Atlantic Memorial Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 2750 Atlantic Avenue, Long Beach, California 90806
- CMS Provider Number
- 055744
- Inspections on file
- 28
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Atlantic Memorial Healthcare Center during CMS and state inspections, most recent first.
A resident with a left upper extremity DVT did not have a care plan that included the location of the DVT or specific instructions for staff to avoid taking blood pressure in the affected arm, despite a request from the responsible party. Staff were unaware of the DVT location and the request, and no signage was present above the resident's bed. The care plan lacked necessary interventions and details, and the facility's policies for person-centered care planning were not followed.
The facility failed to define specific, measurable target behaviors for the use of psychotropic medications in several residents, leading to potential unnecessary medication use. A resident was prescribed risperidone and divalproex without documented specific behaviors or diagnoses, while two other residents had unclear monitoring for psychotropic medication use. Staff interviews revealed a lack of clarity and documentation, increasing the risk of adverse effects.
A facility failed to obtain informed consent from a resident or their responsible party before starting divalproex for mood disorder treatment. The resident, diagnosed with unspecified dementia, had fluctuating decision-making capacity. The Director of Nursing acknowledged the oversight, noting staff confusion about consent requirements for non-antipsychotic medications.
A facility failed to develop a care plan for a resident who was unvaccinated and exposed to Influenza A. Despite having intact cognition and requiring assistance with daily activities, the resident's care plan did not address recent exposure to Influenza A from a roommate. Staff interviews confirmed the absence of a care plan, which was contrary to facility policy requiring updates based on medical changes.
A facility failed to provide a communication device for a nonverbal resident with cognitive communication deficit and dysphagia. Despite the care plan specifying the use of a communication board, observations revealed the absence of such a device in the resident's room. Staff interviews confirmed the device was neither used nor available, potentially hindering the resident's ability to communicate needs.
A resident with cognitive impairment and ADL needs did not receive scheduled personal hygiene care or assistance with eating, leading to discomfort and low self-esteem. Staff interviews revealed that the resident was not assisted with setting up their breakfast tray or positioned for eating, contrary to facility policy.
A resident with a history of myocardial infarction, asthma, and other conditions did not have a bowel movement for several days, leading to vomiting. The facility failed to monitor and report the resident's bowel movements and did not notify the physician as required. Staff interviews revealed a lack of awareness and adherence to monitoring protocols, which could have prevented the resident's symptoms.
Two residents in the facility did not receive oxygen therapy as ordered by their physicians. One resident with COPD had an oxygen concentrator set incorrectly and a nasal cannula on the floor, while another resident returned from dialysis with a nasal cannula not connected to an oxygen source. Staff failed to follow facility policies on oxygen administration and infection control.
A facility failed to accurately account for a dose of hydrocodone/apap 10/325 mg for a resident. An LVN administered the medication but forgot to sign the Controlled Medication Count Sheet, leading to a discrepancy between the count sheet and the medication card. The facility's policy requires immediate documentation after administering controlled medications to prevent risks such as medication diversion or overdose.
The facility failed to follow its Antibiotic Stewardship protocol, leading to two residents being prescribed antibiotics without meeting the necessary clinical criteria. One resident was given Ciprofloxacin for a surgical wound, and another was prescribed Levaquin for pneumonia, despite not meeting the McGeer Criteria. The lack of documentation and communication with physicians contributed to the inappropriate use of antibiotics.
A resident with a history of myocardial infarction, asthma, and other conditions did not receive their scheduled medication due to nausea and vomiting. Despite this, an LVN inaccurately signed the MAR as if the medication was administered and failed to notify the physician. This breach in protocol was recognized by the Infection Preventionist Nurse and the DON, highlighting the importance of accurate documentation to prevent miscommunication.
The facility failed to maintain infection control practices, including improper handling of a nasal cannula for a resident with multiple diagnoses, delayed communication of a positive Influenza A test result for another resident, and failure to implement droplet precautions. These actions increased the risk of infection transmission among residents and staff.
A facility failed to follow its Antibiotic Stewardship protocol for a resident prescribed Ciprofloxacin, despite not meeting infection criteria. The IP did not document notifying the doctor, and the DSD failed to inform the Wound Care Doctor. The DON acknowledged the lack of documentation, contrary to the facility's policy on optimizing antibiotic use.
A resident expressed discomfort with a transportation driver, but the facility failed to document or resolve the grievance. Despite the resident's medical conditions, including ESRD and anxiety disorder, the concern was not recorded in the grievance logs, violating the facility's policy on addressing grievances.
A resident at risk for foot drop experienced a delay in receiving a properly fitted orthotic device due to miscommunication and insurance changes. The facility failed to update the care plan to reflect necessary modifications and specific usage of orthotic devices, leading to confusion among the care team and the resident's responsible party. Interviews revealed a lack of awareness and communication regarding the resident's care plan and orthotic device usage.
Failure to Develop and Implement Resident-Centered Care Plan for DVT
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident with a diagnosis of left upper extremity (LUE) deep vein thrombosis (DVT). The responsible party (RP) for the resident had specifically requested that signage be placed above the resident's bed instructing nursing staff to avoid taking blood pressures in the affected left arm, but this request was not honored or implemented. Additionally, the care plan did not include the location of the DVT or provide specific instructions for staff on how to assess for complications related to the DVT, such as monitoring for pain, swelling, warmth, discoloration in the affected extremity, or signs of pulmonary embolism (PE) like difficulty breathing, cough, and chest pain. Record review showed that the resident had a history of atrial fibrillation, acute embolism, and thrombosis of the left upper extremity deep veins, with severely impaired cognitive skills for daily decision making. Despite these significant medical issues, the care plan lacked necessary interventions and details. Observations confirmed that no sign was present above the resident's bed, and interviews with staff revealed they were unaware of the DVT location or the RP's request. The MDS nurse and DON both acknowledged that the care plan was generic and did not provide adequate information for staff to deliver appropriate care or assessments. The facility's own policies require the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and timeframes, and to involve the resident or their representative in the process. However, the failure to include the RP's request and to specify interventions for the resident's DVT resulted in staff not being properly informed or able to assess for complications, as confirmed by staff interviews and record review.
Failure to Define Measurable Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to define resident-specific, objectively measurable target behaviors related to the use of psychotropic medications for several residents. For Resident 16, the facility did not document specific behaviors related to the use of risperidone and divalproex, which were prescribed for agitation and mood disorder/bipolar disorder, respectively. The Director of Nursing (DON) acknowledged the lack of clear, measurable target behaviors, which are essential for monitoring the effectiveness of the medication and preventing unnecessary prolonged use or dosage increases. Additionally, the facility did not ensure that divalproex was used only for documented conditions or diagnoses. Resident 16's clinical records lacked documentation of a mood disorder or bipolar disorder, which were the stated reasons for prescribing divalproex. The DON confirmed the absence of such documentation and expressed concern about the potential adverse effects of using divalproex without a clear indication. For Residents 43 and 10, the facility also failed to define specific measurable target behaviors for the use of psychotropic medications. Resident 43 was prescribed Seroquel for psychosis manifested by disorganized thoughts, but the monitoring of these thoughts was not specific or measurable. Similarly, Resident 10's care plan indicated monitoring for manic episodes such as visual hallucinations, but there was no documentation of what these hallucinations entailed. Interviews with staff revealed a lack of clarity and documentation regarding the behaviors being monitored, which could lead to unnecessary medication use and potential side effects.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident or their responsible party before initiating treatment with divalproex, a medication used for mood disorders. This oversight was identified during a review of the resident's clinical records, which showed no documentation of education regarding the risks and benefits of the medication prior to its administration. The resident, who was admitted with a diagnosis of unspecified dementia and had fluctuating capacity to understand and make decisions, was prescribed divalproex for mood disorder/bipolar disorder. The lack of informed consent could have prevented the resident from exercising their right to decline treatment. During an interview, the Director of Nursing acknowledged the failure to obtain informed consent, attributing it to possible confusion among staff regarding the necessity of consent for medications not classified as antipsychotics, antidepressants, anti-anxiety medications, or hypnotics. The facility's policy required informed consent for psychoactive medications, but this was not followed. The Director of Nursing expressed concern that without informed consent, the resident might have taken the medication longer than necessary, potentially leading to adverse effects.
Failure to Implement Care Plan for Unvaccinated Resident Exposed to Influenza
Penalty
Summary
The facility failed to develop and implement a person-centered and individualized care plan for a resident who was unvaccinated and exposed to Influenza A. The resident, who had intact cognition, required assistance with daily activities and had a history of diabetes mellitus, hypertension, and osteomyelitis. Despite being offered vaccines and education on their benefits, the resident refused the influenza vaccine. The care plan in place did not address the resident's recent exposure to Influenza A from a roommate, which was a significant oversight given the resident's unvaccinated status. Interviews with facility staff, including a Registered Nurse Supervisor and an Infection Preventionist Nurse, confirmed that there was no care plan developed to address the resident's recent exposure to Influenza. The Director of Nursing also acknowledged the importance of a care plan to ensure staff are informed about the resident's care needs. The facility's policy indicated that care plans should be updated based on identified problems and changes in medical conditions, but this was not done in this case, leading to a potential delay in care for the resident.
Failure to Provide Communication Device for Nonverbal Resident
Penalty
Summary
The facility failed to ensure that a communication device was accessible to a nonverbal resident, identified as Resident 42, who lacked the capacity to speak. This deficiency was identified through observation, interview, and record review. Resident 42 was admitted with diagnoses including cognitive communication deficit and dysphagia, and their Minimum Data Set (MDS) indicated severely impaired daily decision-making skills. The resident's care plan, dated 10/13/2024, specified the use of a communication board to assist with communication, yet during observations on 1/22/2025 and 1/23/2025, no communication device was found in the resident's room. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), revealed that the communication device was not used or available for Resident 42. The LVN admitted to not using a communication device with the resident in the past and was unable to locate one at the nurses' station. The RN confirmed that the resident was supposed to have a communication assistive device to facilitate communication during care, but it was not present at the bedside. This oversight had the potential to place Resident 42 at risk of being unable to communicate needs to staff and could lead to misinterpretation.
Failure to Provide ADL Care for Resident
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care to Resident 51, who was admitted with diagnoses including a urinary tract infection and required assistance with ADLs due to cognitive impairment. The resident's care plan indicated the need for personal hygiene and assistance with eating, yet the ADL records showed that Resident 51 did not receive scheduled showers or personal hygiene care. This lack of care led to the resident feeling unkempt and uncomfortable, impacting their self-esteem and ability to eat breakfast. During an observation, Resident 51 was found lying flat in bed with an untouched breakfast tray, expressing discomfort due to unwashed hands and inability to sit up or pour milk on cereal. Interviews with staff revealed that the resident was not assisted with setting up the breakfast tray or positioning for eating, as the CNA responsible was attending to another resident. The facility's policy requires staff to ensure residents receive necessary ADL care, including personal hygiene and feeding assistance, which was not adhered to in this case.
Failure to Monitor Bowel Movements and Administer Medication
Penalty
Summary
The facility failed to provide necessary care for a resident by not monitoring bowel movements and administering medication for constipation as ordered by the physician. The resident, who had a history of myocardial infarction, asthma, sequelae of cerebral infarction, and hypertension, was admitted with impaired cognitive skills and required moderate assistance with daily activities. The resident did not have a bowel movement from January 16 to January 20, 2025, and experienced vomiting on January 21, 2025. Despite the lack of bowel movements, the physician was not notified, and the resident was not on a stool softener until a Dulcolax suppository was administered on January 21, 2025. Interviews with staff revealed that the CNAs and licensed nurses failed to monitor and report the resident's bowel movement frequency as required. The CNA responsible for the resident was unaware of the lack of bowel movements, and the LVN confirmed that the physician was not notified. The RN Supervisor and Director of Nursing acknowledged that the lack of bowel movements could lead to serious health issues, including abdominal discomfort and nausea. The facility's job descriptions for CNAs and RNs emphasized the importance of monitoring and reporting changes in residents' conditions, which was not adhered to in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that two residents received continuous oxygen as ordered by their physicians. Resident 48, who was diagnosed with malignant neoplasm of the right lung and COPD, was observed with an oxygen concentrator set at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, the nasal cannula was found on the floor, and the resident was not wearing it during meal times. The Licensed Vocational Nurse (LVN) confirmed that the resident should have been on continuous oxygen and that the nasal cannula should be stored properly when not in use to prevent contamination. Resident 70, who had diagnoses including enterocolitis, end-stage renal disease, diabetes, and myocardial infarction, was observed with a nasal cannula not connected to an oxygen source. The resident had returned from dialysis treatment, and the LVN responsible for the resident's care admitted to not verifying the connection of the nasal cannula to the oxygen concentrator. The Infection Preventionist Nurse (IPN) stated that the resident should have been assessed upon return from dialysis to ensure vital signs were stable and the oxygen equipment was properly connected. The facility's policies and procedures regarding oxygen use and medication administration were not adhered to, as evidenced by the improper handling and administration of oxygen therapy for both residents. The Director of Nursing acknowledged the potential dangers of providing incorrect oxygen levels, especially for residents with COPD, and emphasized the importance of following physician orders and infection control practices.
Failure to Accurately Account for Controlled Medication
Penalty
Summary
The facility failed to accurately account for a dose of hydrocodone/apap 10/325 mg, a controlled medication, for Resident 190. During an observation and interview with a Licensed Vocational Nurse (LVN 1), it was discovered that there was a discrepancy between the Controlled Medication Count Sheet and the medication card. The count sheet indicated 14 doses remaining, while the medication card showed only 13 doses. LVN 1 admitted to administering the missing dose to Resident 190 earlier that morning but forgot to sign the Controlled Medication Count Sheet at the time of administration. The facility's policy and procedures for controlled medications, revised in December 2019, require that the licensed nurse immediately document the date, time, amount administered, and their signature on the accountability record after administering a controlled medication. LVN 1 acknowledged that failing to sign off on the narcotic log at the time of administration poses a risk of medication diversion or overdose, potentially leading to medical complications for the resident.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for two residents, leading to the prescription of antibiotics without meeting the necessary clinical criteria. Resident 6 was prescribed Ciprofloxacin for a surgical wound despite not meeting the McGeer Criteria for cellulitis, soft tissue, or wound infection. The Infection Preventionist (IP) acknowledged the lack of documentation regarding notifying the doctor about the criteria not being met, and the Director of Staff Development (DSD) confirmed that the doctor was informed but chose to continue the antibiotic. The Wound Care Doctor was unaware of the McGeer Criteria and was not informed that the criteria were not met. Resident 242 was prescribed Levaquin for pneumonia based on a chest x-ray, despite not meeting the McGeer Criteria for antibiotic use. The Surveillance Data Collection Form indicated that the resident had only two criteria for using Levaquin, lacking symptoms such as cough, sputum production, fever, or leukocytosis. The DSD confirmed the absence of documentation about notifying the physician that the criteria were not met, and the Infection Preventionist Nurse (IPN) noted that the antibiotic use did not align with the facility's surveillance criteria. The facility's policy on unnecessary medications, updated in 2019, states that each resident's medication regimen must be free from unnecessary drugs, defined as those used without adequate indications. The facility's Antibiotic Stewardship Program, reviewed in 2023, aims to ensure antibiotics are used only when necessary and appropriate. However, the lack of adherence to these protocols resulted in the inappropriate prescription of antibiotics for both residents, potentially leading to antibiotic resistance and other adverse effects.
Inaccurate MAR Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the Medication Administration Record (MAR) for a resident who did not receive their scheduled medication due to nausea and vomiting. On the specified date, the resident, who had a history of myocardial infarction, asthma, sequelae of cerebral infarction, and hypertension, experienced two episodes of vomiting at the time their medication was due. Despite this, the Licensed Vocational Nurse (LVN) signed the MAR indicating that the medications were administered, although they were not given due to the resident's condition. The LVN admitted to signing the MAR without administering the medications and did not notify the physician about the resident's inability to take the medication. This inaccurate documentation was acknowledged by both the Infection Preventionist Nurse and the Director of Nursing, who emphasized the importance of accurate MAR documentation to prevent miscommunication and ensure proper resident care. The facility's policy requires that any withheld or refused medication be documented accurately, which was not adhered to in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances, leading to potential risks of infection transmission. Resident 70, who had multiple diagnoses including end-stage renal disease and diabetes, was observed with a nasal cannula that was not connected to an oxygen source and was lying on the floor, potentially contaminated. The Licensed Vocational Nurse (LVN 3) acknowledged the oversight and stated that the nasal cannula should have been stored in a plastic bag when not in use, as per the facility's policy. The Infection Preventionist Nurse (IPN) confirmed that the nasal cannula should have been replaced to prevent possible contamination. In another instance, the facility failed to promptly communicate a positive Influenza A test result for Resident 79 to the physician. Resident 79, who had a history of myocardial infarction and asthma, developed a fever and cough, and a test was conducted. The test result was received by the facility, but the Registered Nurse Supervisor (RN 1) did not notify the physician in a timely manner, nor did she contact the Medical Director when the physician did not respond. This delay in communication could have led to a delay in care for Resident 79 and increased the risk of exposure to other residents and staff. Additionally, the facility did not implement droplet precautions for Resident 79 after the positive Influenza A result was received. No signage or isolation cart was present, and Resident 79 remained in the same room with a roommate. RN 1 did not initiate droplet precautions, waiting instead for instructions from the Director of Nursing and IPN, despite knowing that licensed nurses did not need an order to start isolation precautions. The IPN confirmed that droplet precautions should have been implemented immediately to prevent the risk of transmission to other residents and staff.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement their Antibiotic Stewardship protocol for a resident, leading to the potential for antibiotic resistance due to unnecessary or inappropriate antibiotic use. The resident, who was admitted with chronic and duodenal ulcers and a rectal fistula, was prescribed Ciprofloxacin for an abnormal wound culture. However, the Infection Preventionist (IP) noted that the resident did not meet the criteria for a definitive infection according to McGeers Criteria, and there was no documentation that the medical doctor was informed of this finding. The Director of Staff Development (DSD) confirmed that the doctor was informed but failed to document the response in the progress notes. Additionally, the DSD did not notify the Wound Care Doctor who ordered the antibiotic. The Director of Nursing (DON) stated that the IP should have documented the communication with the doctor in the Nursing Progress Notes. The facility's policy on Antibiotic Stewardship emphasizes the importance of optimizing antibiotic use to prevent resistance and ensure resident safety, which was not adhered to in this case.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to address a resident's grievance regarding discomfort with a transportation driver, as there was no documented resolution or follow-up. The resident, who was admitted with diagnoses including End Stage Renal Disease, anxiety disorder, and major depressive disorder, expressed discomfort with a driver from the transportation company used for hemodialysis trips. The Social Services Assistant reported the concern to the Social Services Manager, who instructed them to file a complaint with the transportation vendor. However, there was no documentation in the resident's medical record regarding the situation or its resolution. Further investigation revealed that the grievance was not recorded in the facility's grievance logs, and the Director of Nursing Services emphasized the importance of documenting residents' concerns to ensure their safety. The facility's policy on grievances, last revised in December 2023, requires the Grievance Official to evaluate, investigate, and take immediate action to resolve concerns and prevent further violations of residents' rights. The lack of documentation and follow-up on the resident's grievance indicates a failure to adhere to this policy.
Failure to Revise Care Plan for Resident at Risk of Foot Drop
Penalty
Summary
The facility failed to revise a resident-centered care plan for a resident at risk for developing permanent foot drop. The deficiency involved a lack of clear and consistent communication from the Interdisciplinary Team (IDT) to the resident's responsible party (RP) regarding changes in insurance payer sources and their impact on the resident's physical therapy plan. Additionally, the direct care team, including licensed nurses, Certified Nurse Assistants (CNAs), and Restorative Nurse Assistants (RNAs), were not adequately educated on the proper use of the resident's orthotic devices, specifically the Ankle Foot Orthosis (AFO) and Pressure Relief Ankle Foot Orthosis (PRAFO). The resident, who had a history of compartment syndrome and major depressive disorder, was admitted with a risk of foot drop. Despite being fitted for an orthotic boot, the resident experienced delays due to miscommunication and insurance changes, resulting in the improper fitting of the device. The care plan did not reflect the necessary modifications or the specific usage of the orthotic devices, leading to confusion among the care team and the resident's RP. The IDT failed to update the care plan to include the pending arrival of a properly fitted orthosis and the specific instructions for using the AFO and PRAFO boots. Interviews with various staff members, including the Director of Rehabilitation (DOR), Physical Therapist (PT), and the Director of Nursing (DON), revealed a lack of awareness and communication regarding the resident's care plan and orthotic device usage. The care team, including CNAs and licensed nurses, were not informed of the resident's care plan goals and interventions, resulting in a delay in care and services. The facility's policies and procedures emphasized the importance of a comprehensive, person-centered care plan developed by the IDT, which was not adhered to in this case.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
