Arbor Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lodi, California.
- Location
- 900 North Church Street, Lodi, California 95240
- CMS Provider Number
- 555164
- Inspections on file
- 29
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Arbor Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A resident with depressive disorder and intact cognition was sitting in a hallway when a former roommate with schizophrenia, depression, and documented hallucinations and mood instability suddenly approached and struck him in the face and head near the nurses’ station. Staff interviews described a pattern of escalating behaviors in the aggressor, including shouting, verbal outbursts, delusional statements about the other resident, reluctance to return to the shared room, and increasing aggression in the weeks before the incident. Despite a PASRR Level 2 determination and care plans noting hallucinations and potential mood problems, the resident was able to physically assault another resident in a common area before an LN could intervene, contrary to the facility’s abuse prevention policy requiring identification, assessment, care planning, and monitoring of residents whose behaviors might lead to conflict.
A resident diagnosed with scabies did not trigger the facility's full surveillance and notification procedures, as the Infection Preventionist failed to conduct the required six-week contact identification and did not provide in-service training or formal notification to all key healthcare personnel. Many staff members, including CNAs, nurses, and housekeeping, were unaware of the case or the necessary precautions, and no documentation of staff education or communication was maintained.
A resident with a history of dehydration, acute kidney failure, and hypertension, who was prescribed diuretics, did not have water within reach despite care plan instructions and facility policy. Staff confirmed the water pitcher was placed out of reach, and the resident was unable to access it, increasing the risk for dehydration.
A resident with a history of dehydration, acute kidney failure, and hypertension, who was prescribed diuretics, did not have water within reach while in bed. Staff confirmed the water pitcher was placed out of reach, and facility policy required fluids to be accessible to residents without restrictions. This failure did not follow the resident's care plan or facility hydration policy.
Three residents experienced deficiencies in accident prevention and supervision, including a resident who was moved before being assessed after a fall and whose physician was not promptly notified of post-fall symptoms, resulting in delayed treatment. Another resident had incomplete post-fall documentation, and a third had incomplete neurochecks and was not provided with required nonskid footwear, despite being at high risk for falls. These failures led to delayed care and increased risk of harm.
A resident with multiple rib fractures did not receive pain medications according to established pain level parameters, with acetaminophen given for higher pain levels than ordered and hydrocodone-acetaminophen administered without clear pain level guidelines. The DON confirmed a lack of documentation for these deviations, and the facility's pain management policy requiring consistent assessment and documentation was not followed.
A resident with muscle weakness and rib fractures, who was on a toileting program, requested to use the bathroom after a fall but was told by a CNA to use her incontinence brief instead. Another CNA and the DON acknowledged this was inappropriate and a dignity concern, as facility policy requires staff to treat residents with respect and respond to their needs.
A resident who lacked mental capacity was administered psychotropic medications without the informed consent of their Responsible Party (RP). The facility had the resident, rather than the RP, sign the consent forms, and the RP was not informed or consulted about the medications or their risks and benefits, contrary to facility policy.
A resident with multiple rib fractures experienced a fall, and the facility failed to notify the resident's Responsible Party (RP) as required. Documentation inaccurately listed the resident as her own RP, and the LPN confirmed that the actual RP was not notified. The DON verified the inaccuracy and acknowledged that the facility's policy required RP notification after such incidents.
A resident received the psychotropic medication quetiapine for several days without an accurate or appropriate diagnosis documented in their clinical record. The medication was ordered for bipolar disorder, but the resident did not have this diagnosis, and the facility's policy requiring a documented indication for psychotropic use was not followed. Both the DON and the physician confirmed the lack of proper diagnosis and rationale for the medication administration.
A resident with hypertension and diabetes was given Losartan without specific hold parameters in the physician's order, and staff did not clarify the order with the MD. The same resident had two significantly elevated BP readings in one day, but the physician was not notified as required by facility policy. Both nursing staff and the DON confirmed these omissions, and the MD stated he was not contacted about the abnormal results.
A resident with significant care needs was inappropriately discharged from an LTC facility to a room and board facility that could not meet her needs. The resident required substantial assistance with daily activities and was reliant on oxygen therapy. Upon arrival, the room and board facility, which only accepted independent residents, sent her to the emergency department. The hospital confirmed the discharge was unsafe, and the resident remained hospitalized for 26 days awaiting proper placement.
A resident with significant care needs was unsafely discharged from an LTC facility to a room and board facility that could not accommodate her. The resident, requiring substantial assistance and being oxygen reliant, was not informed about the type of facility she was transferred to. Upon arrival, she was unable to care for herself and called 911, leading to her transfer to an emergency department. The LTC facility refused to readmit her, citing non-payment and claiming she did not need skilled nursing care, despite the failed discharge plan.
The facility failed to remove expired medical supplies and maintain medication carts in an orderly manner. Expired supplies, including a Mic-Key continuous feed extension set and Covid-19/Flu test kits, were found in the medication storage room. Additionally, loose and broken pills were observed in medication carts across various nursing stations. These findings were verified by LNs and the ADON, highlighting a lapse in adherence to the facility's policies.
The facility used expired Quat strips to measure sanitizer concentration in the kitchen, increasing the risk of foodborne illness for 124 residents. The Dietary Manager and Registered Dietician acknowledged the oversight, and the facility's policies lacked instructions to check expiration dates.
The facility failed to maintain an effective infection prevention and control program. A resident's nasal cannula was found uncovered, and staff did not practice hand hygiene during meal service. Another resident's urinary bag touched the floor, and PPE was not donned for a resident on enhanced precautions. Additionally, a linen cart was partially covered, and a laundry aide's uniform touched clean clothes, all contrary to facility policies.
A resident's dignity was compromised when their urine drainage bag was left exposed to public view, causing embarrassment. The resident, admitted with prostate gland enlargement, had their urine bag visible from the hallway due to an open door. The Infection Preventionist and DON acknowledged the bag should have been covered with a dignity bag.
The facility failed to ensure call lights were within reach for three residents, preventing timely assistance. One resident with multiple fractures had his call light hooked to the wall, another with hemiplegia had it looped away, and a third with cognitive impairment had it on the floor. Staff confirmed these observations, acknowledging the call lights should be accessible.
A resident with mobility issues and a history of falls did not have fall mats placed as per their care plan, increasing the risk of injury. Despite a previous fall incident resulting in a head injury, the necessary fall prevention measures were not in place, as confirmed by an LN during an observation.
A resident with chronic lymphocytic leukemia did not receive their prescribed daily dose of Ferrous Sulfate due to unavailability, as confirmed by an LPN. The facility's policy and the Nursing Practice Act require adherence to medication orders, which was not followed in this instance.
A resident with a contracted right hand and multiple health conditions, including diabetes, did not receive adequate nail care, leading to long fingernails that were not trimmed despite the resident's reports to staff. The facility's policy required licensed nurses or podiatrists to cut the nails of diabetic residents, but there was no documentation of consultation with a podiatrist or other resources to address the resident's nail care needs.
A resident with right-sided paralysis and heart and lung issues felt trapped due to the facility's failure to provide meaningful activities. The resident spent most of the time watching TV in bed, as the facility did not assist in getting him into a wheelchair or provide activity materials. The Activity Director confirmed the lack of engagement and acknowledged the need for more meaningful activities.
A resident with chronic lymphocytic leukemia did not receive a prescribed iron supplement for five days due to unavailability. The resident's medical records showed low red blood cell counts and mean platelet volume. The LN confirmed the medication was unavailable and acknowledged the facility's policy to notify central supply when medications were low. The DON and ADON acknowledged the failure to supply the medication as ordered.
Failure to Adequately Supervise Resident With Psychiatric and Behavioral History, Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and protection from abuse for one resident when another resident physically struck him. A resident with depressive disorder and an intact BIMS score of 14/15 reported that while he was sitting in the hallway minding his own business, his former roommate suddenly approached and hit him on both sides of his head before he could react. A licensed nurse and a CNA both described that the aggressor resident walked toward the victim near the North Nurses Station and hit him in the face, with the licensed nurse stating she saw the aggressor hit the victim twice on the face before she could intervene. The Social Service Director reported that the victim sustained a scratch and redness on the right cheek as a result of being hit. The aggressor resident had been admitted with schizophrenia and depression and had documented auditory and visual hallucinations, including hearing voices and seeing snakes and the devil, as well as a care plan noting potential mood problems with racing thoughts, increased irritability, agitation, and hyperactivity. Staff interviews indicated that this resident had a history of shouting at staff, lunging at staff, and having verbal outbursts, including calling staff devils and talking about snakes. CNAs reported that in the weeks prior to the incident, the resident, who had previously been quiet, became very talkative, expressed delusional beliefs about the other resident having guns and being a bad person, did not want to return to his room, and was observed becoming mad and aggressive. The facility was aware of the aggressor resident’s serious mental illness, as evidenced by a positive PASRR Level 1 screening requiring a Level 2 mental health evaluation and a Level 2 individualized determination report listing services and supports to address mental health needs. The Director of Nursing acknowledged awareness of the resident’s psychiatric diagnosis on admission and stated that the goal was resident safety and that altercations could make residents feel unsafe, fearful, or scared. Despite the known behavioral history, hallucinations, and escalating behaviors, the incident occurred in a common area near the nurses’ station where the aggressor resident was able to approach and hit the other resident before staff could prevent the assault, contrary to the facility’s abuse prevention policy requiring identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict.
Failure to Implement Scabies Surveillance and Staff Notification Procedures
Penalty
Summary
The facility failed to follow its established surveillance plan for the prevention and control of scabies after a resident was diagnosed with the condition. The Infection Preventionist (IP) did not implement the required six-week contact identification list, instead conducting contact identification for only six days. Additionally, the IP did not assign a dedicated care team member to provide care for the affected resident, as specified in the facility's surveillance plan. The facility's policy required the development of a contact identification list for all individuals who may have had direct, physical contact with the case within the previous six weeks, but this was not completed. Key healthcare personnel, including staff from various departments such as environmental services and nursing, were not properly notified or trained on how to recognize and report signs and symptoms consistent with scabies infestation. The IP verbally notified only a limited group of staff during a huddle at the north station, and there was no documentation or sign-in sheet to confirm who attended. Many staff members, including CNAs, housekeepers, and nurses, reported that they were not informed of the scabies case through official channels and did not receive any in-service training or formal communication regarding the diagnosis or necessary precautions. The facility's records showed that no in-service training on scabies was provided after the diagnosis, and there was no documentation of communication or education in the resident's progress notes. The facility's surveillance plan and policy required prompt notification and education of all healthcare personnel and volunteers, as well as the assignment of a dedicated care team and the maintenance of a contact identification list for six weeks. These steps were not followed, resulting in a failure to implement the facility's own infection prevention and control procedures for scabies.
Failure to Ensure Water Was Accessible for Resident at Risk of Dehydration
Penalty
Summary
A deficiency was identified when a resident with a history of dehydration, acute kidney failure, and essential hypertension did not have water available within reach. The resident was admitted with these diagnoses and was prescribed diuretic medications, which increase the risk of dehydration. The resident's care plan included instructions to offer and encourage fluids between meals. However, during observations, the resident was found in bed with the water pitcher placed on a dresser out of reach, and the straw remained wrapped. The resident confirmed being unable to reach the water pitcher. Further interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing, verified that the water pitcher was not accessible to the resident. Staff acknowledged the resident's risk for dehydration due to their medical condition and medication regimen. Facility policy requires that beverages be available and within reach for all residents unless there are fluid restrictions or contraindications, neither of which applied in this case.
Failure to Ensure Hydration Needs Met for Resident on Diuretics
Penalty
Summary
A deficiency occurred when a resident with a history of dehydration, acute kidney failure, and essential hypertension did not have water available within reach. The resident was observed in bed with the water pitcher placed on a dresser out of reach, and the straw remained wrapped. The resident confirmed being unable to access the water. The clinical record indicated the resident was on diuretic medications, which increase the risk of dehydration, and the care plan specified that fluids should be offered and encouraged between meals. A licensed nurse verified that the water pitcher was out of reach and acknowledged the resident's risk for dehydration due to diuretic use. The Assistant Director of Nursing stated that it was expected for all residents without fluid restrictions or contraindications to have water within reach. Facility policy also required beverages to be available and accessible to residents. The failure to provide water within reach did not align with the resident's care plan or facility policy.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three residents. In one instance, a resident with multiple rib fractures fell and was moved by staff before being assessed for injuries, contrary to facility policy and staff training. The licensed nurse involved acknowledged that the resident should not have been moved prior to assessment, and the Director of Nursing confirmed that the correct procedure was to assess for injuries before moving any resident after a fall. Additionally, the resident experienced blurred vision and headaches following the fall, but the physician was not notified of these symptoms until five days later, resulting in a delay in treatment. The physician stated that if he had been informed earlier, he would have ordered the resident to be transferred to the emergency department for evaluation. For another resident, clinical documentation was incomplete following a fall, specifically the post-fall assessment for the night shift was not completed. The Director of Nursing confirmed this omission and explained that post-fall assessments are necessary to ensure there are no hidden injuries and to implement appropriate interventions. In a third case, a resident with hemiplegia and hemiparesis had incomplete neurocheck documentation after a fall, with most vital signs recorded prior to the fall rather than after. Additionally, this resident was observed wearing regular socks instead of the required nonskid footwear, despite care plan interventions specifying the use of nonskid socks to prevent falls. Both a CNA and a licensed nurse confirmed that the resident should have been wearing nonskid socks to reduce the risk of further falls. Facility policies reviewed indicated that residents should be assessed for injuries before being moved after a fall, that post-fall monitoring should occur for at least 72 hours, and that changes in condition should be promptly communicated to the physician. The failures identified in these cases resulted in delayed treatment, incomplete documentation, and failure to follow care plan interventions, all of which had the potential to negatively affect the health and well-being of the residents involved.
Failure to Follow Pain Medication Parameters and Documentation Standards
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for a resident with multiple rib fractures, specifically in the administration and management of pain-relieving medications. The resident's care plan indicated the need for analgesia as per physician orders, with pain levels to be assessed using a numeric scale. However, the Medication Administration Record showed that acetaminophen, ordered for mild pain (1-3), was administered for higher pain levels (4 and 5) without documented rationale. Additionally, hydrocodone-acetaminophen, a narcotic, was administered for pain levels of 3, despite the absence of specific pain level parameters in the physician's order for this medication. The Director of Nursing confirmed that medications were given outside of the ordered parameters and that there was no documentation explaining the rationale for these decisions. The physician stated that pain level parameters are typically included in orders and that hydrocodone would have been intended for moderate pain (4-6), not mild pain. The facility's pain management policy required consistent assessment, management, and documentation of pain and medication effectiveness, which was not followed in this case.
Resident Denied Dignified Access to Bathroom
Penalty
Summary
A resident admitted with muscle weakness and multiple rib fractures was on a toileting program, as indicated in the care plan, which specified assistance with toileting upon rising, before or after meals, at bedtime, and as needed. Following a fall, the resident requested to use the bathroom, but a Certified Nursing Assistant (CNA) informed the resident that she was wearing an incontinence brief and could use it instead of being assisted to the restroom. Another CNA stated that she would never instruct a resident to use their brief if the resident requested to use the restroom and was able to do so with assistance, identifying this as a dignity concern. The Director of Nursing (DON) confirmed that it was inappropriate to deny the resident's request and emphasized the importance of preserving the resident's dignity. Facility policy also required staff to promote and maintain resident dignity and respond to requests for assistance in a timely and respectful manner.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's Responsible Party (RP) was informed and provided consent for the use of psychotropic medications. Despite documentation indicating that the resident did not have the mental capacity to make healthcare decisions, the facility had the resident sign the informed consent forms for quetiapine and escitalopram. The resident received quetiapine for four days and escitalopram throughout their stay without proper informed consent from the RP. Record review and interviews confirmed that the RP was not informed about the use of these medications, nor were the risks and benefits discussed with them. The facility's policy required informed consent for psychotropic medications to be verified prior to use, but this was not followed. The DON acknowledged that the resident lacked capacity and that the RP should have signed the consent forms, while the RP confirmed they were never approached regarding the medications.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify a resident's Responsible Party (RP) after the resident experienced a fall. Review of the resident's admission record indicated the resident had multiple rib fractures on the left side of the ribcage. Documentation in the SBAR Fall Report of Incident incorrectly listed the resident as her own RP and stated that the RP was notified. However, during interviews, the licensed nurse confirmed that he documented the resident as her own RP and did not notify the actual RP. Further review with the Director of Nursing (DON) confirmed that the clinical record was inaccurate and that the RP should have been notified, especially in case the RP wanted to make decisions such as sending the resident to the emergency room. The facility's policy on Fall Prevention and Response required notification of both the physician and the RP following a fall, but this was not followed in this instance.
Psychotropic Medication Administered Without Accurate Diagnosis
Penalty
Summary
A resident was administered the psychotropic medication quetiapine for four days without an accurate or appropriate diagnosis documented in their clinical record. The medication was ordered for bipolar disorder, but the resident did not have a diagnosis of bipolar disorder; their admission record only listed depression among their diagnoses. The Medication Administration Record showed that quetiapine was given from March 7 to March 10, despite the lack of a proper indication for its use as required by facility policy. During interviews, the DON confirmed that the physician's order for quetiapine did not have an accurate diagnosis, emphasizing the importance of matching medications to the resident's documented conditions. The resident's physician also stated that a review of the medications should have been completed and that the facility should have clarified the rationale for prescribing a psychotropic medication. The facility's policy requires that psychotropic medications be used only when necessary and that the clinical record reflect the diagnosis and specific condition being treated, which was not followed in this case.
Failure to Clarify Blood Pressure Medication Parameters and Notify Physician of Elevated Readings
Penalty
Summary
A deficiency occurred when a resident with hypertension and type 2 diabetes mellitus was administered the blood pressure medication Losartan without specific parameters in the physician's order to guide when the medication should be withheld. The medication order did not include instructions regarding minimum systolic blood pressure or heart rate thresholds, and the nursing staff did not clarify the order with the physician. Multiple licensed nurses and the Director of Nursing confirmed that the order lacked these parameters, and it was the facility's usual practice to include such parameters or verify them with the physician. The physician also stated that he expected staff to clarify orders and that parameters should have been in place to prevent adverse effects such as hypotension. Additionally, the same resident experienced two episodes of elevated blood pressure readings, with systolic values of 173 and 168, on the same day during different shifts. These readings were significantly higher than the resident's baseline and outside the normal range. Despite this, there was no documentation that the physician was notified of these abnormal values. Nursing staff and the Director of Nursing acknowledged that the physician should have been informed of these elevated readings, and the physician confirmed that he was not contacted and would have expected notification for such results. Facility policy required licensed nurses to assess, document, and communicate changes in condition, including abnormal vital signs, to the primary care provider. The failure to clarify medication parameters and to notify the physician of significant changes in blood pressure constituted a lack of adherence to professional standards of practice and facility policy, resulting in the identified deficiency.
Inappropriate Discharge to Room and Board Facility
Penalty
Summary
The facility failed to ensure a safe and effective transition of care for a resident who was discharged to a room and board facility that could not meet her care needs. The resident, who was admitted to the facility with diagnoses including morbid obesity, repeated falls, and weakness, required substantial assistance with activities of daily living such as toileting, bathing, and dressing. Despite these needs, the facility discharged her to a location that only accepted residents who were independent in their care needs. Interviews with facility staff revealed that the resident was heavily dependent on assistance for mobility and personal care. The Certified Nurse Assistant and Licensed Nurse both confirmed that the resident required significant help with basic activities and was not capable of independent living. The facility's social services department had communicated to the room and board facility that the resident was ambulatory and needed only toileting assistance, which was inaccurate. Upon arrival at the room and board facility, the resident was unable to manage her care independently and was immediately sent to the emergency department. The room and board facility owner stated that they had been misinformed about the resident's capabilities. The hospital's social worker confirmed that the discharge plan was unsafe and inappropriate, as the resident required a skilled nursing facility due to her care needs and reliance on oxygen therapy. The facility's failure to provide an accurate assessment and safe discharge plan resulted in the resident spending 26 days in the hospital awaiting appropriate placement.
Failure to Safely Discharge and Readmit Resident
Penalty
Summary
The facility failed to readmit a resident after she was transferred to a local emergency department following an unsafe discharge to a room and board facility that could not accommodate her care needs. The resident, who was admitted to the facility in the fall of 2022, had diagnoses including morbid obesity, repeated falls, and weakness. Her Minimum Data Set (MDS) assessment indicated she required substantial assistance with activities such as toileting hygiene, bathing, dressing, and transferring in and out of a tub or shower. Despite these needs, the facility discharged her to a room and board facility that only accepted residents who were independent in their care needs. Upon arrival at the room and board facility, the resident was unable to move or get out of her wheelchair by herself, contrary to what the nursing home had communicated. The room and board facility owner stated that the resident was not informed about the type of facility she was being transferred to and that she was unable to clean herself after using the toilet. Consequently, the resident called 911 and was taken to the emergency department. The hospital's Master of Social Worker confirmed that the room and board facility could not meet the resident's care needs, and she was oxygen reliant without having any oxygen with her. The hospital's physical therapy evaluation recommended that the resident required short to long-term care. The facility's administrator acknowledged a disconnect in the transfer process but did not provide a clear explanation for the failure. The facility's policy on admission, transfer, discharge, and bed-holds emphasized the importance of ensuring a safe and orderly discharge, which was not adhered to in this case. The hospital's social worker noted that the facility refused to take the resident back, citing non-payment of her share of cost and claiming she did not meet the requirements for skilled nursing care, despite the failed discharge plan and the resident's evident need for continued care.
Expired Supplies and Disorganized Medication Carts Found
Penalty
Summary
The facility failed to ensure the removal of expired medical supplies from the medication storage room and maintain medication carts in a clean and orderly manner. During a check of the medication storage room, an expired Mic-Key continuous feed extension set and Covid-19/Flu test kits were found, with expiration dates that had already passed. A Licensed Nurse verified these findings and acknowledged that the expired supplies should have been discarded. The facility's policy requires that expired medications and biologicals be stored separately until they are destroyed or returned to the provider. Additionally, during checks of medication carts in various nursing stations, loose and broken pills, as well as residue, were found in the carts. Licensed Nurses and the Assistant Director of Nursing verified these findings, and it was noted that the facility's expectation was for no loose pills to be present in the medication carts. The Director of Nursing acknowledged the oversight regarding the expired biologicals and clarified that the facility found a manufacturer's memo extending the expiration date of the Covid-19 test kits after the initial inspection.
Expired Sanitizer Strips Used in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by using expired Quaternary Ammonium (Quat) strips to measure the concentration of sanitizer used in the kitchen. During an initial tour of the kitchen, the Dietary Manager (DM) was observed testing the sanitizer level of the Quat solution, which measured at 150 parts per million (ppm). Upon checking, it was verified that the Quat strips being used were expired. The DM acknowledged that the expiration dates of the sanitizer strips should be checked frequently enough to ensure they are not expired. Further interviews revealed that the Registered Dietician (RD) also expected that the expiration dates of the Quat strips should be checked before usage. A review of the facility's policy and procedure on chemical sanitizing did not include instructions to check the expiration date of the strips. Additionally, the facility's Sanitizer Log lacked instructions to verify the expiration date of the test strips. This oversight increased the risk of foodborne illness for the residents consuming meals prepared at the facility, which had a total census of 124 residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations. Resident 116's nasal cannula was found uncovered on top of the oxygen concentrator, contrary to the facility's policy that requires storing tubing in a sanitary manner. The Director of Nurses confirmed the observation and acknowledged the expectation for the oxygen tubing to be covered when not in use. Additionally, during meal service, hand hygiene was not practiced by staff members, as observed with a CNA and an RNA who did not wash their hands after touching residents and before serving drinks, which was against the facility's infection control expectations. Resident 72's urinary bag was observed touching the floor, which posed a risk of bacterial infection. The facility's policy requires that the collection bag and tubing be kept off the floor to prevent contamination. Licensed nurses verified the observation and acknowledged the risk of infection due to the improper positioning of the urinary bag. Furthermore, Resident 38, who was on enhanced precautions, did not have PPE donned by the LN administering insulin, which was a requirement for infection control. Additional deficiencies included a partially covered linen cart and a laundry aide's uniform touching clean personal clothes, both of which were against the facility's infection control policies. The Environmental Services Manager confirmed that clean linens must be fully covered, and uniforms should not touch clean clothes to prevent cross-contamination. The Infection Preventionist reiterated the importance of these practices to maintain a sanitary environment and prevent the spread of infections.
Resident's Dignity Compromised by Exposed Urine Drainage Bag
Penalty
Summary
The facility failed to protect the dignity of Resident 72, who was admitted with a diagnosis of prostate gland enlargement that could cause urination difficulty. During an observation, it was noted that Resident 72's urine drainage bag was hanging at the side of the bed, facing the hallway, with the room door wide open, making it visible from the hallway. The Infection Preventionist confirmed that the urine drainage bag was exposed and should have been covered with a dignity bag. The Director of Nursing, along with the Assistant DON, acknowledged that the urinary drainage bag should have been covered. Resident 72 expressed feeling embarrassed due to the lack of a dignity bag covering the urine drainage bag.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by not ensuring their call lights were within reach, preventing them from obtaining assistance promptly. Resident 479, admitted with multiple fractures and a history of falls, was observed with his call light hooked to the wall, out of reach, despite being alert and oriented. This was confirmed by a Licensed Nurse who acknowledged the call light should be accessible. Similarly, Resident 65, who has hemiplegia and cognitive impairments, was found with his call light looped and hung by the wall, away from his reach. A Certified Nursing Assistant confirmed this observation, stating the call light should be within reach. Resident 1, with hemiplegia and moderate cognitive impairment, was found with his call light on the floor, out of reach, while he was awake and expressing discomfort. This was confirmed by a CNA who stated the call light should be near the resident's bedside. The facility's policy requires call lights to be accessible to residents while in bed, but this was not adhered to, as confirmed by the Assistant Director of Nursing. These observations indicate a failure to meet the residents' needs for timely assistance.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident identified as at risk for falls. The resident, who was admitted with right side paralysis, generalized muscle weakness, and other mobility issues, had a care plan created to manage fall risks. This care plan included interventions such as placing fall mats on the sides of the bed, which were to be implemented by a specific date. However, during an observation and interview, it was noted that the fall mats were not present in the resident's room, contrary to the care plan. The deficiency was further highlighted by a previous incident where the resident had an actual fall, resulting in a head injury and requiring hospital evaluation. Despite this incident, the necessary fall prevention measures were not in place during the surveyor's visit. A licensed nurse confirmed the absence of the fall mats and acknowledged that they should have been placed according to the care plan. This oversight increased the potential for further injury to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of nursing practice for one of the residents, identified as Resident 20, when a prescribed medication was not administered as ordered. Resident 20, who was recently admitted to the facility with a diagnosis of chronic lymphocytic leukemia, had a physician's order for Ferrous Sulfate 325 mg to be taken daily. During a medication administration observation, it was noted that the medication was not given to the resident as per the physician's order. Licensed Nurse (LN 2) confirmed in an interview that the medication was not administered because it was unavailable. The facility's policy and procedure, as well as the Nursing Practice Act Rules and Regulations, require compliance with medication administration orders. The Director of Nursing, along with the Assistant DON, acknowledged that the medication should have been administered as ordered.
Failure to Provide Adequate Nail Care for a Resident with Contracted Hand
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 96, who was unable to perform activities of daily living due to a contracted right hand. Resident 96 was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus, gout, sepsis, and muscle weakness. Despite having intact cognition and no history of rejecting care, the resident's right hand was observed to be contracted with long fingernails and a brownish/blackish substance underneath. The resident reported that the long fingernail had been digging into his skin for a year, and although he informed the nurses, they did not address the issue. Attempts by some nurses to trim the nails were unsuccessful, and the issue was not escalated or documented properly. Interviews with facility staff, including a licensed nurse and the Assistant Director of Nursing (ADON), confirmed the resident's need for assistance with daily care, including nail trimming. The ADON acknowledged that the resident's nails could cause injury due to their length and the inability to trim them. The facility's policy required licensed nurses or podiatrists to cut the nails of diabetic residents, but there was no documentation of consultation with a podiatrist or other resources to address the resident's nail care needs. This lack of action and documentation contributed to the deficiency in care provided to Resident 96.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful ongoing activities for a resident, identified as Resident 120, who was admitted with right-sided paralysis and heart and lung problems. During an observation, the resident was found lying in bed with the TV on and expressed a desire to engage in activities to strengthen his paralyzed side. The resident reported that he spent most of his time watching TV because the facility did not assist him in getting out of bed and into a wheelchair. He expressed a preference for attending group activities and noted the absence of books, magazines, or other activity materials in his room. The resident felt trapped and insignificant due to the lack of engagement and activity options. The facility's policy on residents' rights to refuse activities emphasized offering a wide range of activity programs and ensuring continuous engagement through group programs, one-to-one contacts, or independent leisure materials. However, the care plan for Resident 120, initiated in July, indicated that he would spend most of his time in his room involved in independent leisure pursuits, with interventions including room visit check-ins and offering materials for independent use. An interview with the Activity Director revealed that Resident 120 did not attend group activities, and there was no documentation of one-on-one room visits or a list of activity materials provided. The Activity Director acknowledged that watching TV all day was not a meaningful activity and admitted that the facility should have facilitated more engagement for the resident.
Failure to Administer Prescribed Iron Supplement
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for a resident, resulting in the resident not receiving a prescribed iron supplement, ferrous sulfate, for five consecutive days. The resident, who was recently admitted with chronic lymphocytic leukemia, had a physician's order for ferrous sulfate 325 mg to be administered daily. However, during a medication administration observation, it was noted that the supplement was not given due to its unavailability. The resident's medical records indicated low red blood cell counts and low mean platelet volume, which could be related to the lack of the iron supplement. The Licensed Nurse (LN) confirmed that the medication was unavailable and acknowledged that it was the facility's policy to notify central supply when medications were running low. The Director of Nursing (DON) and Assistant DON also acknowledged that the facility should have ensured the medication was supplied as per the physician's order.
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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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