Alden Terrace Convalescent Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1240 S Hoover St, Los Angeles, California 90006
- CMS Provider Number
- 056237
- Inspections on file
- 23
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Alden Terrace Convalescent Hospital during CMS and state inspections, most recent first.
A resident alleged being hit on the shoulder by another resident, resulting in pain and limited arm movement. Although the incident was witnessed by an OT and assessed by nursing staff, the facility did not report the abuse allegation to the state survey agency within the required two-hour timeframe, as mandated by facility policy.
A resident with epilepsy experienced a seizure, and the facility failed to monitor the resident during the night shift as ordered by the NP. The resident's care plan required monitoring for seizure activity and vital signs, but no documentation or vital signs were recorded during the night shift, contrary to facility policy.
A facility failed to accurately document seizure activity for a resident with epilepsy and diabetes. The MAR incorrectly showed a seizure during a night shift due to an LVN's documentation error, despite confirmation from the LVN and an RN supervisor that no seizure occurred. This resulted in an incomplete and inaccurate medical record, violating the facility's documentation policy.
The facility failed to maintain the dignity of two residents by referring to them as 'feeders' due to their need for feeding assistance. Staff, including an LVN, RNA, and CNA, used this term as part of the RNA feeding program, despite acknowledging it as disrespectful. Both residents required substantial assistance with daily activities, including eating, and were observed being fed while being labeled as 'feeders.' The facility's policy emphasized treating residents with respect and addressing them by their proper names, which was not followed in these cases.
The facility failed to maintain updated advance directives for three residents, resulting in incomplete acknowledgment forms lacking necessary signatures from representatives. These residents, with conditions such as dementia and COPD, had impaired cognition and required assistance with daily activities. The Social Services Director acknowledged the process but did not ensure compliance with facility policy.
The facility failed to maintain safe food storage and sanitation practices, with expired mixed fruits in the refrigerator, stained cups stored as clean, and improper use of kitchen towels. These actions risked cross-contamination and foodborne illness for residents.
A resident's urinary catheter was not anchored as per physician's orders, risking discomfort and dislodgement. Despite the resident's medical conditions requiring careful catheter management, observations showed the catheter unsecured for several days. Staff acknowledged the oversight, which contradicted facility policy and CDC guidelines.
A facility failed to label a resident's nasal cannula with the date, time, and initials, as required by their oxygen administration policy. The resident, with conditions such as dementia and peripheral vascular disease, had orders for oxygen at 2 lpm for shortness of breath. An LVN confirmed the tubing was unlabeled, and the DON stated it should be changed weekly and labeled to prevent infection.
The facility failed to maintain sanitary conditions in the dumpster area, with one dumpster overfilled and uncovered, and trash littering the surrounding area. This was observed during an interview with the Dietary Supervisor, who acknowledged the need for proper trash management. The Maintenance Supervisor confirmed daily cleaning routines, emphasizing the importance of covering trash to prevent pest attraction. Facility policy and FDA guidelines require dumpsters to be closed and free of litter.
A resident's urinal was improperly placed on an oxygen concentrator, touching the oxygen tubing, which violated the facility's infection control policy. This was confirmed by a family member and an LVN, who acknowledged the infection control risk. The resident had a history of dementia and required oxygen for shortness of breath.
A facility failed to notify a resident's designated healthcare decision maker before discharging the resident to a friend's home. Despite attempts to contact the decision maker, the facility proceeded with the discharge based on information from another family member. The primary physician was not informed about the inability to reach the decision maker, contrary to the facility's policy.
A facility failed to provide correct information in a Notice of Proposed Transfer and Discharge for a resident, listing the wrong agency for discharge appeals and omitting the reason for discharge. The resident, with diagnoses including diabetes and vascular dementia, was cognitively intact and required supervision for daily activities. The Care Plan indicated discharge due to improved health, but this was not reflected in the Notice.
A facility failed to isolate a resident suspected of having scabies and did not ensure staff wore PPE, leading to potential infection spread. The resident, showing symptoms, was not isolated from roommates, and staff did not use PPE during care. The Infection Preventionist Nurse confirmed the oversight, and the Director of Nursing acknowledged the care plan was not implemented, violating the facility's scabies prevention policy.
A resident with scabies was not isolated as per the care plan, leading to a deficiency in care. Despite orders for isolation when Elimite was applied, the resident was placed with roommates, and staff did not use PPE. The resident showed signs of scabies, but the facility's policy did not require isolation for prophylactic treatment, resulting in a failure to implement the care plan.
A resident with a history of diabetes and other health issues developed fluid-filled blisters on their left arm, which were not properly assessed or documented by the facility's staff. Despite signs of infection, the wound care specialist was not informed of the resident's diabetes or the presence of drainage. The care plan was delayed, and the resident was eventually hospitalized for cellulitis and sepsis, highlighting deficiencies in documentation and communication.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow and implement its abuse policy for one of three sampled residents after an allegation of abuse was made. On 3/15/25, a resident reported that another resident hit her on the left shoulder, resulting in pain and limited movement of her left arm. The incident was witnessed by an occupational therapist, who intervened and informed the second resident to use the resident's name instead of tapping her. The registered nurse supervisor was notified and assessed the resident, finding no bruising or discoloration, but the resident continued to complain of pain. The nurse practitioner was notified, and orders for pain management and an x-ray were given, with the x-ray result being negative. Despite the resident's allegation of being hit and subsequent pain, the facility did not report the allegation of abuse to the state survey agency within two hours as required by their policy. Interviews with staff, including the assistant director of staff development, confirmed that the facility's policy mandates reporting any abuse allegations to the administrator and the state agency within two hours of awareness. However, the director of nursing and administrator stated they did not report the incident because the occupational therapist witnessed the event and determined that no abuse occurred. The facility's policy on abuse and mistreatment requires reporting all alleged and substantiated violations to the state agency and taking necessary corrective actions based on the investigation results. In this case, the failure to report the allegation in a timely manner constituted a deficiency in following established abuse reporting protocols, regardless of the staff's assessment of the situation.
Failure to Monitor Resident After Seizure
Penalty
Summary
The facility failed to monitor a resident who experienced a change in condition, specifically a seizure, in accordance with professional standards of practice. The resident, who had a history of epilepsy and diabetes mellitus, experienced a petit mal seizure lasting approximately 30 seconds. Following the seizure, the resident's nurse practitioner was notified and gave orders to continue monitoring the resident. However, during the night shift, the facility did not take the resident's vital signs or document any monitoring activities, which was a deviation from the facility's policy on managing changes in condition. The resident's care plan, initiated on the day of the seizure, included goals and interventions to observe for seizure activity and notify the physician as needed. Despite this, the director of staff development confirmed that no vital signs were taken, and no nursing documentation was completed during the night shift. The facility's policy required documentation of vital signs each shift and reassessment of the resident's condition as needed, which was not adhered to in this instance.
Inaccurate Documentation of Seizure Activity
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, specifically regarding the monitoring and documentation of seizure activity. The resident, who had a history of epilepsy and diabetes mellitus, was supposed to be monitored for seizures every shift, with the results documented in the Medication Administration Record (MAR). On a specific date, the MAR incorrectly indicated that the resident experienced a seizure during the night shift, as a result of a documentation error by a licensed vocational nurse (LVN). Upon review, both the LVN and a registered nurse supervisor confirmed that the resident did not have a seizure on the night in question. The LVN admitted to mistakenly entering the wrong information in the MAR, which should have indicated no seizure activity. This error led to an incomplete and inaccurate medical record for the resident, contrary to the facility's policy that requires documentation to be objective, complete, and accurate.
Residents Referred to as 'Feeders' Compromises Dignity
Penalty
Summary
The facility failed to ensure that staff did not refer to residents requiring assistance with feeding as 'feeders,' which compromised the dignity and respect of the residents involved. Specifically, two residents, identified as Residents 101 and 114, were referred to as 'feeders' by various staff members, including a Licensed Vocational Nurse (LVN), a Restorative Nursing Assistant (RNA), and a Certified Nursing Assistant (CNA). This terminology was used because these residents were part of the RNA feeding program, which grouped residents needing feeding assistance together. The use of the term 'feeder' was acknowledged by staff as disrespectful, and it was noted that residents should be treated with respect and dignity. Resident 114 was admitted with diagnoses including adult failure to thrive, chronic obstructive pulmonary disease, hypertension, and muscle weakness, and required substantial assistance with daily activities, including eating. Similarly, Resident 101, who had diagnoses of hypertension and depression, also required maximal assistance with eating and other daily activities. Observations during meal times confirmed that these residents were assisted with feeding while being referred to as 'feeders.' The facility's policy on dignity emphasized treating residents with respect and addressing them by their proper names, which was not adhered to in these instances.
Failure to Maintain Updated Advance Directives
Penalty
Summary
The facility failed to ensure that the advance directives for three residents were complete and updated, which is a violation of the residents' rights to have their medical treatment wishes honored. Specifically, the facility did not maintain an accurate and current copy of the residents' advance directives in their clinical records. This deficiency was identified for three out of four sampled residents, who had various medical conditions including dementia, chronic obstructive pulmonary disease, hypertension, and muscle weakness. The Minimum Data Set (MDS) assessments indicated that these residents had impaired cognition and required assistance with activities of daily living. During an interview, the Social Services Director (SSD) explained the process for obtaining signatures on advance directive acknowledgment forms, which involves the resident's representative and the resident's physician. However, the review revealed that the acknowledgment forms for the three residents lacked the necessary signatures from their representatives. The facility's policy requires that the SSD or designee inquire about the existence of any written advance directives upon admission, but this was not adequately followed, leading to the deficiency.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Thirteen small containers of previously prepared mixed fruits were found in the walk-in refrigerator with an expired use-by date. The cook acknowledged that the fruits were prepared for a previous date and should have been discarded to prevent serving expired food to residents. The Dietary Supervisor confirmed that food should be labeled and dated, and expired items should be discarded according to the facility's policy. Additionally, clean resident cups stored on racks were observed with red color stains, which were identified as thickened cranberry juice stains. The Registered Dietitian stated that the cups should have been rewashed and not placed on racks for air drying, as they could cross-contaminate resident beverages. The Dishwasher admitted that the cup was missed during the checking process, which goes against the facility's policy and procedures for dishwashing and sanitizing equipment and surfaces. Furthermore, wet kitchen wiping cloths were improperly stored on kitchen counters and reused to clean food contact surfaces and equipment. Dietary Aides were observed using the same cloths to clean different surfaces without returning them to a sanitizer solution, as required by the facility's policy. The Registered Dietitian confirmed that kitchen towels should be stored in a sanitizer solution when not in use to prevent cross-contamination, aligning with the U.S. Food and Drug Administration Food Code requirements.
Failure to Anchor Urinary Catheter
Penalty
Summary
The facility failed to properly anchor a urinary catheter for a resident, as per the physician's order, which could lead to discomfort and potential dislodgement. The resident, who was readmitted with conditions including benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary retention, had a physician's order to secure the urinary catheter tubing daily to minimize dislodgement. However, during an observation, it was noted that the catheter was not anchored to the resident's leg, and the resident confirmed it had not been secured for the past two or three days. Further observations and interviews revealed that the catheter was not anchored, and the treatment nurse acknowledged the absence of an anchor, stating it should be in place to prevent dislodgement or tugging. The Director of Nursing also confirmed that the catheter should be anchored to prevent pain and ensure it remains in place. The facility's policy and CDC guidelines emphasize the importance of securing catheters to prevent complications, but these were not followed in this instance.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not labeling the nasal cannula with the date, time, and initials as per the facility's policy on oxygen administration. This oversight was observed during a survey, where the nasal cannula attached to the resident's oxygen concentrator was found undated and exposed to air. The resident, who had been readmitted to the facility with diagnoses including dementia, cerebral aneurysm, and peripheral vascular disease, had physician orders for oxygen administration at 2 liters per minute via nasal cannula as needed for shortness of breath. During interviews, a Licensed Vocational Nurse (LVN) confirmed that the oxygen tubing was not labeled and could not specify when it was attached to the concentrator. The Director of Nursing (DON) stated that oxygen tubing should be changed weekly and labeled to prevent infection. The facility's policy indicated that oxygen equipment should be dated and stored in a clean bag when not in use. The failure to label the nasal cannula had the potential to cause complications associated with oxygen therapy, including infection.
Improper Trash Disposal and Sanitation
Penalty
Summary
The facility failed to maintain the trash stored in the dumpster areas in a sanitary manner. During an observation and interview with the Dietary Supervisor, it was noted that one of the two garbage dumpsters outside the kitchen was overfilled with cardboard boxes and left uncovered. Additionally, the surrounding floor area was littered with various trash items, including plastic utensils, gloves, plastic bags, disposable lunch trays, plates, and a resident meal ticket. This situation was identified as having the potential to attract pests. The Dietary Supervisor acknowledged that the cardboard boxes should be flattened to fit in the dumpster, allowing the lids to close properly. The Maintenance Supervisor confirmed that the housekeeping staff is responsible for cleaning the trash on the floor daily at 2 pm and emphasized the importance of keeping the trash covered to prevent pests. The facility's policy, as well as the FDA Food Code, both require that outside dumpsters be kept closed and free of surrounding litter to prevent access by insects and rodents.
Improper Placement of Urinal on Oxygen Concentrator
Penalty
Summary
The facility failed to implement its infection control policy and procedures by allowing a urinal to be improperly placed on an oxygen concentrator, which was in contact with the oxygen tubing for a resident. This practice was observed during a survey and was confirmed by both a family member and a Licensed Vocational Nurse (LVN). The LVN acknowledged that the urinal should not have been touching the oxygen tubing or the concentrator, as it posed an infection control issue that could lead to respiratory infections. The resident involved had a medical history that included dementia, cerebral aneurysm, occlusion and stenosis of the carotid artery, and peripheral vascular disease. The resident required oxygen administration at 2 liters per minute via nasal cannula as needed for shortness of breath. The facility's infection control policy, reviewed earlier in the year, emphasized maintaining a safe and sanitary environment to prevent disease transmission, which was not adhered to in this instance.
Failure to Notify Healthcare Decision Maker Before Resident Discharge
Penalty
Summary
The facility failed to notify the designated healthcare decision maker for a resident regarding the resident's discharge plan. The resident, who had designated a family member as their healthcare decision maker through a Power of Attorney for Healthcare, was discharged to a friend's home without the facility obtaining consent from the designated decision maker. Despite several attempts to contact the family member, the facility did not succeed in reaching them and proceeded with the discharge based on information from another family member who claimed the designated decision maker did not want to be involved. Additionally, the facility did not inform the resident's primary physician that they were unable to contact the designated healthcare decision maker before proceeding with the discharge. The facility's policy and procedures require notifying the responsible party and providing discharge instructions, which were not adequately followed in this case. The Director of Nursing acknowledged the failure to document the notification to the primary physician about the inability to reach the designated decision maker.
Deficiency in Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide the correct information in the Notice of Proposed Transfer and Discharge for a resident, resulting in a deficiency. The Notice, issued on 9/9/24, contained the incorrect address and telephone number of the agency responsible for handling discharge appeals, listing the state survey agency instead. Additionally, the Notice did not specify the reason for the resident's discharge, which is a requirement. This oversight was confirmed during a review of the Notice with the Medical Record Director, who acknowledged the error and emphasized the importance of providing the correct agency information for appeal purposes. The resident involved was originally admitted to the facility on 3/12/24 and readmitted later with diagnoses including diabetes, difficulty walking, and vascular dementia. The Minimum Data Set indicated that the resident was cognitively intact and required supervision for various daily activities. The Care Plan initiated on 9/9/24 included a physician's order for discharge home, stating that the resident no longer needed the facility's services. However, the Notice failed to reflect this reason for discharge. Interviews with the Director of Nursing confirmed that the resident's health had improved, justifying the discharge, but this was not communicated in the Notice as required by policy.
Failure to Implement Scabies Isolation and PPE Protocols
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment, leading to the potential spread of scabies among residents and staff. Resident 1, who was suspected of having scabies, was not placed in isolation on the date when symptoms were first observed. Despite the presence of rashes and itching, Resident 1 was not isolated from roommates, and no contact precaution signage or PPE cart was available outside the room. Staff members, including CNAs and LVNs, confirmed that they did not wear PPE when providing care to Resident 1, and they were not asked to monitor themselves for symptoms of scabies. The facility's Infection Preventionist Nurse (IPN) acknowledged that Resident 1 showed signs and symptoms of scabies and confirmed that the resident was not isolated during the treatment with Elimite cream. The IPN admitted that the facility's policy, which required isolation precautions for suspected scabies cases, was not followed. Additionally, there was no log or list maintained to monitor staff who were exposed to Resident 1, and the IPN recognized that staff vigilance was lacking. The Director of Nursing (DON) confirmed that Resident 1's care plan, which included contact isolation precautions, was not implemented. The facility's policy and procedures for scabies prevention and control, which required immediate isolation of symptomatic residents and staff education, were not adhered to. This oversight in implementing the care plan and infection control measures contributed to the potential spread of scabies within the facility.
Failure to Implement Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with scabies, a parasitic infestation. The resident was admitted with conditions including benign prostatic hyperplasia and cognitive impairments, requiring maximal assistance for activities of daily living. Despite the physician's order to isolate the resident from roommates when Elimite, a medication for scabies, was applied, the care plan was not followed. The resident was not placed on contact isolation, and staff did not use personal protective equipment when providing care. Observations and interviews revealed that the resident had multiple rashes and was scratching due to discomfort, yet no contact precaution signage or PPE cart was present outside the resident's room. The resident was placed in a room with two roommates, contrary to the care plan's instructions. The Infection Preventionist Nurse confirmed that the resident showed signs of scabies and should have been isolated, but the facility's policy did not require isolation for prophylactic treatment, leading to a failure in implementing the care plan. The Director of Nursing acknowledged that the care plan was not implemented, and the Infection Preventionist Nurse admitted to not maintaining a log to monitor staff exposure to the resident. The facility's policy required the care plan to be implemented upon admission and throughout the assessment process, but this was not adhered to, resulting in a deficiency in care for the resident.
Failure to Document and Communicate Wound Condition Leads to Hospitalization
Penalty
Summary
The facility failed to properly assess and document a resident's wound, leading to inadequate treatment and care. Multiple nurses documented the resident's condition using identical language, indicating a lack of thorough assessment and individual evaluation. The resident, who had a history of diabetes, chronic kidney disease, and dementia, developed fluid-filled blisters on the left upper extremity. Despite the presence of brown drainage and signs of infection, the facility did not inform the wound care specialist of the resident's diabetes diagnosis or the drainage, which could have influenced the treatment plan. The resident's care plan for the blister and risk of infection was not initiated until after the resident had been transferred to a hospital, indicating a delay in addressing the change in condition. Interviews with staff revealed inconsistencies in the assessment and documentation of the wound, with some staff noting significant blistering and drainage, while others did not report these observations. The lack of comprehensive documentation and communication among staff and with the wound care specialist contributed to the resident's condition worsening, resulting in hospitalization for cellulitis and sepsis. The facility's failure to document the wound's characteristics, such as size, drainage, and signs of infection, hindered effective communication with medical professionals and delayed appropriate interventions. The resident was eventually transferred to a hospital where they were diagnosed with severe sepsis and cellulitis, requiring antibiotic treatment and consideration for surgical debridement. The deficiency highlights the need for accurate and timely documentation and communication in managing residents' health conditions.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
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.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
