All Saint's Maubert
Inspection history, citations, penalties and survey trends for this long-term care facility in San Leandro, California.
- Location
- 15731 Maubert Avenue, San Leandro, California 94578
- CMS Provider Number
- 555879
- Inspections on file
- 15
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at All Saint's Maubert during CMS and state inspections, most recent first.
A facility failed to follow infection prevention protocols, including maintaining accurate infection tracking, timely reporting to public health authorities, and proper staff separation between infected and non-infected residents. These failures led to the spread of highly drug-resistant organisms among multiple residents, with staff working across two facilities and providing care to both infected and non-infected individuals.
A facility failed to designate a qualified Infection Preventionist (IP) solely responsible for its infection prevention and control program, instead sharing one IP between two separately licensed buildings. Despite the IP's warnings, staff were scheduled to work in both facilities during an outbreak, resulting in the spread of carbapenemase-resistant organisms (CPOs) among residents with complex medical needs, including those with tracheostomies and ventilator dependence. This cross-contamination was linked to inadequate infection control oversight and staffing practices.
Two residents with complex medical conditions and confirmed KPC infections did not have individualized care plans addressing their infection. The DON stated that the facility focused on isolation procedures rather than creating person-centered care plans for each infection, despite facility policy requiring comprehensive, updated plans for all residents.
The facility failed to separate clean and dirty items in the laundry room, improperly stored personal items with clean linens, and used the same mop head for both clean and dirty areas. Additionally, biohazardous waste was improperly stored, and there was no water management program to monitor Legionella, despite having a policy in place.
A facility failed to protect a resident's clothing from loss or theft. A family member reported missing clothing items after laundering. Observations revealed a bin of unlabeled items in the Laundry Department, which could not be returned to their owners. Interviews confirmed the lack of labeling, contrary to the facility's policy requiring inventory and labeling of residents' belongings.
A resident with chronic osteomyelitis and Stage IV pressure ulcers received inadequate wound care due to inaccurate documentation and improper hygiene practices by nursing staff. The RN misclassified wound stages and failed to measure wound depth, while the CNA used the same gauze for cleaning different areas, risking infection. The DON confirmed these actions were inconsistent with facility policy and NPUAP guidelines.
A resident with chronic osteomyelitis and Stage 4 pressure ulcers received inadequate wound care due to nursing staff's lack of competency. RN 1 incorrectly assessed the wound stages and failed to measure wound depth, while CNA 1 improperly used the same gauze for cleaning different areas, violating infection control practices. The DON confirmed these errors, highlighting a failure to follow NPUAP guidelines and facility protocols.
The facility failed to prevent food contamination during preparation and storage. Two kitchen staff did not wear hair nets, violating policy. Undated canned goods were found in storage, and bloody meat in the refrigerator had an incorrect date, exceeding the recommended thawing period. These issues risked residents consuming outdated food and developing foodborne illnesses.
The facility failed to maintain a safe environment due to nonoperational hallway lights, identified during an observation with the IP and MHD. The DON confirmed the broken lighting posed a safety risk, as nurses relied on these lights to read medication labels. Facility policies required immediate replacement of defective lights to ensure safety and well-being.
The facility breached privacy by displaying personal care information on signage above two residents' beds, visible to unauthorized individuals. This led to one resident feeling exposed and another's responsible party expressing disrespect. The DON acknowledged the signs should have been covered to maintain privacy.
A resident with chronic osteomyelitis and stage 4 pressure ulcers experienced ongoing pain and anxiety during wound treatments due to the facility's failure to update and implement a comprehensive care plan. Despite the resident's ability to communicate his needs, the care plan did not address his pain and breathing difficulties, and he did not receive pain medication for three days. The facility's policy to identify situations where pain might increase was not followed.
A resident with significant medical needs, including anoxic brain damage and hemiplegia, was found without prescribed foam boots for pressure injury prevention. Despite a physician's order and care plan requiring daily application of foam boots, observations showed the resident without them, highlighting a lapse in care by the nursing staff.
A resident with chronic osteomyelitis and pressure ulcers did not receive adequate pain management during wound care procedures. Despite expressing significant pain and requesting medication, the resident was not administered pain relief, leading to recurrent pain and anxiety. The facility's care plans and documentation failed to address and record the resident's pain complaints, and the staff did not follow the facility's pain management policy.
A facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06%. One resident was given a multi-vitamin tablet instead of the prescribed liquid form, and another resident did not receive erythromycin ointment in both eyes as ordered. These errors were observed during medication administration by an RN, highlighting non-compliance with the facility's medication administration policy.
A facility failed to offer a COVID-19 vaccine to a resident, despite having a policy to do so. The resident, who was admitted with chronic osteomyelitis and pressure ulcers, was assessed to have intact mental abilities and was dependent on staff for care. The Infection Preventionist could not provide documentation that the resident was offered the vaccine, indicating a lapse in following the facility's vaccination policy.
Failure to Implement Infection Control Practices Resulting in CRO Outbreak
Penalty
Summary
Facility 1 failed to implement and follow proper infection prevention and control practices, resulting in the spread of Carbapenemase-Resistant Organisms (CROs) among residents. The facility did not maintain an accurate and updated line list for tracking infections, as evidenced by missing laboratory test dates and incomplete records for several residents who became infected. This lack of documentation made it difficult to determine when infections were identified and to monitor the progression of the outbreak. Additionally, the facility had only one Infection Preventionist (IP) shared between two separately licensed facilities, contrary to regulatory requirements, and the administrator was unaware that each facility should have its own IP. The facility also failed to notify the California Department of Public Health (CDPH) in a timely manner about the outbreak. The IP admitted to forgetting to report new cases and was unclear about the reporting requirements, despite facility policies stating that even a single case of a highly communicable infection should be reported. This delay in notification hindered appropriate public health response and oversight during the outbreak. Furthermore, direct care staff were not properly separated between infected and non-infected residents, nor between the two facilities. Staff were scheduled to work in both facilities on the same day, including providing care to residents on contact precautions for KPC and then to residents not on precautions. The scheduling coordinator and DON acknowledged that staff should not have been shared between facilities, especially during an outbreak, and that this practice contributed to the transmission of CROs. Observations confirmed that staff worked double shifts across both facilities, increasing the risk of cross-contamination and further spread of infection among residents.
Failure to Designate a Qualified Infection Preventionist Led to CPO Outbreak
Penalty
Summary
Facility 1 failed to ensure that a qualified and designated Infection Preventionist (IP) was responsible for adequately assessing, developing, implementing, monitoring, and managing the facility's Infection Prevention and Control Program (IPCP). Instead, one IP was assigned to cover both Facility 1 and Facility 2, which are separate entities operating under different licenses. The IP reported that she was required to work across both facilities, averaging 45 hours per week, and stated that each facility required a full-time IP to effectively manage infection control. Despite the IP's instructions to prevent staff from working in both facilities during an outbreak, the scheduling coordinator continued to assign direct care staff to work double shifts in both locations, contributing to the spread of infection. A review of facility records and laboratory reports revealed an increase in Carbapenemase-Resistant Organism (CPO) infections in Facility 1, including cases of Klebsiella Pneumoniae Carbapenemase (KPC), New Delhi Metallo-β-lactamase (NDM), and Carbapenem-Resistant Pseudomonas aeruginosa (CRPA). The affected residents had complex medical histories, including conditions such as encephalopathy, acute respiratory failure, tracheostomy status, ventilator dependence, traumatic brain injury, spastic quadriplegic cerebral palsy, and myotonic muscular dystrophy. The cross-contamination and transmission of these infections to non-infected residents were linked to the failure to implement effective infection control measures and the sharing of staff between the two facilities during an outbreak. Interviews with the IP and the facility administrator confirmed that there was only one shared IP for both facilities, and the administrator was unaware of the regulatory requirement for each facility to have its own IP. The facility's policy stated that the IP should be employed on-site and scheduled with enough time to properly manage the IPCP, but this was not followed. The lack of a dedicated IP for Facility 1 and the continued sharing of staff between facilities during an outbreak directly contributed to the increase and transmission of multi-drug resistant organism infections.
Failure to Develop Comprehensive Care Plans for Residents with KPC Infection
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who tested positive for Klebsiella Pneumoniae Carbapenemase (KPC), a highly drug-resistant infection. Both residents had complex medical conditions, including encephalopathy, acute respiratory failure, tracheostomy status, and, for one resident, ventilator dependence. Laboratory reports confirmed the presence of the KPC gene in both individuals. Despite these findings, a review of their care plans revealed that neither resident had a care plan addressing their KPC infection. During interviews, the DON acknowledged that care plans should have been created for all residents with infections, especially during an outbreak, but admitted that the facility focused only on isolation types rather than individualized plans for specific infections. The facility's policy required individualized, comprehensive care plans with measurable objectives and timetables for each resident, incorporating identified problems and risk factors, and updating plans as residents' conditions changed. However, these requirements were not met for the two residents with KPC infections.
Infection Control Deficiencies in Laundry and Waste Management
Penalty
Summary
The facility failed to implement effective infection control and prevention policies, as evidenced by several observations. In the laundry room, clean items such as mop heads, cleaning cloths, and Restorative Nurses Aids (RNA) slings were stored in the same area as dirty laundry, with no clear separation. Personal items belonging to a staff member, including a sweater, shawl, and a cup of coffee, were found in the area designated for clean resident linens. Additionally, a Laundry Aide mopped both clean and dirty areas with the same mop head and was unaware of the chemicals used in the mopping solution, which was not in compliance with the facility's maintenance policy. In the Soiled Utility Room, used suction canisters were improperly stored with biohazardous sharps containers, contrary to the facility's policy on medical waste segregation. Furthermore, the facility lacked a water management program to monitor and test for Legionella, despite having a policy in place. The Maintenance/Housekeeping Director confirmed the absence of a process to ensure the water system was free of Legionella, which was a requirement according to the facility's Legionella Water Management program.
Failure to Protect Resident's Clothing from Loss
Penalty
Summary
The facility failed to protect a resident's clothing from loss or theft, as observed in the case of one resident among eleven sampled. The deficiency was identified through interviews, observations, and record reviews. A family member reported that the resident had multiple clothing items laundered by the facility that were never returned. During an observation in the facility's Laundry Department, a bin was found containing unlabeled residents' items, including clothing, which could not be returned to their original owners due to the lack of labeling. Interviews with the Maintenance/Housekeeping Director and the Laundry Aide confirmed that the items in the laundry bin were unlabeled, making it impossible to identify their owners. The facility's policy and procedure on personal property indicated that residents' belongings should be inventoried, labeled, and documented upon admission and updated as necessary. However, this procedure was not followed, leading to the loss of the resident's clothing.
Inadequate Wound Care and Documentation
Penalty
Summary
The facility failed to provide wound care consistent with professional standards for Resident 66, who was admitted with chronic osteomyelitis and Stage IV pressure ulcers on both heels and buttocks. The nursing staff inaccurately documented the wound status, with RN 1 incorrectly identifying a Stage IV buttock wound as Stage III and failing to measure the wound depth or tunneling. Additionally, RN 1 misclassified the heel wounds as Stage I, despite them being deep tissue injuries, which should be considered at least Stage II or IV according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. During wound care, RN 1 and CNA 1 did not perform hand hygiene before donning gloves, which is against the Centers for Disease Control (CDC) hand hygiene guidance. CNA 1 improperly cleaned the wound by using the same gauze to clean the anus and then the perimeter of the buttock wound, increasing the risk of infection. The Director of Nursing confirmed these practices were inconsistent with the facility's policy and the NPUAP guidelines. Physician 1, who conducted weekly wound assessments, emphasized the importance of accurate wound assessment and documentation by nursing staff between his visits. He noted that significant changes could occur within the week, and accurate documentation was crucial for effective wound management. The facility's policy required detailed documentation of wound characteristics, which was not adhered to in this case.
Inadequate Wound Care Competency in Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary skills and competencies to perform wound care treatments for Resident 66, who was admitted with chronic osteomyelitis and Stage 4 pressure ulcers on both heels and buttocks. During an observation, Registered Nurse 1 (RN 1) incorrectly assessed the stage of the pressure wounds and did not measure the depth or tunneling of the wounds. RN 1 admitted to still learning how to assess pressure wounds, which indicates a lack of competency in wound care assessment and documentation. Additionally, during the wound care procedure, Certified Nursing Assistant 1 (CNA 1) used the same gauze to clean the resident's anus and the perimeter of the buttock wound, which is against proper infection control practices. The Director of Nursing (DON) confirmed that the CNA should not have used the same gauze for both tasks and that gloves should be changed between handling dirty and clean dressings. The DON also confirmed that RN 1's assessment of the wounds was incorrect according to the National Pressure Ulcer Advisory Panel (NPUAP) guidelines. The physician responsible for Resident 66's weekly wound assessments confirmed that the resident had bilateral Stage IV ischial wounds and deep tissue injury wounds on both heels. The physician emphasized the importance of accurate wound assessment and documentation by nursing staff between his visits, as significant changes could occur. The facility's policy and procedure for pressure injuries also outlined the need for accurate assessment and documentation of wound characteristics, which was not adhered to in this case.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to its policies and procedures designed to prevent food contamination during preparation and storage. During an observation, it was noted that two kitchen staff members, including the Kitchen Manager/Registered Dietitian and a cook, were not wearing hair nets while in the kitchen. This was in violation of the facility's policy, which mandates that dietary staff must wear hair restraints to prevent hair from contacting exposed foods. Additionally, the facility's dry storage room contained several undated cans of food, including diced tomatoes, mandarin oranges, and fruit cocktail, which should have been marked with a use-by date according to the facility's policy. Furthermore, a refrigerator in the facility contained bloody meat in a metal pan, covered with plastic wrap, with a date that was not clearly defined. The meat had been placed in the refrigerator to thaw, but the date on the label was incorrect, and the meat had been in the refrigerator for five days, which exceeded the recommended thawing period. These oversights placed residents at risk of consuming outdated food and developing foodborne illnesses.
Nonoperational Hallway Lights Pose Safety Risk
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment due to nonoperational overhead lights in the hallway of 2-South. This deficiency was identified during an observation and interview conducted on October 24, 2023, at 1:45 p.m., with the Infection Preventionist and the Maintenance/Housekeeping Director. The Director of Nursing and the Administrator confirmed during a subsequent interview that the broken lighting posed a safety risk, as nurses relied on the overhead lights to read medication labels accurately when administering medications. The facility's policy and procedure documents, titled 'Interior General Maintenance' and 'Maintenance Policy & Procedure,' both dated December 31, 2015, were reviewed. These documents indicated that defective light bulbs or buzzers should be replaced immediately and emphasized the importance of maintaining a safe, sanitary, and functional environment to ensure the safety and well-being of residents, staff, and the public. The failure to adhere to these policies placed residents at risk of receiving incorrect medications and increased the risk of falls for residents and visitors.
Privacy Breach Due to Visible Personal Care Signage
Penalty
Summary
The facility failed to respect the privacy rights of two residents by displaying personal care information on signage above their beds, visible to unauthorized individuals. In a shared room, signage above one resident's bed indicated specific care instructions, such as 'Do Not Use Pink Chucks,' while the other resident's signage included instructions like 'Be Careful Turning On Left Side' and 'Only Use Latex Free Condoms.' These signs were visible to any visitors, leading to one resident feeling exposed and the responsible party of the other resident expressing feelings of disrespect. During an interview, the Director of Nursing acknowledged that the signs should have been covered to maintain the residents' privacy and dignity.
Failure to Update Care Plan for Resident's Pain and Anxiety
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced ongoing pain and emotional distress during wound treatments. The resident, admitted with chronic osteomyelitis and stage 4 pressure ulcers on both heels and buttocks, was totally dependent on staff for care and had intact mental abilities. Despite the resident's ability to communicate his needs, the care plan did not address his pain and anxiety during wound treatments, leading to continued suffering. During wound care, the resident reported a pain level of seven out of ten and difficulty breathing when positioned on his right side, a known issue due to a history of a collapsed lung. The resident had repeatedly informed staff of his pain and breathing difficulties, yet the care plan was not updated to reflect these concerns. The Director of Nurses confirmed that the resident had not received pain medication for three days, despite complaints of pain, and there was no documentation of these complaints in the nurse progress notes. The facility's policy required staff to identify situations where pain might increase, such as during wound care, but this was not followed.
Failure to Apply Pressure Injury Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure injury reducing devices were applied for a resident, which had the potential to worsen an existing wound and develop a new one. The resident, who was admitted with anoxic brain damage, hemiplegia, moderate protein-calorie malnutrition, muscle wasting, and dependence on a ventilator, was dependent on staff for all aspects of care, including footwear. A physician's order required foam boots to be applied daily for pressure prevention. Observations revealed that the resident was found without foam boots on multiple occasions. On one occasion, a CNA observed the resident without foam boots and subsequently applied them. The Assistant Director of Nursing confirmed that the care plan required the application and removal of foam boots as per routine order, and that nursing staff were responsible for this task. The facility's policy indicated that nursing staff should document and report current treatments, including support surfaces.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 66, who was admitted with chronic osteomyelitis and pressure ulcers on both heels and bilateral ischium. Despite having a care plan that required assessing pain every shift and administering medication as ordered, the facility did not provide pain medication to Resident 66 prior to a painful wound care procedure. During an observation, Resident 66 expressed a pain level of seven out of ten and requested pain medication, but the attending nurse did not administer any medication, instead advising the resident to 'hang in there.' This lack of action resulted in the resident experiencing recurrent pain and anxiety during daily wound treatments. Further investigation revealed that Resident 66 had not received pain medication for three consecutive days, despite complaints of significant pain. The Director of Nurses confirmed that there was no documentation of the resident's pain complaints in the nurse progress notes, and the care plans did not address wound treatments and associated position changes as potential sources of pain. The facility's policy required staff to identify situations where an increase in pain might be anticipated, such as during wound care, but this was not adhered to. The physician responsible for the resident's care expected nurses to conduct pain assessments and medicate as needed, which was not done in this case.
Medication Administration Errors Result in High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.06% during a medication administration observation. This deficiency involved two residents. Resident 8, who was admitted for protein-calorie malnutrition, muscle wasting and atrophy, and dysphagia, was incorrectly administered a multi-vitamin with minerals tablet instead of the prescribed multi-vitamin with minerals liquid 15 mL. The error was identified during a medication pass observation with RN-2, who confirmed that the tablet was given in place of the liquid form, which was not ordered for Resident 8. Additionally, Resident 65 did not receive the prescribed erythromycin ophthalmic ointment in both eyes as ordered by the physician. During the medication pass, RN-2 applied the ointment only to the right eye, despite the order specifying application to both eyes for an eye infection. The facility's policy on administering medications, which requires adherence to prescriber orders and proper documentation, was not followed in these instances, contributing to the medication errors observed.
Failure to Offer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to implement its COVID-19 Vaccine Policy and Procedure for a resident, identified as Resident 66, among the eleven sampled residents. Resident 66 was admitted to the facility on October 9, 2023, with diagnoses including chronic osteomyelitis and pressure ulcers on both heels and bilateral ischium. The Minimum Data Set (MDS) assessment dated October 13, 2023, indicated that Resident 66 had intact mental abilities, could communicate needs, and was entirely dependent on facility staff for care, including mobility and repositioning. During an interview and record review on October 25, 2023, the Infection Preventionist (IP) was unable to provide documentation that Resident 66 had been offered the opportunity to receive a COVID-19 vaccination. The facility's policy stated that all residents and staff should be offered an approved COVID-19 vaccine unless medically contraindicated. However, there was no evidence that Resident 66 was assessed for eligibility or offered the vaccine, leading to a deficiency in the facility's adherence to its vaccination policy.
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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.
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