Anberry Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Merced, California.
- Location
- 1000 West Yosemite Avenue, Merced, California 95341
- CMS Provider Number
- 555901
- Inspections on file
- 18
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Anberry Post Acute during CMS and state inspections, most recent first.
A resident with a pressure ulcer in the sacral region was not turned and repositioned every two hours as required, leading to incomplete documentation and potential worsening of the ulcer. Despite staff awareness of the need for regular repositioning, the care plan did not specify this requirement, and medical records lacked consistent documentation. This deficiency contributed to the resident's death from septic shock.
The facility failed to inform and document information on how to formulate an advance directive for all residents. Staff interviews revealed that residents were referred to external sources for assistance, and no documentation was made in resident charts. The facility's policy required documentation of discussions about advance directives, but this was not followed, violating residents' rights to be informed.
A facility failed to update a resident's care plan after the resident was discharged from hospice services. Despite the discharge, the care plan was not revised to reflect this significant change in condition, as confirmed by interviews with the LVN, MDSN, and ADON. The resident, admitted with multiple diagnoses, was no longer receiving hospice services, but the care plan remained outdated, contrary to the facility's policy requiring updates after changes in condition.
The facility failed to meet professional standards by not labeling oxygen tubing for three residents, not notifying a physician when a resident's hypertension medication was withheld, and administering an incorrect oxygen flow rate to a resident. These actions put residents at risk of infection and adverse health outcomes.
The facility did not post accurate daily nurse staffing information, failing to include specific hours worked by RNs, LVNs, and CNAs. This oversight left residents and families unable to identify care responsibilities and staffing levels. Interviews revealed a lack of awareness about the requirement to post detailed staffing hours.
The facility failed to provide palatable food, with 79 residents receiving bland broccoli and five residents on puree diets receiving unappetizing salads. The DNS acknowledged the lack of seasoning, and the RD was unaware of residents' dissatisfaction. The facility's regular diet exceeded recommended sodium levels, and the RD did not observe plate waste or consult with kitchen staff about the puree salads.
The facility failed to maintain safe storage and sanitation of food and ice, with an ice machine showing black and pink residues, and a refrigerator containing expired apple juice and sticky substances. Maintenance and dietary staff acknowledged these issues, but documentation and oversight were lacking, potentially risking foodborne illness for residents.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers, as confirmed by interviews with an LVN and the ADON. The facility's policy required written notification, but this was not followed, leaving residents and their representatives potentially unaware of the reasons for transfers.
The facility did not provide written notification of the bed hold policy to residents and their representatives upon hospital transfer, affecting several residents. The BOM stated that notifications were only given verbally and at admission, not upon transfer. The ADON confirmed this practice and acknowledged the importance of written notifications for residents to understand their rights.
Two residents in the facility did not have care plans for oxygen administration, despite having conditions requiring oxygen use. One resident, admitted with COPD and other diagnoses, was observed using oxygen without a care plan in place. Another resident, with emphysema and other conditions, had an oxygen flow rate set higher than usual, also without a care plan. Staff interviews confirmed that care plans should have been initiated upon admission to ensure proper monitoring and safety, as emphasized by facility policies.
The facility failed to store and label medications properly, with expired drugs found in medication carts and an antibiotic with an unreadable expiration date in a refrigerator. Additionally, a medication cart was left unlocked, and loose pills were found unsecured in a resident's room, posing risks of unauthorized access and missed doses.
A facility failed to follow the approved menu for 16 residents when gelatin with whipped topping was served instead of the planned ambrosia pudding. This change was made to use leftover gelatin without consulting the registered dietitian, as required by facility policy. The director of nutritional services described the incident as an isolated oversight.
Two LVNs failed to follow infection control practices, with one entering an isolation room without proper PPE and another neglecting hand hygiene and glucometer sanitization. These actions risked spreading infections, contrary to facility policies.
A resident with diabetes and moderate cognitive impairment had long, untrimmed fingernails, which were not addressed by the facility staff. The resident expressed concern about the potential for infection due to his condition. Observations and interviews with staff confirmed the oversight, highlighting a failure to adhere to the facility's policy on personal hygiene and nail care.
Two residents in the facility were not adequately monitored for behaviors while on psychotropic medications, leading to potential unnecessary medication use. One resident, with dementia and depression, was on quetiapine without behavior monitoring, while another, with bipolar disorder and anxiety, lacked monitoring orders for her prescribed medications. Facility policies requiring behavior tracking and interdisciplinary care planning were not followed.
A resident's request for halal meat was not accommodated by the facility, despite discussions with the RD and CDM. The resident, concerned about protein intake, registered as a vegetarian and relied on family to provide halal meat. The facility's policy on accommodating ethnic food preferences was not followed, and the resident's dietary tray card inaccurately indicated a dislike for all meat.
A facility failed to honor a resident's fluid preferences by providing apple juice despite a documented dislike. The resident's dietary tray ticket contained conflicting information, leading to the provision of fluids inconsistent with their preferences. The resident, who was cognitively intact, expressed dissatisfaction with the facility's failure to honor their preferences, which could impact their nutritional intake and quality of life.
A resident's POLST form was found incomplete, with Section B unmarked, failing to document their end-of-life care preferences. Despite being cognitively intact and having serious health conditions, the resident's wishes for medical interventions were not recorded, as confirmed by the Infection Prevention Nurse and Admission Nurse. The facility's medical records policy emphasizes the need for accuracy and completeness, which was not met in this case.
Failure to Document and Implement Repositioning for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident who was admitted with a pressure ulcer in the sacral region. The resident required turning and repositioning every two hours, but the care plans did not specify this requirement, and the medical records did not document that the resident was turned and repositioned as needed. This lack of documentation and care plan specification led to incomplete and inaccurate records of the resident's care. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, and was dependent on assistance for activities of daily living. The resident's condition included a pressure ulcer of the sacral region, which was not properly managed due to the facility's failure to document and implement a consistent turning and repositioning schedule. Interviews with staff, including LVNs, CNAs, and the DON, revealed that while they were aware of the need to turn and reposition the resident every two hours, this was not consistently documented or reflected in the care plan. The deficiency resulted in the potential worsening of the resident's pressure ulcer and the development of new pressure ulcers, contributing to the resident's death from septic shock. The facility's policies and procedures for wound and skin management and turning and repositioning were not adequately followed, as evidenced by the lack of documentation and care plan updates. The facility's failure to adhere to these standards of care and documentation requirements highlights a significant lapse in the quality of care provided to the resident.
Failure to Inform and Document Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information on how to formulate an advance directive for all 87 residents. This deficiency was identified through interviews and record reviews, which revealed that the facility did not document information on how to obtain an advance directive in resident charts. The Medical Records Director (MRD) stated that the facility referred residents to their primary physician for advance directives and only kept them on file if residents brought them in. The Social Services Director Assistant (SSDA) and the Intake Coordinator (IC) confirmed that no documentation was made in resident charts regarding advance directives, and residents were directed to external sources like the Long Term Care Ombudsman (LTCO) or their primary physician for assistance. The Assistant Director of Nursing (ADON) acknowledged that it was not the facility's practice to document whether education and information on obtaining an advance directive were provided to residents. The facility's policy, dated 4/30/22, required social services to document discussions about advance directives in the resident's medical record, but this was not being followed. The lack of documentation and failure to provide necessary information violated the residents' rights to be informed about advance directives, which are crucial for ensuring their medical wishes are honored if they become unable to make decisions themselves.
Failure to Update Care Plan After Hospice Discharge
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for Resident 45 after the resident was discharged from hospice services. Despite the discharge occurring on November 16, 2024, the care plan was not updated to reflect this significant change in condition. Interviews with the License Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN) revealed that the care plan should have been updated immediately to ensure proper communication and care for Resident 45. The LVN acknowledged receiving a verbal order from the hospice agency to discharge the resident and documented the conversation, but the care plan was not revised accordingly. Resident 45, who was admitted with diagnoses including hemiplegia, hypertension, anxiety, severe protein-caloric malnutrition, muscle weakness, and pain, was no longer receiving hospice services as of November 16, 2024. The Assistant Director of Nursing (ADON) confirmed that the care plan should have been updated by the licensed nurses to reflect the resident's current needs and condition. The facility's policy requires care plans to be reviewed and revised by the interdisciplinary team after each assessment and when changes in the resident's condition occur, which was not adhered to in this case.
Deficiencies in Oxygen Management and Physician Notification
Penalty
Summary
The facility failed to meet professional standards of practice for four residents due to several deficiencies. For three residents, the oxygen tubing was not labeled with the date it was changed, which is a critical step to prevent infection. Observations and interviews with staff confirmed that the nasal cannula tubing for these residents was not dated, and staff acknowledged the importance of labeling the tubing to track when it was last changed. The facility's policy required that nasal cannulas be changed weekly and marked with the date and nurse's initials, but this was not adhered to, putting the residents at risk of infection. Another deficiency involved a resident whose attending physician was not notified when their hypertension medication was withheld due to low blood pressure levels. The facility's policy required that the physician be informed if medication was not administered as prescribed, but there was no documentation indicating that the physician was notified. This oversight could have led to negative outcomes for the resident, as the physician's guidance was not sought when the medication was not given. Additionally, a resident received an incorrect oxygen flow rate, which was set at 4.5 L/min instead of the prescribed 2 L/min. The resident and staff noted the discrepancy, and it was confirmed that the oxygen rate should have been checked regularly and set according to the physician's orders. The failure to administer oxygen at the correct rate could have resulted in adverse effects for the resident, particularly given their medical conditions. The facility's policy emphasized the importance of following physician orders and documenting the oxygen flow rate, but these procedures were not followed in this instance.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted accurately and comprehensively, as required. During an observation, it was noted that the Census and Direct Care Services Hours Per Patient Day (DHPPD) did not include the total number of actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nurse Aides (CNAs). This omission meant that residents and their family members could not identify who was responsible for their care, the number of licensed and unlicensed staff on shift, or the total number of hours staff were working. Interviews with the Administrator and Staff Coordinator revealed a lack of awareness and understanding of the requirement to post specific hours for each category of nursing staff. The Administrator admitted that only CNA hours were posted, and there were no posted numbers for RNs and LVNs. The Staff Coordinator confirmed that the hours posted were for the total hours worked by combined staff and not broken down by specific categories. The facility's policy and procedure on Nursing Staffing Ratio Posting, which requires the posting of actual hours worked by each category of nursing staff, was not followed.
Unpalatable Food Served to Residents
Penalty
Summary
The facility failed to provide palatable and flavorful food to its residents, as observed during a survey. The broccoli served to 79 residents on a regular diet was found to be bland, soggy, and lacking in flavor. The Director of Nutritional Services (DNS) acknowledged that the broccoli was bland and watery, attributing the sogginess to excess moisture from cooking and the lack of flavor to limited seasoning in the recipe. The facility's recipe for seasoned broccoli required only a minimal amount of salt, which was insufficient to enhance the taste. Additionally, the puree salad served to five residents on a puree diet was found to be unappetizing. The Dietary Aid (DA 2) had to use a food processor and blender to achieve the desired consistency, as the recipe did not include any liquid. The puree salad tasted sharp and earthy, and the salad dressing packets provided were difficult to open. The DNS noted that the puree salad tasted better with dressing but was still not very palatable. The Certified Nursing Assistant (CNA 1) reported that residents on puree diets often requested salad dressing, and if it was not provided, she would obtain it for them. The Registered Dietitian (RD) was not involved in resident council meetings and was unaware of the residents' dissatisfaction with the food. The RD stated that the facility's regular diet exceeded the recommended sodium intake for a low-sodium diet, and a more liberalized approach to sodium intake could benefit older adults. The RD relied on others to inform her of residents' preferences and did not observe plate waste or consult with kitchen staff about the puree salads. The facility's failure to address these issues resulted in unpalatable meals, which could lead to decreased food intake and potential nutritional deficiencies among residents.
Deficiencies in Food and Ice Storage and Sanitation
Penalty
Summary
The facility failed to ensure the safe storage, distribution, and serving of food and ice, as evidenced by several observations and interviews. The ice machine was found to have black spots above the water trough and pink residue on the ice grate and sensor, indicating inadequate cleaning. The Maintenance staff acknowledged the presence of these substances and stated that the ice machine is cleaned and sanitized every six months, with the last cleaning occurring approximately six months prior. However, the Registered Dietitian could not provide sanitation review logs for the recent months, highlighting a lack of documentation and oversight. Additionally, a pitcher of apple juice in the nourishment room refrigerator was observed to be past its use-by date, and the refrigerator itself contained a dry, sticky substance on the bottom drawers and a door shelf. The Infection Preventionist and Director of Nutritional Services confirmed that expired items should be discarded immediately and that the refrigerator should be cleaned daily. However, the facility's daily log for stocking and cleaning did not have current dates or staff signatures, indicating a failure in maintaining proper records and ensuring cleanliness. These deficiencies could lead to the growth of microorganisms and potential foodborne illness for the residents.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital for four residents. This deficiency was identified during interviews and record reviews, revealing that neither the residents nor their representatives received written notices explaining the reasons for hospital transfers. Licensed Vocational Nurse (LVN) 1 confirmed that notifications were only made via phone calls, and no written documentation was provided. This practice left residents and their representatives potentially unaware of the reasons for the hospital transfers. The Assistant Director of Nursing (ADON) corroborated that the facility's nurses did not provide written notifications for hospital transfers, relying solely on phone calls. The facility's policy required written notification to residents and their representatives 30 days in advance of a transfer or as soon as the discharge date was known, except in emergencies or other specified situations. However, this policy was not followed, as evidenced by the lack of written documentation in the residents' clinical records.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents and their representatives upon transfer to a hospital, affecting four of eight sampled residents. The Business Office Manager (BOM) admitted that while the business office would call the resident's representative to inform them of the bed hold policy, no written notification was sent. The BOM was unaware that written information was required upon a resident's transfer to the hospital, and written notices were only given at the time of admission. The Assistant Director of Nursing (ADON) confirmed that it was not the facility's practice to provide written bed hold information upon hospital transfer. The ADON acknowledged the importance of written notification, as it allows residents and their representatives to review the information at their own pace and understand their rights to return to their bed in the facility. The facility's policy, dated 1/31/22, indicated that documentation should show how the resident or representative was notified about the transfer and bed hold rights, and a copy of the bed hold consent should be sent with the resident to the hospital and to the resident or their representative.
Failure to Implement Oxygen Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, specifically regarding oxygen administration. Resident 231, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and dementia, did not have a care plan for oxygen use despite being observed with oxygen infusing via a nasal cannula. The Minimum Data Set Nurse (MDSN) and Admission Nurse (AN) acknowledged that a care plan should have been initiated upon admission, as care plans are triggered by physician orders and are essential for assessing and monitoring the resident's condition. Similarly, Resident 235, admitted with conditions such as emphysema, pleural effusion, and atrial fibrillation, also lacked a care plan for oxygen administration. During an observation, Resident 235's oxygen flow rate was set higher than usual, and there was no care plan in place to guide staff on the appropriate administration and monitoring of oxygen. The MDSN and AN confirmed that a care plan should have been established to ensure proper care and safety for the resident. Interviews with Licensed Vocational Nurses (LVNs) further highlighted the importance of care plans in providing specific and appropriate care to residents. The absence of care plans for oxygen use in both residents posed a risk of improper monitoring and administration, potentially leading to negative outcomes. The facility's policies and job descriptions emphasize the necessity of initiating and following care plans to ensure resident-centered care, which was not adhered to in these cases.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. Observations revealed that the refrigerator in section 300-Medroom contained an antibiotic with an unreadable expiration date. Additionally, medication carts 200-Backside and 300-B contained expired medications, including inhalers, lactulose, ferrous gluconate, and insulin. Licensed Vocational Nurses (LVNs) acknowledged that expired medications should not have been present and could lead to ineffectiveness or adverse reactions. The facility also failed to secure medication carts properly. An LVN was observed leaving a medication cart unlocked while administering medications to residents, despite the facility's policy requiring carts to be locked when not directly supervised. This lapse in security could allow unauthorized access to medications, posing a risk to residents and staff. Furthermore, two loose white pills were found on a resident's bedside table while the resident was out of the room. The LVN acknowledged that the pills should not have been left unsecured, as they could be taken by others or result in the resident missing their prescribed medication. The Assistant Director of Nursing (ADON) emphasized the importance of ensuring all medications are taken as prescribed to avoid missed therapeutic effects and prevent other residents from accessing unsecured medications.
Menu Deviation Leads to Unapproved Dessert Substitution
Penalty
Summary
The facility failed to adhere to the planned and approved menu for 16 residents when a dessert not listed on the menu was served. On December 9, 2024, during lunch, the menu indicated that ambrosia pudding was to be served as dessert. However, an observation revealed that gelatin with whipped topping was served instead. This substitution occurred because the previous night's cook made less ambrosia pudding to use up leftover gelatin, as explained by a dietary aide. This deviation from the menu was not communicated to or approved by the registered dietitian, who stated that staff are expected to follow the menus and consult with her if changes are necessary. The registered dietitian and the director of nutritional services were unaware of any previous instances of menu changes without consultation. The director of nutritional services described the incident as isolated and an oversight. The facility's policy and procedure on menus, dated May 1, 2016, requires that menus be written and posted at least one week in advance and followed as planned. The failure to follow the menu as approved had the potential to affect the nutritional intake and meal satisfaction of the residents involved.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
Two Licensed Vocational Nurses (LVN 4 and LVN 7) failed to adhere to infection control practices, compromising the safety and sanitary environment necessary to prevent the spread of infections. LVN 4 entered an isolation room without donning the required personal protective equipment (PPE), specifically an isolation gown, despite the presence of a notice indicating the necessary PPE. The resident in the isolation room was infected with E. coli, and LVN 4 acknowledged the risk of spreading the infection to other residents due to this oversight. LVN 7 was observed neglecting hand hygiene protocols before and after administering medications to different residents. This failure to perform hand hygiene between resident interactions increased the risk of transmitting infections. Additionally, LVN 7 did not properly sanitize a glucometer after use, failing to adhere to the manufacturer's instructions for the required dwell time of the sanitizing solution. LVN 7 admitted to not being trained in the correct procedure for sanitizing the glucometer, which could lead to the spread of bloodborne infections. The facility's policies and procedures, including those for isolation precautions, PPE usage, hand hygiene, and cleaning of point-of-care equipment, were reviewed. These policies emphasize the importance of using PPE, performing hand hygiene, and following manufacturer instructions for equipment cleaning to prevent infection transmission. However, the observed actions of LVN 4 and LVN 7 were inconsistent with these established protocols, highlighting deficiencies in adherence to infection control practices.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, identified as Resident 46, who had long, yellow fingernails that were not cut or filed. During an observation and interview, Resident 46 expressed dissatisfaction with the length of his fingernails and mentioned that as a diabetic, long fingernails could lead to infections if he scratched his skin. The resident could not recall the last time his fingernails were trimmed by the staff. A Certified Nursing Assistant (CNA) acknowledged the issue, noting that the long fingernails were dirty and could harbor bacteria, potentially affecting the resident's ability to eat properly. The CNA admitted that he should have informed the nurse about the resident's request to have his fingernails cut. Further observations and interviews with the Infection Preventionist (IP) and the Assistant Director of Nursing (ADON) confirmed that the resident's fingernails were indeed long and should have been trimmed by the nursing staff. The IP and ADON both recognized the risk of infection and injury due to the long fingernails, especially given the resident's diabetic condition. The facility's policy on Activities of Daily Living (ADL) required staff to assist residents with personal hygiene, including nail care, as needed. However, the staff failed to adhere to this policy, as evidenced by the lack of regular nail care for Resident 46, who was moderately impaired in cognition and had a history of multiple health issues, including diabetes and candidiasis of the skin and nails.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications due to inadequate monitoring and lack of non-pharmacological interventions. Resident 236, who was admitted with multiple diagnoses including dementia and depression, was prescribed quetiapine fumarate for behavioral and psychological symptoms of dementia. However, there was no behavior monitoring implemented to assess the effectiveness of the medication or to determine if non-pharmacological interventions could be used instead. Interviews with staff revealed that monitoring for highs and lows was not conducted, which is crucial to ensure the medication's therapeutic value and to adjust treatment if necessary. Similarly, Resident 32, admitted with bipolar disorder and anxiety, was prescribed multiple psychotropic medications including duloxetine, Seroquel, and Lorazepam. Despite this, there were no monitoring orders in place to track her behaviors or assess the effectiveness of the medications upon her admission or during the month of October. Staff interviews confirmed the absence of necessary monitoring orders, which are essential to ensure the intended use of the medications and to prevent potential side effects. The facility's policies and procedures require the interdisciplinary team to care plan individual interventions, including non-pharmacological and pharmacological treatments, and to track behaviors and medication side effects. However, these protocols were not followed for Residents 236 and 32, resulting in a failure to monitor their conditions adequately and to ensure the medications administered were necessary and effective.
Failure to Accommodate Resident's Halal Meat Preference
Penalty
Summary
The facility failed to accommodate the food preferences of a resident who required halal meat due to religious dietary restrictions. Despite the resident's requests and discussions with the Registered Dietitian (RD) and Certified Dietary Manager (CDM), the facility did not provide halal meat, leading the resident to register as a vegetarian and rely on bone broth ordered online for protein intake. The resident expressed concerns about his protein consumption and had to ask his family to bring halal meat from home, which the facility could only warm but not prepare. Interviews with the CDM, Administrator (ADM), and RD revealed that the facility had previously purchased halal meat and acknowledged the importance of honoring food preferences to prevent weight loss and ensure cultural sensitivity. However, the facility's policy on resident food preferences, which includes accommodating ethnic food preferences, was not followed in this case. The resident's dietary tray card inaccurately indicated a dislike for all kinds of meat, contradicting his expressed preference for halal meat.
Failure to Honor Resident's Fluid Preferences
Penalty
Summary
The facility failed to provide a resident with fluids consistent with their needs and preferences, specifically regarding the provision of apple juice. Despite the resident's standing order for apple juice, it was noted that the resident had a documented dislike for it. During an observation, a cup of apple juice was found on the resident's lunch tray, and the resident expressed that their food preferences were not always honored. The Certified Dietary Manager (CDM) confirmed that the resident's dislike for apple juice was noted on their dietary tray ticket, yet the standing order for apple juice was not updated to reflect this preference. The Registered Dietitian (RD) acknowledged that the resident's food preferences should be honored every time food is served and that the dietary tray ticket was confusing due to the conflicting information. The RD also noted that the resident was selective about their fluids, and incorrect fluid provision could impact their nutritional intake and quality of life. The resident was cognitively intact, as indicated by their Minimum Data Set (MDS) score, and had a medical history that included conditions such as Ogilvie syndrome, hypotension, and signs concerning food and fluid intake.
Incomplete POLST Form for Resident
Penalty
Summary
The facility failed to ensure accurate and complete medical records for one of the nine sampled residents, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST) form for a resident. The POLST form, which is crucial for outlining a resident's end-of-life care preferences, was found to be incomplete as Section B, which details medical interventions, was left unmarked. This section is essential for indicating whether the resident desires full treatment, selective treatment, or comfort-focused treatment. The omission was identified during a review of the resident's records, and it was acknowledged by the Infection Prevention Nurse that the POLST should have been completed to reflect the resident's wishes accurately. The resident in question was admitted to the facility with multiple serious health conditions, including heart failure, kidney failure, hemiplegia, hemiparesis, dysphagia, and pneumonia. Despite these conditions, the resident was assessed as cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. The Admission Nurse confirmed the importance of a complete POLST form for guiding care during emergencies and ensuring that the resident's end-of-life care preferences are respected. The facility's job description for medical records emphasizes the need for accuracy and completeness in clinical documentation, which was not upheld in this instance.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
