Almond View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Williams, California.
- Location
- 1224 E Street, Williams, California 95987
- CMS Provider Number
- 555200
- Inspections on file
- 24
- Latest survey
- November 26, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Almond View Care Center during CMS and state inspections, most recent first.
The facility did not comply with certification requirements for the dietary manager, as the current DM was not certified and had not passed the necessary test. The RD was present only once a month and had been in the role for two months, overseeing multiple facilities. The administrator was aware of the DM's lack of certification but believed the presence of the RD and another certified dietary manager, now serving as the Medical Records Director, would suffice.
The facility failed to promptly address resident grievances, as evidenced by a missing follow-up on a noise complaint from a Resident Council meeting and ongoing food quality issues reported by residents. The facility's policy requires documentation and resolution of grievances, but there was no record of efforts to resolve these issues. The Administrator confirmed that concerns should be addressed by Department Managers and discussed with the IDT.
The facility failed to serve food at an appetizing temperature and texture, as reported by 14 residents. Residents, including those with dementia, diabetes, and Alzheimer's, expressed dissatisfaction with the food being cold, bland, and having mushy vegetables. Complaints also included tough meat and cold soup, indicating a failure to adhere to food preparation guidelines.
Two residents experienced a lack of dignity and respect in their care. One resident's bed was frequently left unmade, despite her inability to make it herself due to age and fear of falling. Another resident overheard staff speaking disrespectfully about her, leading to feelings of fear and mistreatment. The facility's policy on maintaining resident dignity was not adhered to, and the Director of Staff Development had not yet addressed these issues.
The facility failed to maintain a safe and homelike environment, with issues such as missing tiles and exposed wood in the kitchen, extensive rust in tub and shower rooms, and disrepair in residents' rooms. These deficiencies were acknowledged by staff, including the Dietary Manager, Registered Dietician, and Maintenance Supervisor, who noted the need for repairs and the limited maintenance staff available.
A resident with dementia and diabetes was observed with long, dirty fingernails, indicating a failure to include nail care in their care plan. Despite being dependent on staff for personal hygiene, nail care was not documented, and staff confirmed the oversight. The facility's policy requires continuous assessment and updating of care plans, which was not followed.
A resident with dementia and diabetes was found with long, dirty fingernails, indicating a failure in maintaining personal hygiene. Despite being dependent on staff for care, the resident's nails were not properly maintained, as confirmed by a nurse. The facility's policy requires grooming for residents unable to perform ADLs, but this was not provided.
A resident reported rough care by night shift staff to a Licensed Nurse, who informed the Director of Staff Development. Despite the resident's emotional distress and the facility's policy requiring notification to the California Department of Public Health (CDPH), the allegation was not reported. The Director of Nursing was aware but did not consider it abuse, and the Administrator confirmed no report was made.
A resident with severe cognitive impairment was exposed to an outside courtyard during personal care due to an open window shade. The CNA providing care did not close the shade, compromising the resident's dignity. Facility staff, including an LVN and the Activity Director, confirmed the issue, and the CNA acknowledged the oversight.
A resident with Parkinson's and a history of falls was improperly restrained by pillows placed under their mattress, preventing independent movement. The facility's policy on restraint-free care was violated, as the resident could not remove the pillows and was restricted in bed. A CNA confirmed the issue, and the DON acknowledged the pillows should not have been there.
The facility failed to provide necessary assistive devices for two residents, leading to potential fall risks. One resident did not have a call light or urinal within reach, and another lacked anti-rollback brakes on her wheelchair, despite both being at high risk for falls. Staff confirmed the absence and malfunction of these devices, which were required by the residents' care plans.
A resident with dementia and a history of aggression was involved in multiple altercations due to the facility's failure to update and implement an effective care plan. The resident's territorial nature and sensitivity to personal space violations were not adequately addressed, leading to physical confrontations with other residents who entered his room or disturbed him.
A resident with severe cognitive impairment was injured after being pushed by another resident with a history of aggressive behavior. The incident occurred when the injured resident entered the other's room, prompting the push. The facility's policy on preventing resident-to-resident altercations was not effectively implemented, leading to the injury.
Non-compliance with Dietary Manager Certification Requirements
Penalty
Summary
The facility failed to comply with federal regulations regarding the certification qualification requirements for the dietary manager as outlined in the California Health and Safety Code (HSC 1265.4). The dietary manager (DM) at the facility was not certified, as required by the state, and had not passed the necessary test to obtain certification. Despite having been in the role for three years, the DM was scheduled to take the certification test in January 2024. The facility's job description for the dietary manager indicated that certification was a minimum requirement, yet this was not met. The registered dietitian (RD) employed by the facility was present only once a month and had only been in the role for two months, overseeing four other facilities. The administrator acknowledged the lack of certification for the DM and believed that the presence of the RD and another certified dietary manager, who was now serving as the Medical Records Director, would suffice. This oversight had the potential to impact the accuracy of resident assessments, meal distribution, safe food handling, and adherence to sanitation guidelines.
Failure to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to act promptly to resolve resident grievances in a timely manner and demonstrate their response and rationale for their response, potentially violating residents' rights. The facility's policy on Resident and Family Grievances, dated January 24, 2024, outlines that grievances can be voiced verbally during resident or family council meetings. The policy requires staff to record the grievance details, take steps to resolve it, and document the actions taken. The Social Service Designee (SSD) is responsible for keeping residents informed about the progress and resolution of grievances and issuing a written decision. However, during an interview with the Activities Director, it was revealed that there was a missing follow-up from a resident council meeting grievance, specifically regarding a noise complaint from September 17, 2024, which lacked documentation of efforts to resolve it or a conclusion of the investigation. Additionally, during a confidential interview, five residents expressed dissatisfaction with the food quality, stating that hot food was not served hot, cold food was not cold, and the meat was tough and hard to chew. One resident mentioned difficulty swallowing the meat due to its toughness. These food-related grievances had been ongoing and were reportedly brought up in previous council meetings, yet there was no documentation of these complaints in the Resident Council minutes from June to November 2024. The Administrator acknowledged that the facility is supposed to follow up on all concerns raised by Resident Council members and that these concerns should be addressed by Department Managers and discussed with the Interdisciplinary Team (IDT).
Facility Fails to Serve Food at Appetizing Temperature and Texture
Penalty
Summary
The facility failed to ensure that the food served to residents was at an appetizing temperature and palatable texture, as required by their policy and procedure titled 'Food Preparation Guidelines.' This deficiency was observed in 14 out of 21 sampled residents who expressed dissatisfaction with the temperature and texture of the food. The residents reported that the food was often cold, bland, and the vegetables were mushy, which did not meet their expectations for palatability. Several residents with varying degrees of cognitive impairment and medical conditions, such as dementia, diabetes, chronic kidney disease, and Alzheimer's disease, were interviewed. These residents consistently reported issues with the food being served cold and lacking in taste. For instance, one resident with intact cognition expressed that the food was bland and mostly cold, while another resident with severely impaired cognition stated that the food was cold. Additionally, a resident with moderately impaired cognition also mentioned that the food was cold. The dissatisfaction with the food was not limited to its temperature but also included complaints about the texture and quality. Residents mentioned that the meat was tough and hard to chew, and one resident was particularly disappointed when served cold tomato soup, which they had been looking forward to on a cold evening. These observations and interviews highlight the facility's failure to adhere to its own guidelines for food preparation, potentially impacting the residents' nutritional intake and overall well-being.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents, Resident 80 and Resident 92, as observed through various interactions and interviews. Resident 80, who was admitted with hypertensive heart disease, anxiety, and a history of falling, expressed distress over her bed not being made daily. Despite being unable to make her own bed due to age and fear of falling, Resident 80 often found her bed unmade and had to request staff assistance. Observations confirmed that her bed was frequently left stripped of linen, and staff interviews corroborated the resident's claims, indicating a lapse in the facility's adherence to its policy on maintaining resident dignity. Resident 92, diagnosed with hypertension, anxiety, and requiring assistance with personal care, reported overhearing staff speaking disrespectfully about her. During an interview, Resident 92 expressed feeling that staff were reluctant to provide care and treated her with a lack of respect, which was corroborated by her roommate. The roommate noted a difference in how staff interacted with them, describing the communication with Resident 92 as short and sharp. This behavior led Resident 92 to feel afraid to voice her concerns, fearing further mistreatment. The facility's policy on promoting and maintaining resident dignity was not followed, as evidenced by the staff's failure to make Resident 80's bed and the disrespectful communication overheard by Resident 92. The Director of Staff Development acknowledged awareness of these issues but had not yet addressed them, indicating a gap in the facility's response to maintaining a respectful and dignified environment for its residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations of disrepair and uncleanliness. In the kitchen, a drain was found with missing tiles and exposed, water-damaged wood. This issue was acknowledged by the Dietary Manager and Registered Dietician, who confirmed that maintenance had ordered tiles to address the problem. Additionally, two tub and shower rooms were observed to have extensive rust on metal baskets and handrails, as well as corrosion on floor drains and capped-off spigots. These conditions were confirmed by a Licensed Vocational Nurse and the Administrator, who both agreed that the environment was unsatisfactory and required repairs. Further observations revealed that several residents' room doors and walls were in disrepair, with gouges and scrapes exposing wood and drywall. The Maintenance Supervisor acknowledged these findings and noted that repairs were needed. He also mentioned that there was only one full-time maintenance person and a recently hired part-time assistant, which may have contributed to the delay in addressing these issues. The report highlights the facility's failure to provide a homelike environment, as required by their policy, which could potentially lead to injuries and discomfort for the residents.
Failure to Include Nail Care in Resident's Care Plan
Penalty
Summary
The facility failed to include nail care in the comprehensive care plan for a resident, identified as Resident 8, who was observed with long, dirty fingernails while eating with his fingers. This oversight was noted during observations and interviews, where it was confirmed that the resident's nails were approximately one inch in length with a brown substance underneath. The resident, who has diagnoses including dementia and diabetes, was admitted to the facility with a need for assistance with personal care and was assessed as severely impaired for decision-making and dependent on staff for personal hygiene. Interviews with facility staff, including Licensed Nurses C and D, and the Director of Nurses, revealed that nail care was typically performed weekly during showers and activities, but was not included in the resident's care plan. The Activity Director also noted that the resident was usually resistant to care and was unaware of the nail care issue. A review of the facility's care planning policy indicated that care plans should be continuously assessed and updated to meet residents' needs, which was not adhered to in this case.
Failure to Maintain Personal Hygiene for Resident
Penalty
Summary
The facility failed to maintain personal hygiene for a resident who was unable to perform activities of daily living independently. Resident 8, who has diagnoses including dementia and diabetes, was observed with long, dirty fingernails containing black particles. The resident was noted to be severely impaired in decision-making and dependent on staff for personal hygiene, as indicated in the Minimum Data Set assessment. Despite this, the resident's nails were not properly maintained, leading to a deficiency in care. Observations on two separate occasions confirmed the poor condition of Resident 8's nails, with a licensed nurse acknowledging the issue and stating that nail care is typically performed weekly during showers and activities. The Activity Director, who conducts rounds to observe residents, was unaware of the concern regarding the resident's nails, citing the resident's resistance to care. The facility's policy on Activities of Daily Living mandates grooming and personal hygiene for residents unable to perform these tasks, yet this was not adequately provided for Resident 8.
Failure to Report Alleged Abuse to CDPH
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) concerning a resident who reported rough care by night shift staff. The resident, who was capable of making her own decisions and had a good memory score, informed a Licensed Nurse (LN A) about the incident. Despite the resident's emotional distress during an interview, the allegation was not reported to CDPH as required by the facility's policy. Interviews with facility staff revealed that LN A had informed the Director of Staff Development (DSD) about the resident's concerns, who in turn stated that the Director of Nursing (DON) was aware of the situation. However, the DON did not consider the incident as abuse and did not report it. The facility's Administrator confirmed that no report was made to CDPH, indicating a breakdown in communication and adherence to reporting protocols within the facility.
Resident Dignity Compromised Due to Open Window During Personal Care
Penalty
Summary
The facility failed to honor the dignity of a resident when a Certified Nursing Assistant (CNA) provided personal care with the window covering open, exposing the resident to an outside courtyard accessible to staff and other residents. This incident involved a resident with severe cognitive impairment due to Alzheimer's Disease and dementia, who was dependent on staff for toileting needs and was always incontinent. During the observation, the CNA was seen changing the resident's brief with the window shade fully open, allowing visibility from the outside. The deficiency was confirmed through interviews and observations with facility staff, including a Licensed Vocational Nurse (LVN) and the Activity Director, who acknowledged the dignity issue. The CNA admitted to not closing the window shade before providing care, recognizing it as a dignity issue. The Administrator and Director of Nursing also concurred that window shades should be closed to maintain privacy during personal care activities.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as observed when a staff member placed two pillows under the resident's mattress. This action tilted the mattress, preventing the resident from getting out of bed independently. The facility's policy on maintaining a restraint-free environment was not adhered to, as the use of pillows to restrict movement was not justified by any medical treatment or condition. The resident, who had a history of falls and required supervision for transfers, was unable to remove the pillows on his own, which restricted his movement and access to the bed's exit. The resident involved had multiple diagnoses, including Parkinson's disease, diabetes, and a history of falls, which necessitated careful supervision and the use of the least restrictive measures to prevent falls. During an observation, the resident's bed was found with pillows stuffed under the mattress, causing a tilt that forced the resident to roll towards the center of the bed. A CNA confirmed the presence of the pillows and the resident's inability to remove them, while the resident mentioned that a night nurse placed them there to prevent falls. The Director of Nursing acknowledged that the pillows were not supposed to be there.
Failure to Provide Assistive Devices for Fall Prevention
Penalty
Summary
The facility failed to ensure that two residents received necessary assistance devices to prevent accidents, as outlined in their fall prevention care plans. For the first resident, staff did not ensure that the call light and urinal were within reach, which was crucial given the resident's high risk for falls due to conditions such as Parkinson's disease, diabetes, and a history of falling. Observations revealed that the call light was under the bed and out of reach, and the urinal was not present. Interviews with staff confirmed that the call light clip was broken, preventing it from being secured within reach, and the urinal was not provided as required by the care plan. The second resident, who had a history of falling and was severely cognitively impaired, did not have anti-rollback brakes on her wheelchair as required by her fall prevention care plan. This resident had previously sustained a fracture from a fall in the facility and was at high risk for falls. An observation confirmed that the wheelchair next to her bed lacked the necessary anti-rollback brakes, which was corroborated by staff during interviews. These deficiencies in providing essential safety devices and ensuring their proper use placed both residents at risk for falls and potential injuries. The facility's failure to adhere to the residents' fall prevention care plans and ensure the availability and functionality of assistive devices contributed to these safety hazards.
Failure to Implement Effective Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with dementia, paranoid schizophrenia, and anxiety disorder, leading to multiple altercations with other residents. The resident, who had a history of aggressive behavior, was involved in several incidents where he physically confronted other residents who entered his room or disturbed his personal space. Despite the resident's known territorial nature and history of aggression, the care plan was not adequately updated to address these specific behavioral issues. The first altercation occurred when another resident accessed the resident's room through a shared bathroom, resulting in a physical confrontation. Subsequent incidents involved the resident reacting aggressively to perceived intrusions or disturbances by other residents, including an instance where he slammed another resident's face into a door and another where he threatened violence if his roommate was not removed from his bed. These incidents highlight the resident's sensitivity to personal space violations and the facility's failure to implement effective interventions to prevent such occurrences. Interviews with staff and observations revealed that the resident was easily agitated by noise and territorial about his room. Despite these known triggers, the care plan lacked recent updates to address the resident's specific needs and preferences, such as his dislike for others entering his room. The facility's inaction in updating the care plan and implementing effective strategies to manage the resident's behavior contributed to the repeated altercations, placing both the resident and others at risk of harm.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident pushed him, resulting in a rib fracture. The incident occurred when the resident entered another resident's room and began flipping the light switch on and off, prompting the second resident to push him, causing a fall. This incident was reported to the California Department of Public Health, and the injured resident was diagnosed with a new rib fracture and an old rib fracture. The resident who was pushed had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3. He was known to wander into other residents' rooms, which was a behavior observed by multiple staff members. The resident who pushed him had a history of behavioral disturbances, including previous altercations with other residents, and was known to be territorial and easily upset when others entered his room. The facility's policy on resident-to-resident altercations was not effectively implemented, as evidenced by the repeated incidents involving the resident who pushed others. Despite the known history of aggressive behavior and the cognitive impairments of both residents involved, the facility did not adequately prevent the altercation that led to the injury. Interviews with staff and observations confirmed that the resident who was pushed frequently wandered into rooms, and the resident who pushed him had a history of aggressive responses to such intrusions.
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.
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