American River Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 3900 Garfield Avenue, Carmichael, California 95608
- CMS Provider Number
- 555450
- Inspections on file
- 29
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at American River Center during CMS and state inspections, most recent first.
A resident with dementia and a traumatic brain injury, identified as being at risk for elopement, was able to leave the facility unsupervised and undetected for about an hour. The resident's care plan and assessments documented the need for supervision due to cognitive impairment and a history of wandering, but staff did not implement the required supervision as outlined.
The facility failed to store food safely, affecting 96 residents. Observations revealed unlabeled and uncovered food items, including desserts and cheeses, and spoiled tomatoes in the refrigerator. The CDM confirmed these practices were against the facility's policy, posing a risk of foodborne illness.
The facility failed to maintain infection control practices, as a visitor accessed ice unsupervised, and an ice scoop was stored uncovered. Additionally, a CNA did not perform hand hygiene after handling garbage. The Infection Preventionist and Administrator confirmed that only staff should distribute ice, and hand hygiene is crucial to prevent infections.
A facility failed to develop a person-centered care plan for a resident with a UTI and bacteremia. Despite the resident receiving daily Nitrofurantoin Macrocystal as prescribed, there was no care plan in place. The DON and ADON confirmed this oversight, acknowledging potential compromises in nursing care. The facility's policy mandates individualized care plans, which was not followed.
A resident with hemiplegia and thrombosis was not provided with compression stockings as ordered, despite physician instructions for daily use to manage edema. Observations showed the resident's left leg was swollen, and staff confirmed the stockings were not applied. The DON and ADON acknowledged the oversight, which could affect the resident's circulation.
A resident with dementia and a need for personal care assistance did not have her hearing aids applied daily as ordered, despite a physician's order and care plan specifying their use. Observations confirmed the resident was not wearing the aids, and staff interviews revealed non-compliance with the order. The facility's policy on hearing aid care was not followed, resulting in a deficiency.
A resident with multiple sclerosis and quadriplegia was left outside the facility past the agreed time on multiple occasions, unable to contact staff for assistance. Despite having an arrangement to be outside from 9:00 a.m. to 11:00 a.m., the resident was left alone and felt frightened when unable to reach staff. Staff interviews confirmed the arrangement and acknowledged the issue, while the facility's policy emphasized the resident's right to self-determination and communication.
A resident was discharged from the facility without verified home health service arrangements, despite having a disrupted surgical wound requiring specific care. The discharge plan included home health services, but there was no evidence that these were confirmed with the agency. Post-discharge follow-up showed the resident had not been contacted by the home health agency, leading to a lack of necessary wound care. Facility staff confirmed the expectation for social services to ensure these arrangements, which was not met.
A resident with multiple diagnoses, including dementia and osteoporosis, suffered a fracture of unknown origin. Despite the injury being identified, the facility failed to report it to state agencies as required by their policy. The DON confirmed the injury was not reported and acknowledged it could have been a pathological fracture, but no fall was reported.
A resident with multiple diagnoses was left crying and afraid after receiving a cold shower due to an argument between two CNAs about a staffing assignment. The incident highlighted the inappropriate behavior of the CNAs and the impact on the resident's dignity.
A resident with vascular dementia and moderate protein-calorie malnutrition was not readmitted to the facility after hospitalization, despite being eligible for a 7-day bed hold. The facility's Interdisciplinary Team decided against readmission due to unresolved conflicts with the resident's family, violating the resident's rights for readmission.
The facility failed to maintain food safety standards by not properly cleaning the ice machine, allowing rust on food storage racks, and not monitoring freezer temperatures in resident food refrigerators. These deficiencies could lead to food-borne illnesses among residents.
The facility failed to follow therapeutic diets for 14 residents, including those on modified texture, TLC, Renal, and CCD diets, during a lunch meal. The staff did not adhere to the menu, resulting in residents receiving incorrect food items, which could potentially affect their nutritional needs.
The facility failed to document the offering, administration, or refusal of the COVID-19 vaccine for three residents, despite their medical histories and the facility's policy requiring such documentation. The DON confirmed the absence of proper records, and family members reported not receiving recent vaccine offers.
The facility failed to follow infection control standards for two residents. A resident's catheter bag was found lying on the floor, and two CNAs did not wear gowns while providing high-contact care to another resident, contrary to Enhanced Barrier Precautions.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a traumatic brain injury from eloping from the facility. The resident was identified as being at risk for elopement based on an Elopement Evaluation and had a care plan in place that addressed this risk, including a history of wandering and previous elopement at a hospital. The resident's Minimum Data Set assessment indicated impaired cognitive status, and the care plan specifically noted the need for supervision due to alcohol/drug-seeking behavior and elopement risk. Despite these documented risks and care plan interventions, the resident was able to leave the facility unsupervised and undetected. Staff became aware of the resident's absence after being informed by another staff member, and the resident was missing for approximately one hour before being located. Facility policy required adequate supervision for residents at risk of elopement, but this was not implemented as indicated in the resident's care plan. Interviews with facility staff and the administrator confirmed the resident's high risk for elopement and acknowledged that closer supervision should have been provided.
Plan Of Correction
The preparation and/or the execution of this plan of correction do not constitute admission of agreement by the provider of true facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because the provisions of the Federal and State law require it. This Plan of Correction constitutes the facility's credible allegation of compliance. Corrective action accomplished for identified resident(s) affected by the deficient practice: Resident 1 was found and brought back into the facility without incident or injury. Resident placed on 1 on 1 supervision until the wanderguard system for the front door was adjusted with an additional reader on 10/3/2025. How other residents having potential to be affected by the same deficient practice will be identified and what corrective action will be taken: On 10/2/2025, an audit of all residents that triggered at risk for elopement was completed by the Medical Records Director to ensure that they all have appropriate interventions in place. Updates made as identified. Immediate measures and systemic changes put in place to ensure that the deficient practice does not recur: On 10/1/2025 and 10/2/2025, the Director of Staff Development in-serviced CNAs and Licensed Nurses on the elopement policy and procedure and wanderguard devices. A description of the plans and persons responsible for monitoring ongoing performance, and ensuring that the corrective actions are achieved and sustained: The Medical Records Director or designee will conduct an audit for residents triggering as elopement risks weekly to confirm interventions are in place. The results of the audits will be reported to the QAPI Committee meeting monthly for 3 months and then re-evaluated thereafter. Completion Date: 11/4/2025
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, affecting 96 residents who received food from the kitchen. During observations and interviews with the Certified Dietary Manager (CDM), it was confirmed that opened and prepared foods were stored without labeled use-by dates. Specifically, a pan of cinnamon brown sugar blondie dessert and opened packages of processed yellow cheese and sliced cheese were found without any date labels. The CDM acknowledged the importance of labeling food items to track when they were prepared and when they should be used by. Additionally, the facility did not adequately cover or seal opened food packages, which could lead to foodborne illnesses. Observations revealed a pan of prepared dessert and several peanut butter and jelly sandwiches in unsealed bags, as well as a package of hot dogs that were not tightly wrapped. Furthermore, spoiled food was found in the walk-in refrigerator, including two mushy and rotten tomatoes. The CDM confirmed that these practices were not in line with the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated to ensure safe food handling.
Infection Control Deficiencies in Ice Distribution and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations. A visitor was seen accessing and obtaining ice from the nursing unit's ice chest without supervision, which was confirmed by a Certified Nursing Assistant (CNA) and the Director of Staff Development (DSD). The Infection Preventionist (IP) and the Administrator (ADM) both stated that only facility staff should distribute ice, and there was no specific policy written for the usage and distribution of ice from the nursing station ice chest. Additionally, the ice scoop was observed to be stored uncovered on a cart, which was confirmed by both the CNA and the DSD. The IP stated that the ice scoop must be stored covered to prevent exposure to dust or other contaminants. Furthermore, a CNA was observed handling garbage and then handling plastic wrist bands for residents without performing hand hygiene. The ADM confirmed that staff are expected to perform hand hygiene immediately before and after patient care activities. The facility's policy on hand hygiene emphasizes its importance in preventing the spread of infections.
Failure to Develop UTI Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with a urinary tract infection (UTI) and bacteremia. The resident's Admission Record indicated these diagnoses, and the Physician's Orders dated January 6, 2025, prescribed Nitrofurantoin Macrocystal 50 mg to be administered daily for the UTI. The Medication Administration Record confirmed that the medication was administered daily from January 1 through January 10, 2025. However, upon review, it was found that there was no care plan developed specifically for the UTI. During an interview and record review on January 10, 2025, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the absence of a UTI care plan for the resident. The DON acknowledged that nursing care could be compromised without a proper care plan in place. The facility's policy and procedure on comprehensive care plans, dated August 25, 2021, requires an individualized care plan with measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was diagnosed with hemiplegia affecting the left side and acute embolism and thrombosis of the left lower extremity, had compression stockings applied daily as ordered by the physician. The physician's order specified that the compression stockings should be worn during the day and removed at night to manage edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings, and the left lower extremity appeared larger than the right, indicating swelling. Interviews with the resident and staff confirmed that the compression stockings were not offered or applied as required. A Certified Nurse Assistant admitted to not applying the stockings on the observed day. The Director of Nursing and Assistant Director of Nursing reviewed the resident's clinical record and confirmed the physician's order for daily use of compression stockings, acknowledging that failure to comply could compromise the resident's blood circulation. The facility's policy mandates that licensed nurses are responsible for implementing and documenting physician orders, which was not adhered to in this case.
Failure to Apply Hearing Aids as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who required hearing aids, had them applied daily as ordered. The resident, who had diagnoses including dementia and a need for assistance with personal care, had a physician's order to apply both hearing aids in the morning and remove them at night. The care plan also specified the need for the resident to wear bilateral hearing aids every morning and remove them every evening. However, during multiple observations over several days, the resident was not wearing her hearing aids as required. Interviews with facility staff, including a Certified Nursing Assistant and a Licensed Nurse, confirmed that the hearing aids were not applied as ordered, and they were not stored in the medication cart as per the physician's order. The Director of Nursing and the Assistant Director of Nursing acknowledged that the order should have been followed and emphasized the importance of the hearing aids for the resident's communication. The facility's policy on hearing aid care, which aims to maintain the resident's hearing at the highest attainable level, was not adhered to, leading to a deficiency in care.
Failure to Accommodate Resident's Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with multiple sclerosis, quadriplegia, and anxiety, who was dependent on staff for self-care and mobility. The resident had an arrangement with the staff to be taken outside daily from 9:00 a.m. to 11:00 a.m. However, on multiple occasions, the resident was left outside past the agreed time and was unable to contact staff for assistance. On one occasion, the resident attempted to call the facility's front desk but received no response, and on another occasion, the resident was left outside until 11:30 a.m. without being able to contact staff, causing the resident to feel frightened. Interviews with staff confirmed the arrangement for the resident to be outside and acknowledged the issue of the resident being unable to contact staff when needed. The Recreations Assistant confirmed that the resident was left alone and unable to contact a CNA for assistance. The Director of Nursing stated that the resident was able to communicate her needs and preferences, including the times she wanted to be outside and return inside. The facility's policy on Resident's Rights emphasized the resident's right to self-determination and communication with people and services, which was not upheld in this instance.
Failure to Ensure Safe Discharge and Continuity of Care
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was discharged home without verified home health service arrangements. The resident, who had been admitted with cellulitis, a disrupted surgical wound, and required nonsurgical wound dressing changes, was discharged with a plan for home health services including physical therapy, occupational therapy, and skilled nursing services. However, there was no documented evidence that the facility's social services or nursing staff confirmed these arrangements with the home health agency prior to the resident's discharge. The resident's discharge plan indicated that home health services were to start shortly after discharge, with specific instructions for wound care, including the use of a wound vac to be changed every 72 hours. Despite these plans, the resident's post-discharge follow-up revealed that the home health agency had not been in contact, and the resident had left several voicemails without response. This lack of coordination resulted in the resident not receiving the necessary continuity of care for his wound. Interviews with facility staff, including the Director of Nursing, Assistant Director of Nursing, Unit Manager, and Administrator, confirmed that there was an expectation for social services to follow up with the home health agency to ensure services were scheduled to start prior to discharge. The facility's policies required social services to coordinate resident referrals with outside agencies, but this was not done in this case, leading to a failure in ensuring the resident's continuity of care upon discharge.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for a resident, which decreased the potential to protect the resident from a possible allegation of abuse and ensure a safe environment during the investigation. The resident, a female with multiple diagnoses including unspecified dementia, Alzheimer's Disease, osteoporosis, a history of falls, and muscle weakness, was readmitted to the facility. On a specific date, the resident complained of left forearm pain, and an x-ray revealed an acute or possibly subacute fracture of the distal radial diaphysis and a deformity of the distal ulna consistent with a wrist fracture. Despite the injury being identified, the Director of Nursing (DON) confirmed that the fracture was an injury of unknown origin as no fall was reported. The DON acknowledged that the fracture could have been a pathological fracture and conducted an investigation to determine the cause. However, the facility did not report the injury to the appropriate state agencies as required by their policy, which mandates that all injuries of unknown source be promptly reported. The facility's policy also requires a written report of the findings of the investigation to be provided to the appropriate agencies within five working days of the incident.
Failure to Maintain Resident Dignity During Shower
Penalty
Summary
The facility failed to maintain dignity for a resident when two CNAs had an argument regarding a staffing assignment while providing a shower to the resident. The resident, who had multiple diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, dysarthria, aphasia, muscle weakness, and major depressive disorder, was left crying and feeling afraid after receiving a cold shower. The incident occurred when CNA 1 placed the resident in the shower chair and turned on the water to warm up. CNA 1 was then approached by CNA 2, who stated that the assignment had changed. While the CNAs argued about the assignment, the resident was left in the shower with cold water, leading to the resident crying and feeling afraid. The incident was documented in a Report of Suspected Dependent Adult/Elder Abuse and an Investigative Summary Report. During interviews, the resident confirmed that he cried because the water was cold and expressed fear that it might happen again. The Director of Nursing, Social Services Director, and Administrator acknowledged the inappropriate behavior of the CNAs and the impact on the resident. The facility's policies on Resident Rights and Dignity were reviewed, indicating that residents should be treated with kindness, respect, and dignity, and that staff should communicate professionally and outside the hearing range of residents.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to follow its own policy for readmission when a resident was not permitted to return after hospitalization, despite being eligible for a 7-day bed hold. The resident, who had vascular dementia and moderate protein-calorie malnutrition, was transferred to a General Acute Care Hospital (GACH) at the request of his daughter due to concerns about worsening oral candidiasis and poor care at the facility. Despite multiple attempts by the hospital's Case Manager to readmit the resident, the facility repeatedly responded that they were unable to accept the patient. Interviews with the Admissions Director, Director of Nursing (DON), and Administrator confirmed that the resident was eligible for readmission under the facility's bed hold policy. However, the Interdisciplinary Team (IDT) decided not to readmit the resident due to unresolved conflicts between the family and facility staff. This decision was made despite the facility's policy, which prioritizes readmission for residents discharged to the hospital or on therapeutic leave. The facility's actions resulted in a violation of the resident's rights for readmission.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an initial kitchen tour, the ice machine was found to have significant black and brown stains with scratches on the bottom of the evaporator unit. The Maintenance Supervisor confirmed that despite regular cleaning, the stains did not come off, and the scratches were old. The Registered Dietitian noted that the scratches could harbor microorganisms, potentially contaminating the ice. Additionally, the walk-in freezer and refrigerator had food storage metal racks with rust, which was confirmed by the Food and Nutrition Service Director. The rust was noted in a previous inspection but had not been addressed yet. The FDA Food Code requires food-contact surfaces to be smooth and free of imperfections to prevent microorganism attachment and biofilm formation, which can release pathogens to food. Furthermore, the temperature of the freezer sections of the resident's food refrigerators located in nurse stations one and two were not monitored. The Assistant Director of Nurses confirmed that there were no temperature monitor logs for these freezers, and the Director of Staff Developer admitted to not monitoring the freezer temperatures despite being aware of the policy requiring daily monitoring. This lack of monitoring could lead to improper food storage temperatures, increasing the risk of food-borne illnesses among the residents.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to ensure that the menu was being followed for therapeutic diets during lunch on 3/20/24. Seven residents on modified texture diets (Dysphagia mechanical soft and Dysphagia advance) did not receive the required gravy for their meat entree, contrary to the facility's diet guide sheet. Additionally, two residents on a Therapeutic Lifestyle Change (TLC) diet received gravy on their pork chop, which was not in accordance with their dietary requirements. Furthermore, three residents on Renal and CCD/Renal diets received cake instead of the prescribed cookie for dessert and gravy on their pork chop, which was not compliant with their dietary needs. Lastly, two residents on a CCD diet received sweet potato instead of mashed potato as indicated on the menu. During interviews, the Regional Registered Dietitian and the Registered Dietitian acknowledged that the staff did not follow the menu or spreadsheet when preparing meals, which could potentially affect the nutritional needs of the residents. The facility's job description for the cook emphasizes the importance of adhering to menus and portion control standards, including those for special diets, when preparing and serving meals. The failure to follow these guidelines had the potential to compromise the medical and nutritional status of the 14 residents involved.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide documentation for current COVID-19 immunizations for three residents, specifically regarding the offering, administration, or refusal of the vaccine. Resident 7, who has a persistent vegetative state and a history of pneumonia and COVID-19, had no documented current 2023-2024 COVID vaccine information. Similarly, Resident 61, with a diagnosis of cerebral infarct, and Resident 73, with a history of COVID-19, also lacked documentation for the current COVID-19 vaccine. The Director of Nursing (DON) confirmed the absence of documented consents or refusals for these residents during a review of their vaccination records. The DON explained that the previous Infection Preventionist had sent out mass texts to families when vaccines were available, but there was no follow-up to ensure consents were signed. Family members of Residents 61 and 73 confirmed they had not received recent messages offering the COVID-19 vaccine. The facility's policy required that each resident be offered the vaccine and that documentation of education, consent, and administration be maintained in the resident's medical record. The lack of proper documentation and follow-up decreased the facility's potential to prevent or reduce the severity of COVID-19 among its residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control standards for two residents. Resident 204's indwelling catheter bag was observed lying on the floor, contrary to the care plan and facility policy, which stated that catheter bags should be kept off the floor to prevent infection. This was confirmed by a CNA and the DON, who acknowledged that the catheter bag on the floor increased the risk of infection. The facility's policy on catheter care explicitly stated that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. For Resident 7, the facility did not adhere to Enhanced Barrier Precautions (EBP) during high-contact care activities. Two CNAs were observed changing the resident's incontinence brief without wearing gowns, despite a sign indicating that gowns and gloves were required for such activities. One CNA's shirt came into contact with the bed during care. The ADON confirmed that gowns and gloves should be worn during high-contact care to prevent the transmission of infections. The facility's policy on Enhanced Standard/Barrier Precautions emphasized the importance of gown and glove use to prevent the spread of multi-drug resistant organisms.
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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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