Autumn Creek Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Chico, California.
- Location
- 587 Rio Lindo Avenue, Chico, California 95926
- CMS Provider Number
- 056074
- Inspections on file
- 80
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Autumn Creek Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its abuse reporting policy and state law when staff did not report separate allegations of verbal and medication-related abuse involving a resident within the required 2-hour timeframe. A CNA reported that the resident’s responsible party called the resident an addict and threatened to have pain meds discontinued, and the DOR separately observed the responsible party yelling at the resident by phone and heard the resident express fear that her pain meds would be discarded after discharge. The DOR relayed her concerns to the ADMIN, who chose to combine the distinct allegations into a single report and submitted the report late, and both the ADMIN and DOR later acknowledged they did not meet mandated reporter and policy requirements.
Multiple cognitively intact, mobility-impaired residents who required staff assistance for transfers and toileting reported prolonged waits after activating call lights, sometimes 30–60 minutes, leading to incontinent episodes and the need to self-transfer from the bathroom and into bed. One resident stated a CNA entered, turned off the call light, and left without assisting from the toilet, resulting in the resident independently transferring to a wheelchair and then to bed after waiting a long time. Another resident reported being told by agency staff to void in a brief and described nearly daily incontinence due to delayed toileting assistance. Staff interviews and schedules described frequent call-outs, short staffing on specific stations, numerous unanswered call lights, and missed or delayed basic care such as showers, indicating that available CNAs could not consistently respond promptly to residents’ toileting needs.
A resident admitted with diabetes, kidney disease, and depression did not have a baseline care plan for diabetes developed within 48 hours as required by facility policy, and a diabetes care plan was not created until 15 days after admission. The eMAR contained parameters to notify the physician for blood glucose ≥400, and documented blood sugars of 435 and 400, with an alert note showing that a nurse administered ordered medication and contacted the physician after one high reading. The resident reported that blood sugars had been significantly higher since admission and that no one had discussed the elevated levels or management with them. During interview and record review, the DON and ADON acknowledged that diabetes should have been included on the care plan and updated following high blood sugar events.
The facility failed to ensure that NAs were properly trained, certified, and supervised before providing direct resident care. Facility records showed that the site did not have a state-approved NATP, yet multiple uncertified NAs, listed as training aides, were assigned to take vital signs and manage resident assignments, often independently and without required CNA pairing, contrary to the facility’s own job descriptions and "can’t do" list. Review of employment and certification data confirmed that several NAs worked for months while still uncertified, and interviews with CNAs, NAs, and leadership revealed that student and uncertified NAs were routinely used on PM and NOC shifts for direct observation and hands-on care while awaiting certification, despite leadership acknowledging that only another affiliated facility had an approved NATP and that NAs should not be performing direct care before certification.
The governing body failed to ensure that only state‑certified CNAs, or properly supervised NA trainees, provided direct resident care. Facility policies required governing body oversight of administrative policies and specified that NAs in training could not perform direct care tasks such as taking vital signs, feeding, transfers, or changing briefs. Despite this, staffing records and assignment sheets showed multiple uncertified NAs were hired, assigned independent resident care and vital signs duties, and often worked on PM and NOC shifts without consistent CNA pairing. Interviews with the administrator and NAs confirmed that uncertified staff were employed, provided direct observation for fall‑risk residents, took vital signs, and had independent assignments, while leadership acknowledged responsibility for policy oversight and regulatory compliance across the facilities.
A resident with multiple fractures and recent fall did not receive two physician-ordered creams after a nurse failed to transcribe the orders into the EMR, despite the orders being noted following a urology appointment. Facility leadership confirmed the medications were not entered or administered as required.
A resident with a history of stroke and left-sided weakness was forcefully shoved back into a wheelchair by a CNA, as witnessed by another CNA. The incident was reported internally, but the administrator failed to notify authorities within the required two-hour timeframe as specified in the facility's abuse policy.
A resident's representative was not given the resident's personal belongings after the resident's death, as another family member removed the items without proper documentation or updating of the inventory form. Staff could not provide information to the representative about the belongings' removal, resulting in the representative being unable to retrieve them.
A resident with moderate cognitive impairment, mobility issues, and high fall risk experienced four unwitnessed falls in one week after her indwelling catheter was not replaced. The facility did not update the care plan with new interventions, failed to complete required neurological assessments and alert charting, and did not implement a toileting program or increased supervision, despite policy requirements. These failures led to repeated falls, a head injury, and ultimately the resident's death.
A resident with moderate cognitive impairment and unable to make healthcare decisions experienced multiple unwitnessed falls, a dislodged catheter, and a significant change in condition requiring transfer to the ED. Nursing staff failed to notify the responsible party as required, often documenting the resident as her own RP despite clear instructions to contact the daughter. This lack of timely notification prevented the family from being informed and involved in care decisions.
A resident with multiple health issues, including cognitive impairment and mobility difficulties, experienced several unwitnessed falls resulting in a head injury and subsequent death from a subdural hematoma. Despite facility policy requiring timely reporting of such incidents, staff did not notify CDPH of the injury or major accident, as confirmed by the DON, because the resident was transferred to the hospital and did not return.
A resident admitted with an indwelling catheter did not receive an assessment for continued catheter need, and the catheter was discontinued without a physician order. After removal, there was no bladder assessment, bladder training, or care plan update, and required monitoring was not documented. The resident was left to manage toileting without adequate support, resulting in multiple unassisted bathroom trips and several falls.
A staff member was reported to have used profane and disrespectful language toward a resident with moderate cognitive impairment, failing to uphold the facility's standards for dignity and respectful communication. The incident was witnessed by another CNA, and the resident, who has Parkinson's Disease and dementia, recalled hearing swearing but could not identify the staff member involved.
A medication cart was left unlocked and unattended near residents with dementia, containing accessible syringes and a bottle of povidone iodine with a broken cap. Staff interviews confirmed the cart was shared among nursing staff, and the responsible nurse had left early for a family emergency. Facility policy requires carts to be locked when not in use, and staff were aware of previous similar incidents.
A resident with multiple serious medical conditions did not have their Advance Directive (AD) included in their medical record, despite facility policy requiring this upon admission. Staff interviews confirmed that the resident had an AD and the mental capacity to make decisions, but the facility failed to obtain and file the document as required.
A physician documented that a resident was incapable of making healthcare decisions based solely on a diagnosis of cerebral palsy, without adequate assessment or evidence of mental incapacity. Staff interviews and record review indicated the resident was able to communicate wants and needs clearly, and the order was not supported by a comprehensive evaluation.
Nursing staff did not develop or update care plans for two residents with severe cognitive impairment after an altercation in which one attempted to pull the other from bed. Despite facility policy requiring care plan changes following such incidents, both the DON and Social Services Director confirmed that no care plans were created or updated in the medical records.
Two medication carts containing medications, including topical creams, were left unlocked and unattended at a nursing station, making them accessible to residents with dementia and others. A surveyor was able to open the carts without staff intervention, and an LVN later confirmed the carts should have been locked according to facility policy.
A resident with a history of multiple falls and significant mobility and vision impairments did not have bilateral fall mats at the bedside as required by the care plan. Despite the care plan update specifying two mats after previous falls, only one mat was present during observation, and staff confirmed the omission.
A CNA entered the room of a COVID-positive resident wearing only a face shield and gloves, omitting the required N95 respirator and gown as specified by facility and state protocols. Interviews with staff confirmed that full PPE, including gown, gloves, N95, and eye protection, is required for all staff entering the room of a COVID-positive resident until isolation is discontinued.
Three residents, all with significant physical or cognitive impairments and care plans requiring call lights to be within reach, were found unable to access their call lights, which were placed out of reach or on the floor. Staff confirmed the oversight, and a family member reported repeated incidents of a call light being inaccessible, leading the resident to attempt independent movement.
A resident with MRSA in both urine and a wound was not moved to a private room for two weeks, despite available empty rooms, and continued to share a room with two other residents who had open wounds and significant comorbidities. The Infection Preventionist was not informed of room changes, and the Social Service Department made placement decisions without proper communication, resulting in a failure to follow infection control policies and CDC guidelines.
A resident reported a missing ATM card and unauthorized transactions while receiving dialysis. Although the Social Services Director assisted with disputing charges and filing a police report, the incident was not reported to CDPH because the perpetrator was unknown, contrary to facility policy requiring all allegations of misappropriation to be reported.
A resident with chronic pain and multiple health conditions was repeatedly given the wrong dosage of Hydrocodone-Acetaminophen due to staff administering an outdated strength from the medication cart. Nursing staff failed to follow medication administration protocols, resulting in at least nine documented errors over nine days, with inconsistent documentation and lack of required reporting to the DON or responsible party. The resident continued to experience significant pain, and the responsible party was not informed of the errors.
Three residents reported being treated with disrespect by an LPN, who used a demeaning tone and was rough during medication administration. The residents, all cognitively intact and dependent on staff, expressed fear and anxiety due to the LPN's behavior. Staff members corroborated these accounts, describing the LPN as rude and unapproachable. The facility's administrator acknowledged the LPN's poor customer service skills.
A resident experienced a significant decline in health, including shortness of breath and a headache, but the LN failed to notify the physician and the resident's family as required by facility policy. The LN did not document the change in condition or place the resident on alert charting, leading to a negative clinical outcome.
A facility failed to document a resident's change in condition, including new onset of shortness of breath and need for oxygen. The resident, with a history of multiple health issues, was not added to alert charting, and there was no record of physician notification or care plan updates. A nurse admitted to not documenting these changes, and the administrator confirmed the lack of documentation.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and incidents of incontinence among residents. Residents reported waiting 30 to 45 minutes for assistance, with some unable to locate their call lights. Observations showed staff walking past activated call lights without providing help, highlighting insufficient staffing levels.
The facility failed to provide a safe, clean, and homelike environment, with issues such as unlined trash cans, damaged walls and furniture, missing electronics, and non-functional bathroom fans. Staff confirmed these deficiencies, acknowledging the need for repairs and improvements.
The facility failed to store parsley under sanitary conditions, as it was not covered, labeled, or dated in the walk-in refrigerator. Additionally, the walk-in freezer had frost build-up on the ceiling, which was confirmed by both the Dietary Manager and Maintenance Supervisor. These issues were contrary to the facility's policies on food storage and maintenance.
A nurse failed to sanitize a blood pressure cuff between two residents, contrary to the facility's infection control policy. This oversight was acknowledged by the nurse, who stated it was standard practice to clean equipment between residents. Other staff confirmed the importance of this practice for infection control.
Two residents with cognitive impairments were involved in a physical altercation after one reported verbal abuse from the other. Despite facility policies, staff failed to notify administration or separate the residents, leading to the incident. The lack of communication and adherence to procedures contributed to the deficiency.
A resident's medical records regarding skin assessments and treatments were inconsistent, with discrepancies in documentation of a skin tear and bruising. Despite observations by nursing staff, a physician's order was delayed, and a nurse failed to document or report the incident, leading to incomplete records.
A resident in a long-term care facility was verbally abused by an LVN who used inappropriate and threatening language when the resident attempted to assist another resident after a fall. The LVN's behavior was reported by multiple staff members and residents, revealing a pattern of negative interactions with residents. The facility's administration was notified, and the LVN was suspended. The incident violated the facility's abuse prevention policies.
The facility failed to respond timely to residents' requests for assistance, affecting three residents. One resident was left soiled due to a CNA's oversight, another was at risk of falling after being ignored for over 12 minutes, and a third experienced repeated delays in call light responses. These incidents highlight lapses in staff coverage and adherence to facility policies.
A resident in an LTC facility suffered a bruise after a CNA insisted on changing her brief despite her refusal. The resident, who had a history of stroke and was cognitively intact, reported that the CNA pulled on her blankets and remote, causing the injury. Staff interviews indicated the CNA was demanding and did not report the incident as required.
The facility failed to provide sufficient nursing staff, resulting in extended call light wait times for several residents, ranging from 10 to 55 minutes. Residents expressed feelings of neglect and embarrassment, while nursing staff reported being overwhelmed and unable to provide adequate care. Despite a policy indicating staffing adjustments should be made, the current levels were insufficient to meet residents' needs.
A resident with cognitive impairment and multiple health issues was injured by a CNA in a long-term care facility. The CNA, who was from a staffing agency, left the facility without reporting off, and the resident was later found with a significant skin tear on her hand. The injury was discovered by the next shift CNA, and the incident was reported to authorities. The resident described being attacked, and the injury was consistent with being grabbed.
The facility failed to consistently follow physician orders for dialysis dressing management, affecting several residents. A resident with end-stage renal disease experienced clotting of the dialysis access site due to the facility's failure to remove compression dressings within the required timeframe. Similar issues were noted for two other residents, with staff interviews revealing inconsistent practices and a lack of understanding regarding the proper care of dialysis dressings.
The facility failed to provide scheduled showers or baths for two residents who required maximal assistance with ADLs. One resident received only four baths in a month, while another received just one shower. The facility's policy required twice-weekly bathing, but there was no documentation of refusals or updates to responsible parties, indicating non-compliance with the bathing schedule.
An LTC facility administrator directed nursing staff to alter progress notes related to a resident's care, violating regulations and professional standards. The resident, who had chosen CPR in their POLST, experienced an unexpected death. The administrator asked staff to change documentation, including removing timing details and terms like 'asphyxiation,' leading to concerns about the accuracy of medical records.
A resident with a full code status was found unresponsive and without a pulse, but CPR was delayed by 10 minutes due to staff inaction. Despite facility policy requiring immediate CPR, the staff failed to initiate it promptly, leading to a delay in emergency care. Interviews revealed a lack of adherence to CPR protocols, despite recent BLS training emphasizing the importance of immediate action.
A resident in an LTC facility experienced signs of a stroke, including slurred speech and left-sided weakness, but there was a three-day delay in notifying the physician and transferring the resident to the hospital. Despite the facility's policy requiring prompt action for significant changes in condition, staff failed to act in a timely manner, leading to a decline in the resident's health and eventual death.
The facility experienced significant staffing shortages, leading to delayed responses to call lights and missed showers for residents. Observations and interviews revealed that residents waited long periods for assistance, with some receiving only one out of four scheduled showers. Staff reported feeling overwhelmed and unsupported, with management acknowledging the challenges but struggling to maintain adequate staffing levels.
A resident in an LTC facility experienced a delay in medical intervention for a stroke due to staff's failure to promptly identify and report a change in condition. Despite showing symptoms like slurred speech and left-sided weakness, the resident was not transferred to the hospital until three days later, resulting in increased pain and functional decline. Interviews revealed staff's misunderstanding of comfort care policies and the importance of timely intervention.
A resident with intact cognition was upset by inappropriate comments made by a CNA, who told the resident to "stop being a smartass" and later called the resident a "dumbass." The incident, witnessed by another CNA, led to the resident crying and recalling past abuse. The facility's administrator acknowledged the inappropriate language, which affected the resident's dignity.
A resident with a history of falls and mobility issues was discharged from an LTC facility without adequate preparation or family training, leading to her return within 24 hours. The interdisciplinary team failed to ensure a safe discharge plan, and the resident's family was not instructed on how to assist her at home. The discharge was deemed unsafe, and the facility did not discuss the risks or consider an AMA discharge.
The facility failed to maintain essential equipment, including the AC system and lighting, leading to uncomfortable temperatures and inadequate lighting in resident rooms. A resident reported feeling hot due to a non-functional PTAC fan, and two residents were at risk for falls due to non-working lights. Maintenance staff acknowledged the issues, with ongoing repairs not yet completed.
A resident with a history of severe obesity and difficulty walking fell and sustained fractures to her right knee after a CNA and NA failed to use a Hoyer lift for a transfer, as specified in her care plan. The resident experienced severe pain and a delay in physical therapy treatments.
A resident with a history of fractures and obesity fell and sustained knee fractures when a CNA and NA failed to follow the care plan requiring a mechanical lift for transfers. The staff attempted to manually lift the resident, resulting in the fall. Interviews revealed that CNAs lacked access to care plans and relied on verbal communication for transfer status information.
Failure to Timely and Separately Report Allegations of Verbal and Medication-Related Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the State Survey Agency within 2 hours as required by state law and the facility’s Abuse Prevention and Management policy. The policy required the Administrator or designee to notify law enforcement immediately or within 2 hours of an initial report and to send a written report to the Ombudsman, law enforcement, and CDPH within 2 hours. On 2/25/26 at approximately 3:45 p.m., a CNA reported that the resident’s responsible party told the resident she was an addict and that she would contact the physician to have the resident’s pain medication discontinued. This allegation was reported to CDPH at 7:19 p.m., more than three and a half hours after the incident, exceeding the 2-hour reporting requirement. In addition, the Director of Rehabilitation documented that an allegation of abuse was reported to her on 2/25/26 at 4:30 p.m. after she witnessed the responsible party yelling at the resident on the telephone. The resident told the DOR she was concerned that, upon discharge home with the responsible party, her pain medications would be thrown away and stated that the responsible party had mental health issues. The DOR reported her concerns to the Administrator and was instructed to write a statement to be submitted with a similar allegation of abuse. The Administrator stated she planned to combine two distinct allegations involving the same resident into a single report instead of reporting each allegation independently. Both the Administrator and the DOR acknowledged that each allegation must be reported separately and that, as mandated reporters, they did not follow the facility’s abuse reporting policy.
Delayed Response to Call Lights and Toileting Needs Due to Insufficient Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ toileting needs, resulting in prolonged waits after call lights were activated. The CNA job description required CNAs to keep incontinent residents as clean and dry as possible, answer call lights promptly, and assist residents to and from the bathroom promptly. Resident 1, admitted with orthopedic aftercare following surgical amputation, difficulty in walking, and need for assistance with personal care, had a BIMS score of 14 and required partial/moderate assistance with transfers. Resident 1 reported that one evening after dinner and medications, a male staff member took him to the restroom; after he finished and pressed the call light, a female CNA entered, turned off the call light without assisting him out of the bathroom, and left. Resident 1 stated he then transferred himself to his wheelchair, waited approximately 45 minutes for staff to assist him back to bed, and ultimately self-transferred into bed after no one came. Resident 2, admitted with spinal stenosis, difficulty in walking, and need for assistance with personal care, had a BIMS score of 13 and used a wheelchair, requiring partial/moderate assistance for toileting. Her bowel and bladder care plan identified risk for urinary tract infection related to insufficient fluid intake and urine retention secondary to avoidance of voiding in a brief, and directed staff to offer privacy, dignity, and prompt assistance when toileting. Resident 2 stated that staffing levels varied by day and staff, that there were not enough staff to meet her needs, and that the facility was often short staffed on day shift. She reported having to wait 30 minutes to an hour for assistance to use the restroom, leading to incontinent episodes that she felt interfered with her efforts to control bowel and bladder. She stated an agency staff member once told her to void in her brief, another CNA told her to “have fun” when she tried to go to the bathroom on her own, and that she almost daily had incontinent episodes due to waiting for toileting assistance, including an episode where she fell asleep in the bathroom while waiting about 30 minutes for help. Resident 3, admitted with spinal surgery and arthritis and having a BIMS score of 15, used a wheelchair and was dependent on staff for all transfers. Resident 3 reported needing assistance to transfer from bed to wheelchair and that it took a while for staff to answer call lights, stating it seemed the facility was short staffed. She reported having incontinence episodes due to delayed staff response to call lights, stating that by the time staff arrived she had already voided before they could provide a bedpan. Facility records showed that on a specific date, two employees called out on the station where these residents resided, and a CNA was temporarily reassigned there and encountered numerous active call lights. Staff interviews described frequent short staffing, call-outs, and delayed responses to call lights, including an account that a CNA turned off a resident’s call light while the resident remained in the bathroom and that the resident waited a long time and had to get into a wheelchair and into bed independently. These events collectively demonstrate that residents requiring assistance with toileting experienced prolonged waits and unmet care needs due to insufficient and ineffective staffing coverage.
Failure to Develop Timely Baseline Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement an initial person-centered baseline care plan addressing diabetes within 48 hours of admission for one resident. Facility policy titled "Person-Centered Care Planning" required that a baseline care plan, including minimum healthcare information necessary to properly care for each resident and addressing resident-specific health and safety concerns, be developed and implemented within 48 hours of admission. Record review showed that the resident was admitted with diagnoses including diabetes, kidney disease, and depression, yet the initial care plan report created on 2/6/26 did not include a baseline care plan for diabetes care. A diabetes care plan was not created until 2/20/26, which was 15 days after admission. Further record review of the resident’s eMAR showed that on 2/5/26 there was an order to notify the physician if the resident’s blood sugar level was 400 or greater. The eMAR documented blood sugar levels of 435 on 2/11/26 at 5:30 p.m. and 400 on 2/16/26 at 5:30 p.m. An alert note dated 2/11/26 at 8:22 p.m. documented that a licensed nurse administered medication as ordered and contacted the doctor for further orders after the 435 blood sugar reading. During an interview, the resident reported that prior to admission their blood sugar ranged from 55–200, but since being at the facility it had been between 300–500, and stated that no one had discussed the high blood sugars or what was being done to manage them. In a concurrent interview and record review, the DON and ADON confirmed that diabetes should have been included on the resident’s care plan and that the care plan should have been updated when the resident experienced high blood sugars that required physician notification.
Uncertified Nurse Aides Providing Independent Resident Care Without Approved Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurse aides (NAs) who had worked more than four months were trained and competent, and that NAs who had worked less than four months were properly enrolled in an approved training program before providing direct resident care. Facility 1 did not have a California Department of Public Health (CDPH)-approved Nursing Assistant Training Program (NATP), yet employed multiple uncertified NAs identified as "INS-Staff Training Aides." The facility’s own NA job description required enrollment in a CDPH-approved NATP and clinical competency, and an internal "Can and Can't Do" list stated that NAs could not perform any direct resident care, including observation, vital signs, changing briefs, feeding, or transfers. Despite these written expectations, surveyors’ review of staffing records and schedules showed that uncertified NAs were assigned to resident care tasks and vital signs, often independently and without required pairing or supervision by a CNA. Record review of the CNA/NA list and the California CNA registry showed that several NAs were hired, graduated from NATP at another facility, and either remained uncertified or were not yet certified during the time they were assigned resident care duties. For example, NAs were documented as taking vital signs independently on various shifts and being given resident assignments, sometimes after only brief orientation or partial shadowing with a CNA. Some NAs, such as NA 3, were assigned independent resident assignments on night shift before certification, and others, such as NA 5 and NA 6, were repeatedly assigned to take vital signs independently without being paired with a CNA. Interviews with CNAs confirmed that student NAs from the NATP were often hired and then assigned to units working independently rather than strictly shadowing, and that there were many new staff working under these conditions. Interviews with facility leadership and NAs further substantiated that uncertified NAs were providing direct resident care and observation. The Director of Staff Development acknowledged that only Facility 2 had an approved NATP and that NAs for Facility 1 were selected jointly by Facilities 1, 2, and 3, then oriented and paired with CNAs for competencies, but the assignment sheets showed that this pairing did not consistently occur. The Administrator admitted that uncertified NAs had been working on PM and NOC shifts and stated they were unaware that uncertified NAs and NA students were not allowed to be employed or have clinical training at Facility 1. Uncertified NAs themselves reported providing direct observation for fall-risk residents, having independent assignments, and occasionally performing hands-on care when residents were in need, despite still waiting for state certification numbers. The Governing Body representatives confirmed that only Facility 2 was approved for NATP, that Facility 1 and 3 were not approved due to regulatory history, and agreed that NAs should not be feeding and changing residents, while acknowledging their responsibility for oversight of policies and hiring practices across the three facilities.
Governing Body Failed to Prevent Uncertified NAs From Providing Independent Resident Care
Penalty
Summary
The deficiency involves the governing body’s failure to provide adequate oversight of facility administration to ensure that nurse aides were properly certified and competent before providing independent resident care. The facility’s operations manual stated that the governing body engages administrative services to develop policies and procedures for management and operations, and that the governing body reviews and confirms adoption of new and updated policies at least annually. The governing body was also to be informed of any deviations from template policies. Despite this framework, a current CNA/NA employee list showed nine uncertified nursing assistants, and the facility’s own NA job description required that NAs be enrolled in a CDPH‑approved Nursing Assistant Training Program and have clinical competency while enrolled. Additional facility documents showed that NAs were not to provide any direct resident care, including observation, vital signs, changing briefs, feeding, transfers, or any direct care at all. However, review of nursing staff assignment sheets over multiple dates showed uncertified NAs were assigned to take vital signs and given resident assignments, sometimes independently and sometimes with CNAs, contrary to the stated restrictions. Specific review of the CNA/NA list against the California CNA registry revealed multiple NAs who were hired, had completed NATP, but were not yet state certified, and were nonetheless assigned to resident care tasks and vital signs, often not paired with a CNA. Some NAs, such as NA 3, were assigned independent resident assignments on night shift before certification, and others, such as NA 5, NA 6, and NA 9, were repeatedly assigned to take vital signs independently on various shifts while still uncertified. Interviews further confirmed that uncertified NAs and NA students were working on PM and NOC shifts and providing direct resident care. The administrator acknowledged that uncertified NAs were and had been working at the facility and stated they were not aware that uncertified NAs and NA students were not allowed to be employed or have clinical training at the facility, noting that the NATP and clinical routines had been established under previous leadership. Uncertified NAs themselves reported providing direct observation for fall‑risk residents, having independent assignments, and sometimes shadowing CNAs only when the CNA chose to demonstrate care tasks. In a later interview, members of the governing body, including the vice president of operations, regional administrator, and chief clinical officer, stated that only one sister facility had an approved NATP, that the governing body assisted administrators and DONs in creating policies and procedures, and that the administrators and governing body were ultimately responsible for ensuring the NATP program and NA hiring followed federal and state regulations, underscoring the lack of effective oversight that led to uncertified NAs providing resident care.
Failure to Transcribe and Administer Physician-Ordered Medications
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to transcribe physician-ordered medications into the electronic medical record (EMR) for a resident who had recently been admitted with multiple fractures and a recent fall. The resident, who was cognitively intact and able to make their own decisions, attended a urology appointment where the physician prescribed two creams: Clotrimazole cream for skin irritation and Esterace cream for vaginal symptoms. The facility's process involved sending residents to appointments with a blank physician's order form, which the physician completed and the nurse was responsible for reviewing and transcribing into the EMR. Despite the physician's orders being noted and acknowledged by the RN, the two medications were not entered into the EMR, and as a result, the resident did not receive the prescribed treatments during their stay. This failure was confirmed through interviews and record reviews with facility leadership, who verified that the orders were not transcribed and the medications were not provided as directed by the physician.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe as outlined in its own abuse prevention and management policy. According to the facility's policy, all allegations of abuse must be reported to law enforcement and regulatory agencies immediately or within two hours of the initial report. In this incident, a Certified Nursing Assistant (CNA) was observed by another CNA forcefully grabbing a resident's shirt and shoulders and shoving him back into his wheelchair to prevent a fall. Another CNA then made a comment to the resident about why he is not assisted to get up. The incident was reported internally to a Licensed Nurse, but the facility administrator did not notify the California Department of Public Health (CDPH) until the following day, well beyond the required two-hour window. The resident involved had a history of stroke with left-sided weakness and required assistance with care but was able to make his own healthcare decisions. The delay in reporting the abuse allegation was confirmed during an interview with the administrator, who initially believed the reporting timeframe was within 24 hours if there were no injuries. Upon review of the facility's policy, the administrator acknowledged that the correct timeframe was immediately or within two hours, and confirmed that the facility did not adhere to this requirement for the reported incident.
Failure to Return Resident's Personal Belongings to Designated Representative
Penalty
Summary
The facility failed to ensure that a resident's representative was given the opportunity to retrieve the resident's personal belongings following the resident's death. According to facility policy, personal property is to be safeguarded and returned to the resident or their representative upon discharge or death, with documentation of the transfer. In this case, the resident's representative was listed as the emergency contact and next of kin, and the resident's belongings were inventoried upon admission. However, there was no documentation showing that the belongings were returned to the representative after the resident's death. Instead, a family member who was not the designated representative removed the resident's belongings from the facility, as observed by an LVN. The inventory form was not updated to reflect this removal, and staff could not provide documentation or information to the representative regarding which belongings were taken or by whom. The administrator confirmed that the inventory form only documented the intake of belongings and not their release, resulting in the representative being unable to retrieve the resident's personal property.
Failure to Provide Adequate Supervision and Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who experienced four unwitnessed falls within seven days, three of which occurred after her indwelling catheter was not replaced. Despite the facility's fall management policy requiring increased observation and structured routines for residents with multiple falls, the care plan was not updated with new interventions. Nurses did not complete required neurological assessments or alert charting for 72 hours after each unwitnessed fall, and there was no individualized toileting program or bladder assessment after the catheter was removed. These omissions occurred even though the resident had a history of moderate cognitive impairment, muscle weakness, difficulty walking, and was on medications that increased her risk for falls and bleeding. The resident's medical records indicated she required moderate assistance with transfers, toileting, and walking, and had been recommended for 24-hour supervision by therapy staff. After the catheter was not replaced, the resident attempted to toilet herself frequently, leading to repeated falls. Staff interviews revealed that the resident did not use her call light, often shut her door, and needed frequent checks, but there were no special instructions or documented safety checks. Staff also reported insufficient training on updating care plans and a lack of consistent interventions such as one-on-one supervision or increased monitoring, despite recognizing the resident's high fall risk. Following the series of falls, the resident developed a head injury that progressed to a brain bleed, ultimately resulting in hospitalization and death. Documentation reviews confirmed that required post-fall assessments, neurological checks, and care plan updates were not completed as per facility policy. The Director of Nursing and other staff acknowledged these failures, including the lack of a bladder training program and the absence of new interventions after each fall, which were required by the facility's own policies and procedures.
Failure to Notify Responsible Party of Resident Falls and Change in Condition
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's falls, change in condition, and transfer to the emergency department, as required by facility policy. The resident, who was moderately cognitively impaired and unable to make healthcare decisions, experienced four unwitnessed falls, a dislodged indwelling catheter that was not replaced, and a significant change in condition due to a possible head injury. Despite documentation indicating that the resident's daughter was to be notified of any changes, there was no evidence that the RP was informed of these incidents in a timely manner. Record review showed that nursing staff repeatedly documented the resident as her own RP, even after social services noted that the daughter should be contacted for healthcare decisions. Progress notes for each fall and the catheter incident either incorrectly listed the resident as her own RP or lacked documentation of RP notification. When the resident was transferred to the emergency department for further evaluation after a change in condition, the daughter was not contacted until several hours after the transfer, and only a voicemail was left. Interviews with staff confirmed confusion regarding who was the appropriate RP, and the DON acknowledged that the daughter had requested to be notified of any changes but was not. The lack of timely and accurate notification to the RP prevented the family from being aware of the resident's condition changes and participating in care decisions, as required by facility policy.
Failure to Report Injury of Unknown Origin and Major Accident to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin and a major accident involving a resident to the California Department of Health (CDPH) as required by their own policy and state regulations. The resident, who had multiple diagnoses including cognitive impairment, muscle weakness, and difficulty walking, experienced several unwitnessed falls over a period of days. Documentation shows that the resident suffered a head injury resulting in a bruise and bump on the forehead, and subsequently exhibited a change in condition, including altered mental status and abnormal vital signs. Despite these events, which included a significant change in the resident's condition and eventual transfer to the hospital, the facility did not notify CDPH within the required timeframe. The resident was found to have extensive intracranial bleeding on hospital evaluation and later died as a result of a subdural hematoma caused by the unwitnessed fall. The facility's policy required reporting of major accidents and other occurrences affecting resident welfare to the appropriate authorities within 24 hours, but this was not followed in this case. Interviews with facility staff, including the DON, confirmed that the incident was not reported to CDPH because the resident was sent to the hospital and did not return to the facility. The lack of timely reporting delayed the involvement of required agencies in investigating the injury of unknown origin and determining whether abuse or neglect may have been a factor.
Failure to Assess, Document, and Plan Care After Catheter Removal
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who was admitted with an indwelling urinary catheter. Upon admission, the resident had multiple diagnoses including urinary tract infection, overactive bladder, urinary retention, and required assistance with mobility and personal care. The resident's indwelling catheter fell out shortly after admission and was not replaced, but there was no documented assessment to determine the continued need for the catheter, nor was there a physician order to discontinue its use. Following the removal of the catheter, the facility did not conduct an assessment of the resident's bladder status or initiate a bladder training program as required by facility policy. There was also no documentation of alert charting to monitor for signs or symptoms of urinary retention or other complications after the catheter was removed. The resident's care plan was not updated to include interventions or an individualized bowel and bladder training program to address her needs after the catheter was discontinued. Interviews with nursing staff and the DON confirmed that there was no assessment for the need of the catheter, no physician notification or order for discontinuation, and no care planning or bladder training implemented after the catheter was removed. As a result, the resident was left to manage toileting without appropriate support, leading to multiple unassisted bathroom trips and several falls.
Staff Use of Profane Language Toward Resident
Penalty
Summary
A staff member reportedly spoke to a resident using profane language and a disrespectful tone, which did not meet the facility's requirements for maintaining resident dignity and a home-like environment. The resident involved had a history of Parkinson's Disease, cognitive communication deficit, depression, and dementia, with a BIMS score indicating moderate cognitive impairment. The facility's policy prohibits demeaning practices and requires staff to promote dignity and communicate respectfully with residents. The incident was reported when a CNA overheard another CNA telling the resident to "shut the [expletive] up" and to stop screaming, as it was disturbing others. The resident recalled hearing swearing by a staff member but could not identify who or what was said due to confusion. The accused CNA denied recollection of the event, while another CNA confirmed overhearing the profane language directed at the resident. The administrator acknowledged receiving the report and noted that several staff members overheard the incident.
Unattended Unlocked Medication Cart with Accessible Syringes and Iodine
Penalty
Summary
A medication cart on nursing station 4 was found unlocked and unattended, with drawers open and accessible to residents, including those with dementia who were present in the adjacent hallway. The cart contained six 1-ml hypodermic syringes and a 12-ounce bottle of povidone iodine with a broken cap and visible residue. No staff intervened as the cart was inspected, and the closest nurse was unaware of the responsible nurse's whereabouts. The facility's policy requires all medication carts to be locked when unattended. Interviews with staff revealed that the nurse responsible for the cart had left early for a family emergency, and the cart was shared among various nursing staff for wound treatments. Staff acknowledged awareness of the policy and previous incidents of the cart being left unlocked, particularly when the regular treatment nurse was on vacation. The facility had previously been cited for a similar issue with the same cart and location.
Failure to Implement Advance Directive Policy for Resident
Penalty
Summary
The facility failed to implement its policy regarding Advance Directives (AD) for one resident. Upon admission, the facility's policy required staff to obtain a copy of the resident's AD and include it in the medical record, or provide information about ADs if the resident did not have one. Record review showed that the resident was admitted with multiple diagnoses, including cerebral palsy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. Although the resident had signed a Physician Orders for Life-Sustaining Treatment (POLST) form and stated he had an AD, there was no AD or Power of Attorney (POA) document found in his facility records. Interviews with facility staff, including Medical Records, Social Services, and the Director of Nursing, confirmed that the facility did not follow up with the acute care hospital to obtain a copy of the resident's AD, despite documentation indicating the resident had one at the time of admission. Staff acknowledged that the resident had the mental capacity to make his wishes known and that the AD should have been present in the chart, but it was not. The facility did not adhere to its own policy for securing and maintaining advance directive documentation for this resident.
Inappropriate Physician Order for Healthcare Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that a physician's order regarding a resident's capacity to make healthcare decisions was appropriate and based on a thorough evaluation. The physician documented that the resident was incapable of making healthcare decisions, citing cerebral palsy as the reason, without further explanation or evidence of mental incapacity. Record review showed the resident had a diagnosis of cerebral palsy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment, but staff interviews revealed that the resident was able to make his wants and needs known and had clear speech. Multiple staff members, including Social Services, Medical Records, and the Director of Nursing, confirmed that the resident appeared alert, oriented, and capable of communicating effectively. The physician later acknowledged that cerebral palsy is primarily a physical condition and, in this case, should not have been used as the sole basis for determining mental incapacity. The physician's order was not supported by a comprehensive assessment of the resident's decision-making capacity, leading to an inappropriate assignment of a healthcare decision maker.
Failure to Update Care Plans After Resident-to-Resident Altercation
Penalty
Summary
Nursing staff failed to develop or update care plans for two residents following a resident-to-resident altercation. Both residents had significant cognitive impairments, as indicated by their low BIMS scores, and complex medical histories including stroke, morbid obesity, anxiety, chronic pain, alcohol abuse, leg fracture, and muscle weakness. The altercation involved one resident attempting to pull another from her bed, but no injury was sustained. Despite this incident, a review of the medical records showed that no care plans were written or updated for either resident after the event. Facility policy requires prompt action to prevent and address resident-to-resident altercations, including reviewing the incident with nursing leadership and making necessary changes to care plans. However, interviews with the Director of Nursing and Social Services Director confirmed that care plans addressing the altercation were missing from the records. Both staff members acknowledged that care plans should have been created or updated for the involved residents, but this was not done.
Unattended Unlocked Medication Carts with Accessible Medications
Penalty
Summary
Two medication carts were found unlocked and unattended at Nursing Station Three, with medications, including topical creams, accessible to individuals in the area. The surveyor was able to open the carts without being questioned or observed by staff, despite the presence of residents with dementia nearby. A Licensed Vocational Nurse later confirmed responsibility for the cart and acknowledged it should have been locked. Facility policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with carts locked when not attended.
Failure to Follow Fall Prevention Care Plan for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a significant fall history. The resident, who had been admitted after cranial surgery for a brain tumor and had visual loss in one eye, required substantial assistance with mobility and was at high risk for falls. The care plan, updated after a fall, specified the use of bilateral fall mats at the bedside. Despite this, only one fall mat was present during observation, and staff interviews confirmed that the care plan required two mats. The resident herself noted the absence of the second mat and recalled that it had previously been removed. The facility's fall management policy required post-fall evaluations and care plan updates, as well as adherence to interventions listed in the care plan. Multiple falls had occurred for this resident after the care plan was updated to include bilateral fall mats, yet the intervention was not consistently implemented. Staff, including the resident's nurse and the DON, acknowledged the care plan's requirements were not met at the time of observation.
Failure to Follow PPE Protocols for COVID-Positive Resident
Penalty
Summary
A Certified Nurses Assistant (CNA) entered the room of a resident who was confirmed to be COVID positive without wearing the required personal protective equipment (PPE). The CNA was observed wearing only a face shield and gloves, but was not wearing a mask or a gown, as mandated by both facility policy and state guidance. The facility's infection prevention protocol, as well as the California Department of Public Health's guidance, specifically require staff to wear an N95 respirator, gown, gloves, and eye protection when entering the room of a COVID positive resident. During interviews, the CNA stated that full PPE was only necessary if physically touching the COVID positive resident, which contradicted the established protocols. Other staff members, including another CNA, an LVN, and the Unit Manager, all confirmed that the correct protocol is to wear complete PPE, including a gown, gloves, N95 respirator, and eye protection, until the resident is no longer in isolation. The failure to follow these protocols was identified through observation, interviews, and record review.
Call Lights Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were available for use and within reach for three of five residents sampled. According to facility policy, call alert devices are to be placed within the resident's reach and staff are to answer call alerts promptly. For one resident with heart failure, dysphagia, and major depressive disorder, and another with parkinsonism, chronic pain, and anxiety, both were found lying in bed unable to locate or reach their call lights, which were observed on a nightstand behind and to the side of their beds. Both residents were dependent on staff for toileting, dressing, personal hygiene, and transfers, and their care plans specifically required that call lights be within reach. A CNA confirmed that the call lights were not accessible and admitted forgetting to return them to the residents' reach. A third resident, who had COPD, required assistance with personal care, had difficulty walking, and a history of falls, was also affected. This resident's care plan required the call light to be within reach and for staff to encourage its use. The resident's family member reported multiple instances of finding the call light on the floor, and noted that the resident would attempt to get up independently, resulting in frequent falls. The administrator confirmed that call lights should always be within reach and that it was not facility practice for them to be out of reach.
Failure to Implement Infection Control Program for Residents with MDROs
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as required, specifically in the management of residents with multidrug-resistant organisms (MDROs). A resident tested positive for MRSA in both urine and a wound but continued to reside in a shared room with two other residents for approximately two weeks after the positive result. Facility policy and CDC guidelines require that residents with MDROs be placed in private rooms or cohorted with others with the same organism, especially when they have conditions that may facilitate transmission. Despite the availability of multiple empty rooms during this period, the resident was not moved to a private room until much later. The two other residents sharing the room had significant comorbidities and open wounds, making them particularly vulnerable to infection. One of these residents was later diagnosed with cellulitis and prescribed antibiotics, though no wound culture was performed to determine if MRSA was present. The decision to move residents between rooms was made by the Social Service Department without adequate communication with the Infection Preventionist (IP), who was not aware of the room changes or the availability of private rooms at the time. The IP acknowledged that, in retrospect, the resident with MRSA should have been placed in a private room immediately upon receiving the positive result. Interviews with facility staff, including the Nursing Unit Manager and Director of Nursing, confirmed that there was a lack of communication and coordination between departments regarding infection control measures and resident placement. The facility's own policies, as well as CDC guidelines, were not followed in this instance, resulting in the potential for the spread of infection among vulnerable residents. The deficiency was directly related to failures in communication, policy implementation, and timely action by the infection control team.
Failure to Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the California Department of Public Health (CDPH) as required by its own policy and state regulations. A resident, who was cognitively intact and responsible for his own healthcare decisions, reported his ATM card missing to the Social Services Director (SSD) after discovering unauthorized transactions while he was at a dialysis center. The SSD assisted the resident by contacting the bank, disputing charges, and filing a police report, but did not notify CDPH of the suspected misappropriation. Interviews with both the SSD and the Administrator confirmed that the incident was not reported to CDPH because the identity of the person who took the card was unknown. The facility's policy required reporting all allegations of abuse and misappropriation, regardless of whether the perpetrator was identified. The omission resulted in the potential for financial abuse to go unrecognized and unresolved within the facility.
Failure to Accurately Administer and Document Narcotic Pain Medication
Penalty
Summary
Nursing staff failed to accurately administer and document narcotic pain medications for a resident with chronic pain and multiple comorbidities, including chronic ulcers, heart failure, respiratory failure, and end-stage renal disease. The resident was prescribed Hydrocodone-Acetaminophen 10-325 mg to be given every six hours as needed for moderate to severe pain. However, review of the Individual Narcotic Record (INR) and Medication Administration Record (MAR) revealed inconsistencies, including documentation errors, missing signatures, and lack of clarity regarding medication administration. On multiple occasions, the INR showed that a tablet was removed and marked as an error without proper explanation or required signatures, while the MAR indicated the medication was given. Further investigation revealed that the resident was administered the incorrect dosage of Hydrocodone-Acetaminophen (5-325 mg instead of the prescribed 10-325 mg) on at least nine occasions over a nine-day period. The error occurred due to the presence of both old and new medication packs in the medication cart, and nursing staff failed to verify the correct strength before administration. The facility's policies required adherence to the seven rights of medication administration and proper documentation and reporting of medication errors, but these procedures were not followed in this case. Additionally, there was no evidence that medication errors were reported to the Director of Nursing, the attending physician, or the resident's responsible party as required by facility policy. The resident's responsible party was unaware of the medication errors and reported that the resident continued to experience significant pain. The lack of proper documentation, communication, and adherence to medication administration protocols resulted in multiple medication errors and inadequate pain management for the resident.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect by Licensed Nurse (LN) D. The nurse was reported to have spoken to residents in a demeaning tone, rushed through medication administration, and was not gentle during the process. This behavior was observed and reported by both residents and staff members, indicating a pattern of disrespectful and rough treatment. Resident 9, who was cognitively intact and dependent on staff for all activities of daily living, expressed fear and distrust towards LN D, citing her roughness and disrespectful attitude. Similarly, Resident 8, also cognitively intact and dependent on staff, reported increased anxiety due to LN D's behavior and expressed fear of reporting her. Resident 6, with a similar dependency and cognitive status, described LN D as rude and disinterested in her job, which affected the resident's perception of care. Interviews with staff members, including Certified Nursing Assistants and other Licensed Nurses, corroborated the residents' accounts. They described LN D as rude, paranoid, and unapproachable, with a tendency to yell at both staff and residents. The facility's administrator acknowledged LN D's poor customer service skills but was unaware of her behavior towards residents. Previous corrective actions had been taken against LN D for violations related to safety and pain management, indicating ongoing issues with her conduct.
Failure to Notify Physician and Family of Resident's Change in Condition
Penalty
Summary
The facility failed to update a change of condition for a resident, identified as Resident 1, when the Licensed Nurse (LN) did not notify the physician about the resident's need for oxygen due to a new onset of shortness of breath. Additionally, the LN did not inform the resident's family or responsible party about a major decline in the resident's health status. This oversight resulted in a negative clinical outcome for the resident. The facility's policy on Change of Condition Notification requires that a Licensed Nurse notify the resident's attending physician and legal representative or an appropriate family member when there is a significant change in the resident's physical, mental, or psychosocial status. Despite this policy, the LN failed to call the attending physician immediately when Resident 1 experienced unexpected shortness of breath, which is considered an emergency situation according to the policy. Furthermore, the LN did not document any notes about the resident's change in condition or place the resident on alert charting. Interviews with facility staff revealed that the LN did not take appropriate action when informed of the resident's symptoms, such as a headache and difficulty breathing. The LN admitted to not informing the responsible party and only texting the physician instead of calling. The facility administrator confirmed that the LN did not follow the required procedures, including failing to document the change of condition and not updating the responsible party.
Failure to Document Change in Resident's Condition
Penalty
Summary
The facility failed to ensure timely, accurate, and complete documentation for a resident when there was a change in condition. The facility's policy required that a licensed nurse document the date, time, and pertinent details of any incident and subsequent assessment in the nursing notes, including the time the attending physician was contacted and any orders received. Additionally, the policy required updating the care plan to reflect the resident's current status and documenting the incident in the 24-hour report. However, during a record review, it was found that there were no progress notes for nursing documentation indicating the resident's new onset of shortness of breath, the need for oxygen, notification to the physician, or an update to the responsible party. The resident was also not added to alert charting for communication for all staff per facility policy. The resident involved had a medical history that included diabetes, cerebral vascular accident, congestive heart failure, severe protein malnutrition, dysphagia, altered mental status, heart disease, high blood pressure, seizures, chronic pain, and tobacco use. Despite being cognitively intact with a BIMS score of 13 out of 15, the resident was totally dependent on staff for all activities of daily living. During interviews, a licensed nurse admitted to not documenting any changes for the resident, not making entries in the nurses' notes, not documenting communication with the physician, and not adding the resident to alert charting. The facility administrator confirmed the lack of documentation and noted the absence of notes for administering oxygen to the resident.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient and qualified nursing staff to meet the needs of residents, resulting in prolonged response times to call lights. This deficiency was observed in multiple instances where residents were left waiting for assistance, leading to incidents of bowel and bladder incontinence. Residents reported that call lights were often left unanswered for extended periods, sometimes taking 30 to 45 minutes or more, causing them to soil themselves and experience humiliation. Several residents, including those with moderate to severe cognitive impairments, were unable to locate their call lights or had them placed out of reach. In some cases, residents had to rely on roommates to call for help or physically go to the nurse's station to request assistance. Observations revealed that staff members walked past rooms with activated call lights without providing assistance, further highlighting the inadequacy of staffing levels and response times. Interviews with residents and the Director of Nursing confirmed the ongoing issue of delayed responses to call lights. The facility's policy and job descriptions for CNAs and LVNs emphasize the importance of promptly answering call lights and ensuring they are within residents' reach. However, the facility's failure to adhere to these policies resulted in compromised resident care, as evidenced by the numerous complaints and observations of unmet needs.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several areas being unclean and in disrepair. In the Station One shower room, a trash can was found to contain trash without a liner and had brown material smeared inside. Resident 28's room was observed to have significant damage, including deeply scratched plasterboard, chipped molding on the restroom door, and a bedside table with missing laminate exposing dirty, porous fiberboard. Additionally, a wall-mounted electronic device outside room three was missing, leaving a broken mounting plate and exposed electronic cord. Further observations revealed that built-in wooden cabinets in several rooms were chipped, scratched, and uncleanable. Resident 92's bathroom ceiling fan was covered in greyish debris and was non-functional. Interviews with staff confirmed these deficiencies, with the Maintenance Supervisor acknowledging the disrepair and indicating that improvements were underway. The facility's policies on maintaining a clean and safe environment were not adhered to, potentially impacting residents' well-being.
Improper Food Storage and Freezer Maintenance
Penalty
Summary
The facility failed to ensure that food was stored under sanitary conditions, as evidenced by the improper storage of parsley in the walk-in refrigerator. During an observation, it was noted that a metal pan containing parsley was not covered, and the parsley appeared shriveled and dry. Additionally, a clear plastic bag within the same pan contained a larger quantity of parsley that was neither labeled nor dated. The Dietary Manager confirmed these observations, acknowledging that the parsley should have been covered, labeled, and dated according to the facility's policy on food storage and handling. Furthermore, the facility did not maintain the walk-in freezer in a condition free from frost build-up. During an initial tour, frost was observed on multiple areas of the ceiling in the walk-in freezer. Both the Dietary Manager and the Maintenance Supervisor confirmed the presence of frost, with the Maintenance Supervisor noting that the frost had recently started to accumulate and persisted despite removal efforts. This failure to maintain the freezer in good repair was contrary to the facility's maintenance policy, which requires the building to be kept in good working order and free from hazards.
Failure to Sanitize Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to adhere to its infection prevention and control program when a Licensed Vocational Nurse (LVN K) did not sanitize a blood pressure cuff between using it on two residents, Resident 74 and Resident 42. This action was observed on February 4, 2025, at 1:10 PM, when LVN K took a blood pressure reading from Resident 74 and then immediately proceeded to use the same cuff on Resident 42 without cleaning it. During a concurrent interview, LVN K acknowledged the oversight, stating that cleaning blood pressure cuffs between residents is standard nursing practice, but she had forgotten to do so. Further interviews with other staff members, including LVN L and the Infection Prevention Nurse (IP J), confirmed that it is standard practice to clean reusable equipment between residents to prevent the spread of infection. LVN L was observed following this practice and emphasized the importance of infection control due to the prevalence of illnesses. The facility's policy, last revised on January 1, 2012, aligns with CDC and OSHA guidelines, requiring the cleaning and disinfection of reusable items between residents. The failure to follow this policy resulted in a potential risk for spreading infection and illness among residents.
Failure to Prevent Resident Abuse Leads to Altercation
Penalty
Summary
The facility failed to prevent abuse between two residents, Resident 16 and Resident 63, which resulted in a physical altercation. Resident 16, who has chronic obstructive pulmonary disease, diabetes, and dementia, reported verbal abuse from their roommate, Resident 63, who has hemiplegia, dysarthria, and depression. Despite Resident 16's complaints about derogatory statements made by Resident 63, the facility did not separate the residents, leading to an incident where they threw water at each other. The facility's policies on abuse prevention and resident safety were not followed. Staff members, including Licensed Nurses A and B, were aware of the verbal disputes but did not notify the administration or the Social Services Director (SSD) as required. Instead, they chose to monitor the situation and pass the information to the next shift. The SSD was not informed of the issues over the weekend, and no room change was initiated despite Resident 16's request. Interviews with staff revealed a lack of communication and adherence to procedures for handling resident disputes. The Director of Staff Development indicated that staff should have contacted the SSD or administration and separated the residents if the SSD was unavailable. However, this protocol was not followed, resulting in the altercation between the residents.
Inconsistent Documentation of Skin Assessments and Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident 16, regarding skin assessments and treatments. The inconsistency in documentation was observed in several instances. Initially, a Long-Term Care Evaluation noted no skin changes, but subsequent notes by the Director of Nursing and other Licensed Nurses documented a skin tear and bruising on the resident's left hand. Despite these observations, a physician's order to monitor the bruising was not documented until four days after the initial incident. Additionally, a Care Plan problem was revised to include the skin tear, but a later Skin Check note again indicated no skin changes. The deficiency was further highlighted during interviews with nursing staff. Treatment LN D could not find documentation about a pink foam dressing on the resident's hand, and LN C admitted to not documenting or notifying the Skin Team about the incident when the resident's hand was injured. LN C applied a dressing and did not follow the facility's policy for reporting and documenting skin-related conditions. This lack of documentation and communication among staff members led to incomplete records, which could potentially impact the resident's skin care and treatment.
Verbal Abuse by LVN in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Licensed Vocational Nurse (LVN 1). The incident involved LVN 1 using inappropriate and threatening language towards a resident (Resident 1) who was attempting to assist another resident (Resident 2) after a fall. LVN 1 told Resident 1 to mind his own business and threatened to kill him if he called 911. This interaction was unexpected for Resident 1, who had previously had a good relationship with LVN 1. Resident 1's mental capabilities were intact, as indicated by a BIMS score of 14/15. Further interviews with staff and residents revealed a pattern of negative behavior by LVN 1 towards residents. Certified Nursing Assistants (CNAs) and other staff members reported that LVN 1 often spoke negatively about residents and expressed a belief that residents were intentionally trying to agitate her. LVN 1 was also reported to have made inappropriate comments to Resident 2, who has dementia, wishing harm upon her. Resident 2's mental capabilities were not intact, as indicated by a BIMS score of 99, and she was diagnosed with dementia and generalized anxiety disorder. The facility's administration was notified of the incident, and LVN 1 was suspended. Multiple staff members, including other nurses, confirmed the inappropriate behavior of LVN 1, and residents expressed feeling unsafe when she was on duty. The facility's abuse prevention policies clearly state that any form of abuse is not condoned, yet the actions of LVN 1 were in direct violation of these policies, leading to a deficiency in protecting residents from abuse.
Failure to Respond Timely to Residents' Requests
Penalty
Summary
The facility failed to ensure timely response to residents' requests for assistance, affecting three residents. Resident 3, who had a stroke and required assistance with personal care, was left soiled because the assigned CNA forgot to return after a lunch break. The family member had to change the resident, highlighting a lapse in staff coverage during breaks. The facility's policy requires CNAs to answer call lights promptly, but this was not adhered to, resulting in the resident's dignity being compromised. Resident 4, who had a history of falls and Parkinson's disease, was left calling for help for over 12 minutes while leaning on her bedrail, posing a risk of falling. Despite being near the nursing station, three staff members walked past without responding to her call light. The assigned CNA did not inform the team of her break, leading to a lack of coverage and delayed assistance. The facility's care plan for Resident 4 emphasized the need for prompt response to requests for assistance, which was not met. Resident 5, with COPD and requiring assistance with personal care, experienced multiple instances of delayed response to her call light. The responsible party reported these delays, indicating a pattern of neglect in attending to the resident's needs. The facility's policy and job descriptions emphasize the importance of prompt response to call lights, yet the staff failed to comply, affecting the resident's quality of life and care.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a CNA insisted on changing the resident's brief despite the resident's refusal. The incident resulted in a 4.5 cm x 5 cm bruise between the resident's thumb and first finger, leaving the resident feeling angry and humiliated. The facility's policy on abuse prevention, which prohibits any form of resident abuse, was not adhered to in this situation. The resident, who had a history of stroke and required assistance with personal care, was cognitively intact as indicated by a BIMS score of 14. On the night of the incident, the resident reported that the CNA pulled on her blankets and, despite her protests, continued to insist on changing her brief. When the resident attempted to reach for her bed remote to sit up and communicate, the CNA pulled the remote from her hand, causing the bruise. The resident felt that the CNA acted deliberately and was intimidated by the CNA's actions. Interviews with staff revealed that the CNA did not report the incident as required by facility policy. The CNA claimed not to have heard the resident's refusal and did not leave the room when asked. Other staff members noted that the CNA was demanding and became rough when residents refused care. The incident was corroborated by other staff who observed the bruise and heard the resident's account of the event.
Inadequate Staffing Leads to Extended Call Light Wait Times
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by extended call light wait times for four out of five residents sampled. Residents reported waiting between 10 to 55 minutes for assistance, which led to feelings of neglect, embarrassment, and concerns about skin integrity. Despite some residents expressing overall satisfaction with their stay, the prolonged wait times for call lights were a significant issue, with one resident mentioning incidents of waiting while wet and another experiencing accidents due to delays. Interviews with nursing staff, including Licensed Vocational Nurses and a Registered Nurse, revealed that they felt overwhelmed and unable to provide the level of care their residents deserved. The staff reported working extended hours and dealing with heavy workloads, which contributed to their inability to respond promptly to residents' needs. The facility's policy on staffing, revised in 2012, indicated that adjustments should be made to meet residents' needs, but the current staffing levels were insufficient, as noted by both residents and staff.
Resident Injured by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from injury, resulting in a skin tear on the resident's left hand. The resident, who had difficulty walking, falls, a fractured leg, colon cancer, and vascular dementia, was unable to complete a mental assessment and was assessed with moderate cognitive impairment. On the morning of the incident, a Certified Nursing Assistant (CNA) from a staffing agency was assigned to the resident during the night shift. The CNA left the facility without reporting off to anyone, and the resident was later found with a significant skin tear and bleeding by the next shift CNA. The facility's administrator confirmed that the CNA had abandoned her shift, and attempts to contact her were unsuccessful. Interviews with staff and the resident revealed that the resident described being attacked by a woman, consistent with the description of the CNA. The Licensed Vocational Nurse (LVN) who administered the resident's medication earlier that morning did not observe any skin tear at that time. The next shift CNA discovered the injury and reported it immediately. The resident's injury was described as a curved, thumb-shaped skin tear with a deep bruise, suggesting it may have been caused by being grabbed. The incident was reported to the state, police, and ombudsman, but the CNA involved denied any knowledge of the injury.
Inconsistent Dialysis Dressing Management
Penalty
Summary
The facility failed to adhere to physician orders regarding the care of dialysis dressings for several residents, which could potentially lead to complications. Resident 2, who was admitted with conditions including end-stage renal disease, diabetes, and dementia, had issues with the management of his dialysis access site. The facility did not consistently remove the compression dressing from Resident 2's dialysis site four hours after treatment, as ordered by the physician. This oversight was noted by the Dialysis Social Services, who reported that on at least two occasions, Resident 2 returned to dialysis with the bandage still on, leading to clotting of the access site and requiring surgical intervention. The report also highlights similar issues with Residents 3 and 4, who experienced inconsistent care regarding the removal of their dialysis dressings. Resident 3's dressing was observed to remain on beyond the recommended four-hour period, and Resident 4 reported that her bandage sometimes stayed on too long, causing irritation. Interviews with facility staff, including Licensed Vocational Nurses and a Certified Nursing Assistant, revealed a lack of consistent practice and understanding regarding the removal of dialysis dressings. Some staff members were unaware of the specific time frame for removing the dressings, while others admitted to not always following the protocol. The inconsistency in following the standard of care for dialysis dressings was acknowledged by the Dialysis Social Services and the facility's unit manager. The unit manager was aware of the issue and indicated that not all staff were informed about the correct procedures. This lack of consistent practice and communication among staff members contributed to the deficiency in providing appropriate dialysis care for the residents involved.
Failure to Provide Scheduled Showers or Baths
Penalty
Summary
The facility failed to ensure that two residents received their scheduled showers or baths, as required for assistance with activities of daily living (ADLs). Resident 1, who required maximal assistance with transfers, toileting, bathing, and dressing, only received four baths or showers in April 2024, despite the facility's policy of twice-weekly bathing. There were no documented refusals or updates to Resident 1's responsible party regarding the missed baths. Resident 1 had multiple diagnoses, including a need for assistance with personal care, high blood pressure, and chronic obstructive pulmonary disease. Resident 2, who was cognitively intact and able to make her own medical decisions, only received one shower in April 2024. She confirmed in an interview that she only received one shower during her stay. The facility's Licensed Nurse and Director of Nursing confirmed that showers and baths are scheduled twice weekly and that any refusals should be documented and communicated to the charge nurse. However, the lack of documentation indicated that the scheduled bathing was not completed for these residents.
Administrator's Directive to Alter Medical Records
Penalty
Summary
The facility failed to comply with applicable Federal, State, and local laws, regulations, and accepted professional standards and principles, as evidenced by the actions of the administrator. The administrator directed several nursing staff members to alter progress notes related to the care of a resident, which is a violation of California Penal Code, Section 471.5, that prohibits fraudulent alteration of medical records. Specifically, the administrator requested a Registered Nurse (RN) to reword her progress note and directed two Licensed Nurses (LNs) to change their progress notes, which could lead to inaccurate documentation of care provided. The report highlights the case of a resident who was readmitted to the facility with diagnoses including dysphagia following a cerebral infarction and required assistance with personal care. The resident had chosen to have Cardiopulmonary Resuscitation (CPR) in the event of no pulse and not breathing, as indicated in the Physician Orders for Life-Sustaining Treatment (POLST). However, discrepancies in the documentation of the resident's unexpected death were noted. A Licensed Nurse documented the timeline of events, including the initiation of CPR and the arrival of Emergency Medical Services (EMS), but was later asked by the administrator to redraft the note to remove the timing details, which the nurse refused to do. The administrator's actions included instructing a nurse to remove the term 'asphyxiation' from a progress note, fearing it might be interpreted as the cause of death. This request was made despite the nurse's insistence that the original note was accurate. The administrator's influence over the staff, including making a nurse sign an agreement to comply with any requests, created an environment where staff felt pressured to alter medical records, compromising the integrity of the documentation and potentially affecting the quality of care provided to residents.
Delayed CPR Initiation for Full Code Resident
Penalty
Summary
The facility failed to immediately initiate Basic Life Support (BLS), including Cardiopulmonary Resuscitation (CPR), for a resident who was found unresponsive and without a pulse. The resident, who had a full code status indicating a desire for full treatment in life-threatening situations, was discovered by a Licensed Nurse (LN A) at 5:45 pm. Despite the resident's full code status, CPR was not initiated until 10 minutes later, at 5:55 pm, which delayed the provision of emergency care. The facility's policy, aligned with the American Heart Association guidelines, requires immediate initiation of CPR by certified staff when a resident is found unresponsive with no pulse or respirations. However, LN A, upon finding the resident unresponsive, did not start CPR immediately. Instead, LN A sought confirmation from another nurse, who also did not initiate CPR, and then checked the resident's code status. This delay was contrary to the facility's policy, which mandates immediate CPR initiation and specifies that only a licensed physician can declare a resident dead. Interviews with staff revealed a lack of awareness and adherence to the facility's CPR policy. LN A expressed a wish to have known the resident's code status beforehand to act promptly. Another nurse, LN B, highlighted that recent BLS training emphasized the importance of knowing residents' code statuses and starting CPR immediately if a resident is found without a pulse or breathing. The Director of Nursing confirmed that the expectation was for CPR to be initiated immediately, but the staff did not follow this protocol, leading to a significant delay in emergency response.
Delayed Stroke Response in Resident
Penalty
Summary
The facility failed to promptly notify the Medical Director, who was the attending physician, of a significant change in condition for a resident experiencing signs and symptoms of a stroke. The resident, who was initially admitted with cellulitis, difficulty in walking, and high blood pressure, showed signs of a stroke, including slurred speech and left-sided weakness. Despite these symptoms, there was a delay in notifying the physician and transferring the resident to the hospital, resulting in a three-day delay in receiving appropriate treatment. The facility's policy on change of condition required prompt notification of the resident's physician and family in the event of significant changes, such as signs of a stroke. However, staff observations and progress notes indicated that the resident's condition deteriorated over several days without appropriate action being taken. The resident was noted to be pale, lethargic, and had difficulty swallowing, yet there was no immediate notification to the physician or transfer to the hospital until the Director of Nursing intervened. Interviews with staff revealed a lack of understanding of the facility's comfort care policy and the importance of timely intervention in cases of suspected stroke. The resident, who was on comfort-focused treatment, expressed a desire to be transferred for further evaluation, but this was not acted upon until much later. The delay in treatment contributed to the resident's significant decline in functional abilities and eventual death within a month of admission.
Staffing Shortages Lead to Delayed Care and Missed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly during the week of March 30, 2024, through April 5, 2024. This staffing shortage resulted in multiple nursing stations being inadequately staffed, leading to significant delays in responding to call lights and providing necessary care. Observations and interviews revealed that residents experienced long wait times for assistance, with call lights going unanswered for extended periods. For instance, a call light in one room was not answered for 30 minutes, and residents reported having to ambulate to seek help due to the lack of timely response from staff. The deficiency also affected the residents' ability to receive scheduled showers and other activities of daily living (ADLs). Several residents, including those with specific medical needs such as a colostomy bag or a history of amputation, did not receive the scheduled number of showers, with some receiving only one out of four scheduled showers. The lack of adequate staffing also impacted the timely administration of medications, with reports of medications being administered 30 minutes late. Interviews with staff indicated that the shower team, which was supposed to consist of 4-5 CNAs, was often understaffed or nonexistent, further exacerbating the issue. Staff interviews highlighted a culture of overwork and stress, with many staff members feeling overwhelmed and unsupported by management. There were reports of staff taking extended breaks, feeling pressured to work double shifts, and experiencing emotional stress due to the workload. The facility's use of outside registry staff was mentioned, but these staff members often did not show up for scheduled shifts, compounding the staffing issues. The Director of Nursing and Administrator acknowledged the staffing challenges, noting efforts to address chronic call-outs and underperformance among CNAs, but the deficiency persisted, affecting the quality of care provided to residents.
Delayed Stroke Recognition and Response
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies to promptly identify and report a change in condition for a resident, leading to a significant delay in medical intervention. The resident, who was experiencing signs and symptoms of a stroke, was not transferred to the hospital until three days after the initial symptoms were observed. This delay resulted in increased pain and discomfort for the resident, who suffered significant declines in functional abilities, including slurred speech, left-sided weakness, and inability to swallow. The facility's policy on change of condition required staff to promptly inform the resident, consult with the primary care physician, and notify the resident's legal representative or family member when a significant change in condition occurred. However, despite multiple observations of the resident's declining condition by various staff members, including pale appearance, mumbling speech, and decreased level of consciousness, there was a failure to notify the physician in a timely manner. The Director of Nursing eventually assessed the resident and suspected a stroke, leading to the resident's transfer to the hospital. Interviews with staff revealed a lack of understanding of the facility's comfort care policy and the importance of timely medical intervention. The Director of Nursing acknowledged that the staff should have recognized the signs and symptoms of a stroke and that the resident should have been sent to the hospital earlier. The resident, who was on comfort-focused treatment, expressed dissatisfaction with the care received, indicating a failure to meet the resident's needs and preferences.
Inappropriate Staff Communication Upsets Resident
Penalty
Summary
The facility failed to ensure that a direct care staff member interacted and communicated in a manner that promoted the mental and psychosocial well-being of a resident. This deficiency involved a Certified Nursing Assistant (CNA) who made inappropriate comments to a resident, referred to as Resident 9. The incident occurred when CNA G, along with another CNA, entered Resident 9's room to assist the roommate. Resident 9, who had intact cognition as indicated by a BIMS score of 15, expressed feelings of being treated like a prisoner. In response, CNA G told Resident 9 to "stop being a smartass," which upset the resident and led to crying. Further investigation revealed that CNA G had made additional derogatory comments, calling Resident 9 a "dumbass" and suggesting that the resident was acting like a child. These interactions were witnessed by another CNA, who also made an inappropriate comment. The facility's administrator acknowledged the incident, stating that the language used was inappropriate and affected the resident's dignity. Resident 9, who had a history of diabetes and required assistance with personal care, was visibly upset during an interview, recalling past abuse and expressing distress over the language used by the staff.
Unsafe Discharge Planning Leads to Resident's Return
Penalty
Summary
The facility failed to develop and implement a safe and successful discharge plan for a resident, resulting in her return to the skilled nursing facility within 24 hours after being discharged. The resident, who had a history of falling, muscle weakness, morbid obesity, and heart disease, was discharged home without ensuring that she and her family were adequately prepared for her care. The interdisciplinary team did not provide necessary training to the family members who were to become her caregivers, nor did they discuss the risks and benefits of returning home or the possibility of an Against Medical Advice (AMA) discharge. The resident's medical records indicated that she required a slide board for transfers and was unable to stand or walk independently. Despite these challenges, the discharge planning review noted that her family would be her caregivers, although they were not trained to assist her. The resident expressed that she was unable to perform transfers independently and always required assistance from facility staff. After being discharged, she was unable to get out of bed and became stuck on the toilet, necessitating a call to 911 and her subsequent return to the facility. Interviews with facility staff, including the Director of Therapy, Business Office, Social Service Assistant, and Administrator, revealed that the resident's discharge was considered unsafe. The Director of Therapy confirmed that the resident was still a maximum assist with walking and transferring, and there was no documentation of family training. The Business Office stated that the resident was informed her benefits had run out, and she would need to pay or apply for assistance, which had not yet been approved. The facility staff confirmed that the risks of returning home were not discussed with the resident, and the discharge should have been classified as AMA.
Failure to Maintain AC and Lighting Systems
Penalty
Summary
The facility failed to maintain essential equipment, specifically the Central Air Conditioning (AC) system and Packaged Terminal Air Conditioners (PTAC) on Stations 3 and 4, leading to uncomfortable temperatures during warmer months and resident discomfort. During an observation, room temperatures in several resident rooms without working fans and chilling coils were recorded as high as 79.3 degrees Fahrenheit. A resident expressed feeling warm and hot in her room, and it was confirmed that her PTAC fan had not been fixed. Maintenance staff acknowledged the issue but indicated that repairs were ongoing and not yet completed. Additionally, the facility failed to ensure proper lighting in a resident room, putting two residents at risk for falls. During an observation, it was noted that the room was dark, and a resident had to request assistance to use another bed's light due to non-functional lights above Beds A and C. Maintenance staff confirmed the issue and admitted they were unaware of the non-working lights. It was also noted that the window air conditioning unit in the same room needed reinstallation, which had not been completed. Maintenance efforts were ongoing, with some AC fan motors replaced, but issues with chilling coils persisted.
Failure to Implement Safe Transfer Plan Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the plan of care for a safe transfer was implemented for a resident when a CNA and an NA did not use a Hoyer lift and assisted the resident to a standing position. The resident, who was unable to stand, was lowered to the floor, resulting in an avoidable fall that caused fractures to her right knee, pain, and a delay in physical therapy treatments. The resident had a history of a displaced trimalleolar fracture of the right lower leg, morbid obesity, and difficulty walking. Her records indicated she required assistance and support for transfers and was not steady, only able to stabilize with staff assistance. The resident's care plan specified the use of a Hoyer lift for transfers with the assistance of two staff members. Despite this, the CNA and NA attempted to assist the resident to stand, leading to her fall. The incident occurred when the CNA and NA were preparing the resident for a shower. The resident offered to stand to facilitate the removal of her brief, and the CNA assisted her to stand, but the resident's legs gave out. The CNA was unable to support the resident's weight, resulting in the resident hitting her knee on the floor. The resident was subsequently diagnosed with fractures in her right knee and experienced severe pain, requiring changes in her pain medication regimen.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to provide competent nursing care to a resident when a CNA and an NA did not follow the care plan for safely transferring the resident from her wheelchair to her shower chair. The resident, who had a history of a displaced trimalleolar fracture, morbid obesity, and difficulty walking, required a mechanical lift for transfers with two-person assistance. Despite this, the CNA and NA attempted to manually lift the resident, resulting in the resident falling and sustaining fractures to her right knee, causing pain and a delay in physical therapy treatments. The incident occurred when the CNA and NA realized the resident still had her brief on after being transferred to the shower chair. The CNA decided to lift the resident manually to remove the brief, despite the resident's care plan indicating the need for a mechanical lift. The resident was unable to support her weight and slid to the floor, injuring her right knee. The resident was assessed by nursing staff and transported to an acute care hospital, where fractures were confirmed, and a soft cast was applied. Interviews with the staff revealed that CNAs did not have direct access to residents' care plans or transfer status information and relied on verbal communication from other CNAs or nurses. The Director of Staff Development confirmed that there was no documented in-service training for the CNA involved in the incident, and the Director of Nursing acknowledged that CNAs did not have a system to look up specific care needs. The lack of proper communication and training contributed to the failure to follow the resident's care plan, leading to the avoidable fall and injury.
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.
