Beachside Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington Beach, California.
- Location
- 7781 Garfield Avenue, Huntington Beach, California 92648
- CMS Provider Number
- 555027
- Inspections on file
- 22
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Beachside Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain complete and accurate clinical records for several residents. For one resident who died, staff described detailed assessments and observations around the time of death, but these were not documented in the chart, nor were the names and titles of staff involved. Another resident with dysphagia and a GT was ordered NPO, yet physician orders and the MAR listed several medications as given by mouth instead of via GT, despite staff stating all medications were administered through the tube. A third resident’s treatment and monitoring orders for antifungal cream and a low air loss mattress had multiple PM shifts on the TAR left blank, with no initials or codes to show whether care was provided. For a discharged resident, the IDT care plan review form was missing numerous required entries, including participation, team member names, advance directive details, discharge planning information, and signatures or indications of agreement, and there was no set of vital signs documented at the time of discharge even though the discharge note stated the resident left with stable vital signs.
Surveyors identified multiple failures in food safety and sanitation, including improperly stored and unlabeled food items, unsanitary kitchen equipment, and maintenance issues such as a missing tile and rusted surfaces. These deficiencies were confirmed by staff and affected nearly all residents receiving dietary services.
Two residents did not receive care and services according to physician orders and facility policy. One resident with memory impairment was repeatedly served meals in bed despite an order to be up in a chair, and staff confirmed the order was not followed. Another cognitively impaired resident wore a wander-monitoring bracelet for elopement prevention, but there was no physician order or care plan in place for its use, as confirmed by staff and record review.
Three residents experienced significant unplanned weight loss due to the facility's failure to follow RD recommendations, notify physicians and representatives, and update care plans. One resident's severe weight loss was not communicated to the physician, another's nutritional status was not reassessed or addressed by the IDT, and a third resident's meal refusals and intake were not properly documented or care planned. The DON and staff confirmed these deficiencies and missing documentation.
A resident receiving enteral feeding via gastrostomy tube did not have tube placement verified prior to the start of feeding, as required by facility policy and physician orders. An RN initiated the feeding without performing the necessary placement check, and later confirmed this omission. The DON acknowledged the deficiency.
Two residents did not receive proper respiratory care as required by physician orders and facility policy. One resident's oxygen was not administered as ordered, with the nasal cannula disconnected and oxygen saturation below the target level until corrected by staff. Another resident's nasal cannula tubing was not dated and lacked a storage bag, contrary to policy, with staff confirming these omissions.
A nurse failed to follow physician orders during medication administration for two residents, resulting in a medication error rate of 7.41%. One resident received metformin without food, contrary to the order to administer with meals, and another was given Advil for severe pain when it was only prescribed for mild to moderate pain. Both residents were cognitively intact, and the errors were confirmed by the nurse.
Surveyors found that medication carts and the medication storage room were not maintained in a clean and sanitary manner, with expired medications not disposed of and oral, rectal, and external medications stored together. Nursing staff and the DON acknowledged these deficiencies, which were not in accordance with facility policy.
Staff did not follow recipes or physician diet orders, resulting in residents receiving incorrect food textures and portion sizes. Some residents were served chopped instead of regular textured diets due to insufficient food preparation, and others received incorrect portion sizes because meal cards were not properly checked. These issues were confirmed by staff and administration.
The facility did not ensure complete and accurate medical record documentation for two residents, including missing documentation of advance directive discussions on a POLST form for a resident with moderate cognitive impairment, and lack of recorded monitoring for a peripheral IV site during antibiotic therapy for another resident. These deficiencies were confirmed by facility staff.
A resident receiving hospice care did not have the hospice care team included in an IDT meeting following a significant change in condition, despite facility policy and hospice contract requirements for collaborative care planning. Facility staff confirmed the omission and acknowledged the need for hospice participation to ensure coordinated care.
Staff failed to follow infection control protocols by not performing hand hygiene before and after resident contact, during medication administration, and when moving between residents. An OTA and two LVNs were observed not washing hands or changing gloves as required, despite facility policies mandating these practices to prevent infection transmission.
Essential kitchen equipment, including the ice machine and low temperature dishwasher, was not maintained in a clean and safe condition, with observed residue, missing parts, and improper chlorine levels. Additionally, required temperature monitoring of the residents' dining room refrigerator was not consistently performed or documented according to facility policy.
A resident was not treated with dignity during a Foley catheter removal as multiple staff were present without permission, including male staff, causing the resident distress. Additionally, the resident's medications were administered late, affecting her ability to participate in physical therapy. The DON acknowledged these deficiencies.
A resident with multiple health conditions did not receive her scheduled 0900 medications until 1030, contrary to the facility's policy of administering medications within one hour of the prescribed time. This delay was confirmed by the resident, LVN, and through a review of the MAR and Medication Admin Audit Report.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own policies and accepted professional standards for multiple residents, including one who died in the facility and others with active and closed records. For one deceased resident, the record contained only brief progress notes indicating the time of death, confirmation by two licensed nurses, notification of family and administration, and completion of postmortem care. The record did not include documentation of the detailed observations, assessments, vital signs, interventions, or changes in condition surrounding the resident’s death, nor did it identify the names and titles of staff who performed these assessments and interventions. In interview, the LVN assigned to the resident at the time of death described specific assessment actions she took when notified the resident was unresponsive, including checking for a carotid pulse, observing for respirations, and attempting to obtain an oxygen saturation reading, and confirmed that all such observations and staff identities should have been documented but were not. The DON also verified that these elements should have been recorded to provide an accurate and complete account of the resident’s condition. For another resident with dysphagia and a gastrostomy tube (GT) who was ordered NPO, the physician’s orders in the medical record specified that several medications (famotidine, ferrous sulfate, and acetaminophen) were to be administered by mouth. The MAR for the month showed these medications were documented as given via the oral route on multiple occasions. In interview, an LVN stated that this resident was NPO and received all medications via GT, and acknowledged that the ordered route should have been changed to reflect the actual route of administration. The DON was informed and acknowledged that the orders and documentation did not accurately reflect the care being provided. For a third resident, the facility failed to document wound treatment and monitoring as ordered. The physician’s orders included application of antifungal cream 2% to the perineal area every shift and monitoring of a low air loss mattress every shift. Review of the TAR showed multiple PM shifts on which there were no nurse initials or codes to indicate whether the antifungal treatment or mattress monitoring had been completed or, if not, why they were not completed. An LVN reviewed the record and verified these blanks. The Administrator and DON were informed and acknowledged these missing entries. For another discharged resident, the facility failed to complete and accurately document the IDT Care Plan Review and to record vital signs at the time of discharge as required by policy. The IDT Care Plan Review form for this resident’s baseline care plan meeting was missing multiple required elements, including whether the resident participated in care plan development, any explanation if the resident did not participate, the names of social services, activities, and attending physician, verification of admission record information, documentation of advance directive choices, additional comments, the social services plan of care, the summary of the discharge plan, and documentation that the resident or representative had been notified of their rights and agreed with the plan of care. It also lacked documentation of whether the physician or healthcare practitioner participated in and agreed with the care plan review. The SSD and DON both stated they attended the IDT meeting but could not recall details and verified the missing information on the form. Additionally, although the record contained earlier vital signs and a discharge note stating the resident was discharged with stable vital signs, there was no documented set of vital signs obtained just prior to discharge to show the resident’s medical status at that time. An RN confirmed that vital signs should have been taken at discharge, and the DON stated that the expectation was for nurses to obtain vital signs just prior to discharge.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines as evidenced by improper storage, labeling, and maintenance of food items, as well as unsanitary kitchen equipment and conditions. Observations included pumpkin pies and bagels lacking expiration dates, a box of tater tots placed directly on the floor before being returned to the freezer, and a bottle of buttermilk ranch without an opened or expiration date. Additional findings included a bread knife with a melted handle, a missing tile on the drain near the ice maker, and a vent above the stove with a grey web-like formation. Several bread products were found with expired or missing dates, and staff confirmed these items should have been discarded or properly labeled. Further inspection revealed unsanitary kitchen equipment, such as pans with sticky residue and discoloration, a can opener with brown residue, and sticky stains on the floor between beverage machines. A melted and discolored pole with rust was also observed beneath the dish drying table. Staff interviews confirmed these findings and acknowledged the need for proper cleaning and maintenance. These deficiencies affected 57 of 59 residents who received dietary services from the facility's kitchen.
Failure to Follow Physician Orders and Develop Care Plans for Resident Safety Devices
Penalty
Summary
The facility failed to provide necessary care and services as ordered for two residents. For one resident with impaired memory, there was a physician's order specifying that the resident should be up in a chair for all meals. Despite this, multiple observations over several days showed the resident eating breakfast in bed, and staff interviews confirmed awareness of the order but did not consistently follow it. The resident indicated a preference to be in the wheelchair during meals, and staff acknowledged the importance of this positioning, particularly to help prevent aspiration, as the resident's bed could not be elevated to 90 degrees. For another resident with cognitive impairment, a wander-monitoring bracelet was in use for elopement prevention. However, the facility did not obtain a physician's order or develop a care plan for the use of the wander guard, as required by facility policy. Staff interviews and record reviews confirmed the absence of necessary documentation, including informed consent and a care plan, despite the resident wearing the device since admission.
Failure to Address and Manage Significant Resident Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to provide appropriate nutritional services to maintain acceptable parameters of nutritional status for three residents experiencing significant weight loss. For one resident with moderate cognitive impairment, there was a severe weight loss of 15 lbs in seven days. The Registered Dietitian (RD) recommended dietary fortification, but there was no documentation that these recommendations were communicated to the physician or addressed by the Nutrition Interdisciplinary Team (IDT). The Director of Nursing (DON) confirmed that the physician was not notified and no follow-up occurred regarding the resident's weight loss. Another resident, who was cognitively intact and receiving enteral nutrition, experienced an unplanned severe weight loss of 16 lbs (8.33%) in 21 days. The RD and IDT did not analyze or implement necessary interventions in response to this weight loss, and there was no evidence that the physician or the resident and/or their representative were notified. The care plan was not revised to address the significant weight loss, despite facility policy requiring such actions. Both the RD and DON verified the lack of evaluation, notification, and care plan updates for this resident. A third resident, with multiple comorbidities including CHF, diabetes, and CKD, had issues with meal refusal and missing documentation regarding food and fluid intake. The resident's weight upon admission was not accurately recorded, and there was no care plan developed to address the refusal of meals. Multiple instances of missing documentation for meal and fluid intake were identified, and staff confirmed that no care plan was initiated for the resident's meal refusals. The DON acknowledged that the facility failed to record the resident's weight at admission and verified the missing documentation.
Failure to Verify GT Placement Prior to Enteral Feeding
Penalty
Summary
The facility failed to ensure that a gastrostomy tube (GT) placement check was performed prior to initiating enteral feeding for a resident receiving tube feeding. According to the facility's policies and procedures, staff are required to verify tube placement before each feeding and medication administration by observing tube length, checking for respiratory distress, auscultating for a whooshing sound after injecting air, and checking the pH of aspirate. Physician orders for the resident also specified that tube placement and patency must be checked before and after giving medications and before starting tube feeding. On the day of the incident, a resident was observed in bed with the enteral feeding equipment connected but turned off. A registered nurse (RN) entered the room, primed and connected the enteral feeding tube, and started the feeding without checking the GT placement as required. The RN later confirmed that he did not verify the tube's placement before starting the feeding, acknowledging that this step should have been completed. The Director of Nursing (DON) was informed and acknowledged the findings.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents requiring oxygen therapy. For one resident, a physician's order specified continuous oxygen administration at two liters per minute via nasal cannula to maintain oxygen saturation above 90%. However, the resident was observed lying in bed with the oxygen set at 3.5 liters per minute, but the nasal cannula was not connected to the resident or the oxygen machine. The resident's oxygen saturation was found to be 86%, below the normal range, until the nasal cannula was properly applied and the oxygen flow adjusted to the ordered rate, resulting in improved saturation. For another resident with a diagnosis of acute respiratory failure with hypoxia, the facility failed to ensure that the nasal cannula tubing was dated and that a storage bag was provided for the tubing when not in use, as required by facility policy. The nasal cannula was observed to be undated and no storage bag was present. Staff confirmed that the required dating and storage procedures had not been followed for this resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 7.41%. During medication administration, a nurse did not follow physician orders for two residents. For one resident, metformin, which was ordered to be given with meals, was administered without food or a meal present. The nurse confirmed that the medication was not given as prescribed. The resident was cognitively intact, as indicated by a BIMS score of 13, and had an active order specifying the medication should be taken with meals for diabetes management. In another instance, the same nurse administered Advil (ibuprofen) to a resident who reported a pain level of 8, despite the physician's order specifying the medication was to be given only for mild to moderate pain (pain level 4-6). The nurse verified that the medication was given outside the prescribed pain level parameters. This resident was also cognitively intact, with a BIMS score of 15. These actions were not in accordance with the facility's policy and procedures for safe and timely medication administration as prescribed.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications as required by professional standards and its own policies. During inspections of two medication carts, surveyors observed that both carts were not maintained in a clean and sanitary manner, with visible dried residues and sticky medication build-up. Additionally, an expired bottle of Glucosamine Chondroitin Complex was found in one cart and had not been disposed of as required. These findings were verified by the licensed nursing staff present during the inspections. Further inspection of the Medication Storage Room revealed four expired bottles of docusate sodium that had not been properly disposed of. Medications intended for oral, rectal, and external use were found stored together on the same shelf, contrary to facility policy, which requires separation of oral and external medications. Facility staff, including the RN and DON, acknowledged these deficiencies during interviews. No specific residents or patient conditions were mentioned in relation to these findings.
Failure to Follow Menus, Recipes, and Physician Diet Orders
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received meals in accordance with physician orders and established recipes. During observation, a staff member did not follow the recipe for preparing pureed egg rolls and cream of rice, including not measuring ingredients and not following the correct sequence of preparation. The staff member acknowledged confusion and confirmed that the recipes were not followed as required. Additionally, several residents were not served the correct diet texture as ordered by their physicians. Five residents who were supposed to receive regular textured diets were instead served chopped textured food due to insufficient preparation of the regular textured Beef and Broccoli stir fry. This was confirmed by both the cook and the dietary resource, who stated there was not enough food prepared to meet the residents' prescribed dietary needs. Medical record reviews confirmed that these residents had specific physician orders for regular texture diets. Portion sizes were also not adhered to, as one resident received a smaller portion of Beef and Broccoli than ordered because the kitchen ran out of food. Another resident, who was supposed to receive a small portion of rice, was served using the wrong scoop size. Staff interviews confirmed that meal cards were not properly checked to ensure correct portion sizes were served. These failures were acknowledged by the staff and administration during the survey.
Incomplete Medical Record Documentation for Advance Directives and IV Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Physician Orders for Life-Sustaining Treatment (POLST) form did not document whether the resident had formulated an advance directive or if this was discussed with the resident or their legally recognized decision maker. The form was later updated by the Social Services Director (SSD), but there was no documentation showing that the update was communicated to the resident's physician prior to the modification. The resident had a moderately impaired cognitive status, as indicated by a BIMS score of 9. For another resident, there was a lack of documented evidence that the peripheral IV site was monitored for complications or signs of infiltration during the administration of intravenous vancomycin for a wound infection. The resident was unable to recall details about the IV site, and the registered nurse confirmed that there was no documentation of IV site monitoring in the medical record. Both deficiencies were acknowledged by facility leadership during interviews.
Failure to Include Hospice Team in Interdisciplinary Care Planning
Penalty
Summary
The facility failed to ensure collaborative care planning between hospice and facility staff for a resident receiving hospice services, as required by both facility policy and the hospice contract agreement. According to the facility's policy, a coordinated plan of care involving the facility, hospice agency, and resident/family should be developed, with the hospice agency retaining overall professional management responsibility. The hospice services agreement also specifies that a registered nurse from the hospice agency is responsible for participating in interdisciplinary team (IDT) meetings. For one resident under hospice care, medical record review revealed that there was no documented evidence of hospice team participation in the IDT meeting following a significant change in the resident's condition. The resident was cognitively moderately impaired and had been admitted under hospice care. Interviews with facility staff, including the Infection Preventionist (IP), DON, and Administrator, confirmed that the hospice team was not included in the IDT meeting, despite their ongoing involvement in the resident's care.
Failure to Follow Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by staff, as evidenced by multiple observed incidents of non-compliance with hand hygiene protocols. An occupational therapy assistant (OTA) was observed assisting a resident to the bathroom, removing gloves, and then handling clean items and donning new gloves without performing hand hygiene. The OTA acknowledged not washing hands after glove removal, which was contrary to the facility's hand hygiene policy. Additionally, a licensed vocational nurse (LVN 1) was observed during medication administration for two residents, failing to perform hand hygiene before and after taking blood pressure, during medication preparation and administration, and between medication administrations for different residents. Another LVN (LVN 7) was observed assisting two residents with oxygen therapy, moving between them without changing gloves or performing hand hygiene. Both LVNs confirmed the observations and recognized the lapses in infection control. The facility's policies require hand hygiene before and after resident contact and after glove removal, but these were not followed during the observed events.
Failure to Maintain Kitchen Equipment and Temperature Monitoring
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a clean and safe operating condition, as evidenced by several observations and interviews. The ice machine was found with white flaky residue and brown buildup on both the outside panel and the base near the ice maker door. The Maintenance Director confirmed that cleaning focused only on the inside of the ice maker door and was unaware of the buildup on the exterior, despite the facility's policy requiring all equipment to be kept clean and in good repair. The low temperature dishwasher was observed with missing handle covers and brown discoloration on both handles. Additionally, chlorine levels in the dishwasher were found to be over 200 PPM, exceeding the posted reference range of 50-100 PPM. Dietary staff confirmed the excessive chlorine levels and indicated that an Ecolab technician had recently adjusted the machine, which may have caused the change. Despite this, the Dishmachine Temperature and Sanitizing Agent Log for the month showed only 100 PPM recorded for all previous checks, suggesting a discrepancy between actual and documented levels. Temperature monitoring of the residents' dining room refrigerator was also not performed according to facility policy. The temperature log lacked entries for the PM shift and was missing a recorded temperature for one morning. Staff and the Registered Dietitian verified that evening shift temperatures were not being recorded as required. These failures were acknowledged by facility leadership during the survey.
Failure to Ensure Dignity and Timely Medication Administration
Penalty
Summary
The facility failed to treat a resident with dignity during the removal of an indwelling urinary Foley catheter. The staff did not obtain permission from the resident for multiple staff members to be present during the procedure, which included two male and one female staff. The resident expressed feeling upset, embarrassed, and violated by the presence of multiple staff members, particularly male staff, during the procedure. Interviews with the staff involved confirmed that permission was not sought from the resident for the presence of additional staff, and the Director of Staff Development acknowledged that only one licensed nurse is typically required for such a procedure. Additionally, the facility failed to administer medications to the same resident in a timely manner. The medications scheduled for 0900 hours were not administered until 1030 hours, which is beyond the one-hour window specified in the facility's policy. The resident reported not receiving her knee patch and meloxicam for pain management, which affected her ability to participate in physical therapy. The Medication Administration Record confirmed the delay in administering the medications, and the Licensed Vocational Nurse verified the late administration. The Director of Nursing was made aware of both deficiencies and acknowledged the findings. The failure to treat the resident with dignity and the delay in medication administration had the potential to negatively impact the resident's well-being, as noted in the report.
Delayed Medication Administration for Resident
Penalty
Summary
The facility failed to provide timely pharmaceutical services to a resident, identified as Resident 2, by not administering medications as ordered. The facility's policy requires medications to be administered within one hour of their prescribed time. However, on the day of the survey, Resident 2 did not receive her scheduled 0900 hours medications until 1030 hours, which was beyond the one-hour window. This delay was confirmed through interviews with the resident and LVN 1, as well as a review of the Medication Administration Record (MAR) and Medication Admin Audit Report. Resident 2, who was admitted to the facility with diagnoses including muscle spasms, hypertension, multiple sclerosis, and osteoarthritis, reported not receiving her knee patch and meloxicam for pain management. The delay in medication administration was further corroborated by LVN 1, who acknowledged the late administration of medications. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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