Bay Marina Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, California.
- Location
- 2919 Fruitvale Ave, Oakland, California 94602
- CMS Provider Number
- 056280
- Inspections on file
- 44
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bay Marina Post Acute during CMS and state inspections, most recent first.
Nursing staff did not obtain timely dental services for a resident who was cognitively able to report symptoms and complained of toothache, burning gums, difficulty chewing, and ongoing pain, despite documented missing/broken teeth and irritated gums. An RN recorded significant oral findings and notified the physician, but the dental consult was not actually scheduled until seven days later. Key staff, including the RD and an RN caring for the resident, were unaware of the dental issues, while the DON confirmed ongoing oral discomfort managed only with pain medication. A later hospital CT showed numerous bilateral dental caries, and the consulting DDS stated he would have expected immediate notification and clearer communication from the facility when the resident first reported oral pain.
A resident with cognitive impairment, history of traumatic brain injury, ataxia, and repeated falls was discharged via Uber to an assisted living setting without documented pre-discharge planning or a discharge care plan, despite facility policy requiring early and coordinated discharge planning. Although a medication list was documented as sent to the next provider, it was not provided to the resident, and a home health RN later found the resident without discharge medications or a medication list and had to obtain this from the facility. The Discharge Planning Review Form was completed after the discharge and lacked the resident’s or family member’s signature, and there was no documented follow-up with the family member who had previously contacted the facility about discharge and financial benefit arrangements. Assisted living staff reported the resident’s unsafe wandering, unusual gait without a walker, and episodes of leaving and becoming homeless, while the assisted living owner noted uncertainty about who controlled the resident’s financial benefits.
A resident with end stage renal disease developed new skin discoloration on the face and hand, which was documented by staff but not reported to the charge nurse or investigated as required by facility policy. Interviews confirmed that nursing staff did not follow procedures for reporting and investigating changes in condition.
Two residents receiving dialysis did not receive their prescribed medications as ordered due to unavailability in the medication cart. Staff substituted medications with incorrect dosages or alternative products, including using medications labeled for other residents and lower doses than prescribed. The facility did not follow its policy to reorder medications in advance, resulting in missed or incorrect medication administration.
The facility did not ensure that a resident's transfer or discharge was conducted in a manner that met their needs and preferences, nor did it adequately prepare the resident for a safe transition.
A resident with a history of stroke experienced emotional distress after a CNA yelled, used profanity, and made derogatory remarks in response to a comment from the resident. The CNA's actions were in direct violation of the facility's abuse prevention policy, which prohibits verbal mistreatment.
A CNA verbally abused a resident with a history of stroke, and despite the facility's policy requiring immediate removal of staff accused of abuse, the CNA continued to provide direct care after the incident. Time records confirmed the CNA worked additional shifts before separation, contrary to established abuse reporting procedures.
A resident with hypertension and epilepsy, who was cognitively intact, was physically and verbally abused by a visitor who entered a shared room, accused the resident of theft, and slapped the resident in the face, causing an abrasion and pain that required emergency evaluation. Staff attempted to intervene, but the visitor continued the abusive behavior before eventually calming down.
A resident with a history of hypertension and epilepsy, who was cognitively intact, reported being physically assaulted by a visitor, resulting in a visible injury. The facility failed to thoroughly investigate the incident, did not interview all staff witnesses, and did not submit the required investigation summary to the State Survey Agency within five working days, as mandated by policy.
A resident's family member reported to staff that a nurse called the resident 'stupid,' but both an RN and a Medical Records staff member failed to notify CDPH or the Ombudsman or submit the required SOC 341 abuse report within the facility's mandated two-hour timeframe.
Two residents experienced deficiencies related to accident hazards and supervision: one resident with neurological and mobility impairments was provided a bed with wheels that did not lock, causing fear of falls, while another resident with a history of TBI and depression, assessed as at risk for elopement, was left unsupervised during smoking and left the facility undetected, with no care plan or investigation documented.
A resident with a history of hemiparesis and hemiplegia fell during a physical therapy session. The PTA guided the resident to the floor, but the LVN failed to assess the resident for injuries or notify the doctor, resulting in delayed treatment for a hip fracture. The facility's policy requires immediate assessment and notification following falls.
The facility failed to honor the dietary preferences of two residents, leading to a deficiency in resident self-determination. One resident, with a diagnosis of Adult Failure to Thrive, was served turkey salad despite disliking turkey, while another resident with Unspecified Protein-Calorie Malnutrition was given milk against their preference for juice. The facility's policy to provide meals consistent with residents' preferences was not followed.
A resident with end-stage renal disease felt upset and disrespected after a Rehabilitation Coordinator told him he was being kicked out of the facility. The incident, witnessed by an RN, was not handled according to the facility's policies on resident rights and discharge procedures. The Social Worker and Director of Nursing confirmed that the resident was not ready for discharge and that the RC's actions were inappropriate.
A resident with Neuralgia and Neuritis did not receive their prescribed Gabapentin on two occasions due to unavailability. The facility staff failed to notify the physician or obtain a new order to skip or delay the dose, contrary to the facility's medication administration policy.
A resident with dementia and delusional disorder threw a flower vase at her roommate, causing a lip wound and hospital transfer. The facility was aware of ongoing conflicts and previous aggressive behavior but failed to implement a care plan to prevent such incidents, violating their abuse prevention policy.
The facility failed to maintain proper food storage and preparation standards, with the walk-in fridge exceeding safe temperatures and beverages stored improperly. Ground beef was thawing without proper labeling or logs, and the kitchen environment was excessively hot, with an ineffective AC unit. These conditions risked food contamination for 90 residents.
A resident was moved to a different room without receiving the required written notification explaining the reason for the change. The resident, who was cognitively intact, was informed verbally on the day of the move, but the Social Service Director did not provide a written notice as required by the facility's policy.
A resident was denied re-admission to a facility after hospitalization, despite available beds. The resident, with a history of hemiplegia and other conditions, was discharged from a hospital following neurosurgery. Facility staff cited non-compliance as the reason for refusal, although the resident wished to return.
A resident with severe cognitive impairment showed signs of difficult breathing and tested positive for COVID-19, but the LVN failed to notify the physician or family. The LVN placed the resident on oxygen but did not report the condition change to another LVN during her break. Upon returning, the resident was found unresponsive, leading to a Code Blue. Facility policy requires immediate notification of such changes, which was not followed.
The facility failed to provide appropriate foot care for two residents, resulting in significant discomfort and potential health risks. Both residents had overgrown, discolored, and thickened toenails, and had not received podiatry services for over four months. Despite requests for nail care, the facility did not provide the necessary services, and records lacked documentation of any offers or declinations of toenail care.
Failure to Provide Timely Dental Consultation for Resident with Oral Pain
Penalty
Summary
Facility nursing staff failed to provide timely dental services after a resident reported significant oral pain. The resident, who had a history of hemiplegia following a stroke and documented missing or broken teeth, was cognitively able to report symptoms and did so, describing toothache, burning sensations in the upper and lower gums, difficulty chewing, and ongoing pain. An eInteract Change in Condition Evaluation completed by an RN on 3/9/2026 documented the resident’s report of toothache with burning gums, multiple missing and dark discolored teeth, cracked teeth, loss of lower teeth, and irritated gums. The physician was notified and a referral for a dental consultation was noted, and progress notes on 3/10/2026 indicated staff were monitoring the toothache and burning gum sensation, with gums described as slightly irritated and the resident continuing to report discomfort. Despite these findings and the facility’s Oral Healthcare & Dental Services policy stating that a consultant dentist would provide emergency dental care as needed, the actual dental consult was not scheduled until 3/16/2026, seven days after the initial complaint of oral pain. During interviews, the RD and an RN caring for the resident stated they were unaware of any issues with the resident’s teeth or chewing, and the DON confirmed the resident’s oral discomfort and that staff continued to administer pain medication. The DON acknowledged that nursing staff should have been more proactive in addressing the symptoms, which could indicate infection. A CT head and neck angiography performed at the hospital later showed numerous bilateral dental caries, and the dental consultant stated he would have expected immediate contact from staff upon the resident’s complaint of oral pain and emphasized the need for clear communication from the facility to his office. The resident reported still having pain during a subsequent interview.
Failure to Implement Effective Discharge Planning Leading to Post-Discharge Instability
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with multiple cognitive and physical impairments. The resident was admitted with diagnoses including cognitive communication deficit, a history of traumatic brain injury, ataxia, and repeated falls, and had a BIMS score of 12 indicating moderate cognitive impairment. The facility’s own policy required that discharge planning begin upon admission, with an initial discharge assessment within seven days and a discharge care plan developed by Social Services with the IDT. However, the Director of Nursing confirmed that the clinical record contained no evidence of discharge planning prior to the actual discharge date and no discharge care plan was developed. An IDT note documented that a family member had contacted the facility about discharge plans and was working on financial benefits, but there was no further documentation of coordination or follow-up with the family member regarding these plans. On the day of discharge, the resident was sent in an Uber to an assisted living facility with medications and a medication list documented as provided to the subsequent provider, but not to the resident. The Discharge Planning Review Form was completed and signed the day after discharge and lacked the resident’s or family member’s signature. Following discharge, a home health RN reported that when she assessed the resident for home health admission, the resident did not have a medication list or discharge medications, requiring the home health office to contact the facility for this information. Staff at the assisted living reported that the resident claimed to self-administer medications but did not show which medications, ambulated without a walker in an unusual manner, and frequently wandered off to an unknown shelter. The assisted living owner reported that the resident occasionally left the home, sometimes becoming dirty after being homeless for a few days, and that although the resident received financial benefits, they did not know who the payee was or who was receiving the money.
Failure to Report and Investigate Change in Resident Condition
Penalty
Summary
The facility failed to ensure that a change in a resident's condition was reported and properly investigated. A resident with multiple diagnoses, including end stage renal disease, was noted in progress notes to have new skin discoloration on the face and hand, and subsequently on the left eye and nose over several days. Despite these documented changes, nursing staff did not report the new skin discoloration to the charge nurse, and no investigation into the cause of the discoloration was initiated by the facility. Interviews with facility staff confirmed that nurses are expected to report any change in a resident's condition to the charge nurse for further investigation, as outlined in the facility's policy on unusual occurrence reporting. However, the responsible LVN admitted to not reporting the discoloration, and the Minimum Data Set Coordinator confirmed that no investigation was conducted. This failure to follow reporting and investigation procedures resulted in the deficiency.
Failure to Provide and Administer Prescribed Medications for Dialysis Residents
Penalty
Summary
The facility failed to ensure that routine medications were available and administered as ordered for two residents receiving dialysis. For one resident with end stage renal disease, hyperlipidemia, and gastro-esophageal reflux disease, several prescribed medications were not present in the medication cart, including atorvastatin, famotidine, Nephro-Vite Rx, sevelamer hydrochloride, and metoclopramide. Instead, staff administered alternative medications not matching the physician's orders, such as using a higher dose of famotidine labeled for another resident, substituting regular multivitamins for Nephro-Vite Rx, using sevelamer meant for a discharged resident, and giving a lower dose of metoclopramide than prescribed. For another resident with end stage renal disease and chronic pain syndrome, the required medications calcium carbonate 1250 mg and nortriptyline 75 mg were not available in the medication cart. Staff administered a lower dose of calcium carbonate than ordered. The facility's policy required medications to be reordered five days before they were needed, but this process was not followed, resulting in the unavailability of necessary medications for these residents.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. There is no mention of specific residents, medical history, or conditions at the time of the deficiency.
Verbal Abuse by CNA Resulting in Resident Distress
Penalty
Summary
A resident with a history of stroke and no documented behavioral symptoms reported that a Certified Nursing Assistant (CNA) entered his room, yelled, and used profane language towards him. During an interview, the facility administrator confirmed that the CNA admitted to telling the resident, 'You are ugly too,' after the resident allegedly called her ugly. The resident stated that the CNA used to curse at him and that the situation caused him emotional distress. The facility's abuse prevention policy prohibits any form of resident abuse, including verbal mistreatment, but the CNA's actions violated this policy.
Failure to Immediately Remove Staff Following Alleged Verbal Abuse
Penalty
Summary
A certified nursing assistant (CNA) verbally abused a resident by yelling and cursing at them during the night. The resident, who had a history of stroke but no behavioral symptoms such as hallucinations or delusions, reported the incident to staff. The CNA admitted to responding to the resident with a derogatory comment after the resident made a remark about her appearance. The resident stated that the CNA had previously cursed at him and that the situation was upsetting. Despite the facility's policy requiring immediate suspension and removal of staff accused of abuse during an investigation, the CNA continued to provide direct care to residents following the reported incident. Time card records confirmed that the CNA worked additional shifts after the alleged abuse before her official separation from the facility. This failure to immediately remove the CNA from resident care did not align with the facility's established abuse reporting procedures.
Failure to Protect Resident from Abuse by Visitor
Penalty
Summary
A deficiency occurred when a family member (FM) of a resident entered a shared room and physically and verbally abused another resident. The FM, who was upset and accused staff of mistreating her sibling, began yelling, throwing objects, and then slapped the other resident in the face. The resident, who had a history of hypertension and epilepsy and was cognitively intact according to a recent BIMS assessment, sustained an abrasion on the left eyelid and complained of pain, which led to an emergency department evaluation. Multiple staff interviews confirmed that the FM was visibly upset, made threats, and accused the resident of stealing a TV remote. The FM physically attacked the resident, holding his arms and slapping him, while also calling him derogatory names. Staff, including a registered nurse and an infection preventionist, attempted to intervene and de-escalate the situation, but the FM continued to yell and refused to leave the room immediately. The resident appeared frightened and asked the FM to go away. Documentation in the resident's medical record, including an eINTERACT Change in Condition Evaluation and interdisciplinary team notes, confirmed the physical injury and the circumstances of the incident. The facility failed to protect the resident from abuse by a visitor, resulting in physical harm and emotional distress.
Failure to Investigate and Report Alleged Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an alleged incident of physical abuse involving a resident and a visitor, and did not report the results of the investigation to the State Survey Agency within the required five working days. The incident involved a resident with a history of hypertension and epilepsy, who was cognitively intact at the time, and who reported being physically assaulted by the sister of another resident. The visitor entered the room, accused staff of mistreatment, became agitated, and physically struck the resident, resulting in a scratch and discoloration on the resident's eyelid. This account was corroborated by a registered nurse who witnessed the aftermath and documented the injury. Despite the seriousness of the allegation and the visible injury, the facility administrator was unable to provide evidence that all staff who witnessed the incident were interviewed as part of the investigation. The administrator only provided a handwritten note from an interview with the alleged perpetrator, who denied the incident, and acknowledged that the investigation summary was not completed in a timely manner. Additionally, the administrator did not review or reconcile the nurse's documentation with the visitor's denial. The facility's policy required a written report of the results of all abuse investigations to be submitted to the California Department of Public Health Licensing and Certification within five working days of the reported allegation. However, the investigation summary was not completed or sent within this timeframe, and there was no evidence of a comprehensive investigation as required by policy.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to follow its policy and procedure to immediately report an alleged abuse incident involving a resident. Specifically, the sister of a resident with a diagnosis of chronic pain informed both a Registered Nurse (RN) and a Medical Records (MR) staff member that an unknown nurse had called the resident 'stupid.' Both the RN and MR staff acknowledged that they did not complete or submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the California Department of Public Health (CDPH) or the Ombudsman, nor did they notify these authorities of the alleged abuse as required. The facility's policy, revised in March 2018, mandates that the Administrator or designated representative notify CDPH, the Ombudsman, and Law Enforcement by telephone within two hours of an abuse allegation, and submit a written SOC 341 report within the same timeframe. Despite this, the initial notifications and required documentation were not completed by the staff members who first received the allegation, resulting in a delay in reporting the incident to the appropriate authorities.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
Two deficiencies were identified regarding the facility's failure to provide an environment free from accident hazards and to ensure adequate supervision of residents. For one resident with a history of epilepsy, hemiplegia, hemiparesis, right foot drop, and previous falls, the facility replaced her bed with one whose wheels did not lock. The resident, who was cognitively intact, reported that the bed moved whenever she repositioned herself, causing fear of falling. The Environmental Service Director confirmed the bed had been replaced two weeks prior but was unaware of any current issues with the bed. Another deficiency involved a resident with a history of myocardial infarction, depression, traumatic brain injury, and a need for assistance with personal care. This resident was assessed as being at risk for elopement upon admission, but the elopement evaluation lacked clinical suggestions or comments, and no baseline care plan was created to address the risk. Documentation showed that the resident was last seen after requesting to smoke and subsequently left the facility undetected. Multiple staff notes confirmed the resident's absence, and at the time of the survey, the facility did not know the resident's whereabouts. The facility's policy required assessment of elopement risk upon admission and documentation of preventative interventions, as well as specific actions to be taken if a resident was found missing. However, the clinical record did not indicate that these procedures were followed, and there was no documentation of an investigation or contact with the resident or family after the elopement.
Failure to Assess and Notify After Resident Fall
Penalty
Summary
The facility failed to ensure that their skilled nursing licensed staff provided care based on professional standards for a resident who experienced a fall. The resident, who had a history of hemiparesis and hemiplegia following a cerebral infarction, was participating in a physical therapy session aimed at strengthening her core. During the session, the resident leaned forward unexpectedly, and the Physical Therapy Assistant (PTA) guided her to the floor. Despite the fall, the licensed nurse did not immediately assess the resident for injuries or notify the doctor, which is a requirement according to the facility's Fall Management Program. The incident resulted in unnecessary pain and a delay in treatment for the resident, who was later found to have sustained a left hip fracture. The PTA reported the fall to the Licensed Vocational Nurse (LVN) and the Director of Rehabilitation, but there was no documentation indicating that the doctor was notified or that an immediate assessment was conducted. The LVN acknowledged the importance of assessing the resident and notifying the doctor following a fall, but failed to do so in this instance. The facility's policy requires that the Director of Nursing and/or the Administrator be notified of fall incidents as soon as possible, along with the resident's attending physician and responsible party.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to honor the dietary preferences of two residents, leading to a deficiency in resident self-determination. Resident 1, who was admitted with a diagnosis of Adult Failure to Thrive, had a BIMS score of 15, indicating intact cognitive status. Despite this, Resident 1 was served a turkey salad for lunch, which was against their stated preference as indicated on their meal ticket. The Kitchen Director acknowledged that the staff should have adhered to the meal ticket, and the Assistant Director of Nursing emphasized the importance of respecting residents' food preferences to prevent them from feeling disrespected and potentially eating less. Similarly, Resident 2, admitted with Unspecified Protein-Calorie Malnutrition and a BIMS score of 13, was served milk with their lunch, contrary to their stated dislike. Resident 2 expressed a preference for juice instead. The Kitchen Director confirmed that milk should not have been provided. The facility's policy, which mandates that the Dietary Department provide meals consistent with residents' preferences and physician orders, was not followed in these instances, resulting in the deficiency.
Resident Disrespected by Rehabilitation Coordinator
Penalty
Summary
The facility failed to treat a resident with respect and dignity when the Rehabilitation Coordinator (RC) informed the resident that he was being kicked out of the facility. The resident, who had been living in the facility for about two and a half years, was diagnosed with end-stage renal disease and required dialysis three times a week. The resident reported feeling upset and disrespected after the RC told him that the Administrator wanted him out, which was witnessed by a Registered Nurse (RN). The RN confirmed witnessing the incident, noting that the RC's communication with the resident was not polite, leaving the resident visibly upset and stressed. The Social Worker (SW) stated that a care conference should have been held to discuss discharge plans, as the resident was not ready to be discharged due to his medical condition and lack of a place to go. The SW emphasized that discharging the resident without a home would have been unsafe. The Director of Nursing (DON) acknowledged that the RC should not have discussed discharge plans with the resident, as it was not within her responsibilities. The facility's policy and procedure on resident rights and discharge procedures were reviewed, indicating that residents should be treated with kindness, respect, and dignity, and that proper notice and procedures should be followed for discharge. The RC's actions were deemed unacceptable by the DON, as they did not align with the facility's policies.
Failure to Administer Gabapentin as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received Gabapentin as prescribed by their physician, which had the potential to cause unnecessary pain. The resident was admitted with a diagnosis of Neuralgia and Neuritis and had a doctor's order for Gabapentin to be administered every evening for neuropathy pain. However, the medication was not available on two occasions, and the resident missed their doses on those days. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that the missed doses were not communicated to the doctor, nor was a new order obtained to skip or delay the dose. The facility's policy required medications to be administered as prescribed, with a one-hour window before or after the scheduled time, but this was not adhered to in this case.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident threw a flower vase at her, resulting in a wound on her lip and necessitating transfer to an acute care hospital for treatment. The incident occurred in the room shared by the two residents, where a disagreement over the room's sliding door shades escalated. The resident who committed the act had a history of dementia and delusional disorder, with documented physical and verbal behavior symptoms directed toward others. Prior to the incident, staff were aware of the ongoing conflict between the two residents but failed to take adequate measures to prevent the altercation. The facility's Director of Nursing acknowledged that there was a previous incident involving the same resident who exhibited aggressive behavior towards another resident, yet no care plan was developed to address these behaviors. The facility's policy on abuse prevention emphasizes the importance of care planning and monitoring for residents with behaviors that might lead to conflict, but this was not adhered to in this case. The lack of a care plan and failure to address the resident's aggressive behavior contributed to the incident, highlighting a deficiency in the facility's ability to ensure a safe environment for its residents.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as observed during a survey. The walk-in fridge's temperature was recorded between 40-48 degrees Fahrenheit, exceeding the recommended maximum of 40 degrees. Beverages were stored without labels and at temperatures above 40 degrees. Additionally, four packages of ground beef were found thawing in the fridge without proper labeling or a thaw log, and the fridge's temperature was not conducive to safe thawing practices. The Dietary Manager acknowledged these issues, noting the absence of a thawing log and the inappropriate fridge temperature for thawing meat. The kitchen environment was also found to be excessively hot, with temperatures ranging from 85 to 98 degrees Fahrenheit, which could have affected the fridge's temperature. A temporary portable air conditioning unit was in place but was ineffective, blowing warm air and covered in lint, dust, and dirt, indicating it had not been cleaned in over a month. The Dietary Manager and Maintenance staff confirmed the AC unit's ineffectiveness and the kitchen's high temperatures, which should not exceed 80 degrees. These conditions posed a risk of food contamination, potentially leading to foodborne illness for the 90 residents in the facility.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to provide written notification to a resident before a room change, violating the resident's right to receive such notice. The resident, who was cognitively intact according to the Minimum Data Set (MDS) assessment, was informed verbally about the room change on the same day it occurred, without receiving a written explanation for the move. During an interview, the resident expressed feeling that insufficient time was given before the room change. The Social Service Director (SSD) acknowledged completing the Notification of Room Change form but admitted not providing a copy to the resident. The facility's policy and procedure, dated March 2018, requires that residents receive timely advance written notice, including reasons for room changes, which was not adhered to in this instance.
Facility Refusal to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite having available beds. The resident, who had been admitted with hemiplegia, hemiparesis, dysphagia, and chronic obstructive pulmonary disease, was transferred to an acute care hospital for a stroke and underwent neurosurgery. Upon discharge, the resident was ready to return to the facility, but the facility refused re-admission, citing non-compliance with daily care and facility rules. Interviews with facility staff, including the Director of Staff Development and the Charge Nurse, confirmed the decision not to allow the resident's return, despite the availability of three vacant male beds. The resident expressed a desire to return to the facility, as he had no other place to go. This refusal to readmit the resident after hospitalization was identified as a deficiency, with potential psychosocial distress implications for the resident.
Failure to Notify Physician and Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician and representative of a significant change in the resident's health condition. The resident, who had a severe cognitive impairment, exhibited signs of difficult breathing and tested positive for COVID-19. Despite these changes, the responsible Licensed Vocational Nurse (LVN) did not inform the physician or the resident's representative. The LVN placed the resident on oxygen but did not report the change in condition to the other LVN on duty during her break. Upon returning from her break, the LVN found the resident unresponsive, leading to a Code Blue being called. Interviews with facility staff, including the LVN involved and another LVN, revealed that the facility's policy requires immediate notification of the physician and family in the event of a significant change in a resident's condition. The facility's administrator confirmed this requirement. However, the LVN admitted to not notifying the physician or the resident's representative, which could have delayed necessary medical intervention. The facility's policy on Change of Condition Notification emphasizes the importance of promptly informing relevant parties to ensure appropriate medical assessment and coordination.
Failure to Provide Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for two residents, resulting in significant discomfort and potential health risks. Resident 1, who was admitted with a diagnosis of diabetes, had not received podiatry services for over four months since her admission. Her toenails were observed to be dark brown, overgrown, curved, and thickened, causing her discomfort and preventing her from wearing socks or walking. Despite her requests for nail care, the facility did not provide the necessary podiatry services. The facility's records did not document any offers or declinations of toenail care for Resident 1 during this period. Similarly, Resident 2, who was admitted with severe protein-calorie malnutrition and deep vein blood clots, also had not received podiatry services. Her toenails were discolored, overgrown, curved, and thickened, causing discomfort from the sheets and blankets touching her feet. This discomfort made her feel sad and uncared for. The facility's records also lacked documentation of any offers or declinations of toenail care for Resident 2. The social worker responsible for arranging podiatry appointments was unable to find any records of referrals for both residents, despite the facility's policy stating that podiatry care should be offered to any resident requiring it.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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