Anaheim Crest Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 3067 W Orange Avenue, Anaheim, California 92804
- CMS Provider Number
- 555445
- Inspections on file
- 33
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Anaheim Crest Nursing Center during CMS and state inspections, most recent first.
The facility failed to protect resident privacy when an outside performer recorded residents during an activity and posted the videos on social media without appropriate consent. One resident with severe cognitive impairment had a consent form allowing photography only for a facesheet, and the responsible party stated no permission was given for videos or social media posting, noting that the online content included humiliating comments. Another cognitively intact resident had consented only to photography for a facesheet, dietary card, and medication records, and reported seeing the performer record residents with a personal phone without expecting the footage to be uploaded. The Admissions Coordinator and Administrator confirmed that neither resident’s consent authorized social media use, and the Administrator acknowledged allowing the performer to record the event without checking residents’ consents or imposing restrictions.
The facility failed to ensure that written transfer/discharge notices, including bed-hold and return policies, were provided directly to residents and/or their representatives when three residents were transferred to an acute care hospital. In multiple cases, staff documented that notices were "provided" but recorded the method as sending the forms with transfer paperwork to the hospital via paramedics, rather than giving them to the resident or responsible party. For one resident with severe cognitive impairment and another with a sudden change in mental status, the notices were completed by nursing staff but routed with hospital transfer documents instead of being clearly delivered to the responsible party. For a third resident with moderate cognitive impairment, the section indicating that a written copy was provided was left blank, while the method again showed it was sent with transfer paperwork. During interviews, the DON and nursing staff described a routine practice of verbally informing residents/families and placing the notice forms in an envelope for the hospital, with no consistent documentation that the written notices were actually given to the residents or their representatives.
A resident with moderate cognitive impairment alleged that an LVN engaged in inappropriate physical contact. The incident was reported to a CNA, who informed the LVN, but the LVN did not escalate the allegation to a supervisor. The facility delayed reporting the abuse allegation to the state agency, contrary to its policy requiring immediate notification.
Surveyors found that kitchen utensils and equipment were not properly cleaned, maintained, or air dried, with multiple items observed to have residue, watermarks, and fuzzy films. Some utensils were damaged or worn out, and the kitchen hood was found with greasy residue. These deficiencies were acknowledged by the DSS and affected the majority of residents consuming food prepared in the kitchen.
A resident was found with a topical pain medication left at the bedside for self-application without a physician's order, assessment, or care plan authorizing self-administration. Nursing staff confirmed that medications should not be left at the bedside, and the DON verified that required documentation and orders were missing.
Two residents were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. One resident with decision-making capacity had the call light on the floor and could not locate it, while another resident with severe cognitive impairment had the call light clipped to the wall and was unable to use it. Both situations were confirmed by an LVN and the DON.
Two residents did not have comprehensive, individualized care plans reflecting all required interventions. For one, the care plan for mood and behavioral symptoms omitted non-pharmacological interventions listed in the psychoactive medication consent. For the other, the care plan did not address PASARR Level II recommendations, despite a history of mental health conditions. Staff confirmed these omissions during interviews and record reviews.
Surveyors found expired biohazard spill kits on a crash cart and observed hydrocortisone cream stored unlocked and mixed with food thickener and other items on a medication cart. The MDS Coordinator confirmed these practices did not follow facility policy for secure and appropriate medication storage.
A resident's POLST form was inaccurately completed, indicating that an advance directive was not available, even though a Durable Power of Attorney had been uploaded into the electronic medical record. Facility staff confirmed the documentation should have reflected the presence and review of the advance directive, but this was not done.
The facility failed to ensure proper infection control practices, including not cleaning a call light after it was picked up from the floor and placed on a resident's bed, not communicating infection surveillance data for antibiotic stewardship to the physician when a resident was prescribed antibiotics without meeting infection criteria, and not screening pneumonia cases for possible Legionnaire's disease or coordinating water system testing as required by policy.
Dietary staff did not follow the prescribed portion size for pureed Mandarin Oranges, serving four ounces instead of the required three ounces as outlined in facility policy and recipes. The DSS confirmed that the correct scoop was not used, resulting in residents receiving a larger portion than planned.
The facility did not update care plans for two residents to reflect their current needs. One resident's care plan required monitoring the effectiveness of a skin treatment, but staff did not evaluate or document this as directed. Another resident's care plan included encouraging verbalization of feelings, even though the resident was unable to communicate due to cognitive decline. Staff confirmed these interventions were not appropriate or followed, and the care plans were not revised accordingly.
A resident with dysphagia and no decision-making capacity received enteral feeding, but the enteral water feeding bag was not changed within the required 24-hour period as per facility policy. This was confirmed by an LVN and acknowledged by the DON during the survey.
The facility did not ensure that daily nurse staffing information, detailing the total number and actual hours worked by licensed and unlicensed nursing staff per shift, was posted as required. During an observation and interview, an RN and an LVN were unable to locate the required posting and confirmed it was missing.
A resident receiving IV antibiotics for a venous ulcer/cellulitis had a peripheral IV site that was not labeled according to facility policy, missing the time of insertion, staff initials, and catheter details. Additionally, there was no documentation in the medical record to confirm that the IV site was changed as indicated on the label, and the DON confirmed this lack of documentation.
A resident with COPD was observed using a nasal cannula for oxygen therapy that was not labeled or dated as required by facility policy. An RN confirmed the omission, noting that labeling is necessary for staff to know when to change the cannula, and the DON verified the findings.
A resident was given a 50 mg tablet of zinc sulfate instead of the prescribed 220 mg by an LVN, despite clear physician orders and facility policy requiring accurate medication administration. The error was confirmed through record review and staff interviews, with the DON acknowledging the nurse did not verify the order or medication prior to administration.
Surveyors observed that both outside garbage dumpsters had lids that were not fully closed due to bulky boxes and trash bags, preventing proper containment of waste. The Maintenance Director confirmed that the lids should be closed for infection control, and facility policies require tightly closed, leakproof containers for waste disposal.
A facility failed to report an abuse allegation involving a resident to the CDPH, L&C Program in a timely manner, as required by its policy. The resident, who was cognitively intact, alleged abuse due to missed meals, unanswered call lights, and retaliation. The facility attempted to report the incident but mistakenly faxed the report to its own number instead of the correct CDPH, L&C Program's number.
The facility failed to meet food safety and sanitation standards, including improper monitoring of TCS foods, inadequate hand hygiene practices, and poor labeling and storage of food items. These deficiencies were confirmed by the DSS and had the potential to cause foodborne illnesses among residents.
The facility failed to ensure call lights and bed controls were within reach for two residents, potentially impacting their psychosocial well-being and delaying care. A resident's call light and bed remote were found out of reach, confirmed by an RN, while another resident's call light was observed on the floor, verified by an LVN and the DON.
A facility failed to notify a resident's representatives and the LTC Ombudsman in writing about the resident's transfer to an acute care hospital. The resident, who lacked decision-making capacity, was transferred twice without the required notifications. The facility's policy mandates written notification of transfer details and appeal rights, but the Medical Records Department did not send these notices.
A facility failed to provide a written bed hold policy to a resident's representative during hospital transfers, as required by their policies. The resident, who lacked decision-making capacity, was transferred twice without the representative receiving the necessary documentation. Interviews with staff confirmed the oversight, with the Medical Records Department unable to provide evidence of compliance.
A resident experienced a delay in receiving a stat chest x-ray, ordered due to a change in condition and low oxygen saturation. The facility's policies required timely communication and documentation, but the medical record lacked details on the x-ray's completion time and follow-up actions. Interviews confirmed the expectation for stat orders to be completed within four hours, highlighting a deficiency in care and documentation.
The facility failed to provide appropriate dialysis care for two residents, with inconsistencies in fluid intake documentation for one resident and incomplete dialysis communication forms for another. The discrepancies in fluid intake records and inaccurate post-dialysis assessments were verified by staff, highlighting a failure to accurately monitor and document critical care information for residents on dialysis.
The facility failed to properly dispose of medications for a discharged resident, maintain sanitary conditions of medication carts, and ensure proper storage of IV medication. Additionally, a resident had unsecured medications at the bedside, posing a risk of access by other residents.
A resident was not provided with the prescribed therapeutic diet, as they were served double portions without a physician's order. The resident was supposed to receive a fortified/high protein diet with pureed/level 4 texture and thin consistency. The error was identified when a CNA served two trays based on an incorrect meal ticket. Licensed nurses were responsible for checking trays, but both the RN and DON confirmed the absence of an order for double portions.
The facility did not follow its policy for labeling and storing food brought by visitors, leading to unlabeled and outdated items in the residents' refrigerator. Staff interviews revealed inconsistencies in labeling practices, with some items lacking resident names and dates, and others not being discarded after the use-by date, posing a risk of foodborne illness.
The facility failed to maintain accurate medical records for two residents. A resident's closed record was incomplete, missing critical information on the Transfer Discharge Report. Another resident's POLST form lacked a physician's signature, necessary for validating the resident's life-sustaining treatment preferences. These deficiencies were confirmed by the DON and RN during interviews and record reviews.
A resident with severe cognitive impairment and end-stage Alzheimer's disease did not receive coordinated hospice care due to incomplete visit schedules and lack of documentation. The facility failed to ensure the hospice aide provided required showers, and hospice staff lacked access to the resident's care plans.
The facility failed to implement their Quality Assessment and Assurance (QAA) plan, lacking documentation to show evaluation of action plans for repeated deficiencies cited at F578, F684, F812, and F880. During an interview, the Administrator could not provide evidence of monitoring or reevaluation, as the 2021 QAPI binder was in storage, indicating a lack of ongoing evaluation and documentation.
The facility failed to maintain infection control practices, with lint buildup in laundry dryers and improper handling of a resident's call light. Additionally, an LVN did not perform hand hygiene after picking up a marker from the floor, risking infection spread.
A resident with no decision-making capacity experienced a significant respiratory change, becoming non-responsive with low oxygen saturation. Despite physician orders for immediate interventions, the facility failed to update the care plan to address this change. Staff interviews confirmed the oversight, with the DON acknowledging the need for a care plan update.
The facility failed to accurately post the DHPPD nurse staffing form, missing key information such as actual nursing hours and the DON's signature. This was confirmed by the DON and Administrator, who acknowledged the form only showed projected hours.
A facility failed to document the return of a resident's personal belongings at discharge, as required by its policies. During a review, it was found that the discharge section of the Resident's Clothing and Possessions Form was left blank, lacking necessary signatures and dates. Although RN 1 stated the belongings were returned, the absence of documentation indicates non-compliance with procedures.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to the front door alarm not being activated. The resident was found in the parking lot with injuries, highlighting deficiencies in monitoring and alarm activation by the staff.
A resident admitted after hip surgery with a Stage 4 pressure injury did not receive a timely wound consult. The wound physician's visit was delayed by two weeks, despite weekly visits to the facility. Staff admitted to missing the consult.
Failure to Obtain Proper Consent for Resident Photography and Social Media Posting
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal privacy and maintain confidentiality of medical and personal information when an outside performer recorded and posted videos of residents on social media without appropriate consent. Facility policies on confidentiality and on photography, video, audio, and electronic recordings required that release of resident information, including video, be handled in accordance with resident rights and that written consent be obtained from the resident or legal representative before taking any photographs or recordings for marketing or promotional purposes. Despite these policies, the Administrator stated she consented to the performer video recording the performance, including residents who attended the activity, without any restrictions and without verifying whether residents’ existing consents covered social media or activity performance recordings. For one resident with severe cognitive impairment (BIMS score 0), the medical record showed a Consent for Photography limited to use for the facesheet only, signed by the responsible party. The responsible party confirmed that he did not consent to any photography or video recording by the performer or to posting on social media, and reported that the posted photos and videos included humiliating comments. For another cognitively intact resident (BIMS score 13), the Consent for Photography allowed use for the facesheet, dietary card, and medication records only. This resident stated he did not consent to photography or video recording for social media and observed the performer recording the performance and residents with a personal phone, without expecting the recordings to be uploaded. The Admissions Coordinator, Administrator, and DON all verified that the consents for these residents did not include permission for social media use, confirming that the facility failed to follow its own consent requirements and resident-specific limitations on photography.
Failure to Provide and Document Required Written Transfer/Discharge Notices to Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required written Transfer and Discharge Notices, including bed-hold and return policies, directly to residents and/or their representatives when residents were transferred to an acute care hospital. Surveyors cited SOM Appendix PP, F483.15(c)(3), which requires that before a transfer or discharge, the facility must notify the resident and the resident’s representative in writing and in a language and manner they understand. The facility’s own policy dated 10/2022 states that notice of transfer is to be provided to the resident and representative as soon as practicable before transfer, and that notice of bed-hold and return policies must be provided within 24 hours of an emergency transfer, with documentation in nursing notes of appropriate orientation and preparation of the resident. For one resident with severe cognitive impairment (BIMS score 0) who fell and had hypotension, the progress notes showed the responsible party was at the bedside during the transfer to the hospital. The Notice of Transfer and Discharge dated the same day was completed by an LVN and indicated that a written copy was provided to the responsible party, but the method documented was that it was sent with transfer paperwork to the acute hospital via paramedics. For a second resident, who had capacity to understand and make decisions and experienced a sudden change in mental status leading to transfer, the Notice of Transfer and Discharge was completed by an RN and also indicated that a written copy was provided to the responsible party, yet again the method documented was that it was sent with the transfer paperwork to the acute hospital. For a third resident with moderate cognitive impairment (BIMS score 9) who was transferred to the hospital after a fall with injury and later readmitted, the Notice of Transfer and Discharge completed by an RN had the section for “Written copy of the Notice of Transfer and Discharge Provided” left blank, while the method section showed it was sent with transfer paperwork to the acute hospital. During interviews, the DON and nursing staff described a practice of placing the Notice of Transfer and Discharge, along with other clinical documents, in an envelope given to paramedics for the hospital, while verbally informing residents or responsible parties of the transfer and bed-hold. The DON acknowledged that the notice, discharge, and bed-hold information were on one form and that the facility relied on verbal notification, and the RN who transferred one resident stated she verbally informed the responsible party and handed the notice to him but did not document this in the medical record. Another LVN stated she sent the notice with the hospital transfer records and did not confirm awareness of the facility’s policy, resulting in a lack of documented evidence that written notices were actually provided to the residents or their representatives as required.
Failure to Timely Report Resident's Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for timely reporting of a reasonable suspicion of a crime, specifically regarding an allegation of sexual abuse made by a resident against a staff member. According to the facility's policy, all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but no later than two hours, to the appropriate authorities, including the State licensing/certification agency. In this case, the resident alleged that a Licensed Vocational Nurse (LVN) engaged in inappropriate physical contact, including positioning her vagina on the resident's elbow and straddling and thrusting against the resident. The resident reported the incident to a Certified Nursing Assistant (CNA), who then informed the LVN of the allegation. The LVN, who was the alleged perpetrator, did not report the allegation to a supervisor, stating she did not know how to report when she was involved in the incident. The facility reported the abuse allegation to the California Department of Public Health (CDPH) Licensing & Certification Program several days after the incident occurred, as evidenced by the SOC 341 form. The resident involved had a history of moderate cognitive impairment but was assessed as having the capacity to understand and make decisions. Interviews with the resident, CNA, and LVN confirmed the sequence of events and the delay in reporting. The administrator acknowledged the findings during the survey. The failure to report the allegation in a timely manner was a direct violation of the facility's own policy and regulatory requirements.
Deficient Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's kitchen related to food safety and sanitation. During an initial kitchen tour, numerous kitchen utensils, including scoops, spatulas, serving spoons, and measuring spoons, were found to be dirty with dry crusted residue, watermarks, and fuzzy films. These utensils were not clean to sight and touch, and the Dietary Services Supervisor (DSS) acknowledged that they needed to be rewashed and air dried to prevent cross contamination and bacteria growth. Additionally, several utensils were observed to be in poor condition, such as being discolored, peeling, burnt, deformed, or worn out, which compromised their ability to be properly cleaned and maintained as required by facility policy and the USDA Food Code. Further observations revealed that some heavy-duty blenders, clear plastic pitchers, and a measuring pitcher used for beverages were stored while still wet and stacked on top of each other, rather than being air dried as required. The DSS confirmed that all kitchen utensils and equipment should have been air dried to prevent bacteria growth. The kitchen hood over the stove was also found to have black dirt and greasy residue, despite a cleaning schedule and recent service by an outside company. The DSS acknowledged that the hood should not have greasy residue due to fire hazard and contamination risks. A review of facility policies and procedures, as well as relevant USDA Food Code sections, confirmed that the observed practices did not meet required standards for cleanliness, maintenance, and storage of kitchen equipment and utensils. The deficiencies were noted to have the potential for cross contamination and foodborne illnesses for the residents consuming food prepared in the facility's kitchen. At the time of the survey, 69 of 72 residents were consuming food prepared in the kitchen.
Failure to Assess and Document Resident Self-Administration of Medication
Penalty
Summary
The facility failed to determine if it was safe for a resident to self-administer medication, as required by its own policy and regulatory standards. During an observation, a resident was found with a medication cup containing Diclofenac Sodium topical gel 1% at the bedside, which the resident stated was left by nursing staff for later self-application. The nurse present confirmed that licensed staff were not supposed to leave medications at the bedside, indicating a deviation from established procedures. A review of the resident's medical record revealed there was no physician's order, assessment, or care plan authorizing or addressing self-administration of medication. The resident's history and physical examination indicated the capacity to understand and make decisions, but there was no documentation of an interdisciplinary team assessment to determine if self-administration was clinically appropriate or safe. The Director of Nursing confirmed the absence of required documentation and orders for self-administration of medications for this resident.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of nineteen sampled residents, as required by facility policy and individual care plans. For one resident with decision-making capacity, the call light was observed on the floor under the bed, out of reach, and the resident was unable to locate or use it. This was confirmed by both the resident and an LVN, who acknowledged the call light was not accessible and stated that it should be within reach for resident safety and communication. For another resident with severe cognitive impairment and a history of neurological weakness and confusion, the call light was found clipped to the wall, also out of reach. The resident was unable to locate or use the call light to request assistance and did not know who had placed it there. This was similarly confirmed by an LVN, who stated the call light should be accessible, and by the DON, who verified the findings. Both residents had care plans specifying that call lights should be within reach, but these interventions were not followed.
Failure to Develop Comprehensive, Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents, as required by their own policies and regulatory standards. For one resident, the care plan addressing mood and behavioral symptoms did not include all interventions listed in the resident's Informed Consent Renewal for psychoactive medications. Specifically, non-pharmacological interventions such as encouraging exercise, empathetic listening, individualization of care choices, positive reinforcement, repositioning, and social service or activity visits were documented in the consent form but were not reflected in the resident's care plan. Interviews with facility staff, including an LVN and the MDS Coordinator, confirmed that these interventions were practiced but not formally included in the care plan documentation. For another resident, the facility did not develop a care plan that addressed the recommendations from a PASARR Level II evaluation. The PASARR Level II evaluation, conducted by a psychologist, outlined several personalized care recommendations, including ongoing psychotropic medication monitoring and education, mental health rehabilitation activities, ADL training, supportive services, psychotherapy or counseling, psychiatry consultation, and neuropsychology consultation. Despite these recommendations and the resident's medical history of anxiety disorder, depressive disorder, and bipolar disorder, the care plan did not reflect these individualized interventions. Facility staff, including the MDS Coordinator, Administrator, and DON, verified during interviews and record reviews that the care plans for both residents were incomplete and did not incorporate all required interventions. These omissions were identified through observation, interviews, medical record reviews, and review of facility policies and procedures.
Improper Medication Storage and Expired Supplies
Penalty
Summary
The facility failed to ensure that medications and biologicals were handled securely, accurately labeled, and stored appropriately, as required by their own policies and professional standards. During an observation, a crash cart was found to contain two packages of a biohazard spill kit that had expired over five years prior. The contents of these kits included disposable gloves, absorbent towels, disinfectant wipes, hand sanitizer wipes, a plastic scoop with scraper, absorbent powder, a twist tie, and a red biohazard trash bag. The MDS Coordinator confirmed that these expired medical supplies should have been disposed of. In a separate observation, a medication cart was found with an unlocked transparent box compartment attached to its side. Inside, two packets of hydrocortisone acetate cream 1% were stored together with multiple packages of food thickener, a tape measure, medication label directions, and batteries. The MDS Coordinator acknowledged that the cream should have been locked in the treatment cart and not stored with food or other items, verifying the improper storage and lack of security for these medications.
Inaccurate POLST Documentation for Advance Directive
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the documentation on the resident's Physician Orders for Life-Sustaining Treatment (POLST) form. Review of the medical record revealed that the POLST indicated the resident's advance directive was not available, despite the fact that a Durable Power of Attorney had been uploaded into the electronic medical record prior to the completion of the POLST. During interviews, facility staff confirmed that the POLST should have reflected the presence and review of the advance directive, but this was not accurately documented. This inaccuracy was verified by both the Social Services Director and the Director of Nursing during the survey.
Infection Control Deficiencies: Inadequate Disinfection, Antibiotic Stewardship, and Legionella Surveillance
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required by its own policies and CDC recommendations. During an observation, an LVN picked up a call light from the floor in a resident's room and placed it on the resident's bed without cleaning or disinfecting it, despite facility policy requiring such items to be cleaned after contact with the floor. The LVN acknowledged the oversight when informed, and the DON verified the incident. Additionally, the facility did not ensure that infection surveillance data for the antibiotic stewardship program was properly communicated to the physician. A resident was prescribed antibiotics for a suspected UTI, but the resident did not meet McGeer's Criteria for a true infection. There was no documentation that the physician was notified about the signs and symptoms or that the criteria for infection were not met, as confirmed by both the Infection Preventionist and the DON. The facility also failed to screen pneumonia cases for possible Legionnaire's disease, as required by its Legionella surveillance policy. Multiple cases of healthcare-associated pneumonia were identified over several months, but there was no coordination between the Infection Preventionist and the Maintenance Director regarding Legionella testing or discussion of pneumonia cases in infection control meetings. The last water system test for Legionella was conducted in the previous year, and the Maintenance Director only performed testing when instructed by the Administrator.
Failure to Follow Prescribed Portion Sizes for Pureed Mandarin Oranges
Penalty
Summary
The facility failed to ensure that menus were followed and residents' nutritional needs were met when the correct portion sizes for pureed Mandarin Oranges were not adhered to during meal preparation. Specifically, during an observation of puree preparation, dietary staff used a number 8 scoop (four ounces) instead of the required number 10 scoop (three ounces) as specified in the facility's recipe and portion control policy. This resulted in residents receiving a larger portion than planned. The Dietary Services Supervisor (DSS) acknowledged that the dietary staff did not follow the established portion size guidelines and should have used the correct scoop as indicated on the facility's spreadsheet and policy.
Failure to Revise Care Plans for Individual Resident Needs
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident, the care plan included interventions for fragile skin that required monitoring the effectiveness of zinc oxide cream treatment. However, medical record reviews and staff interviews revealed that the effectiveness of the treatment was not being evaluated or documented, despite the care plan's directive. Staff, including LVNs and the DON, confirmed that maintenance treatments were not evaluated for effectiveness, and the care plan intervention to monitor effectiveness was not being followed or considered necessary. For another resident, the care plan included an intervention to encourage verbalization of feelings, despite documentation and staff interviews indicating the resident had no capacity to understand or make decisions and was rarely or never understood. The resident was unable to verbalize needs, and staff acknowledged that the intervention was not realistic or appropriate for the resident's current cognitive status. The care plan had not been updated to reflect these changes, and the intervention remained inaccurate.
Failure to Change Enteral Water Feeding Bag Within 24 Hours
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary gastrostomy tube (GT) care and services for a resident receiving enteral feeding. Specifically, the facility did not change the resident's enteral water feeding bag within the required 24-hour period, as outlined in the facility's policy and procedure for enteral feedings. The policy, revised in November 2018, states that administration sets for open-system enteral feeding must be changed at least every 24 hours or as specified by the manufacturer. The resident in question had a medical history of dysphagia and lacked the capacity to make decisions. Medical orders indicated the resident was to receive Diabetisource AC formula and free water via GT. During an observation, it was noted that the enteral feeding water bag had been prepared more than 24 hours prior, and this was confirmed by an LVN, who acknowledged the bag should have been changed within the 24-hour timeframe. The DON also verified and acknowledged these findings.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, was posted as required. During an observation and interview, a registered nurse and a licensed vocational nurse were unable to locate the posted staffing information at the nursing station. Both staff members confirmed that the information, which should have been available, was missing and could not be found at the time of the surveyor's request.
Failure to Properly Label and Document IV Site for a Resident
Penalty
Summary
A deficiency was identified when a resident receiving intravenous (IV) antibiotic therapy for a left lower leg venous ulcer/cellulitis did not have their peripheral IV (PIV) site properly labeled according to facility policy. During an observation, the PIV label was found to be missing the time of insertion, the initials of the staff member, and the length and gauge of the catheter. The registered nurse present confirmed these omissions. The facility's policy required that the label include the date and time of insertion, initials, and catheter details, but these were not present on the observed label. Further review of the resident's medical record and IV administration record revealed inconsistencies regarding documentation of the IV site change. Although the label on the IV site indicated a change on a specific date, there was no corresponding documentation in the nurse's notes or IV administration record to confirm that the site was changed as required. The Director of Nursing verified the absence of this documentation during a review.
Failure to Label and Date Nasal Cannula for Oxygen Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care in accordance with its own policies and procedures for one resident with a diagnosis of COPD. The facility's policy required that nasal cannulas be labeled or dated when changed or replaced, and that oxygen tubing be changed weekly. During an observation, a resident was seen using a nasal cannula that was not labeled with the date, and this was confirmed by an RN, who acknowledged that the lack of labeling could prevent staff from knowing when to change the cannula. The DON was also informed and verified these findings. The resident had a physician's order for oxygen to be administered via nasal cannula as needed, based on oxygen saturation levels.
Incorrect Dosage of Zinc Sulfate Administered
Penalty
Summary
A deficiency occurred when LVN 8 failed to administer zinc sulfate to a resident as ordered by the physician. During a medication administration observation, LVN 8 provided the resident with a 50 mg tablet of zinc sulfate instead of the prescribed 220 mg tablet. This discrepancy was confirmed through medical record review and direct interview with LVN 8, who acknowledged the error. The facility's policy and procedure for administering medications requires that medications be given in accordance with the prescriber's orders, including the correct dosage and timing. The resident involved had a history and physical examination indicating capacity to understand and make decisions. The physician's order for zinc sulfate 220 mg daily was clearly documented in the resident's order summary report. The Director of Nursing (DON) reviewed the findings and confirmed that the licensed nurse should have checked both the physician's order and the medication prior to administration. The failure to administer the correct dosage of zinc sulfate as ordered constituted a lapse in following established medication administration protocols.
Improper Storage of Garbage in Facility Dumpsters
Penalty
Summary
The facility failed to ensure proper storage and disposal of garbage in both of its outside dumpsters. Observations revealed that one dumpster lid was partially propped open by bulky boxes, and on a separate occasion, another dumpster lid was prevented from fully closing due to trash bags. These conditions were confirmed by the Maintenance Director, who acknowledged that the dumpster lids should be completely closed for infection control purposes. A review of the facility's policies and procedures indicated that all waste, including kitchen and infectious waste, should be disposed of in a safe and appropriate manner, with garbage containers kept in good condition and tightly closed. The FDA Food Code also requires outside garbage receptacles to have tight-fitting lids to prevent pest and rodent entry. The facility's failure to keep dumpster lids closed was directly observed and verified during the survey.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. This failure occurred when the facility did not report an allegation of abuse involving a resident to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program in a timely manner. The facility's policy on abuse prevention and mandated reporting requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the state licensing/certification agency. Allegations resulting in serious bodily injury must be reported within two hours, while other allegations must be reported within 24 hours. In this case, a resident, who was cognitively intact with a BIMS score of 15, alleged that she was abused in the facility because her meals were not delivered, staff were not answering her call lights, and she was being retaliated against. The facility attempted to report the abuse allegation on the same day it was made, but the fax containing the report was mistakenly sent to the facility's own fax number instead of the CDPH, L&C Program's fax number. This error was confirmed during an interview with the Administrator, who verified that the fax transmission log showed the report was sent to the incorrect number.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards in the kitchen, as observed during a survey. The deficiencies included improper monitoring of Time/Temperature Control for Safety (TCS) foods, which are crucial to prevent the growth of bacteria that can cause foodborne illnesses. Specifically, the facility did not document or monitor the cooling process of hot dogs served to residents, which should have been recorded in the Cooling Log. This oversight was confirmed by the Dietary Services Supervisor (DSS), who acknowledged that the hot dogs were not properly monitored after being served. Additionally, the facility did not ensure proper hand hygiene practices among dietary staff. An employee was observed changing tasks and handling clean dishes without washing hands between glove changes, which is a critical step to prevent cross-contamination. The DSS confirmed that the staff did not follow the hand hygiene policy, which requires washing hands before donning new gloves and between different tasks. The facility also failed to maintain proper labeling and storage of food items. Several items in the refrigerator were not labeled with open or use-by dates, and some food past its use-by date was not discarded. Furthermore, kitchen equipment and utensils were not stored in sanitary conditions, with some items found wet and with food residues. The DSS verified these findings and acknowledged that the equipment should be properly cleaned and air-dried before storage. These lapses in food safety and sanitation practices had the potential to cause foodborne illnesses among the residents.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, impacting their ability to access necessary assistance. Resident 115's call light and bed remote control were found hanging on the bedside drawer handle, out of the resident's reach, during an initial tour. This was confirmed by RN 1, who acknowledged that these items should have been placed within the resident's reach on the bed. Resident 115 was observed sleeping at the time of the tour, and the medical record review indicated the resident had been admitted and readmitted to the facility on unspecified dates. Similarly, Resident 3's call light was observed on the floor during the initial tour, making it inaccessible to the resident. This observation was verified by LVN 4, who confirmed that the resident would not be able to reach the call light in its current position. A subsequent observation the following day found the call light still on the floor, with the DON verifying that Resident 3 would not be able to reach it. These deficiencies in ensuring call lights and bed controls were within reach had the potential to negatively impact the residents' psychosocial well-being or delay their receipt of care.
Failure to Notify Resident's Representatives and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify a resident's representatives and the Office of the State Long-Term Care Ombudsman in writing about the resident's transfer to an acute care hospital. This deficiency was identified for one of the two sampled residents reviewed for hospitalization. The facility's policy and procedure for transfer or discharge, dated October 2022, requires that residents and their representatives be notified in writing of the specific reason for transfer, the effective date, the location to which the resident is being transferred, and the resident's right to appeal the transfer. Additionally, the policy mandates that a copy of the notice be sent to the LTC Ombudsman. In the case of the resident involved, the medical record review revealed that the resident lacked the capacity to understand and make decisions. Physician orders indicated transfers to the acute care hospital on two separate occasions. However, the medical records did not contain written notifications of these transfers to the resident's representatives or the LTC Ombudsman. Interviews with the RN and the Medical Records Department (MRD) confirmed the absence of these notifications. The MRD acknowledged the responsibility to send these notices but failed to do so for the identified transfer dates.
Failure to Provide Written Bed Hold Policy
Penalty
Summary
The facility failed to provide a written bed hold policy to the resident's representative upon the transfer of a resident to an acute care hospital. This deficiency was identified during a review of the facility's policies and procedures, which require that residents and their representatives be notified in writing of the bed hold policy when a transfer occurs. The review of the medical records for a specific resident, who lacked the capacity to understand and make decisions, revealed that the required written notices were not provided during two hospital transfers. Interviews with facility staff, including a registered nurse and a member of the Medical Records Department (MRD), confirmed the oversight. The MRD acknowledged that it was their responsibility to send the written bed hold policy to the resident's representative upon transfer, but they were unable to provide evidence that this was done for the transfers in question. This failure to provide the necessary documentation had the potential to leave the resident's representative uninformed about their rights regarding the resident's return to the facility after hospitalization.
Delayed Stat X-ray and Inadequate Documentation
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained the highest practicable physical well-being. The deficiency involved a delay in obtaining and processing a stat chest x-ray for a resident who had a change of condition, was non-responsive, and had a low oxygen saturation level. The physician ordered a stat chest x-ray, but the result was not received until more than a day later, posing a risk for delayed care and intervention. The facility's policies and procedures required timely communication and documentation of diagnostic tests, but the medical record review showed a lack of documentation regarding the time the x-ray was completed, follow-up attempts with the x-ray company, and follow-up on the x-ray results. Interviews with the RN and DON confirmed the expectation for stat orders to be completed within four hours and acknowledged the failure to document necessary follow-up actions. The deficiency was identified during a closed medical record review of the resident who had no capacity to understand and make decisions and had expired.
Inaccurate Dialysis Care Documentation for Two Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents, Residents 32 and 39, who required such services. For Resident 39, there were inconsistencies in the documentation of fluid intake between the Medication Administration Record (MAR) and the Fluid Intake with Meals form. The discrepancies were noted on multiple dates in May 2024, where the recorded fluid intake on the MAR did not match the amounts documented on the Fluid Intake with Meals form. This inconsistency was verified by both RN 1 and the Director of Nursing (DON), indicating a failure to accurately monitor and record the resident's fluid intake, which is critical for a resident on dialysis with a fluid restriction order. For Resident 32, the facility failed to ensure that dialysis communication forms were completed and accurate. The resident, who had a right upper chest permanent catheter, had incomplete or inaccurately documented post-dialysis assessments on several dates in May 2024. Specifically, the breathing patterns and breath sounds were not documented, and the presence of a bruit was incorrectly marked, which is not applicable for a resident with a catheter instead of an AV fistula. RN 1 confirmed these inaccuracies and emphasized the importance of assessing breathing patterns and breath sounds post-dialysis to identify any complications. The deficiencies in documentation and assessment for both residents were acknowledged by the facility's Administrator and DON. These failures in providing accurate and complete dialysis care documentation had the potential to impact the appropriate care and treatment of the residents involved.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to properly dispose of medications for a discharged resident, Resident 684. During an inspection, a box of hydrocortisone suppositories intended for Resident 684 was found stored with the facility's house supply of rectal medications. RN 1 confirmed that Resident 684 had been discharged and the medication should have been disposed of according to the facility's policy. Additionally, the facility did not maintain medication carts in a sanitary condition. During inspections, Medication Cart 3 was found with a bottle of Povidine-Iodine Solution that had dried solution on the top, and the drawers contained sticky brown residue. Similarly, Medication Cart 1 had a bottle of ProStat with sticky reddish residue. Both RN 1 and LVN 6 acknowledged these findings, indicating that the carts and medication bottles should be clean and free of residue. The facility also failed to ensure proper storage of IV medication for Resident 75. An uncovered IV saline bag with an attached vial of cefepime was found in the medication room refrigerator, despite the manufacturer's instructions to protect the medication from light and not prepare it in advance. Furthermore, Resident 21 was observed with ibuprofen and hydrogen peroxide at the bedside, which were not stored securely, posing a risk of access by other residents. The MDS Coordinator confirmed that Resident 21 refused to store the medications in a locked box, and the DON stated that medications should be stored securely.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a resident with the prescribed therapeutic diet, as observed during a survey. The resident was prescribed a fortified/high protein diet with pureed/level 4 texture and thin consistency. However, the resident was served double portions, which was not part of the physician's order. This discrepancy was noted when a CNA was observed feeding the resident two trays, as indicated on the meal ticket, which incorrectly listed double portions. Further investigation revealed that the licensed nurses were responsible for checking the trays before they were distributed to residents. During interviews, both the RN and the DON confirmed that there was no physician's order for double portions for the resident. The facility's policy and procedure for therapeutic diets, which requires diets to be prescribed by the attending physician, was not followed in this instance, leading to the potential risk of the resident's nutritional needs not being met.
Failure to Properly Label and Discard Food Brought by Visitors
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the labeling and storage of food items brought in by family members or visitors for residents. During an inspection, it was observed that several food items in the residents' refrigerator were not labeled with the resident's name, room number, or the date the food was brought in, as required by the facility's policy. Specific items included a Kentucky Fried Chicken bag, a container of tres leches cake, and other food containers that were either undated or lacked the resident's name. Additionally, some items were past their use-by dates, which were not discarded as per the policy. Interviews with staff, including the DSS, CNA, and DON, revealed inconsistencies in the implementation of the labeling and discarding procedures. The DSS confirmed the findings and acknowledged that the refrigerator should be checked and cleaned daily. However, CNA 4 admitted to not labeling the food items with the date, only with the room number and resident's name. The DON stated that food items should be labeled with the resident's name and date and discarded after 72 hours, but this practice was not consistently followed. These lapses in following the established procedures had the potential to cause foodborne illnesses among the medically vulnerable resident population.
Incomplete Medical Records and Unsigned POLST
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for two residents, which could potentially impact the delivery of services. For Resident 78, the closed medical record was incomplete, as the Transfer Discharge Report lacked essential information such as the date and time of transfer and discharge, the date and time of the mortician's pick-up, and details about personal effects sent. This was confirmed during an interview with the Director of Nursing (DON), who acknowledged the incomplete documentation. For Resident 18, the facility did not obtain a physician's signature on the POLST form, which is necessary for the form to be valid. The POLST indicated the resident's preference for CPR, but there was no documented evidence of a physician's signature, which is required to confirm that the order aligns with the resident's medical condition and preferences. This oversight was verified by RN 1 during a medical record review and was acknowledged by both the Administrator and the DON.
Failure in Coordination of Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the hospice provider for a resident receiving hospice services. The resident, who had severe cognitive impairment and was diagnosed with end-stage Alzheimer's disease, was admitted to hospice services. However, the hospice monthly personalized visit schedules for the resident were incomplete, and there was no evidence that the hospice aide had provided the required showers twice per week. The facility's policy and procedure required collaboration with the hospice provider to ensure quality care, but the hospice plan of care was not available or reviewed by hospice staff. Interviews with facility staff revealed that the hospice aide visit summaries were not completed, and the facility staff were not checking the hospice records. The hospice aide was supposed to visit the resident twice per week, but the sign-in sheets showed only five visits in May, and there was no documentation of the care provided. Further interviews indicated that the hospice staff did not have access to the resident's care plans, which were kept in an electronic record-keeping system. The hospice binder was outdated, lacking a current list of hospice staff. The facility's shower schedule indicated that the hospice aide was responsible for the resident's showers on specific days, but there was no confirmation that these showers were provided as scheduled.
Failure to Implement QAA Plan and Monitor Deficiencies
Penalty
Summary
The facility failed to implement their Quality Assessment and Assurance (QAA) plan of action, as evidenced by the lack of documentation showing an evaluation of the facility's action plan. This was necessary to determine if the facility had achieved and sustained improvement for repeated deficient practices cited at F578, F684, F812, and F880. These deficiencies were identified during the Recertification survey completed on August 13, 2021. The facility's policy and procedure for the Quality Assurance and Performance Improvement (QAPI) Program, revised in February 2020, outlined the process for identifying and correcting quality deficiencies, including developing and implementing corrective actions and monitoring their effectiveness. During an interview and document review on May 31, 2024, the Administrator and Administrator-in-Training (AIT) were unable to provide documented evidence that the facility had monitored, reevaluated, and trended the repeated deficient practices. The Administrator mentioned that the 2021 QAPI binder had already been placed in storage, indicating a lack of ongoing evaluation and documentation of the corrective actions taken.
Infection Control Lapses in Laundry and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices in several areas, leading to potential safety hazards and the risk of infection spread among staff and residents. During an inspection, it was observed that two laundry dryers had a noticeable buildup of lint, which the Maintenance Director confirmed should be cleaned out every hour to prevent fire hazards. Additionally, the facility's staff did not adhere to infection control protocols when handling a resident's call light. On two separate occasions, the call light was placed back on the resident's bed without being disinfected after falling on the floor, as confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Furthermore, the facility's hand hygiene practices were not consistently followed. An LVN was observed picking up a black permanent marker from the floor and then using a laptop keyboard without performing hand hygiene, contrary to the facility's policy. Although the LVN later disinfected the marker and performed hand hygiene before entering a resident's room, the initial lapse in protocol was acknowledged by the LVN. These deficiencies highlight lapses in maintaining a clean and safe environment, as outlined in the facility's policies and procedures.
Failure to Update Care Plan for Respiratory Change
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a change in condition. The resident, who lacked the capacity to understand and make decisions, was admitted to the facility and later experienced a significant change in their respiratory condition, becoming non-responsive with a low oxygen saturation level of 76%. Despite these changes, the resident's care plan did not include any management strategies for the respiratory condition. Interviews with facility staff, including a registered nurse and the Director of Nursing (DON), confirmed the absence of an updated care plan addressing the resident's respiratory issues. The DON acknowledged that a care plan should have been developed to manage the resident's change in condition, indicating a lapse in the facility's protocol for updating care plans in response to significant health changes.
Inaccurate DHPPD Nurse Staffing Form Posting
Penalty
Summary
The facility failed to ensure the Direct Care Services Hours Per Patient Day (DHPPD) nurse staffing form was accurately posted, which could lead to inaccurate staffing information being provided to the public. The review of the facility's documents from 5/28/24 to 5/31/24 revealed missing information such as the facility address, license number, designated census periods, actual nursing hours worked, actual DHPPD hours, average census, and the signature of the Director of Nursing (DON) or designee to verify the accuracy of the information. This lack of documentation was confirmed during an observation and interview with the DON, who acknowledged that the form was completed but not signed. Further interviews with the Administrator and DON confirmed that the facility's DHPPD nurse staffing hours form had been updated two weeks prior but did not include actual nursing hours worked, only projected hours. The Administrator verified these findings and acknowledged the deficiency in the documentation process. The failure to accurately document and verify the DHPPD nurse staffing information was confirmed by both the Administrator and the DON during the interviews.
Failure to Document Return of Resident's Belongings at Discharge
Penalty
Summary
The facility failed to ensure that the personal belongings of a resident, identified as Resident 76, were properly recorded at discharge. This deficiency was identified during a closed medical record review and interview with RN 1. Resident 76 was admitted to the facility and later transferred to an acute care hospital. The review of the Resident's Clothing and Possessions Form, dated shortly before the transfer, indicated that Resident 76 had personal items including two coins, $11.00 in cash, a pink lighter, and a red pocketknife. However, the discharge section of the form, which should have documented the return of these belongings, was left blank, lacking the necessary dates and signatures from both the resident/responsible party and the nurse. RN 1 confirmed that the form was not completed as required, acknowledging that the discharge section should have been filled out to verify the return of Resident 76's belongings. Despite RN 1's statement that the belongings were given to Resident 76, the absence of proper documentation on the form indicates a failure to adhere to the facility's policies and procedures regarding the release of a resident's personal belongings. This oversight had the potential to result in the loss of the resident's personal items.
Failure to Prevent Resident Elopement Due to Inactive Door Alarm
Penalty
Summary
The facility failed to ensure the front door alarm was activated when no one was monitoring the front entrance, resulting in a resident eloping from the facility undetected. The resident, who had severe cognitive impairment and was identified as an elopement risk, was found in the facility's parking lot with injuries. The facility's policy required monitoring and necessary precautions for residents at risk of wandering and elopement, but these measures were not adequately implemented in this case. The resident's medical records indicated a history of wandering and a previous incident where the resident was found in the parking lot. Despite this, staff members, including the LVN and RN, did not consider the resident an elopement risk and failed to activate the front door alarm. On the day of the incident, the resident was last seen in the lobby watching TV and was later found missing from their room. A Code Yellow was initiated, and the resident was eventually found in the parking lot with injuries requiring hospital treatment. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the resident's elopement risk and the activation of the front door alarm. The Maintenance Director confirmed that the alarm should have been activated between 1930 and 2000 hours, but the charge nurse admitted to not setting the alarm on the day of the incident. The DON acknowledged the resident's elopement risk and the need for staff in-service training to address the deficiencies in monitoring and alarm activation.
Failure to Ensure Timely Wound Care
Penalty
Summary
The facility failed to ensure timely wound care for a resident who was admitted following hip surgery and had a Stage 4 pressure injury. The resident's physician ordered a wound consult on 1/4/24, but the initial visit from the wound physician did not occur until 1/18/24, two weeks later. Interviews with the treatment nurse and an RN revealed that the wound physician visited the facility weekly, and the resident should have been seen on 1/11/24. The treatment nurse admitted to missing the consult, and the RN confirmed that the staff failed to arrange the wound consult in a timely manner.
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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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