Anaheim Point
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 3415 W Ball Road, Anaheim, California 92804
- CMS Provider Number
- 555688
- Inspections on file
- 34
- Latest survey
- March 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Anaheim Point during CMS and state inspections, most recent first.
A resident's personal belongings, including valuable items, were not labeled with her name or included in her inventory list. Despite the resident informing staff and providing updates, the inventory was not updated and the facility's policy for labeling and documenting property was not followed. Staff confirmed the inventory was outdated and the belongings were not properly recorded.
The facility did not follow its abuse prevention policy when a resident alleged emotional distress caused by two LVNs. Despite the policy requiring immediate suspension of accused staff pending investigation, the nurses remained on duty during the inquiry. The administrator acknowledged not following the policy, and both nurses confirmed they were not suspended while the investigation was conducted.
Surveyors found that several residents were self-administering medications such as eye drops, pain relief creams, and sprays without required assessments, physician orders, or care plan documentation. Nursing staff confirmed that the facility's policy for evaluating and authorizing self-administration was not followed, and medical records lacked necessary approvals and documentation.
A resident who is always incontinent and has a high BMI did not receive a properly fitted diaper after the facility's vendor stopped supplying the preferred brand and size. The resident reported discomfort and repeated bed wetting, and a CNA confirmed the provided diapers were too small. The issue persisted for at least two weeks despite the resident's requests.
A resident with dementia and a history of falls had a care plan requiring floor mats on both sides of the bed. Observations showed that only one mat was in place, and an LVN confirmed the care plan was not fully implemented, resulting in a deficiency.
The facility did not ensure continuous monitoring and documentation for a resident receiving IV antibiotics for a urinary tract infection, as required by policy, and failed to clearly identify and communicate the code status for another resident with severe cognitive impairment on hospice. Nursing staff were unable to immediately determine the code status due to incomplete documentation, and monitoring for adverse reactions to antibiotics was not performed or recorded as expected.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment was able to leave the facility undetected after episodes of wandering and expressing a desire to go home, without timely updates to the care plan or staff communication; another resident at high risk for falls did not have bilateral floor mats in place as ordered by the physician, with only one mat observed during multiple checks.
A resident with ESRD receiving regular dialysis did not have their AV shunt site consistently or appropriately assessed for bruit and thrill as required by physician orders and facility policy. Documentation showed multiple instances where the absence of bruit and thrill was recorded, but there was no evidence that a physician was notified. Staff interviews confirmed a lack of understanding and follow-through regarding documentation and notification protocols.
A resident with severe cognitive impairment and dependent for bed mobility was provided with bilateral upper half side rails, despite an assessment indicating side rails were not needed. The care plan addressed grab bars rather than side rails, and staff confirmed the discrepancy between the assessment and the actual use of side rails, resulting in exposure to accident hazards.
A resident received hydrocodone-acetaminophen for severe pain, but the administration of this controlled medication was not documented on the Medication Administration Records as required by facility policy. Both an LVN and the DON confirmed the absence of documentation for two instances when the medication was dispensed.
Expired culture swabs and wound dressings were found in a treatment cart, and a resident was observed with an unopened container of over-the-counter eye drops at their bedside without a physician's order. Both issues were acknowledged by nursing staff and the DON, and the resident involved had moderately impaired cognition.
A resident on a NAS diet with specific dietary preferences did not receive the required protein components in her chef salad, receiving only lettuce, shredded carrots, and purple cabbage instead of the full recipe. The resident, who was trying to lose weight for knee surgery, reported not receiving enough protein, and facility staff confirmed the salad was not prepared according to the established recipe.
A resident with a history of stroke and a contracted, weak hand was not provided with the required built-up utensils and lip plate during meals, as ordered by the physician and documented in the care plan. Observations showed the resident using regular utensils, and staff confirmed the need for adaptive equipment to assist with eating.
Staff failed to wear required hair restraints in the kitchen and did not properly cover a canister of brown rice in dry storage, as confirmed by the Dietary Services Supervisor and Cook. These lapses occurred while preparing food for a large number of residents, in violation of facility infection control and food storage policies.
Two residents receiving hospice care did not have proper documentation or assurance of scheduled hospice aide visits, with missing records for several weeks and incomplete hospice consent forms. Facility and hospice staff confirmed the lack of documentation and unclear visit schedules, resulting in incomplete records and uncertainty about whether hospice services were provided as ordered.
A resident with severe cognitive impairment and dependent for bed mobility was observed using bilateral upper side rails without documented evidence of a required bed entrapment assessment. Facility policy mandated such assessments upon admission or changes in bed equipment, but the maintenance department was not notified about the resident's bed, and inspection logs showed no record of assessment for this bed.
The facility did not implement required testing and monitoring of disinfectant chemical levels in its water supply as outlined in its water management and Legionella control policies. Additionally, the laundry room and equipment were observed to be unclean, with visible stains, residue, and wall damage, as confirmed by the Housekeeping Supervisor.
The facility failed to implement its antibiotic stewardship program, resulting in inconsistent and inaccurate infection control documentation, lack of clear use of McGeer's criteria for infection assessment, and discrepancies in the evaluation and documentation of a resident who was prescribed antibiotics for diarrhea. These failures were acknowledged by the IP and DON.
A resident who was discharged home with hospice services was incorrectly coded in the MDS as being discharged to a short-term general hospital. The MDS Coordinator confirmed the error, which was made by the MDS Assistant, and the DON acknowledged the findings during review.
The facility did not ensure that POLST forms for two residents included documentation regarding advance directives, and medical records for two other residents were found incorrectly filed in another resident's chart. These documentation errors were confirmed by nursing staff during record reviews.
Two of six facility dumpsters were found with lids open and garbage inside, with the refuse preventing the lids from closing fully. This was observed and verified by the Administrator, and the condition did not comply with requirements for tight-fitting lids to prevent pest entry.
A resident's care plan was not updated to include treatment for left foot arterial wounds, despite physician orders. The omission was confirmed by the DON, highlighting a failure to provide individualized care.
A facility failed to ensure a resident receiving enteral feeding via a PEG tube was positioned with the head of the bed elevated 30 to 45 degrees, as required by policy. The resident was observed lying flat while receiving Jevity 1.5 at 50 ml per hour, posing a risk of aspiration. This was confirmed by an LVN and acknowledged by the DON.
A facility failed to ensure proper PPE use during high-contact care for a resident with a PEG tube, Foley catheter, and wounds. A CNA was observed handling the resident's Foley catheter without gloves and a gown, contrary to the facility's Enhanced Barrier Precautions policy. This lapse was confirmed by interviews with the CNA, an RN, and the DON.
A facility failed to store a resident's medication properly, as a bubble pack of potassium chloride was found on the nursing station counter instead of in the medication cart. An LVN confirmed the medication belonged to a resident and acknowledged it should have been stored securely. The ADON was informed and took possession of the medication.
A facility failed to inventory a resident's personal property upon admission and discharge, leading to missing items. The resident reported missing belongings after returning from a hospital transfer, but the social worker did not document the inventory. The DON confirmed the lack of documentation, highlighting a deficiency in safeguarding resident property.
A resident reported feeling humiliated after a CNA threw towels at her and instructed her to dry herself without assistance. The Activities Assistant documented some allegations but failed to report a specific incident to the Administrator, who was unaware of the allegations. The facility did not implement its policies and procedures related to abuse reporting, risking inadequate investigation and prevention of further abuse.
A resident who claimed to have slipped in the shower and complained of rib pain did not have a complete physical assessment documented in their medical record. Although an RN observed a small red line on the resident's rib cage, this observation was not recorded, contrary to the facility's policy requiring detailed documentation of incidents and assessments.
A resident with an indwelling urinary catheter due to obstructive uropathy had a physician's order for routine weekly changes, contrary to the facility's policy and CDC guidelines. The facility's policy stated that catheters should be changed based on clinical indications, not at fixed intervals. This discrepancy was confirmed by the IP and DON, who acknowledged the increased risk of infection due to routine changes.
Failure to Label and Document Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft by not ensuring that the resident's belongings were labeled with her name and included in her inventory list. During an observation and interview, the resident was found to have several valuable items in her room, such as a laptop, bluetooth headphones, a lap desk, and a music box, none of which were labeled or documented in her inventory. The resident stated she had informed staff whenever new items were brought in and had provided a list to the social services department, as instructed by nursing staff. A review of the resident's inventory form showed it had not been updated since her admission, and did not reflect the current belongings in her possession. Staff interviews confirmed that the inventory list was not updated to include the new items, and that the resident's personal property was not labeled. Staff acknowledged that the process for updating the inventory was not followed, despite being aware that the resident had accumulated many belongings over her long-term stay. The facility's policy required staff to label residents' belongings, update the inventory list when new items were brought in, and review the inventory for accuracy during quarterly care plan conferences. However, documentation from the most recent care plan meeting did not show that the inventory was discussed or updated. Multiple staff members, including CNAs, LVNs, the social services director, and the ADON, verified that the inventory list was outdated and that the resident's property was not properly labeled or recorded.
Failure to Suspend Staff Pending Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse prevention and management policy for one resident who alleged emotional distress caused by two nurses. According to the facility's policy, any employee accused of abuse must be immediately removed from resident care and suspended pending the outcome of the investigation. However, after a resident reported that two nurses had yelled at him and caused emotional distress, the facility did not suspend the identified nurses during the investigation period. Both nurses confirmed in interviews that they were aware of the allegations but were not suspended while the investigation was ongoing. The investigation was initiated after the resident's report and concluded a few days later, ultimately finding the claim unsubstantiated. Despite this, the facility's own documentation and staff interviews confirmed that the required suspension of the accused staff did not occur. The administrator acknowledged that the policy required suspension but chose not to follow it based on his own assessment of the situation, rather than adhering to the written procedures. The resident involved was able to make his needs known but was not able to make medical decisions independently.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that four residents were properly assessed and authorized to self-administer medications, as required by facility policy. During observations, surveyors found that these residents had various medications, including Refresh eye drops, Biofreeze pain relief cream, Bactine Max pain-relieving spray, and other topical pain relievers, stored at their bedsides or in nightstand drawers. Each resident reported self-administering these medications without prior assessment or approval from the interdisciplinary team (IDT) or the attending physician. Medical record reviews for each resident revealed the absence of required documentation, including assessments for self-administration capability, physician's orders permitting self-administration, and care plan entries addressing the self-administration of medications. In addition, there were no physician's orders for the medications themselves in the residents' records. Interviews with nursing staff confirmed that the facility's process was not followed, as none of the residents had been evaluated for their ability to safely self-administer medications, nor had the necessary approvals or documentation been obtained. The facility's policy mandates that residents may only self-administer medications after a licensed nurse completes an assessment, the IDT and attending physician approve, and a written order is obtained. The policy also requires that self-administration be documented in the care plan and medication administration record (MAR). These steps were not completed for the four residents involved, resulting in a failure to ensure safe self-administration of medications.
Failure to Provide Properly Fitted Incontinence Products
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not providing a properly fitted diaper. The resident, who is cognitively intact with a BIMS score of 14, is always incontinent of bladder and bowel, stands 68 inches tall, and weighs 405 lbs. During an observation and interview, the resident reported that the current diaper was too small, did not fit properly, and resulted in her bed being soaked multiple times a day. The resident also stated she had requested a properly fitting diaper for two weeks without resolution and expressed emotional distress over the situation. A CNA confirmed that the resident previously wore a 6x size diaper but was recently provided with smaller 4x or 5x sizes, which did not adequately cover the required area. The Central Supply In-charge explained that the facility's vendor no longer supplied the preferred Prevail diaper brand and had substituted it with a different, supposedly comparable size. The DON acknowledged the findings and confirmed the unavailability of the preferred diaper from the vendor.
Failure to Implement Bilateral Floor Mats for Fall Risk Resident
Penalty
Summary
A deficiency was identified when the facility failed to fully implement a comprehensive care plan intervention for a resident at risk for falls. The resident, who had dementia, impaired cognition, poor safety awareness, and a documented history of ongoing falls, had a care plan in place that required bilateral floor mats to be positioned on both sides of the bed as a fall prevention measure. Medical record review confirmed this intervention was part of the resident's care plan. Multiple observations conducted on the same day revealed that only one floor mat was consistently in place on one side of the resident's bed, while the opposite side lacked a floor mat. This was verified during an interview with an LVN, who acknowledged the absence of the second floor mat and confirmed that the care plan called for bilateral mats. The failure to implement this intervention as specified in the care plan constituted the deficiency.
Failure to Monitor IV Antibiotic Reactions and Document Code Status
Penalty
Summary
The facility failed to provide necessary care and services for two residents in the areas of IV antibiotic monitoring and advance directives. For one resident who was receiving IV antibiotics for an ESBL-positive urinary tract infection, there was no documented evidence of continued monitoring for adverse reactions to the medication or for worsening symptoms of the infection. Facility policy required licensed nurses to assess and document the resident’s condition every shift during the course of IV antibiotic therapy, but this was not done. Interviews with nursing staff confirmed that such monitoring and documentation were expected but not completed. For another resident with severe cognitive impairment who was on hospice services, the facility failed to clearly identify and communicate the resident’s current code status. The resident’s POLST form in the hospice binder was blank, and there was no physician’s order or care plan entry reflecting the code status. Although a scanned POLST indicating DNR status was found in the electronic health record, this information was not readily accessible or reflected in other key documentation. Nursing staff were unable to immediately determine the resident’s code status and stated that, in the absence of clear documentation, they would default to providing full code interventions. These deficiencies were identified through observation, interviews, and medical record review, and were acknowledged by facility staff. The lack of proper monitoring and documentation had the potential to result in residents not receiving care and services in accordance with their needs and treatment preferences.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with severe cognitive impairment and a diagnosis of dementia was observed wandering the unit, expressing a desire to go home, and was later found to have left the facility premises undetected. Despite documented episodes of wandering and confusion, the resident's care plan was not updated to address the increased risk of elopement, and staff were not informed of the need for enhanced supervision or specific interventions prior to the incident. Another resident, identified as being at risk for falls due to dementia, impaired cognition, and poor safety awareness, had a physician's order for bilateral floor mats as a safety intervention. However, during multiple observations, only one floor mat was in place, with the other side of the bed lacking the required mat. This was confirmed by staff, who acknowledged the omission and indicated that the second mat would be implemented in accordance with the physician's order. The facility's policies and procedures required assessment and care planning for elopement risk and resident safety upon admission, quarterly, and with any change in condition. In both cases, the facility did not follow its own protocols for reassessment and implementation of necessary safety interventions, resulting in residents being exposed to accident hazards and inadequate supervision.
Failure to Appropriately Assess and Monitor Dialysis Access Site
Penalty
Summary
The facility failed to ensure appropriate and consistent assessment and monitoring of a resident's dialysis access site. According to the facility's policy and physician's orders, the resident's arteriovenous (AV) shunt in the right arm was to be assessed for bruit and thrill every shift, with documentation of the findings and immediate physician notification if either was absent. Medical record review revealed multiple instances where the AV shunt was documented as negative, zero, or X for thrill and bruit, indicating absence, but there was no evidence that the physician was notified as required. Additionally, some documentation used 'NA' without clear understanding among staff of its meaning in this context. Interviews with licensed staff and the assistant director of nursing confirmed that the negative, zero, and X notations indicated absence of thrill and bruit, and that the physician should have been notified immediately in such cases. The staff acknowledged that the dialysis access site was not properly assessed and that the required notifications were not made. The resident involved had end-stage renal disease (ESRD) and received dialysis three times a week, with a care plan in place to monitor for complications related to dialysis, but the facility did not follow the established protocols for monitoring and response.
Failure to Prevent Unnecessary Side Rail Use for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident assessed as not needing side rails was not provided with them. Despite a completed Bed Rail Assessment indicating that side rails were not indicated, the resident was observed on multiple occasions with bilateral upper half side rails elevated. The resident's plan of care addressed the use of grab bars rather than side rails, and the medical record included a physician's order for bilateral half side rails as enablers. The facility's policy required a Bed Rail Evaluation prior to installation or use of any bed rail, but this process was not followed as documented in the assessment. The resident in question had severe cognitive impairment and was dependent on staff for bed mobility. The bed, which included the side rails, was brought into the facility with the resident, who was under hospice care. Staff verified that the side rails were not indicated according to the assessment, yet the rails remained in use, and the care plan did not address their presence. These actions and omissions resulted in the resident being exposed to accident hazards related to side rail use.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation of controlled medication administration for one resident. According to the facility's policy and procedure, licensed nurses are required to chart the drug, time administered, and initial their name with each medication administration, and record the time and dose in the patient's individual medication record. For one resident, there was a physician's order for hydrocodone-acetaminophen to be administered as needed for severe pain. The resident's individual narcotic record showed that the medication was dispensed and signed out on two occasions. However, a review of the resident's Medication Administration Records (MARs) for the relevant months did not show documentation of the administration of the hydrocodone-acetaminophen for the two instances when it was dispensed. Both an LVN and the DON verified that the required documentation was missing from the MARs, confirming that the facility did not follow its own policy for documenting the administration of controlled medications.
Failure to Properly Store and Dispose of Medications and Supplies
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored and disposed of according to professional standards and facility policy. During an inspection of a treatment cart, expired culture swabs and Allevyn Classic Adhesive dressings were found in the cart, and the LVN confirmed these items were expired and should have been discarded. The Director of Nursing (DON) was informed and acknowledged the presence of these expired supplies in the treatment cart. Additionally, a resident was observed with a sealed, unopened container of Wallgreens Redness Relief eye drops at their bedside. The resident stated they had purchased the eye drops while out on a pass, and the LVN verified the presence of the medication at the bedside, stating that medications should not be kept there. Review of the resident's medical record showed no physician order for the eye drops, and the resident was assessed as having moderately impaired cognition. The DON was made aware and acknowledged this finding.
Failure to Follow Chef Salad Recipe for Resident on NAS Diet
Penalty
Summary
The facility failed to follow the established recipe for chef salad when preparing a meal for one resident. The resident, who was on a no added salt (NAS) diet with regular texture and consistency, had a care plan goal to maintain weight status and had specific dietary preferences and dislikes documented. Despite these orders and preferences, the resident received a salad consisting only of lettuce, shredded carrots, and purple cabbage, without the required protein components such as turkey, ham, cheese, or hard-cooked eggs as specified in the facility's chef salad recipe. The resident expressed disappointment at not receiving enough protein with her salad, which she had been ordering more frequently in an effort to lose weight for an upcoming knee surgery. Review of the resident's meal card confirmed her dietary restrictions and preferences, including a request for chef salad with ranch dressing only. The Dietary Supervisor and Administrator acknowledged upon review that the chef salad was not prepared according to the recipe. This failure to follow the menu and recipe had the potential to result in the resident not receiving adequate nutrition as per her diet orders.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and a contracted, weak left hand was not provided with the required adaptive eating equipment as ordered by the physician. Observations during meal times showed the resident using regular utensils instead of the prescribed built-up utensils and lip plate, despite documentation in the care plan and meal tab indicating the need for these assistive devices. The facility's policy stated that adaptive equipment recommended by occupational therapy should be provided and consistently placed on the resident's tray. Interviews with staff confirmed the resident's need for built-up utensils due to limited hand strength and verified that the physician's order for these devices was in place. The resident reported difficulty using standard utensils, and staff acknowledged the importance of the adaptive equipment for the resident's ability to eat. The deficiency was further substantiated by a review of the resident's medical record, which documented the need for built-up utensils and a lip plate with all meals.
Failure to Follow Kitchen Infection Control and Food Storage Policies
Penalty
Summary
The facility failed to ensure that staff adhered to infection control and food storage policies in the kitchen. During an observation, the Dietary Services Supervisor (DSS) was seen inside the kitchen preparing breakfast without wearing a required hair restraint, despite having a beard and mustache. The DSS confirmed that he should have been wearing a hair restraint in accordance with the facility's policy, which mandates clean hair to be covered with an effective restraint in all kitchen and food storage areas. Additionally, a canister containing brown rice was found in the dry storage room without a lid, contrary to the facility's policy that requires opened dry storage products to be placed in containers with tight-fitting lids. Both the Cook and the DSS acknowledged that the canister should have had a lid to maintain cleanliness and infection control. These observations were made while the kitchen was preparing food for 123 residents, as indicated by the facility's diet count.
Failure to Ensure Provision and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure the provision and documentation of hospice services for two residents who were admitted to hospice care. For one resident, there was a physician's order and care plan specifying that a certified hospice aide should provide care twice per week. However, the medical record and hospice sign-in sheets showed missing documentation for several scheduled visits, with some weeks lacking any evidence that the hospice aide provided care. There was also no documentation that the facility coordinated with the hospice provider regarding these missed visits. For the second resident, the facility did not clarify or document the frequency of hospice agency staff visits, including those by the certified hospice aide, skilled nursing, social services, and chaplain. The hospice binder for this resident contained multiple blank and unsigned forms, including the POLST and various consent and notification documents. The medical record lacked evidence of certified hospice aide visits for two months, and the hospice calendar and flowsheet only reflected visits from the MSW and RN, with no documentation of aide visits. Interviews with facility and hospice staff confirmed the absence of required documentation and the lack of clarity regarding visit schedules. The DON, who served as the hospice coordinator, verified that the necessary forms were incomplete and that visit frequencies were not documented in the physician's order or care plan. These failures resulted in incomplete records and a lack of assurance that hospice services were provided as ordered.
Failure to Conduct Bed Entrapment Assessment for Resident Using Side Rails
Penalty
Summary
The facility failed to ensure that a bed inspection and entrapment assessment were conducted for one resident who was using bilateral upper side rails. The resident, who had severe cognitive impairment and was dependent on staff for bed mobility, was observed multiple times with the side rails elevated. Although the facility's policy required entrapment assessments upon admission, readmission, or a change of bed or mattress, there was no documented evidence that such an assessment was completed prior to the installation of the side rails for this resident. The resident's bed had been brought into the facility with the side rails already installed, and staff interviews confirmed that the maintenance department was not notified about the bed or the need for an entrapment assessment. Review of facility logs, including the Bed Side Rails Inspection Log and the Bed Entrapment Risk Checklist for the relevant month, showed no record that the resident's bed was inspected or assessed for entrapment risk. The maintenance staff stated that they were responsible for monthly bed inspections and entrapment assessments but had not been informed about this particular bed. Both the Maintenance Director and Maintenance Assistant verified that the resident's bed was not included in their inspection or assessment records.
Failure to Implement Infection Control Measures and Maintain Laundry Cleanliness
Penalty
Summary
The facility failed to maintain its infection prevention and control program as required, specifically by not implementing the testing, monitoring, and establishment of acceptable ranges for disinfectant chemical levels throughout the facility's water supply. Despite having a policy and procedure for water management and a plan for Legionella control, the facility had not begun the required testing and monitoring of chlorine and chloramine levels in the water system. The Infection Preventionist confirmed that this process had not yet started, and acceptable ranges for these chemicals had not been established at the time of the survey. Additionally, the facility did not maintain the laundry room and equipment in a clean and sanitary condition. Observations revealed that the outside of a washing machine door and its pipes had significant brown stains and white mineral-like residue, and the wall next to the machine was damaged with cracks and a gap between the wall and baseboard. The Housekeeping Supervisor acknowledged these findings during the inspection.
Failure to Implement Antibiotic Stewardship and Accurate Infection Control Documentation
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in multiple deficiencies related to infection control documentation and assessment. Specifically, the infection control data recorded in the surveillance log for January 2025 did not match the information documented in the Infection Control Report for the same period. The Infection Preventionist (IP) confirmed that these discrepancies affected the infection control process, staff education, and discussions in QAPI meetings. Additionally, the facility's mapping for healthcare-associated infections (HAI) was incomplete, as one resident with an eye/ear infection was not included in the mapping for January 2025. The facility was unable to provide documentation showing the use of McGeer's criteria to determine if residents met the criteria for true infection. The IP stated that she referenced the long version of the McGeer's form but could not produce documentation to support this. The Infection Screening Evaluation form used by the facility was inconsistent with McGeer's criteria, particularly for gastrointestinal tract infections, and did not clearly indicate how the criteria were met or not met. The IP acknowledged these inconsistencies and the lack of clear documentation. A review of the medical record for a resident revealed further issues with the assessment and documentation of infection. The resident was prescribed Ampicillin for symptoms of diarrhea, with the Infection Screening Evaluation indicating that McGeer's criteria for gastroenteritis were met. However, the surveillance log and progress notes stated that the resident did not meet McGeer's criteria. Despite this, the antibiotic was continued as ordered. The DON confirmed these findings, highlighting inconsistencies in the assessment and documentation process for antibiotic use.
Inaccurate MDS Coding for Discharge Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was coded accurately for one resident. Medical record review showed that the resident was admitted with the capacity to understand and make decisions and had a physician's order to be discharged home with hospice services, as requested by the resident and their power of attorney. However, the Discharge MDS was incorrectly coded to indicate discharge to a short-term general hospital instead of to home with hospice. The MDS Coordinator confirmed that the MDS Assistant had coded the discharge status incorrectly, and the Director of Nursing acknowledged the findings during interviews.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to accurately maintain medical records for three residents. For two residents, review of their Physician Orders for Life-Sustaining Treatment (POLST) forms revealed that Section D, which pertains to advance directives, did not contain documentation indicating whether the residents had formulated an advance directive. This omission was confirmed during interviews and concurrent record reviews with a licensed vocational nurse, who acknowledged the missing information in both cases. Additionally, during a medical record review for another resident, it was discovered that the medical records of two other residents had been incorrectly filed within this resident's chart. This error was verified by a registered nurse during the review, who confirmed that the records were misplaced and subsequently removed them from the incorrect file.
Improper Storage of Garbage in Dumpsters
Penalty
Summary
The facility failed to ensure proper storage of garbage in two out of six dumpsters, as observed during a facility inspection. The lids of these dumpsters were found open, with garbage inside preventing the lids from fully closing. This condition was directly observed and verified by the Administrator through photographic evidence. The 2022 FDA Food Code requires outside garbage receptacles to have tight-fitting lids or covers to prevent the scattering of garbage, breeding of flies, or entry of rodents. The improper storage of garbage was attributed to the dumpsters being propped open by the accumulated refuse inside. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Care Plan Revision Deficiency for Wound Management
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to reflect the current wound care treatment and interventions for each individual wound site. Specifically, the care plan did not include goals and interventions for the resident's left foot first metatarsal head and base arterial wounds, despite having a physician's order for treatment. This oversight was identified during a review of the resident's medical records, which showed that the care plan included other wound sites but omitted the left foot arterial wounds. The deficiency was confirmed during an interview and medical record review with the Director of Nursing (DON), who acknowledged that the care plan should have been updated to include all wound sites currently undergoing treatment. The resident had multiple wounds requiring specific care, including pressure injuries and skin tears, but the omission of the left foot arterial wounds from the care plan posed a risk of not providing individualized and person-centered care.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to provide necessary tube feeding care and services for a resident, identified as Resident 3, who was receiving enteral feeding via a PEG tube. The facility's policy required the head of the bed to be elevated 30 to 45 degrees during enteral feedings to prevent complications. However, during an observation on November 6, 2024, Resident 3 was found lying flat in bed while receiving Jevity 1.5 at 50 ml per hour through a feeding pump. This observation was confirmed by LVN 3, who acknowledged that the head of the bed should have been elevated to prevent the risk of aspiration. The Director of Nursing also acknowledged the finding later that day.
Inadequate PPE Use During High-Contact Care
Penalty
Summary
The facility failed to implement proper infection control practices, specifically in the use of personal protective equipment (PPE) during high-contact care activities for a resident. The deficiency was observed when a certified nursing assistant (CNA) handled a resident's Foley catheter without donning gloves and a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy. This policy, aligned with CDC guidelines, mandates the use of PPE during activities such as dressing, bathing, transferring, and device care to prevent the transmission of multidrug-resistant organisms (MDROs). The resident involved had a PEG tube, Foley catheter, and wounds, necessitating EBP. Despite the presence of signage indicating the need for PPE, the CNA did not adhere to these precautions. The incident was confirmed through interviews with the CNA, a registered nurse (RN), and the Director of Nursing (DON), all of whom acknowledged the requirement for PPE use during high-contact care activities to prevent infection transmission.
Improper Medication Storage
Penalty
Summary
The facility failed to ensure proper storage of medications for a nonsampled resident, identified as Resident E. During a facility tour, a bubble pack containing potassium chloride extended release 20 mEq, labeled with Resident E's name, was found on the nursing station counter. This medication was prescribed as a potassium supplement to be taken in the morning. A Licensed Vocational Nurse (LVN) confirmed the medication belonged to Resident E and acknowledged it should have been stored inside the medication cart. The Assistant Director of Nursing (ADON) was informed of the situation and took possession of the medication.
Failure to Inventory Resident's Personal Property
Penalty
Summary
The facility failed to conduct an inventory of a resident's personal property in accordance with its policies and procedures, leading to a potential risk of loss or theft of the resident's belongings. Upon admission, the facility's policy required that a personal property inventory be conducted and documented in the resident's medical record. However, for Resident 2, there was no documentation of such an inventory being conducted at the time of admission. This oversight meant that there was no official record of the personal items the resident brought into the facility. When Resident 2 was transferred to an acute care hospital and later returned to the facility to collect his belongings, he discovered that several personal items were missing. Despite informing the social worker about the missing items, the resident did not receive a follow-up regarding the issue. The social worker confirmed that she assisted the resident in retrieving some items but did not document the inventory of the personal property released to the resident, as it was not part of her duties. The Director of Nursing (DON) confirmed that the facility's policy required documentation of personal property upon both admission and discharge, with signatures from both the resident and staff. However, the DON acknowledged that Resident 2's medical record lacked any documentation of his personal property, making it impossible to verify what items were brought in or released. This failure to adhere to the facility's policy resulted in an inability to account for the resident's belongings, highlighting a deficiency in safeguarding resident property.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to implement its policies and procedures related to abuse reporting for one of the sampled residents. The Activities Assistant did not report an abuse allegation to the Administrator when a resident informed her that a CNA was mad and threw towels on the resident's bed. This failure had the potential for the abuse allegation not to be investigated thoroughly, posing a risk of not providing appropriate actions to prevent further abuse. The resident, who had the capacity to understand and make decisions, reported feeling humiliated after an incident where a CNA threw towels at her and instructed her to dry herself without assistance. The Activities Assistant documented some of the resident's allegations but failed to report the specific incident of the CNA throwing towels on the bed to the Administrator. The Administrator was unaware of these allegations, acknowledging that all allegations of abuse should be reported to him.
Incomplete Documentation of Resident's Physical Assessment
Penalty
Summary
The facility failed to ensure that information obtained from a physical assessment was documented in the medical record for one of the residents. According to the facility's policy and procedure titled 'Change of Condition Notification,' a licensed nurse is required to document the date, time, and pertinent details of any incident and subsequent assessment in the nursing notes. However, in the case of a resident who claimed to have slipped in the shower and complained of pain in the left rib cage, the documentation was incomplete. The resident's SBAR for Change In Condition noted the incident and the physician's recommendation for neuro checks but lacked specific documentation regarding the assessment of the resident's left rib cage. During an interview, RN 3 confirmed that she was informed of the resident's alleged fall and conducted a physical assessment. Although the resident did not allow a complete assessment of the left rib area, RN 3 observed a small red line without swelling on the resident's left rib cage. RN 3 acknowledged that she failed to document this observation in the resident's medical record, which was necessary to maintain an accurate medical record. This oversight had the potential to result in an incomplete understanding of the resident's health condition due to the lack of documentation.
Routine Catheter Changes Increase Infection Risk
Penalty
Summary
The facility failed to ensure the routine changes of an indwelling urinary catheter order were clarified with the physician for a resident, which had the potential to increase the risk of urinary tract infections (UTIs). The facility's policy and procedure, revised in June 2021, stated that indwelling urinary catheters should not be changed at arbitrary fixed intervals but rather based on clinical indications such as infection, obstruction, or when the closed system is compromised. However, the medical record for the resident showed a physician's order to change the indwelling urinary catheter weekly on Sundays, which was not aligned with the facility's policy or the CDC's guidelines for catheter maintenance. The resident, who had moderately impaired cognitive skills, was admitted with an indwelling urinary catheter due to obstructive uropathy secondary to benign prostatic hyperplasia (BPH). Despite the facility's policy and CDC guidelines, the resident's catheter was scheduled for routine weekly changes, which was verified by both the Infection Preventionist (IP) and the Director of Nursing (DON) during interviews. The DON acknowledged that the routine changes increased the risk of infection and stated that the indwelling urinary catheters should be changed as needed to help reduce this risk.
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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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