Berkley East Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 2021 Arizona Ave, Santa Monica, California 90404
- CMS Provider Number
- 555748
- Inspections on file
- 75
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Berkley East Healthcare Center during CMS and state inspections, most recent first.
A CNA recorded and posted a video of a cognitively impaired resident on social media without obtaining consent, violating facility policies and the resident's rights to privacy and dignity. The resident and responsible party were unaware of the recording and posting, and staff confirmed that no consent was documented. Facility policies prohibit such actions, and the incident was confirmed through interviews and record review.
A resident with multiple comorbidities and cognitive impairment was discharged home alone without sufficient follow-up on interdisciplinary team recommendations for a caregiver or consideration of assisted living, despite documented safety concerns and family input. The facility provided brochures for caregiver agencies, but did not ensure necessary post-discharge care or document adequate discharge planning as required by policy.
A resident with severe cognitive impairment and chronic wounds repeatedly removed their own wound dressings due to itchiness, but staff did not develop an individualized care plan to address this behavior. Facility staff and the DON acknowledged the lack of a care plan, despite policy requirements for comprehensive, person-centered care planning.
A resident with diabetes, peripheral vascular disease, and a chronic non-pressure ulcer did not receive a wound consultation from a Wound Provider Specialist, and staff failed to consistently monitor and maintain wound dressings as ordered. The resident frequently removed dressings due to discomfort, and no care plan was developed to address this behavior. Additionally, the Treatment Administration Record was inaccurately documented, including entries for care provided after the resident had been transferred out of the facility.
A high fall-risk resident with dementia and impaired cognition experienced two unwitnessed falls while attempting to ambulate to the bathroom without assistance. Despite a care plan that included using call lights and providing assistance, the resident's cognitive impairments and tendency to overestimate their abilities were not adequately addressed. Facility staff acknowledged the need for more direct supervision, such as a sitter, only after the falls occurred, highlighting a gap in proactive fall prevention strategies.
A breach of resident confidentiality occurred when a family member found medical records of other residents in a resident's room. The documents included sensitive information such as medical, demographic, and financial details, violating HIPAA and the facility's privacy policy. The Case Manager and Facility Administrator confirmed the breach, acknowledging that such records should not be accessible to unauthorized individuals.
The facility failed to manage its Cubex medication dispensing system properly, as the DON did not review daily reports for 11 months. Additionally, non-controlled drug dispositions were not recorded by two nurses as required, and outdated medications were found in a medication cart. These deficiencies could lead to medication errors and discrepancies.
The facility did not follow standardized recipes for residents on mechanical soft and dysphagia diets, serving incorrect food textures that could pose a choking risk. Observations showed that residents received sliced turkey instead of ground turkey and regular rice instead of pureed rice, contrary to the menu and food production guide. The Dietary Supervisor and Registered Dietitian confirmed the importance of adhering to texture-modified diets.
The facility failed to clean and sanitize an ice scooper daily, as required by its policy, leading to unsanitary conditions with red stains and sticky residue. The Dietary Supervisor admitted the lack of a cleaning log, and the Dishwasher confirmed no record of cleaning times. This oversight risked cross-contamination for 101 out of 102 residents receiving ice.
A facility failed to label a resident's enteral feeding bottle, which was required by policy to ensure correct administration and infection control. The resident, with severe cognitive impairment and total dependence on staff, was receiving Glucerna 1.5 via a gastrostomy tube. The LVN could not confirm when the bottle was first administered, and the DON confirmed the labeling requirement. This oversight posed a potential risk for complications.
A facility failed to obtain a physician's order for CPAP use for a resident with obstructive sleep apnea upon admission, delaying the order by two days. Additionally, staff lacked training on CPAP/BIPAP machines, with no documented competency checks or in-service training. The Director of Staff Development had not conducted necessary training, and the Director of Nursing acknowledged the risks of inadequate training.
A facility failed to provide a hemodialysis (HD) emergency kit at the bedside for a resident with end-stage renal disease (ESRD), risking delayed intervention during emergencies like bleeding. The resident, dependent on staff and cognitively impaired, did not have the kit due to family members taking them home, as confirmed by an LVN. The DON stated the kit is essential for managing bleeding emergencies, aligning with facility policy requiring kits at the bedside and on crash carts.
The facility failed to ensure staff competency in using CPAP/BIPAP machines, crucial for residents with respiratory conditions. A resident with sleep apnea did not have a CPAP order on admission, and staff interviews revealed a lack of training. The Director of Staff Development had not conducted training, and employee files lacked competency records, despite facility policy requiring trained personnel for CPAP use.
A facility failed to verify informed consent for psychotropic medications Lexapro and Seroquel for a resident with impaired cognitive skills. The resident, unable to make medical decisions, was administered these medications without proper consent from a representative. Staff interviews revealed that the informed consent process was not followed, as the consent should have been obtained from the resident's representative.
A discrepancy was found in the labeling of a controlled medication at a facility, where a bottle of morphine sulfate was labeled as containing 15 ml, but the packaging indicated 30 ml. This inconsistency was discovered during an inspection of discontinued medications meant for destruction. The facility's policy requires such discrepancies to be addressed, but this was not done, posing a potential risk for medication diversion.
The facility failed to maintain a reach-in freezer, resulting in significant ice buildup that affected food quality. The ice accumulation made it difficult to open the freezer door and compromised the storage conditions of food items, as observed with a discolored package of plant-based turkey alternative. Despite the Dietary Supervisor's request for maintenance over a month prior, the issue persisted, potentially impacting 101 out of 102 residents who consume meals from the facility's kitchen.
A resident's ring, documented on the inventory list upon admission, was not reimbursed after it went missing. The Social Services Assistant was informed by the resident's representative and completed a theft loss form, but the issue remained unresolved. The Administrator questioned the facility's responsibility due to the delayed report and lack of a receipt, and the facility's policy on lost property was not fully executed.
A resident with severe cognitive impairment and multiple diagnoses was transferred to a hospital without their representative being informed in writing about the bed-hold policy. The facility's policy requires written notification prior to transfers, but no bed-hold order or notice was documented. The DON confirmed the oversight.
A resident was not readmitted to the facility after hospitalization, despite the facility's policy allowing for such returns. The resident, with conditions like hypertensive heart disease and emphysema, was sent to a hospital due to low blood oxygen levels. Upon discharge, the facility's clinical staff decided not to readmit the resident, citing an inability to meet their needs, without providing the required notice or documentation.
Two residents experienced significant weight loss, but their care plans were not updated to address this issue. One resident lost 5.6% of their weight, and another lost 10.4%, yet the Registered Dietitian's recommendations for appetite stimulants were not incorporated into their care plans. Interviews revealed confusion over responsibility for care plan updates, with the Director of Nursing indicating that any licensed staff could revise them, while the RD believed it was the nursing staff's duty.
A resident with conditions including cellulitis, diabetes, and Parkinson's experienced confusion and hallucinations. Despite family concerns and a physician's order for a urinalysis, the facility failed to document the change in condition or conduct the test. The DON confirmed the lack of documentation and test execution, indicating a breach in facility policies.
A facility failed to provide a BIPAP machine for a resident who required continuous oxygen therapy. The resident, with a history of respiratory failure and COPD, was admitted without a BIPAP machine, and the facility did not follow its process for reviewing pre-admission documents. Attempts to use the resident's home BIPAP machine were unsuccessful due to missing parts, and a new machine ordered by the facility was incompatible. This oversight placed the resident at risk for inadequate oxygenation.
The facility failed to document glucometer QC results on multiple days and did not secure the medication disposal bin, risking inaccurate blood sugar readings and medication diversion. The DON confirmed the lapses, which violated the facility's policies on glucometer testing and medication disposal.
The facility failed to implement its infection control policy, as staff members did not perform hand hygiene after resident contact, and visitors were not screened before entry. Observations showed staff moving between resident rooms without washing hands, and visitors entering without masks or temperature checks. The absence of staff at the front desk during lunch breaks left visitors unscreened, despite an active COVID-19 outbreak.
A power outage in an LTC facility left 88 residents without power for over 30 minutes due to a delayed generator start. A resident was unable to use their CPAP machine and had to sleep on a deflated mattress. The delay was caused by a breaker switch not being in the 'ON' position, which was discovered after a significant delay.
A resident with COPD and asthma was found with an albuterol inhaler at their bedside, which they used without facility authorization. The resident required assistance for daily activities and had not been assessed for self-medication. An LVN confirmed that the facility was administering the inhaler and expressed concern about potential double dosing, as the resident was not allowed to self-administer medications according to facility policy.
A resident with a history of falls and cognitive impairment was left unattended in the bathroom, resulting in a fall and a mild displaced fracture of the right femoral neck. Despite being assessed as high risk for falls, the resident was left alone, leading to the incident. Staff interviews revealed a lack of communication regarding the resident's needs, contributing to the deficiency.
A resident with a history of falls and multiple medical conditions experienced a fall and was not properly assessed for injuries by an LVN. The LVN failed to perform a thorough neuro check, relying only on the resident's verbal denial of pain. This oversight delayed the diagnosis of a right hip fracture, as the resident later expressed pain during a physical therapy session. The facility's policy required a comprehensive assessment after falls, which was not followed.
A resident with a history of falls and multiple medical conditions fell and sustained a hip fracture due to inadequate staffing at a facility. The resident required assistance with toileting, which was not provided due to CNA shortages. On the day of the incident, only three CNAs were available for a shift, each responsible for 14-15 residents, leading to delays in care and the resident being left unattended.
A resident with hypertension and other medical conditions did not receive her antihypertensive medications on time, as observed during a survey. The LVN responsible admitted to administering the medications late, beyond the facility's policy of within one hour of the prescribed time. The delay was attributed to the time taken by residents to take their medications, despite the LVN starting the medication pass on time.
A resident experienced respiratory distress due to the facility's failure to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation. The NRBM was set to an insufficient oxygen flow, and the reservoir bag was not fully inflated, leading to inadequate oxygen delivery.
The facility failed to ensure that licensed nurses had the skills and knowledge to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation for a resident. The resident was found with low oxygen saturation, and the staff set the oxygen flow incorrectly, leading to inadequate oxygen delivery. The facility's training on oxygen use was based on personal experience rather than a structured curriculum, and staff did not adhere to the facility's policy for using the NRBM.
The facility failed to develop a discharge care plan for a resident with multiple diagnoses and severely impaired cognition. Despite the issuance of eviction notices, the care plan was not initiated or updated in a timely manner, as required by facility policies.
Violation of Resident Privacy and Dignity Through Unauthorized Social Media Posting
Penalty
Summary
Certified Nursing Assistant (CNA) 1 violated a resident's rights to privacy, dignity, and respect by recording a video of the resident without obtaining consent from either the resident or the resident's responsible party. The resident, who had severe cognitive impairment and required moderate to maximal assistance with activities of daily living, was not aware that a video was being taken or that it would be posted on social media. The facility's policies explicitly prohibit staff from taking or releasing images or recordings of residents without explicit written consent, except under specific circumstances such as investigations or emergencies. Despite these policies, CNA 1 admitted to posting a video of the resident on her personal Instagram story and to FaceTiming friends while in the resident's room. The Director of Nursing (DON) and other staff confirmed that the images and video were of the resident and that no consent had been obtained. The resident's responsible party expressed shock and concern over the incident, emphasizing the resident's desire for privacy and the lack of understanding or consent regarding the sharing of images. The responsible party also highlighted the resident's vulnerability and the potential for harm to the resident's dignity and self-esteem. Interviews with facility staff, including social services and nursing leadership, confirmed that taking photos or videos of residents without proper consent is a violation of both facility policy and resident rights. The facility's review of records found no documentation of consent for the images or video. The incident was reported to the district office, and the facility's policies regarding privacy, use of personal devices, and protection of protected health information were reviewed and found to have been violated by CNA 1's actions.
Failure to Ensure Safe and Adequate Discharge Planning
Penalty
Summary
The facility failed to provide sufficient preparation and orientation for a safe and orderly discharge for one resident. The interdisciplinary team (IDT) did not follow up on the care conference recommendations regarding discharge planning during the resident's admission. Although the care plan and discharge planning review identified that the resident lived alone and would require a caregiver (CG) for safety, there was no documented evidence that these recommendations were fully implemented or followed up. The resident had multiple diagnoses, including infrarenal abdominal aortic aneurysm, type II diabetes mellitus, muscle weakness, and major depressive disorder, and was noted to have moderately impaired cognitive skills and fluctuating capacity to make decisions. The resident's family expressed concerns about his safety living alone, and the general acute care hospital social worker recommended discharge to an assisted living facility (ALF) due to the resident's comorbidities and home situation. Despite these concerns, the resident was discharged home alone with home health services, and there was no documentation confirming that a caregiver was arranged or that ALF was presented as an option. Interviews with staff revealed that while the resident was provided with brochures for caregiver agencies, he stated he could not afford a caregiver, and no information about ALF was given. The facility's policy required documentation of discharge planning and arrangements for post-discharge care, but the medical record did not reflect adequate follow-up or evidence that the necessary care and services were provided upon discharge.
Failure to Develop Individualized Care Plan for Wound Dressing Removal Behavior
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive, individualized care plan addressing a resident's behavior of removing their own wound dressings. The resident, who had a history of surgical aftercare, Type II diabetes mellitus, peripheral vascular disease, and a chronic non-pressure ulcer on the right ankle, was assessed as having severely impaired cognitive skills and required moderate to maximal assistance with activities of daily living. Despite these needs and the resident's behavior of removing wound dressings due to itchiness, there was no care plan in place to address this specific behavior. Interviews with facility staff confirmed that the behavior was known, as the resident would often be found with dressings removed, and staff acknowledged that a care plan should have been developed to address this issue. The Director of Nursing stated that the absence of a care plan for this behavior could put the resident at risk, and that such incidents should have been documented and communicated to the physician. Review of facility policies confirmed the requirement for comprehensive, person-centered care plans with measurable objectives and timeframes for each resident.
Failure to Obtain Wound Consultation, Maintain Wound Care, and Ensure Accurate Documentation
Penalty
Summary
The facility failed to obtain a wound consultation and assessment by a Wound Provider Specialist (WPS) for a resident admitted with multiple risk factors for poor wound healing, including Type II diabetes mellitus, peripheral vascular disease, and a chronic non-pressure ulcer of the right ankle. Despite the resident's complex medical history and the presence of surgical and arterial wounds, there was no documentation of a WPS evaluation from admission through the resident's discharge. Nursing staff noted that the resident was supposed to be seen by the WPS, but the consultation did not occur, and the resident's wounds and skin integrity were not evaluated by a specialist. Additionally, the facility did not ensure that wound dressings were monitored and maintained according to physician orders. The resident exhibited behaviors such as removing wound dressings due to discomfort, leaving wounds exposed. Nursing staff acknowledged that dressings were often found removed during their shifts, and there was no care plan developed to address the resident's behavior of removing dressings. The facility's Director of Nursing confirmed that staff should have reapplied dressings to keep wounds clean and dry as ordered, but this was not consistently done. The facility also failed to maintain accurate and objective documentation in the Treatment Administration Record (TAR). The TAR indicated that all skin treatments were documented as given, even on dates when the resident was no longer present in the facility due to transfer to an acute care hospital. The Director of Nursing identified this as fraudulent documentation, as it did not reflect the resident's actual presence or care provided. These deficiencies were contrary to the facility's policies and procedures regarding wound care, documentation, and consulting physician practices.
Inadequate Supervision Leads to Recurrent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a high fall-risk resident, resulting in two unwitnessed falls. Resident 1, who has a history of falls, dementia, and impaired cognition, experienced falls on 2/5/2025 and 3/19/2025 while attempting to ambulate to the bathroom without assistance. Despite being identified as a high fall risk, the resident was not adequately supervised, leading to these incidents. Resident 1's care plan included interventions such as using call lights for assistance and providing help with activities of daily living. However, the resident's cognitive impairments and tendency to overestimate their abilities were not sufficiently addressed, as evidenced by the resident's repeated attempts to ambulate independently. Interviews with facility staff revealed that the resident often did not ask for assistance and had a history of frequent falls, indicating a need for more direct supervision. Observations and interviews highlighted the resident's confusion and reluctance to seek help, as well as the facility's lack of effective fall prevention measures, such as bed alarms or a consistent one-to-one observation. The facility's policy on fall risk management was not effectively implemented, as the resident continued to experience falls despite being identified as high risk. The staff's acknowledgment of the need for a sitter or other interventions came only after the falls occurred, indicating a gap in proactive fall prevention strategies.
Breach of Resident Confidentiality and Privacy
Penalty
Summary
The facility failed to protect and safeguard the personal and medical records of 11 out of 13 sampled residents, violating their rights to privacy. This deficiency was identified during a survey when a family member of a resident found a stack of documents in a resident's room that did not belong there. These documents contained sensitive medical and personal information of other residents, which should have been kept confidential according to the facility's policy and procedures. The documents found included other residents' medical records, demographics, financial information, insurance details, clinical information, and personal living information. The Case Manager confirmed that these documents were not supposed to be in the resident's room and acknowledged that their presence there was a violation of the Health Insurance Portability and Accountability Act (HIPAA). The exposure of these records to unauthorized individuals was a breach of confidentiality and privacy, as it made sensitive information accessible to other residents and their families. The Facility Administrator also confirmed that the presence of these documents in the resident's room was a violation of HIPAA. The facility's policy, titled 'Confidentiality of Information and Personal Privacy,' mandates that access to resident personal and medical records should be limited to authorized staff and business associates. The incident was reported to the facility's HIPAA compliance officer, and a case was opened to address the breach of privacy.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper management and oversight of its medication dispensing system, Cubex, for at least 11 months. The Director of Nursing (DON) was unable to access or review daily activity and discrepancy reports from the Cubex system, as required by facility policy. Despite the system being installed in the facility, the DON did not recall reviewing any reports, and it was discovered that the facility had not received any reports since the system's installation. The facility pharmacy corrected the email address in the system, which allowed the facility to start receiving autogenerated reports. This lack of oversight had the potential to lead to medication errors and discrepancies. Additionally, the facility did not adhere to its policy regarding the disposition of non-controlled drugs, which requires the presence and signatures of two licensed nurses. For at least 8 months, the medication disposition logs showed only one nurse's signature, except for one instance. Furthermore, outdated medications were found stored in a medication cart, specifically two inhalers with open dates indicating they should have been discarded. The failure to remove expired medications from the cart was confirmed by the DON, who acknowledged that the inhalers should have been disposed of according to the facility's policy.
Failure to Follow Dietary Guidelines for Texture-Modified Diets
Penalty
Summary
The facility failed to adhere to the standardized recipes for the lunch menu on 12/16/24, specifically for residents on mechanical soft and dysphagia diets. Observations revealed that 25 residents on a mechanical soft diet received Cajun country rice with sliced turkey instead of the prescribed ground turkey. Additionally, a resident on a dysphagia diet was served baked fish instead of ground fish and regular rice instead of pureed rice, contrary to the food production guide. These deviations from the menu were confirmed during interviews with Cook1, who acknowledged the mistake and the potential risk of choking due to incorrect food textures. The Dietary Supervisor and Registered Dietitian confirmed that the menu should have been followed, emphasizing the importance of texture-modified diets to prevent choking. The facility's policy and procedures, as well as specific recipes, indicated that meats for mechanical soft diets should be ground, and for dysphagia diets, the fish should be ground and rice pureed. The failure to follow these guidelines was observed during a taste test, where the food served did not meet the required texture modifications, posing a risk to the residents' safety.
Failure to Maintain Sanitary Conditions for Ice Scooper
Penalty
Summary
The facility failed to ensure safe food handling practices by not cleaning and sanitizing an ice scooper daily as per the facility's policy and procedure titled 'Ice Procedures.' During an observation, the ice scooper was found stored in an unsanitary condition with red stains and a sticky texture, which the Dietary Supervisor (DS) attributed to juice residue. The DS acknowledged that the ice scooper is used to transfer ice into water and juice pitchers for residents and admitted that the facility does not maintain a log or record of when the ice scooper is cleaned. This oversight had the potential to result in harmful bacteria growth and cross-contamination, affecting 101 out of 102 residents who received ice from the facility. The Dishwasher (DW), who works morning shifts, confirmed that he washed the ice scooper that morning but could not recall the exact time and also stated that no record is kept of the cleaning schedule. The facility's policy, dated 2018, requires that ice scoops be washed daily by the PM Dishwasher or specified on the daily cleaning schedule. The 2022 U.S. Food and Drug Administration Food Code mandates that surfaces of utensils and equipment contacting food be cleaned routinely to prevent the development of microorganisms. The facility's failure to adhere to these guidelines and maintain proper records contributed to the deficiency.
Failure to Label Enteral Feeding Bottle
Penalty
Summary
The facility failed to label the enteral feeding of Resident 141, who was admitted with diagnoses including tongue cancer, dysphagia, and endocarditis. The resident's Minimum Data Set indicated severe cognitive impairment and total dependence on staff for various activities, including feeding. The physician's orders specified the administration of Glucerna 1.5 via a gastrostomy tube at a controlled rate, with specific instructions for labeling and infection control. However, during an observation, it was noted that the enteral feeding bottle was not labeled, and the Licensed Vocational Nurse (LVN) present could not confirm when the bottle was first administered. The Director of Nursing confirmed that the facility's policy requires labeling of enteral feeding bottles with the resident's name, room number, and feeding rate to ensure correct administration and infection control. The facility's policy on enteral nutrition, revised in 2018, outlines the necessary components of complete orders, including labeling instructions. The failure to label the feeding bottle as per policy posed a potential risk for complications associated with enteral feeding, such as infection.
Failure to Obtain Physician's Order and Train Staff on CPAP/BIPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of a CPAP machine for a resident diagnosed with obstructive sleep apnea upon their admission. The resident was admitted with a diagnosis that included obstructive sleep apnea and polyneuropathy, yet there was no physician order for CPAP use on the day of admission. The order was only documented two days later. The resident's care plan was initiated a day after admission, indicating the need for CPAP/BIPAP machine use, but the lack of timely physician orders posed a risk for respiratory distress. Additionally, the facility staff, including registered nurses and licensed vocational nurses, lacked training on the use of CPAP/BIPAP machines. Interviews with the staff revealed that they had not received any training on how to use these machines, and there was no documentation of annual skills competency checks or in-service training in their employee files. The Director of Staff Development acknowledged the importance of such training but had not yet conducted it. The Director of Nursing also noted the potential risks of inadequate training, such as increased carbon dioxide levels and respiratory distress, but could not provide evidence of previous training sessions.
Absence of Hemodialysis Emergency Kit at Bedside
Penalty
Summary
The facility failed to ensure that a hemodialysis (HD) emergency kit was available at the bedside for a resident with end-stage renal disease (ESRD), which is crucial for managing potential emergencies such as accidental bleeding. The resident, who was admitted and readmitted to the facility with diagnoses including ESRD, metabolic encephalopathy, and generalized muscle weakness, was dependent on staff for activities of daily living and had cognitive impairment. During an observation, it was noted that the HD emergency kit was not present at the bedside, and a Licensed Vocational Nurse (LVN) confirmed that the kits were no longer kept at the bedside due to family members taking them home. The Director of Nursing (DON) acknowledged that the HD emergency kit should be at the bedside for easy access in case of emergency bleeding, which could lead to hypovolemic shock if not promptly addressed. The facility's policy on the care of residents with ESRD, reviewed in January 2024, indicated that an emergency kit should be provided at the bedside and on crash carts. The absence of the HD emergency kit at the bedside had the potential to delay life-saving interventions during accidental bleeding, as stated by both the LVN and the DON.
Lack of Staff Competency in CPAP/BIPAP Use
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the use of CPAP/BIPAP machines, which are critical for treating residents with sleep apnea and other respiratory conditions. Resident 191, who was admitted with a diagnosis of obstructive sleep apnea, did not have a physician order for CPAP use on the day of admission, although it was later added. Interviews with staff, including a Registered Nurse and two Licensed Vocational Nurses, revealed that they had not received training on the use of CPAP/BIPAP machines at the facility, despite the potential for serious consequences such as respiratory distress if the machines are not used correctly. The Director of Staff Development, who had been employed for one month, acknowledged the importance of staff being knowledgeable about CPAP/BIPAP use but had not yet conducted relevant training. The Director of Nursing mentioned that a previous in-service training had been conducted but could not provide documentation. A review of employee files confirmed the absence of annual skills competency checklists or in-service training records for CPAP/BIPAP use. The facility's policy stated that only qualified and properly trained personnel should administer oxygen through a CPAP mask, highlighting a gap between policy and practice.
Failure to Verify Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to properly verify informed consent before administering psychotropic medications Lexapro and Seroquel to a resident. The resident, who was admitted with diagnoses including encephalopathy, sepsis, and heart failure, was found to have severely impaired cognitive skills and required total assistance with daily activities. Despite this, the facility's records indicated that informed consent was verified directly with the resident, who lacked the capacity to make medical decisions. The sections of the informed consent forms that should have indicated the resident's capacity to consent were left blank. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, revealed that the informed consent process was not properly followed. The RN Supervisor acknowledged that the consent should have been obtained from the resident's representative, given the resident's inability to make medical decisions. The Director of Nursing explained that informed consent is crucial to ensure that residents or their representatives are aware of the risks and benefits of medications. The facility's policy required that a surrogate decision maker be identified if a resident lacks capacity, but this was not adhered to in this case.
Discrepancy in Controlled Medication Labeling
Penalty
Summary
The facility failed to ensure that the label on a controlled medication matched the correct quantity received, which had the potential for diversion of controlled medications. During an observation at Nursing Station 1, a bundle of discontinued controlled medications was found wrapped together in a locked compartment. A Licensed Vocational Nurse (LVN) stated these medications were to be brought to the Director of Nursing (DON) for disposition. However, the DON was in a meeting, and the medications were handed off to a Registered Nurse (RN) for later destruction with the facility pharmacist. Among these medications was a bottle of morphine sulfate labeled as containing 15 ml, but the prints on the box and bottle indicated 30 ml, creating a discrepancy. The Quality Assurance nurse and the DON confirmed that the quantity sent by the pharmacy did not match the label and the delivery receipt, which indicated a delivery of 15 ml. The facility's policy and procedures require that improperly or inaccurately labeled medications be rejected and returned to the pharmacy, but this was not adhered to in this instance. The incident was identified as having the potential for diversion, as the accountability record showed no indication of use, and the bottle was reportedly unopened.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the reach-in freezer in good operating condition, leading to significant ice buildup inside and outside the freezer. This ice accumulation was observed on the ceiling, walls, door, and gasket of the freezer, making it difficult to open the door. The ice buildup had the potential to affect the quality of food stored within, as evidenced by a package of plant-based turkey alternative food that showed frost buildup and discoloration. The freezer's condition was noted during an observation in the kitchen, and the Dietary Supervisor acknowledged awareness of the issue, having requested maintenance to address it over a month prior. The Maintenance Supervisor indicated that an outside vendor had serviced the freezer over a year ago, but was unaware of the current ice issue until the observation. The facility's policies from 2018 emphasize the importance of maintaining kitchen equipment in good working order and ensuring the cleanliness and functionality of refrigerators and freezers. Despite these policies, the freezer's condition was not addressed in a timely manner, resulting in the potential for compromised food quality for 101 out of 102 residents who rely on the facility's kitchen for meals.
Failure to Reimburse Missing Ring
Penalty
Summary
The facility failed to protect a resident from potential misappropriation of property by not reimbursing a missing ring that was included on the resident's inventory list upon admission. The resident, who was admitted with multiple health conditions including metabolic encephalopathy and chronic respiratory failure, had an inventory list that documented two yellow rings with an emerald. Upon a subsequent admission, only one ring was listed, and the facility did not resolve the issue of the missing ring. The Social Services Assistant (SSA) was informed by the resident's representative (RR) about the missing ring and was shown a picture of a similar ring from the internet. The SSA completed a theft loss form and submitted it to the Administrator for reimbursement. However, the SSA did not document an unknown staff member's statement that the resident was wearing the ring when transferred to a General Acute Care Hospital (GACH), nor did they update the RR with this information. The Director of Social Services confirmed that the issue was unresolved. The Administrator acknowledged the missing ring was reported two months after the resident's transfer to the GACH, which led to questions about the facility's responsibility. The facility's policy required documentation and investigation of lost or stolen property worth $100 or more, but the lack of a receipt for the ring and the delayed report complicated the situation. The facility did not report the incident to the police due to the time lapse, and communication with the RR ceased, leaving the issue unresolved.
Failure to Provide Bed-Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to inform a resident's representative in writing about the bed-hold and return policy when the resident was transferred to a General Acute Care Hospital. This deficiency was identified during a review of the facility's policy and procedures, which require that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves. The policy outlines the rights and limitations regarding bed-holds, the reserve bed payment policy for Medicaid residents, the facility per diem rate for non-Medicaid residents, and details of the transfer. The resident involved had been admitted to the facility with diagnoses including hypertensive heart disease, emphysema, and dysphagia, and had severely impaired cognitive skills requiring moderate assistance for daily activities. The resident was transferred to the hospital due to low blood oxygen levels, but there was no documentation of a bed-hold order or notice in the resident's medical records. The Director of Nursing confirmed that there was no bed-hold notice completed, which should have been provided to the resident's responsible party.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident following hospitalization, contrary to its policy and procedure for transfer or discharge. The resident, who had been admitted with conditions including hypertensive heart disease, emphysema, and dysphagia, was sent to a general acute care hospital due to low blood oxygen levels. After the hospital indicated the resident was ready for discharge, the facility's business development team received the referral for readmission. However, the clinical staff, including the Director of Nursing (DON) and the Administrator, decided not to readmit the resident, citing an inability to accommodate the resident's needs. The DON stated that the facility could meet the resident's post-hospitalization care plan but was unaware of the hospital's referral. The facility did not provide reasonable and appropriate notice or documentation explaining why they could not accommodate the resident after hospitalization. The facility's policy requires that residents sent to an acute care setting be permitted to return unless the facility cannot meet their needs, in which case written notification and appeal rights must be provided. The facility did not follow this procedure, resulting in the resident remaining in the hospital.
Failure to Revise Care Plans for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plans for two residents who experienced significant weight loss. Resident 1, admitted with conditions such as hypertensive heart disease, emphysema, and dysphagia, showed a weight decrease from 107 pounds to 100 pounds over a short period. Despite the Registered Dietitian (RD) noting a 5.6% weight loss and recommending an appetite stimulant, the care plan initiated on 7/10/2024 was not updated to reflect these changes. Similarly, Resident 2, with diagnoses including respiratory failure and Type II Diabetes Mellitus, experienced a weight drop from 132 pounds to 121 pounds, equating to a 10.4% loss within a month. The RD also suggested an appetite stimulant for Resident 2, but the care plan remained unchanged since its initiation. Interviews with the RD and the Director of Nursing (DON) revealed a lack of clarity regarding responsibility for updating care plans. The RD believed it was the nursing staff's duty to revise care plans, while the DON stated that any licensed staff, including the RD, could make revisions. The facility's policy indicated that care planning for weight loss should be a multidisciplinary effort, involving the physician, nursing staff, dietitian, consultant pharmacist, and the resident or their legal surrogate. The failure to update the care plans for these residents placed them at risk for further weight loss.
Failure to Document Change in Condition and Execute Physician's Order
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident by not ensuring proper documentation and execution of medical orders. The resident, who was admitted with conditions including cellulitis, diabetes mellitus, and Parkinson's Disease, experienced a change in condition characterized by confusion and hallucinations. Despite the family's concerns and a physician's order for a urinalysis to investigate these symptoms, there was no documentation of the change in condition or the physician's order in the resident's medical record. Additionally, the urinalysis was not conducted as ordered, which was confirmed by the Director of Nursing during a review of the resident's records. The facility's policies and procedures require documentation of changes in condition and the processing of test requisitions, but these were not followed. Interviews with the Director of Nursing and the Licensed Vocational Nurse involved revealed a lack of documentation and failure to carry out the physician's order, highlighting deficiencies in the facility's adherence to its own policies.
Failure to Provide BIPAP Machine for Oxygen-Dependent Resident
Penalty
Summary
The facility failed to ensure the availability of a BIPAP machine for a resident who was oxygen-dependent and required continuous oxygen therapy. The resident, a female with a history of respiratory failure, COPD, and dependence on supplemental oxygen, was admitted to the facility without a BIPAP machine from 6/21/2024 to 6/25/2024. Despite the physician's order for the family to bring the home BIPAP machine, the machine was not available, and the resident was placed on a nasal cannula instead. The Director of Nursing (DON) admitted that the facility's process for reviewing pre-admission documents was not followed, as the necessary paperwork was not reviewed before the resident's admission. This oversight led to the absence of a BIPAP order in the resident's physician orders from 6/21/2024 to 7/3/2024. The facility's staff attempted to use the resident's home BIPAP machine, but it was missing a part, and efforts to contact the family for the missing part were unsuccessful. The facility's central supply ordered a new BIPAP machine, but it was not compatible with the resident's needs, lacking a tube to connect to the oxygen. The resident's original machine was eventually made operational, but the resident frequently removed the mask, leading to decreased oxygen saturation levels. The facility's failure to ensure the availability and proper setup of the BIPAP machine placed the resident at risk for shortness of breath and inadequate oxygenation.
Failure to Document Glucometer QC and Secure Medication Disposal
Penalty
Summary
The facility failed to document Quality Control (QC) results for the glucometer on multiple days, as required by their policy. This deficiency was identified during an interview and record review with the Director of Nursing (DON), where it was found that the Daily Quality Control Record for Blood Glucose Testing had blank entries on several dates. The DON acknowledged that QC for the glucometer should be conducted every night during the 11 p.m. to 7 a.m. shift and documented accordingly. The absence of these records could lead to inaccurate blood sugar readings and subsequent incorrect insulin administration. Additionally, the facility did not adhere to its medication disposal policy. During an observation and interview with the DON in the medication storage room, it was noted that the medication disposal bin was not secured properly, allowing easy access to intact pills of various colors and sizes. The DON confirmed that the bin's top should be closed, and pills should be destroyed by adding hot water. The unsecured bin posed a risk of medication diversion, where medications could be removed and reused. The facility's policy on medication disposal, revised in 2019, outlines specific procedures for the secure disposal of unused medications, including controlled substances. These procedures include retaining unused controlled substances in a locked area, disposing of non-controlled substances according to state and federal guidelines, and ensuring that controlled substances are rendered non-retrievable. The failure to follow these procedures could lead to unauthorized access and potential misuse of medications, compromising resident safety.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to implement its infection control policy to prevent the spread of COVID-19 and other diseases. Observations revealed that several staff members, including a Licensed Vocational Nurse (LVN 1), a Certified Nursing Assistant (CNA 1), and Central Supply staff (CS 1 and CS 2), did not perform hand hygiene after contact with residents and their environment. LVN 1 and CNA 1 acknowledged the need for hand hygiene to prevent infection spread, yet were observed entering and exiting resident rooms without washing hands or using hand sanitizer. Similarly, CS staff were seen moving between resident rooms and touching equipment without performing hand hygiene, despite acknowledging the potential for infection transmission. Additionally, the facility failed to ensure visitors were screened before entry. Observations in the lobby showed no staff present to conduct screenings, allowing visitors to enter without masks, temperature checks, or completing COVID-19 questionnaires. The Admissions Coordinator and Administrator confirmed the absence of staff at the front desk during lunch breaks, leaving visitors unscreened. The Director of Nursing and Infection Preventionist Nurse emphasized the importance of hand hygiene and visitor screening, especially during an active COVID-19 outbreak, to prevent further spread of infection.
Delayed Generator Start Causes Power Outage
Penalty
Summary
The facility failed to ensure that the emergency generator started and transferred power within 10 seconds after a power outage, resulting in a lack of power for over 30 minutes for all 88 residents. On the night of the incident, the generator did not start promptly due to a breaker switch not being in the 'ON' position, which was discovered by the Maintenance Assistant after a delay. This delay in power restoration affected the residents, including one who was unable to use their CPAP machine and had to sleep on a deflated low-air loss mattress, causing discomfort. The Director of Maintenance and the Maintenance Assistant provided conflicting accounts of the generator's usual start time, with the Assistant indicating a delay of 20-30 minutes on the night of the outage. The facility's policy required the generator to operate as designed, but the maintenance records did not indicate that critical equipment like the CPAP machine and mattress were connected to generator-powered outlets. The Director of Maintenance was responsible for maintaining the generator, but the incident revealed a lapse in ensuring the generator's readiness and the staff's ability to manage the situation effectively.
Medication Management Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that a resident's albuterol sulfate medication was not left unattended. The resident, who was admitted with diagnoses including emphysema, COPD, and asthma, had mildly impaired cognitive skills and required moderate to maximal assistance for activities of daily living. Despite this, the resident's albuterol inhaler was found at their bedside, labeled with their name, and was reportedly brought from home. The resident stated they used the inhaler themselves whenever needed, indicating a lack of assessment for self-administration of medication. During an observation and interview, a Licensed Vocational Nurse (LVN) confirmed that residents should be assessed for their ability to self-administer medications. The LVN noted that the facility was administering the albuterol inhaler for the resident and had their own medication supply. The presence of the resident's personal inhaler at the bedside was against the facility's policy, which requires medications to be administered as prescribed and only by authorized personnel. The LVN expressed concern that the resident might be at risk of respiratory issues due to potential double dosing, as the facility had not authorized the resident to self-administer medications.
Resident Left Unattended Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed as high risk for falls, resulting in the resident being left unattended in the bathroom. This oversight led to the resident falling and sustaining a mild displaced comminuted subcapital fracture of the right femoral neck. The resident, who had a history of falls and cognitive impairment, was found on the bathroom floor by staff after being left alone in his room. The resident's medical history included atrial fibrillation, congestive heart failure, cervical fractures, and repeated falls, which necessitated the use of a neck brace and increased supervision. The resident's care plan specifically indicated the need for assistance with toileting and not leaving the resident unattended. Despite these precautions, the resident was left alone, leading to the fall and subsequent injury. Interviews with staff revealed a lack of communication and understanding of the resident's needs. The CNA assigned to the resident was not fully aware of the resident's fall risk and required level of assistance, partly due to a lack of a proper handover and being short-staffed. The facility's policy on fall management was not adequately followed, as the resident's supervision needs were not communicated effectively to all staff members, contributing to the incident.
Failure to Perform Accurate Neuro Check After Resident Fall
Penalty
Summary
The facility failed to accurately perform a neuro check on a resident after a fall, which could have delayed necessary medical intervention. The resident, who had a history of falls and was at high risk for recurrent falls, was found on the bathroom floor but initially denied any pain. The resident had multiple medical conditions, including atrial fibrillation, congestive heart failure, and a history of falls, which made him dependent on assistance for daily activities and decision-making. On the morning following the fall, an LVN conducted a neuro check but did not properly assess the resident's leg strength or pain, relying solely on the resident's verbal denial of pain. This oversight was significant because later that morning, the resident expressed pain during a physical therapy session, leading to a delayed diagnosis of a right hip fracture. The LVN admitted to not performing a thorough assessment, which could have identified the resident's pain earlier. The facility's policy required a comprehensive assessment following a fall, including checking for changes in consciousness, range of motion, and functional mobility. However, the LVN did not adhere to these protocols, as confirmed by the Director of Nursing, who stated that proper neuro checks involve assessing limb strength and not just asking about pain. This failure to follow established procedures contributed to the delay in identifying the resident's injury.
Inadequate Staffing Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate certified nursing assistants (CNAs) to meet the needs of its residents, specifically impacting one resident who required assistance with toileting. This deficiency resulted in the resident falling while unattended in the bathroom, leading to a right hip fracture. The resident, who had a history of falls and was at high risk for recurrent falls, was admitted with multiple medical conditions, including atrial fibrillation, congestive heart failure, and a recent cervical fracture. The resident's care plan included fall precautions and assistance with toileting, which were not adequately provided due to staffing shortages. On the day of the incident, the facility was short-staffed, with only three CNAs available for the 3:00 p.m. to 11:00 p.m. shift, each responsible for 14-15 residents. This was due to two CNA call-offs, and the facility attempted to cover the shortage by calling in additional CNAs who arrived later in the shift. The CNAs on duty were unable to attend to all residents promptly, leading to delays in responding to call lights and providing necessary assistance. The resident in question was left unattended, resulting in a fall and subsequent injury. Interviews with staff revealed that the facility's staffing projections were based on the previous day's census and anticipated admissions. However, the actual staffing levels were insufficient to meet the needs of high-acuity residents, such as the one involved in the incident. The facility's policy required sufficient staffing to provide care according to residents' care plans, but this was not achieved, contributing to the resident's fall and injury.
Untimely Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to administer antihypertensive medications timely for Resident 4, a [AGE] year-old female with a history of hypertension, COPD, diabetes mellitus, asthma, and aftercare following shoulder joint prosthesis. The resident was admitted on 5/15/2024, and her physician orders included Amlodipine Besylate, Lisinopril, and Metoprolol, all to be administered for hypertension with specific instructions to hold if the systolic blood pressure was less than 100. On 5/31/2024, during an observation and interview, LVN 4 was found administering these medications late, acknowledging that they were due at 9:00 a.m. but were being given after 10:45 a.m. The LVN noted that the resident's blood pressure was 141/71, taken at 7:00 a.m., and admitted to not rechecking it before administering the medication. The facility's policy, revised in 4/2019, requires medications to be administered within one hour of their prescribed time unless specified otherwise. LVN 4 cited that some residents take a long time to take their medications, which contributed to the delay, despite starting the medication pass at 8:00 a.m. This practice was in violation of the facility's policy and placed Resident 4 at risk of elevated blood pressure due to the untimely administration of her antihypertensive medications.
Failure to Apply Non-Rebreather Oxygen Mask Correctly
Penalty
Summary
The facility failed to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation for a resident, leading to inadequate oxygen delivery. The resident, a male with multiple diagnoses including Parkinson's Disease, Asthma, and Heart Disease, was admitted on 4/27/2024. On 5/11/2024, the resident experienced anaphylaxis and was found with a red flushed face, low oxygen saturation (79%), and low blood pressure. The Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) initially administered oxygen via nasal cannula at 2 liters per minute (lpm), but the resident's oxygen saturation remained in the 80s. The RNS then received an order to use the NRBM but set the oxygen flow to only 5 lpm, which was insufficient to fully inflate the reservoir bag. The LVN placed the NRBM on the resident without fully inflating the bag, and although oxygen was flowing, the bag remained mostly flat. The resident's oxygen saturation improved to 94% but dropped if the mask was removed. The paramedics, upon arrival, noted that the bag was not adequately inflated and increased the oxygen flow, although the facility's oxygen regulators only went up to 10 lpm. The facility's policy and procedure for using a non-rebreather mask require the oxygen flow to be set between 10-15 lpm to ensure the reservoir bag is fully inflated during exhalation and only partially deflates during inspiration. The deficiency in applying the NRBM correctly could have caused the resident to remain in respiratory distress. The facility's failure to follow the proper procedure for using the NRBM, including not setting the oxygen flow to the required 10-15 lpm and not fully inflating the reservoir bag, led to inadequate oxygen delivery in an emergent situation. This incident highlights the importance of adhering to established protocols for respiratory care to ensure resident safety and effective treatment during emergencies.
Failure to Properly Apply Non-Rebreather Oxygen Mask
Penalty
Summary
The facility failed to ensure that licensed nurses had the skills and knowledge to correctly apply a non-rebreather oxygen mask (NRBM) in an emergent situation for one of three sampled residents. Resident 1, a male with multiple diagnoses including Parkinson's Disease, Asthma, and Heart Disease, was found with a red flushed face and an oxygen saturation (O2 sat) of 79% without supplemental oxygen. The Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) initially placed the resident on 2 liters per minute (lpm) of oxygen via nasal cannula, which did not sufficiently improve the O2 sat. The RNS then received an order to use the NRBM but set the oxygen flow to only 5 lpm, which was insufficient to fully inflate the reservoir bag, leading to inadequate oxygen delivery. When the paramedics arrived, they noted that the bag on the mask was not inflated enough and increased the oxygen flow, which the facility's equipment could only support up to 10 lpm. The Director of Staff Development (DSD) demonstrated the use of the NRBM but also failed to fully inflate the reservoir bag before placing it on a mannequin. The DSD admitted to not having a lesson plan for the oxygen training conducted on 5/10/2024 and stated that the training was based on personal experience rather than a structured curriculum. Further observations revealed that another Registered Nurse (RN) also failed to fully inflate the reservoir bag before placing the mask on a resident. The facility's policy and procedure for using a non-rebreather mask clearly stated that the oxygen flow should be set to approximately 15 lpm and the bag should be fully inflated before placing the mask on the resident. The lack of proper training and adherence to the facility's policy led to the deficient practice, which could have caused Resident 1 to remain short of breath and potentially placed other residents at risk.
Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop a care plan for discharge planning for a resident, which was identified during an interview and record review. The resident, a male with multiple diagnoses including Parkinson's disease, chronic kidney disease, dementia, anxiety, adult failure to thrive, and dysphagia, was admitted to the facility and had severely impaired cognition. The resident was totally dependent on staff for various activities of daily living and was under hospice care. Despite the resident's complex medical needs and the issuance of eviction notices, the facility did not develop or update a comprehensive discharge care plan in a timely manner, as required by their policies and procedures. During a review of the resident's care plan, it was found that the discharge planning care plan was initiated only after the second eviction notice, and it did not include information about the first eviction notice or the appealed discharges. The Director of Nursing (DON) acknowledged that discharge planning should have started at the first care plan meeting upon admission and should have been updated after each meeting with the family. The facility's policies indicated that a comprehensive care plan should be completed within seven days of the resident assessment and revised as needed, but this was not followed in the case of the resident, leading to a deficiency in discharge planning.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
