Yuba City Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Yuba City, California.
- Location
- 1220 Plumas St, Yuba City, California 95991
- CMS Provider Number
- 055092
- Inspections on file
- 28
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Yuba City Post Acute during CMS and state inspections, most recent first.
A facility failed to report an incident where a family member exposed himself to a resident in a shared room. The resident, who was cognitively intact, felt uncomfortable but did not perceive it as abuse. Despite the facility's policy requiring all abuse reports to be filed with authorities, no report was made, placing all residents at risk for unreported abuse allegations.
The facility failed to provide adequate nursing staff, resulting in unanswered call lights and delayed assistance for residents. This affected residents with varying cognitive and physical needs, leading to incidents such as prolonged waits for assistance, being left in soiled briefs, and delayed pain management. Interviews revealed that staff breaks often left call lights unanswered, impacting residents' well-being.
Two residents in a facility experienced medication regimen review deficiencies. One resident was prescribed Seroquel without proper evaluation by the Psychotropic IDT, and it was combined with donepezil, potentially causing adverse effects. Another resident received oxybutynin ER instead of the ordered IR formula, leading to potential medication build-up. The facility's policies for medication reviews were not adequately followed, resulting in unreported medication irregularities.
A facility failed to maintain a medication error rate below 5 percent, with errors involving two residents. One resident received the wrong formulation of oxybutynin over several months, while another did not receive pain medication despite expressing severe pain. The errors were due to incorrect administration and failure to follow pain assessment protocols.
The facility failed to properly store and label medications, leading to several deficiencies. Discontinued medications were not removed, and unlabeled medicated creams were found in treatment carts. A used syringe was improperly stored, and expired medications were administered. Additionally, an unlicensed staff member had access to the locked Medication Room, posing risks of medication misuse and drug diversion.
The facility's food services failed to provide palatable meals, with residents frequently receiving cold and unappetizing food. Multiple residents, including those with cognitive impairments and medical conditions like diabetes and COPD, reported dissatisfaction with the meals' temperature and taste. A taste test confirmed the food was served below the expected temperature, and staff were unaware of the residents' complaints, indicating a failure to adhere to the facility's meal service policy.
The facility failed to provide adequate supervision for residents with wandering and agitated behaviors, impacting safety and privacy. A resident with Down syndrome and another with Alzheimer's disease frequently wandered into other rooms without proper care plans. Additionally, a resident with severe cognitive impairment exhibited agitation by throwing items, yet no interventions were documented. Staff were aware of these behaviors, but the DON was not informed, leading to a lack of appropriate interventions.
The facility failed to update care plans for two residents with wandering behaviors, despite reports from other residents and staff observations. Resident 34, with seizures and Down syndrome, and Resident 50, with Alzheimer's and other conditions, wandered into other residents' rooms, causing disturbances. The care plans lacked interventions for these behaviors, and the DON was unaware of the specific incidents, contrary to facility policy requiring care plan revisions when resident information changes.
A resident with dementia and multiple fractures did not receive adequate pain management due to the facility's reliance on a numeric pain scale, which the resident could not consistently use. Despite showing clear signs of pain, the resident was not administered prescribed pain medication, as staff failed to utilize the PAINAD scale for nonverbal pain assessment. Additionally, the facility did not notify the physician about the resident's frequent refusal of pain medications, leading to a deficiency in pain management.
A facility failed to review and attempt Gradual Dose Reduction (GDR) for a resident on four psychotropic medications for 50 days. The resident, admitted with Alzheimer's dementia and other conditions, was on hospice care and unable to make healthcare decisions. Despite policies requiring monthly medication reviews, the resident's medications had not been reviewed by the Psychotropic IDT since admission. The facility's staff acknowledged the need for a review, but it had not been conducted, potentially leading to adverse side effects.
A facility failed to honor a resident's food preferences and did not serve accurate portion sizes. A resident reported being served disliked food, and dietary records confirmed the oversight. Additionally, during meal service, fish portions were not consistently weighed, leading to inaccurate serving sizes. Staff acknowledged the failure to ensure correct portions.
The facility failed to maintain kitchen equipment in good repair, with pots and fry pans showing black buildup and missing protective layers, confirmed by the CDM. The facility's sanitation policy was not followed, and although new equipment was reportedly ordered, documentation did not confirm timely action.
A facility failed to report an abuse allegation involving two cognitively impaired residents to the appropriate authorities. One resident made verbal threats and gestures towards another, but the incident was not communicated to local, state, and federal agencies as required. The Director of Nursing was unaware of the incident until informed by CDPH staff, highlighting a lapse in the facility's internal reporting process.
Failure to Report Incident of Exposure by Family Member
Penalty
Summary
The facility failed to report an incident of potential abuse involving a resident and a family member of another resident. The incident occurred when a family member of another resident exposed himself to a resident in their shared room. The resident, who was cognitively intact and capable of making their own medical decisions, reported feeling uncomfortable but did not perceive the incident as abuse. Despite the resident's feelings, the facility's policy required all reports of abuse or mistreatment to be promptly reported to local, state, and federal agencies, which was not done in this case. Interviews with the Social Services Director and the Administrator confirmed awareness of the incident. The Social Services Director had interviewed both the resident and the family member involved, and the resident expressed a desire to be discharged from the facility. The Administrator confirmed that the investigation was complete, and no report was filed because the resident did not wish to pursue the matter or consider it abuse. This inaction was contrary to the facility's policy and placed all residents at risk for unreported allegations of abuse.
Inadequate Staffing Leads to Unanswered Call Lights
Penalty
Summary
The facility failed to provide sufficient and qualified nursing staff to meet the needs of residents, resulting in unanswered call lights and delayed assistance. This deficiency affected 11 out of 30 residents, including those with severe cognitive impairments and those who are cognitively intact but require assistance due to physical limitations. Residents reported waiting for extended periods, sometimes up to two hours, for staff to respond to their call lights, leading to situations where they were left in soiled briefs, on the toilet, or in bed without necessary assistance. Specific incidents included Resident 28, who has severe cognitive impairment, waiting 30 minutes for assistance while on the toilet, and Resident 215, who is cognitively intact, experiencing regular delays of 30 minutes or more for call light responses. Resident 45 reported waiting two hours for assistance, resulting in urination accidents, while Resident 57, who has a history of falls, waited 45 minutes for pain medication. Resident 365, who requires oxygen management, waited 40 minutes for assistance during a breathing issue, highlighting the critical nature of timely staff response. Interviews with residents and resident council members revealed that staff breaks often left call lights unanswered, with entire shifts taking breaks simultaneously, leaving only the medication cart nurse available. This practice contributed to the delays in responding to residents' needs, impacting their physical, mental, and psychosocial well-being. The facility's policies and job descriptions emphasize prompt response to call lights, yet these were not adhered to, resulting in significant deficiencies in care.
Medication Regimen Review Deficiencies
Penalty
Summary
The facility failed to ensure complete Medication Regimen Reviews (MRR) for two residents, leading to potential medication irregularities and adverse effects. For one resident, the use of Seroquel, a psychotropic medication, was deemed appropriate by the Consultant Pharmacist (CPH) despite the lack of evaluation by the Psychotropic Interdisciplinary Team (IDT) 50 days after admission. The resident was receiving Seroquel in combination with donepezil, which could reduce the effectiveness of donepezil and cause nervous system side effects. The CPH did not report any medication irregularities, and the resident's medication regimen was not reviewed for potential adverse effects or the necessity of the psychotropic medication. Another resident received oxybutynin extended-release (ER) tablets instead of the immediate-release (IR) formula ordered by the Medical Director. This error went undetected and unreported by the CPH, resulting in the resident receiving a longer-lasting dose of oxybutynin, which could lead to adverse effects from excessive medication build-up. The error was identified during a medication administration observation, and the CPH acknowledged the mistake, noting that the ER formula should have been questioned by the in-house pharmacists. The facility's policies and procedures for medication regimen reviews and antipsychotic medication use were not adequately followed. The Consultant Pharmacist and other healthcare professionals involved in the medication review process did not identify or address the medication irregularities, leading to potential harm to the residents' physical, mental, and psychosocial well-being. The lack of timely and thorough medication reviews contributed to the deficiencies observed in the care of these residents.
Medication Errors and Pain Management Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors identified out of 29 opportunities, resulting in a 6.9 percent error rate. For Resident 25, a Licensed Nurse (LN D) administered oxybutynin extended-release (ER) 5 mg tablets instead of the prescribed oxybutynin chloride immediate-release (IR) 5 mg tablets. This error occurred over a period from June to August, with the ER formula being administered 83 times in August alone. The error was confirmed by the Registered Pharmacist and the Consultant Pharmacist, who noted that the ER formula should only be given once daily, not three times a day as it was administered. For Resident 216, LN D failed to administer scheduled or as-needed pain medications despite the resident expressing a pain level of 10 on a scale of 1 to 10. The resident, who had multiple diagnoses including muscle weakness, repeated falls, and rib fractures, was observed in pain but did not receive any pain medication. LN D did not administer oxycodone, the available pain medication, because the resident could not articulate a pain scale, and LN D did not believe the resident was in pain. Additionally, the resident had refused lidocaine patches and Tylenol on several occasions, but this was not communicated to the physician as required by the facility's policy. The Director of Nursing (DON) acknowledged the medication errors and expressed frustration over the nursing staff's failure to recognize nonverbal indications of pain in Resident 216. The facility's policies on administering medications and pain assessment were not followed, contributing to the deficiencies observed. The report highlights the need for adherence to medication orders and proper pain assessment protocols to prevent such errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and supplies, leading to several deficiencies. Discontinued medications were not removed from active medication areas, as observed with potassium chloride packets in Medication Cart A. Additionally, six multi-dose tubes of non-controlled medicated creams were found in Treatment Cart 1 without patient-specific labeling, posing a risk of administering medications without a physician's order. A used oral medication syringe was improperly stored with a bottle of liquid Keppra, raising concerns about infection control. Further deficiencies were noted with an open and undated bottle of glucose test strips, which should have been labeled with an 'Opened on' date to ensure effectiveness. Loose pills were found in Medication Cart A, creating a risk for medication diversion. An expired bottle of ketoconazole shampoo was being used on a resident, and an expired IV line filter was found in Treatment Cart 2, both of which should have been discarded to maintain medication effectiveness and safety. The report also highlighted a security issue where the Housekeeping Supervisor, an unlicensed staff member, had access to the locked Medication Room, which contained emergency medication kits and potentially hazardous medications. This access was against the facility's policy, which states that only authorized personnel should have access to locked medications. These failures collectively posed risks of medication misuse, drug diversion, and exposure to harmful pathogens for all 58 residents.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility's food and nutrition services department failed to provide palatable meals to residents, as evidenced by multiple complaints about the temperature and taste of the food. Observations and interviews revealed that residents frequently received meals that were cold and unappetizing. During a taste test, the Certified Dietary Manager and Registered Dietician found that the food items, such as French fries and pureed fish, were served at temperatures below the expected standard for hot meals, confirming the residents' complaints. Several residents, including those with cognitive impairments and various medical conditions such as diabetes, COPD, and dysphagia, reported dissatisfaction with the meals. They described the food as cold, tasteless, and visually unappealing. Some residents compared the food to hospital meals and expressed frustration over the lack of variety and excessive salt. The dissatisfaction was not limited to individual residents, as a confidential interview with Resident Council members echoed similar concerns about the quality and temperature of the meals. The facility's policy on meal service emphasized the importance of serving hot food hot and cold food cold, yet the staff, including the Food Service Support, Certified Dietary Manager, and Registered Dietician, were unaware of the residents' dissatisfaction. This lack of awareness and failure to adhere to the facility's meal service policy contributed to the deficiency, potentially leading to unintended weight loss among residents.
Inadequate Supervision and Care Planning for Wandering and Agitated Residents
Penalty
Summary
The facility failed to provide adequate supervision for three residents who exhibited wandering and agitated behaviors, leading to potential safety and privacy concerns. Resident 34, diagnosed with seizures, Down syndrome, and developmental disorder of speech and language, was observed wandering into other residents' rooms without a care plan addressing this behavior. Interviews with other residents confirmed that Resident 34's wandering was a frequent occurrence, causing discomfort and requiring staff intervention. Despite awareness of this behavior, the Director of Nursing (DON) was not informed, and no interventions were documented in the care plan. Resident 50, with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, also wandered into other residents' rooms. Although the care plan mentioned elopement, it lacked specific interventions for when Resident 50 intruded on others' privacy. Interviews revealed that Resident 50's behavior was bothersome to roommates and other residents, with one resident expressing a threat of harm if the behavior continued. Staff confirmed the wandering behavior but were unaware of any care plans or interventions to address it. Resident 28, with severe cognitive impairment and a history of agitation, was observed throwing items in the hallway. Despite staff awareness of Resident 28's behaviors, there was no care plan detailing interventions for managing increased agitation and poor impulse control. Interviews with staff and residents indicated that Resident 28's behavior was a regular occurrence, yet the DON was not informed, and no interventions were in place to ensure the safety and well-being of other residents.
Failure to Revise Care Plans for Wandering Behaviors
Penalty
Summary
The facility failed to revise care plans for two residents, Residents 34 and 50, to address their wandering behaviors. Resident 34, who was admitted with diagnoses of seizures and Down syndrome, was observed by other residents to wander into their rooms, causing disturbances. Despite these observations, Resident 34's care plan did not include any interventions for wandering behavior, as confirmed by the Director of Nursing (DON) during a review. Resident 50, diagnosed with Alzheimer's disease, anxiety, depression, and obsessive-compulsive disorder, also exhibited wandering behaviors. Although Resident 50's care plan included an elopement risk, it did not address the resident's tendency to wander into other residents' rooms. This behavior was reported by other residents, including Resident 48, who expressed discomfort and threatened harm if the behavior continued. Staff interviews confirmed awareness of the wandering behaviors but revealed a lack of specific interventions in the care plans. The facility's policy required care plans to be revised when resident information changed, but this was not done for Residents 34 and 50. The DON was unaware of the specific wandering incidents and stated that staff should have reported these changes to her for care plan revision. The failure to update the care plans placed the residents at risk for harm and potentially affected their physical, mental, and psychosocial well-being.
Inadequate Pain Management for Resident with Dementia
Penalty
Summary
The facility failed to manage the pain of Resident 216, who was admitted with fractured lumbar vertebrae, multiple fractured ribs, COPD, and dementia. Despite exhibiting clear signs of pain, such as grimacing, frowning, and rocking in a wheelchair, Resident 216 did not receive appropriate pain medication. The resident was unable to verbalize a specific number on the pain scale due to severe cognitive impairment, which led to the failure to administer pain medication as per the medical doctor's orders. During observations and interviews, it was noted that Resident 216 was in visible discomfort, holding their ribs and exhibiting facial expressions indicative of pain. Licensed nurses repeatedly asked the resident to rate their pain on a numeric scale, but the resident struggled to provide a consistent response. Despite acknowledging the resident's pain, the nurses did not administer the prescribed Oxycodone, as they relied solely on the numeric pain scale and did not utilize alternative assessment tools suitable for residents with dementia. The facility's policy on pain assessment and management was not followed, as the staff failed to use the Pain Assessment in Advanced Dementia (PAINAD) scale, which considers nonverbal cues such as facial expressions and body language. Additionally, the staff did not notify the physician about the resident's frequent refusal of pain medications, as required by the facility's policy on changes in a resident's condition or status. This oversight resulted in inadequate pain management for Resident 216.
Failure to Review Psychotropic Medications and Attempt GDR
Penalty
Summary
The facility failed to review indications for continued use or attempt Gradual Dose Reduction (GDR) for a resident receiving four psychotropic medications for 50 days. The resident, who was admitted with Alzheimer's dementia, mood disturbance, and other conditions, was on hospice care and unable to make healthcare decisions. The medications included lorazepam, Seroquel, trazodone, and sertraline, which were prescribed for anxiety, mood disorder, insomnia, and OCD, respectively. Despite the facility's policy requiring monthly medication reviews, the resident's psychotropic medications had not been reviewed by the Psychotropic Interdisciplinary Team (IDT) since admission. The facility's policies and procedures outlined the need for regular medication regimen reviews to ensure appropriate indications, dosages, and durations of use. However, the Consultant Pharmacist's review in July and August did not result in any recommendations for changes, and the Medical Director was on vacation during August, missing the monthly review. Interviews with staff revealed that the resident's aggressive behaviors had improved, but the Psychotropic IDT had not yet evaluated the need for GDR or the appropriateness of the medications. The Director of Nursing acknowledged that the indication for Seroquel was based on hospice orders and that the Psychotropic IDT would review the medication regimen in October. Despite the resident's improved behavior, the facility had not performed a GDR or reviewed the psychotropic medications for unnecessary use. The report highlights the lack of timely medication review and GDR attempts, which could potentially lead to adverse side effects for the resident.
Failure to Honor Food Preferences and Serve Accurate Portions
Penalty
Summary
The facility failed to honor a resident's food preferences and did not serve accurate portion sizes, leading to potential health impacts. One resident, who was cognitively intact and had a history of gastro-esophageal reflux disease and major depressive disorder, reported that the facility continued to serve broccoli despite their documented dislike for it. The facility's dietary records confirmed that the resident's food preferences were not reflected on meal tickets, indicating a failure to honor the resident's food choices as per the facility's policy. Additionally, during a meal service observation, the facility did not provide the correct portion size of fish to residents. The Certified Dietary Manager instructed staff to weigh the fish portions, but the staff member did not consistently use a scale, resulting in varying portion sizes. The Registered Dietician and Certified Dietary Manager acknowledged that without weighing each portion, there was no assurance that residents received the accurate portion size of three ounces as required by the facility's policy.
Deficient Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain kitchen equipment in good repair, as observed during a survey. The pots and fry pans in the kitchen had a black buildup on the outside, and the protective layer on the inside of the fry pans was missing, exposing the metal. Additionally, one fry pan had a thick, black residue on the inside where food was cooked. This condition was confirmed by the Certified Dietary Manager (CDM) during an observation and interview. The facility's policy and procedure on sanitation required all equipment to be kept clean and in good repair, which was not adhered to in this instance. The CDM stated that new pots and pans had been ordered the previous week, but the provided email, dated the same day as the observation, did not include a date indicating when the order was placed. This discrepancy suggests a lack of timely action to address the equipment's poor condition, which had the potential to contaminate food and negatively impact resident health.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the appropriate local, state, and federal agencies, including the California Department of Public Health (CDPH). The incident involved a Certified Nurse Assistant (CNA) observing one resident making verbal threats and shaking a fist at another resident. Despite the incident being reported to a Licensed Nurse (LN) and subsequently to the Director of Nursing (DON), the allegation was not communicated to the necessary authorities as required by the facility's policy and procedure on abuse investigation and reporting. The residents involved had significant cognitive impairments and were not responsible for their own decisions. One resident, who was on hospice care, was reported to have been touching the other resident, which led to the altercation. The facility's failure to report the incident placed all residents at risk for unreported abuse allegations. The DON was not made aware of the incident until it was brought to attention by CDPH staff, indicating a breakdown in the facility's internal reporting process.
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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