and monitoring of specific target behaviors for its use. The resident's Minimum Data Set indicated a BIMS score of 99, showing an inability to complete the cognitive assessment. A family member requested Seroquel, which was not included in the discharge orders from the emergency room, leading to a new physician order for the medication without specifying its indication or monitoring requirements. The Licensed Vocational Nurse confirmed that the family member requested the medication, and the physician was contacted to obtain the order. The Pharmacy Consultant noted that a new admission review recommended monitoring target behaviors and side effects, but this was not documented in the medication administration record. The facility's policy on antipsychotic medication use requires documentation of the necessity and monitoring of such medications, which was not adhered to in this case.
Infection Control Breach in Covid-19 Isolation Room
Penalty
Summary
The facility failed to adhere to infection prevention practices for a resident in a Covid-19 isolation room. During an observation, it was noted that the door to the isolation room was open, contrary to infection control guidelines. The resident in question was admitted with acute pulmonary edema and acute and chronic respiratory failure with hypoxia, and was confirmed Covid-19 positive on the day of the observation. A Licensed Vocational Nurse confirmed the resident's Covid-19 status and acknowledged that the door should have been closed. The Infection Preventionist also stated that the door should remain closed to contain the infection, aligning with CDC guidelines that require the door of a room with a suspected or confirmed SARS-CoV-2 infection to be kept closed.
Inadequate Infection Control Practices for Emergency Crash Carts
Penalty
Summary
The facility failed to implement proper infection control practices for three out of four emergency crash carts. Specifically, crash carts B and C contained oropharyngeal airway (OPA) kits that were not stored in their original packaging and lacked labels indicating shelf-life expectancy or expiration dates. During an observation with the Director of Nursing and the Infection Control Preventionist Nurse (ICPN), it was confirmed that the OPAs were stored in plastic bags without proper labeling. The Central Supply (CS) staff acknowledged that the OPAs had been stored improperly for some time and could not locate the original packaging. Additionally, crash cart A contained OPAs stored in plastic bags with a yellowish substance and no expiration date. The ICPN confirmed the presence of the substance and the lack of labeling. Furthermore, crash carts B and C contained a Yankauer suction tip and an adult nasal oxygen cannula, both without shelf-life expectancy or expiration dates. The facility's policy required that emergency carts be maintained with a checklist and that medical supplies be replaced as needed if packaging was compromised, but these protocols were not followed.
Failure to Conduct Thorough Investigations of Resident Altercations
Penalty
Summary
The facility failed to conduct thorough investigations and report the outcomes for several alleged altercations involving residents. Specifically, the investigation summaries for altercations between Residents 2 and 3, Residents 1 and 2, and Residents 4 and 5 did not indicate whether the facility was able to determine if the altercations occurred. During interviews and record reviews, it was confirmed that there were no conclusions documented for these incidents, indicating a lack of thoroughness in the investigation process. The facility's administrator acknowledged that the 5-day follow-up investigations were not thorough or clear, and they did not adhere to the facility's policy and procedure for abuse reporting and investigation. The policy requires that all reports of resident abuse be thoroughly investigated and documented, with findings reported to local, state, and federal agencies. However, the facility's follow-up investigation reports failed to provide sufficient information to describe the results of the investigations or indicate any corrective actions taken if the allegations were verified.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to ensure that three residents were kept free from constipation due to not following physician orders for bowel management interventions. Resident 8, who had diagnoses including hemiplegia, metabolic encephalopathy, constipation, and dementia, did not have a bowel movement from May 9 to May 12, 2024. Despite physician orders for Milk of Magnesia (MOM), Bisacodyl suppository, and Fleet enema, these interventions were not administered as prescribed. MOM was not given from May 1 to May 16, and Bisacodyl and Fleet enema were delayed or improperly administered. Resident 9, diagnosed with dementia and requiring assistance with personal care, experienced constipation episodes from May 5 to May 9, May 14 to May 17, and May 24 to May 27, 2024. The physician orders included MOM, mineral oil enema, and Bisacodyl suppository, but none of these were administered throughout May 2024. Similarly, Resident 10, with conditions such as anemia, atrial fibrillation, and chronic systolic heart failure, did not have bowel movements from May 26 to May 29, 2024. Despite having orders for MOM, Fleet enema, and Bisacodyl suppository, these were not given during May 2024. Interviews with facility staff revealed a lack of adherence to the bowel management protocol. Licensed Vocational Nurse A acknowledged that residents should be considered constipated after 48 hours without a bowel movement and that MOM should be administered first, followed by other interventions if necessary. However, the MARs did not reflect the administration of these medications. The Director of Nursing confirmed that CNAs report bowel movements in the electronic health record, and nurses are responsible for checking and following up with the constipation protocol. The facility's policy indicated that the nurse should review records daily and administer medication as ordered, which was not followed in these cases.
Failure to Inform Responsible Party of Resident's Appointment
Penalty
Summary
The Social Service Director (SSD) at the facility failed to inform the responsible party (RP) of a resident about the resident's appointment with a psychologist. This oversight was identified during an interview and record review, where it was found that the SSD did not document the communication of the appointment date to the RP in the social service notes. The SSD acknowledged the lapse in documentation, which is crucial for ensuring that the RP can participate in the resident's treatment decisions. The resident involved had multiple complex medical conditions, including Hemiplegia and Hemiparesis following a cerebral infarction, aphasia, dementia, Parkinsonism, major depressive disorder, and bipolar disorder. The resident was not self-responsible and had a designated RP to make decisions on their behalf. Despite receiving verbal permission from the RP to sign consent for a psychological evaluation, the SSD did not document informing the RP about the psychologist's appointment date, which led to the RP being unable to attend the session.
Use of Space Heater in Rehabilitation Room
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident when a space heater was used in the rehabilitation room. This deficiency was identified during an interview with a resident who reported that the therapy staff could not turn up the space heater, and she was not allowed to have a space heater or heating pad, while the rehabilitation staff used a space heater. The resident mentioned that the space heater had been in use for six months due to a malfunctioning heating unit, which left the rehabilitation room cold without it. During a facility tour, a space heater was observed plugged in and turned on under a desk in the rehabilitation room. The rehabilitation staff confirmed the use of the space heater for four to six months due to issues with the facility's heating and cooling system. The Director of Nursing acknowledged the observation and removed the space heater, stating that staff could not use it. The Maintenance Supervisor confirmed that space heaters were not allowed and could not provide maintenance logs for the heating and cooling system. The facility's policy indicated that residents should be provided with a safe, clean, comfortable, and homelike environment.
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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