Auburn Ravine Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 750 Auburn Ravine Road, Auburn, California 95603
- CMS Provider Number
- 555645
- Inspections on file
- 18
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Auburn Ravine Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically abused by her roommate, who had a known history of aggression toward both staff and other residents. The roommate grabbed the resident's wrist and covered her mouth, causing pain and distress. Staff and other residents reported ongoing issues with the roommate's aggressive behavior, which had not been adequately addressed, resulting in repeated disturbances and harm.
Two staff members failed to wear required PPE, specifically gowns, while performing wound care on a resident under enhanced barrier precautions for chronic wounds, despite clear facility policies and signage. Additionally, a contracted hairdresser who regularly interacted with residents had not received ongoing infection prevention and control training, contrary to facility agreements and expectations.
The facility failed to develop and implement comprehensive care plans for four residents. Two residents prescribed psychotropic medications lacked care plans for their use, while another resident with a Wander/Elopement Alarm (WEA) also had no care plan. Additionally, a resident with a WEA and a history of disorientation and dementia had no care plan addressing the device's use, despite facility policies requiring such plans for at-risk residents.
The facility failed to adhere to professional standards by prescribing psychotropic medications without proper indications or monitoring for two residents, not labeling or dating nasal cannulas and humidifiers for three residents, and not following physician orders for oxygen delivery. Additionally, two residents had incomplete monitoring orders for Wander/Elopement Alarms (WEA), and one resident had a WEA applied without a physician's order.
The facility failed to ensure the Dietary Supervisor met state educational requirements, leading to deficiencies in meal distribution, food texture preparation, and sanitation. The Registered Dietitian's involvement was limited, focusing mainly on clinical duties rather than food service oversight. Several sanitation issues were identified, including improper cooling of cooked chicken and unclean kitchen equipment.
The facility failed to follow professional standards for food safety, including improper cooling of cooked chicken, lack of temperature monitoring for ambient foods, and poor sanitation practices. Observations revealed wet and dirty serving pans, expired bread, and unclean ice machines. The Registered Dietitian acknowledged the need for staff training and adherence to proper procedures.
The facility failed to maintain a clean environment as the only garbage dumpster outside was not securely closed due to deformed lids, leaving a gap. This was confirmed by the Dietary Supervisor and acknowledged by the Director of Clinical Operations, who noted the lack of a policy on dumpster conditions. The deficiency posed a risk for pest infestation and disease spread, violating the FDA Food Code 2022.
A CNA in the facility was found to be working with an expired license, as confirmed by the DON and DSD. Despite being aware of the impending expiration, the CNA continued to work without a valid license, which is against the facility's policy and state law. This oversight had the potential to impact the care of all 55 residents.
The facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene protocols and inadequate PPE use in the laundry department. Environmental Service staff and a CNA were observed skipping hand sanitation, while the Linen Room Technician processed soiled linens without proper PPE. Additionally, the facility did not monitor washing machine water temperatures, failing to meet the required standards for effective disinfection.
The facility failed to implement an effective IPCP, leading to inappropriate antibiotic prescriptions and inadequate infection control training. The IP could not provide a proper tracking tool for residents on antibiotics, resulting in unnecessary prescriptions for two residents. Additionally, the facility lacked sufficient hand hygiene training, increasing the risk of infection transmission.
The facility failed to ensure that both contracted and facility-employed CNAs received the required in-service training, including dementia management and abuse prevention. Interviews and record reviews revealed a lack of documentation proving that CNAs completed at least 12 hours of continuing education per year. The facility was responsible for ensuring training completion, but could not provide evidence of compliance.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with sepsis and urine retention and another with dementia and pneumonia. Both residents did not receive a copy of their care plans or information about their care goals, leading to confusion about their treatment. The DON and DCO confirmed the oversight, which violated the facility's policy requiring timely care plan development and communication.
A facility experienced a medication error rate of 22.58% due to late administration of medications to four residents. Errors included late administration of morphine, pramipexole, omeprazole, gemfibrozil, gabapentin, a lidocaine patch, cephalexin, and lisinopril. The DON confirmed the errors and emphasized the importance of following physician orders.
The facility failed to follow the prescribed menu for therapeutic diets, affecting residents' nutritional intake. Regular portion diets were under-served, pureed diets received incorrect bread items, and modified diets were given the wrong type of dinner rolls. Additionally, small portion diets lacked accurate measurements, leading to inconsistencies in serving sizes.
The facility failed to provide the correct food texture for residents on a puree diet, serving pureed ziti with cheese that contained chunks, contrary to IDDSI standards. This posed a risk for residents with swallowing difficulties, as confirmed by the Dietary Supervisor and Registered Dietician.
A resident was prescribed lorazepam PRN indefinitely, contrary to the facility's policy limiting PRN psychotropic medication orders to 14 days. The DON and DCO confirmed the order lacked a stop date, posing potential risks of medication interactions, confusion, and falls.
A resident with dysphagia and COPD was found with moldy food in their room, brought by family and not properly stored or labeled. A CNA confirmed the food was moldy, and the DON stated that personal food items should be labeled and stored correctly. The facility's policy requires perishable foods to be stored in resealable containers and discarded if spoiled.
A resident with multiple health issues, including dementia and mobility impairments, was unable to reach their call light, which was tied to the bed, while seated in a chair. Staff confirmed the call light should have been accessible, as per facility policy, to allow the resident to communicate their needs.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and agitation was not protected from physical abuse by her roommate, who had a history of aggressive behavior. The incident involved the roommate placing her hand over the resident's mouth and grabbing and squeezing her wrist while the resident was being cared for by a CNA. The resident complained of pain during the incident, and the roommate's actions were witnessed by staff. Prior to this event, the roommate had a documented pattern of aggressive and disruptive behavior toward both staff and other residents, including taking belongings, becoming combative, and making roommates uncomfortable. Staff interviews confirmed that the roommate had been moved multiple times due to issues with previous roommates, including an incident where she was caught putting a pillow over another resident's head. Despite these ongoing concerns, the roommate continued to be placed with new roommates, resulting in repeated disturbances and discomfort for others. The facility's policies require protection of residents from abuse by anyone, including other residents, and mandate measures to address factors that may lead to abusive situations. However, the facility failed to prevent the abusive incident, as evidenced by the roommate's continued aggressive behavior and the harm experienced by the resident. Interviews with staff and other residents further corroborated the roommate's pattern of aggression and the negative impact on those sharing a room with her.
Failure to Follow Infection Control Protocols During Wound Care and Lack of Training for Contracted Staff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in two key areas. First, two staff members did not adhere to required personal protective equipment (PPE) protocols while performing wound care on a resident who was under enhanced barrier precautions (EBP) due to chronic wounds. Despite clear signage and care plan instructions indicating the need for both gown and gloves during high-risk care activities such as wound care, the staff were observed wearing only gloves. Both the treatment nurse and the wound doctor confirmed during interviews that they did not wear gowns during the procedure, acknowledging this was not in compliance with facility policy and increased the risk of wound contamination. The resident involved had a history of cellulitis and required assistance with personal care. Physician orders and the care plan specifically documented the need for EBP every shift, and the resident was listed as requiring these precautions due to chronic wounds. Facility policies outlined that EBP includes the use of both gown and gloves during high-contact care activities, such as wound care, to prevent the spread of infection. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that staff are expected to follow these protocols to minimize infection risks. Additionally, the facility failed to provide ongoing infection prevention and control training to the facility hairdresser, a contracted employee who regularly interacted with residents. The hairdresser reported not receiving any ongoing infection control training or participating in facility in-service sessions, despite an agreement requiring adherence to infection control policies. The IP confirmed that the hairdresser had never attended infection control in-services, and the DON stated that all staff, including contracted personnel, should follow the infection prevention and control program to prevent the spread of infections among residents.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents. Resident 2 and Resident 36 were prescribed psychotropic medications, sertraline and seroquel respectively, but their care plans did not include any documentation or strategies for the use of these medications. Resident 10, who had an order for a Wander/Elopement Alarm (WEA), also lacked a care plan addressing the use of this device. The Director of Nursing confirmed the absence of these care plans, acknowledging that comprehensive person-centered care plans should be completed within 21 days and include specific physician orders. Additionally, Resident 56, who had a history of disorientation, apraxia, and dementia, was observed with bruises around the right eye and face, and a WEA on the right ankle. Despite the presence of the WEA, there was no comprehensive care plan for its use. The facility's policy on wandering and elopements stated that care plans should include strategies and interventions for residents identified as at risk for wandering or elopement, but this was not implemented for Resident 56. The facility's policy on comprehensive person-centered care plans also emphasized the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in these cases.
Deficiencies in Medication Management and Equipment Labeling
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for several residents. Psychotropic medications were prescribed for two residents without appropriate indications, manifestations, or monitoring of behaviors. Specifically, one resident was prescribed sertraline for depression without an order for monitoring feelings of sadness or loneliness, and another resident was prescribed quetiapine for depression without indications or orders to monitor behaviors. The Director of Nursing acknowledged the need for specific indications and monitoring orders for psychotropic medications, as outlined in the facility's policy. Additionally, the facility did not properly label or date nasal cannulas and humidifiers for three residents, and oxygen was not provided per physician orders. One resident was observed receiving oxygen at a higher rate than prescribed, and the nasal cannula and humidifier were not labeled. Another resident's oxygen cannula was not dated, and the facility's practice of labeling and changing oxygen tubing weekly was not followed. The Director of Nursing and Director of Clinical Operations confirmed the expectation for labeling and changing oxygen tubing. Furthermore, the facility failed to have complete monitoring orders for Wander/Elopement Alarms (WEA) for two residents, and one resident had a WEA applied without a physician's order. The facility's policy required physician consultation and documentation of attempts to exit the building before applying a WEA. The Director of Nursing and Director of Clinical Operations confirmed the need for monitoring orders for WEAs, and the facility was unable to provide a policy for the use of WEAs. The lack of care plans and physician orders for WEAs was also noted for one resident who had a fall and was wearing a WEA without documentation or orders.
Deficiencies in Dietary Services Due to Unqualified Supervisor
Penalty
Summary
The facility failed to ensure that the Dietary Supervisor (DS) met the state's educational qualification requirements, as mandated by federal regulations, to effectively manage the food and nutrition services. The DS, who started the position in September 2023, was not certified as a Dietary Services Supervisor (DSS) or Certified Dietary Manager (CDM) and was still in the process of taking courses to become CDM certified. This lack of qualification led to lapses in the delivery of food and nutrition services, including issues with meal distribution accuracy, modified food texture accuracy, and safe food handling and sanitation. The Registered Dietitian (RD) was contracted to provide consultations and oversee food safety and sanitation, food preparation, meal service, and food storage. However, the RD's involvement was primarily focused on clinical work, with only a small portion of their time dedicated to food service operations. The RD was unaware that the DS was not qualified for the position and did not meet state standards. The RD's contract allowed for a maximum of 20 hours per week, with a significant portion of this time allocated to clinical duties rather than food service oversight. During the survey, several deficiencies were identified, including improper meal distribution, incorrect preparation of puree food textures, and numerous sanitation issues such as improper cooling of cooked chicken, expired bread not being discarded, and unclean kitchen equipment. The DS was responsible for staff in-services but had only conducted one since starting the position. The Regional Operations Director (ROD) was aware of the DS's lack of qualifications and acknowledged the requirements after reviewing state standards.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food storage, preparation, and distribution. During an inspection, it was observed that the cool down process for cooked chicken breasts was not performed, and there was no temperature monitoring before storing them in the refrigerator. The Dietary Supervisor confirmed the absence of a cooling log entry for the chicken, and the cook admitted to not following the cool down procedure, acknowledging it as a mistake. This oversight was corroborated by the Registered Dietitian, who emphasized the importance of the cool down procedure for food safety. Further observations revealed that the facility lacked a system for cooling ambient foods, such as chicken salad, and staff were not practicing temperature monitoring or using cooling logs. The Dietary Supervisor initially stated there was no policy for ambient foods but later confirmed the existence of a process that was not being followed. Additionally, metal serving pans were found stacked wet with brown and white substances on them, and expired bread was not discarded, indicating a lapse in food safety practices. The Registered Dietitian acknowledged the need for staff training and adherence to proper labeling and storage guidelines. The facility also exhibited poor sanitation practices, as evidenced by a dirty microwave, cutting boards with gouges and a rancid odor, and personal beverage containers stored in the food preparation area. Ice machines in the kitchen and nourishment rooms were found with pink and black slimy substances, indicating inadequate cleaning. The Maintenance Supervisor and an outside vendor technician confirmed the presence of these substances, suggesting insufficient scrubbing during cleaning. The Registered Dietitian noted the importance of maintaining cleanliness in the ice machines, as outlined in the facility's policy and FDA Food Code.
Improper Garbage Disposal Due to Deformed Dumpster Lids
Penalty
Summary
The facility failed to maintain a clean environment for residents and visitors due to improper disposal of garbage and refuse. During an observation and interview, it was noted that the only garbage dumpster located outside the facility was not securely closed because the lids were deformed, leaving a two-inch gap. This condition was confirmed by the Dietary Supervisor, who acknowledged the need for either repair or replacement of the dumpster lids. The Director of Clinical Operations later confirmed that the facility lacked a policy regarding dumpster conditions and that the maintenance department had contacted a waste management company to purchase new lids. This deficiency was identified as a potential risk for pest infestation and disease spread, as per the FDA Food Code 2022, which requires outside receptacles to have tight-fitting lids.
Expired CNA License in Facility
Penalty
Summary
The facility failed to ensure that one of its Certified Nursing Assistants (CNA), referred to as CNA 2, had a valid CNA license. This deficiency was identified during a survey involving observation, interview, and record review. The Director of Nursing (DON) confirmed that CNA 2's license had expired, and the Director of Staff Development (DSD) acknowledged awareness of the impending expiration but allowed CNA 2 to continue working without a renewed license. CNA 2 also confirmed that her license had expired and she had not yet received a renewal. The facility's policy requires all nursing staff to meet competency requirements as defined by state law, which includes maintaining a valid license. The California Health and Safety Code mandates that certificate holders receive notice 90 days before their license expiration, but non-receipt of this notice does not exempt them from renewing their license on time. The failure to ensure CNA 2's license was current had the potential to affect the care of all 55 residents in the facility, as they could receive care from an unqualified individual.
Infection Control Deficiencies in Hand Hygiene and Laundry Practices
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene protocols. Environmental Service staff were seen entering and exiting resident rooms without performing hand sanitation, despite being trained in these practices. One staff member admitted to rushing and skipping hand sanitation to save time, while another handled dirty towels without gloves and then touched a resident's clean blanket without sanitizing her hands. A Certified Nursing Assistant also failed to use available alcohol-based hand sanitizers when moving between resident rooms. In the laundry department, the facility did not ensure the use of adequate Personal Protective Equipment (PPE) when processing soiled linens. The Linen Room Technician only used disposable gloves and was not trained to wear a gown or face shield, which are necessary for handling potentially contaminated materials. The Infection Preventionist confirmed the lack of PPE and acknowledged that staff should be wearing gloves, gowns, and face shields when dealing with dirty linens. Additionally, the facility did not monitor the water temperatures of the washing machines, which is crucial for effective disinfection of linens. The Linen Room Technician and Maintenance Supervisor were unaware of the required temperature settings for washing and drying linens. The facility's policy indicated that laundry should be processed in hot water at 160 degrees Fahrenheit for 25 minutes, but the current setup did not meet these standards, as the water heater was set to 131 degrees Fahrenheit and the dryer temperatures were not monitored.
Deficiencies in Antibiotic Monitoring and Infection Control
Penalty
Summary
The facility failed to develop, implement, and monitor an effective Infection Prevention and Control Program (IPCP) concerning the use of antibiotics. The Infection Preventionist (IP) was unable to provide a proper tracking tool for monitoring residents on antibiotics and could not confirm the clinical indications for antibiotic use. During an interview, the IP admitted to using a facility map to track residents with Urinary Tract Infections (UTIs) but could not identify specific residents or confirm laboratory indicators such as urinalysis or culture and sensitivity tests. This lack of proper tracking led to the inappropriate prescription of antibiotics, as evidenced by Resident 35 being prescribed Ciprofloxacin without laboratory confirmation of a UTI, and Resident 29 being on Cephalexin for 48 days without any laboratory examinations to justify its use. The facility also lacked adequate tools for tracking antibiotic use, as confirmed by the Director of Clinical Operations (DCO). The DCO acknowledged that the Electronic Health Records (EHR) system, which was supposed to include tracking tools, was still in development and not yet active. This absence of a functional tracking system contributed to the inability to monitor infections and antibiotic use effectively, further exacerbating the issue of inappropriate antibiotic prescriptions. Additionally, the facility failed to provide adequate infection control in-services for staff, particularly concerning hand hygiene. The IP was unable to produce sufficient attendance records for handwashing in-services, with only six staff members attending the sessions documented. This lack of comprehensive training and monitoring of hand hygiene practices increased the risk of infectious disease transmission among residents and staff, further highlighting the deficiencies in the facility's infection control program.
Deficiency in CNA Training Documentation
Penalty
Summary
The facility failed to ensure that both contracted and facility-employed Certified Nursing Assistants (CNAs) received the required in-service training, including dementia management and abuse prevention, as mandated by regulations. This deficiency was identified through interviews, observations, and record reviews, which revealed that three out of four sampled Contracted Certified Nursing Assistants (CCNAs) and three out of five sampled facility-employed CNAs did not have documentation proving they completed at least 12 hours of continuing education per year. The Director of Clinical Operations and the Staffing Coordinator were unable to provide evidence of completed mandatory training for the CCNAs, and the Director of Staff Development did not have a specific training plan for them, relying instead on staffing agencies to provide the necessary training. Further investigation into the facility's contracts with staffing agencies showed that the facility was responsible for ensuring the completion of mandatory training for contracted staff. However, the facility could not produce documentation to support that the CCNAs and CNAs had completed the required training. The Regional Operations Director confirmed the lack of training records for both contracted and facility-employed CNAs. The facility's policy and procedure on the competency of nursing staff, as well as the Facility Assessment Tool, emphasized the necessity of in-service training to ensure the competence of nurse aides, particularly in dementia management and abuse prevention, but these requirements were not met.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were developed, implemented, and signed by the resident or responsible party within 48 hours of admission for two residents. Resident 260 was admitted with diagnoses including sepsis and urine retention and was observed with a urinary catheter. The resident reported not receiving a copy of the baseline care plan or being informed about their care goals upon admission. Similarly, Resident 261, admitted with dementia and pneumonia, was observed with an oxygen concentrator out of reach and was unsure about its use. This resident also confirmed not receiving a baseline care plan or being informed about their care plan. During a review with the DON and DCO, it was confirmed that the baseline care plans for both residents were not completed within the required 48-hour timeframe. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative, with documentation of the delivery method in the medical record. The failure to adhere to this policy resulted in residents and staff being unaware of the residents' care plans.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 22.58% error rate during a medication administration observation. This deficiency involved four residents who received their medications at incorrect times. Resident 1 was given morphine ER and pramipexole over three hours late. Resident 18 received omeprazole and gemfibrozil after breakfast instead of 30 minutes prior, as prescribed. Resident 28 was administered gabapentin and a lidocaine patch significantly later than scheduled. Resident 29 received cephalexin and lisinopril nearly three hours after the prescribed time. The errors were confirmed during observations and interviews with the licensed nurses responsible for administering the medications. The Director of Nursing acknowledged that the nurses did not adhere to physician orders, emphasizing the importance of timely medication administration, particularly for antibiotics. The facility's policy on medication administration, which requires adherence to physician orders, was not followed, contributing to the high medication error rate.
Menu Non-Compliance in Therapeutic Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for therapeutic diets during a lunch meal, affecting the nutritional intake of residents. Specifically, 44 residents on regular portion size diets received only two scoops (8 oz.) of pasta instead of the prescribed three scoops (12 oz.). This discrepancy was acknowledged by the Dietary Supervisor (DS) during an interview, who confirmed that the residents should have received the full portion as indicated in the facility's Diet Extensions document. Additionally, five residents on pureed texture diets were served pureed garlic bread sticks instead of the prescribed soaked white dinner rolls. The DS acknowledged this error during an interview and confirmed that the Diet Extensions document specified soaked white rolls for these residents. Furthermore, 16 residents on various modified diets, including IDDSI Level 5 Minced and Moist, Heart Healthy/Cardiac, and Renal diets, received wheat dinner rolls instead of the specified white dinner rolls, as confirmed by the DS. The facility also failed to provide accurate portion sizes for residents on small portion diets. The DS admitted that the current menu system did not include specific measurements for small portions, leading to inconsistencies in serving sizes. This issue was further corroborated by the Registered Dietician, who emphasized the need for accurate portion sizes to prevent potential weight loss in residents. The facility's documents, including the Diet Extensions and job descriptions, did not provide clear guidance on portion sizes for small diets, contributing to the deficiency.
Inappropriate Food Texture for Residents on Puree Diet
Penalty
Summary
The facility failed to provide the appropriate food texture for five residents who were on a puree texture diet. These residents received pureed ziti with cheese that contained chunks of pasta and tomato, which is not suitable for individuals with swallowing and/or chewing difficulties. The Dietary Supervisor confirmed that the texture of the pureed pasta was lumpy and not smooth as required, posing a potential risk for choking or aspiration. During an interview, the Registered Dietician expressed disappointment with the puree's texture, noting that the kitchen staff and cook needed more training. The facility's procedure for pureed pasta indicated that the final product should be smooth and lump-free, in accordance with the IDDSI Framework for texture-modified foods. However, the observed puree did not meet these standards, leading to the deficiency.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. Resident 10, who was admitted with diagnoses including dementia without behavioral disturbance or anxiety and recurrent depressive disorders, was prescribed lorazepam on an as-needed (PRN) basis indefinitely. This prescription was not aligned with the facility's policy, which limits PRN orders for psychotropic medications to 14 days unless reviewed for continued use or discontinuation. During a review of Resident 10's Order Summary Report, it was confirmed by the Director of Nursing (DON) and the Director of Clinical Operations (DCO) that the lorazepam order was PRN and lacked a stop date. The facility's policy, dated July 2022, specifies that psychotropic medications should not be prescribed on a PRN basis unless necessary for a diagnosed condition documented in the clinical record, and PRN orders should be limited to 14 days. The failure to adhere to this policy had the potential to cause medication interactions, confusion, and falls for Resident 10.
Failure to Ensure Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure safe food handling and storage for a resident, identified as Resident 2, who was admitted with diagnoses including dysphagia and chronic obstructive pulmonary disease (COPD). During an observation, a transparent plastic container with a red lid was found on Resident 2's bedside table, containing indistinguishable food items with greenish-blue spots and fuzzy growth. Resident 2 was unsure of the contents, stating that their family had brought the food some time ago. A Certified Nursing Assistant (CNA 1) confirmed the presence of moldy food in the container and acknowledged the potential health risk if Resident 2 had consumed it. The Director of Nursing (DON) confirmed that personal food items brought by family should be labeled with the resident's name, date, and time, and stored properly. The facility's policy indicated that perishable foods should be stored in resealable containers in a refrigerator and discarded if they show signs of spoilage, such as mold growth.
Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a call light was accessible for a resident, identified as Resident 11, which had the potential to result in unmet needs and delayed staff response. Resident 11 was admitted to the facility in 2016 with multiple diagnoses, including spastic hemiplegia, contracture, polyarthritis, dementia, and a history of falling. The resident's Minimum Data Set indicated moderate memory problems and dependency on staff for mobility and care related to incontinence. During an observation, Resident 11 was found sitting in a padded chair, slumped to one side, with a strong odor of feces, and unable to reach the call light, which was tied to the bed. Interviews with staff, including a Certified Nurse Assistant and a Licensed Nurse, confirmed that the call light was out of reach and acknowledged that it should have been accessible to Resident 11. The Director of Staff Development and the Director of Nursing both stated that they expected call lights to be within reach of residents to ensure they can communicate their needs. The facility's policy on the call system, dated September 2022, indicated that residents should have a means to call staff for assistance from their bed, toileting, and bathing facilities.
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.
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