Berkley Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 6600 Sepulveda Blvd, Van Nuys, California 91411
- CMS Provider Number
- 056253
- Inspections on file
- 51
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Berkley Post-acute during CMS and state inspections, most recent first.
A resident admitted with type 2 DM, hemiplegia/hemiparesis after CVA, and glaucoma had physician orders for bedtime Atorvastatin and Semglee (insulin glargine) starting on the day of admission. The medications were not available at the scheduled bedtime dose and were delivered by the pharmacy early the following morning. The MAR showed the 9 p.m. doses were not administered and were coded as medication not available. Nursing staff did not notify the physician of the missed doses, and there was no documentation of any communication or clarification of orders, despite facility policies requiring timely pharmaceutical services and thorough charting.
A resident with multiple medical conditions, including diabetes and a gastrostomy, was not provided a comprehensive nutritional assessment within seven days of readmission, as required by facility policy. The assessment was completed on the twelfth day, despite documented weight loss and the resident's dependence on staff for daily care. Both the RD and DON confirmed the delay, which did not meet the facility's established protocols.
The facility did not document room temperature checks for three days, as required by their policy, potentially affecting residents' comfort. The Maintenance/Housekeeping Director confirmed the lack of documentation, and the responsible Maintenance Assistant admitted to not performing the checks due to forgetfulness and being busy.
Two unidentified and unlabeled medication tablets were found in a medication cart at Nursing Station 1, violating the facility's medication labeling and storage protocols. The IPN confirmed the labeling requirements, and LVN1 admitted to forgetting to discard the tablets. The DON emphasized the need for proper storage to ensure medication effectiveness.
The facility failed to manage medication administration and fall prevention, leaving medications unattended for two residents without proper assessments and not providing fall mats for a high-risk resident, increasing safety hazards.
The facility failed to document attempts of non-pharmacological interventions before administering PRN opioid medication to two residents, increasing the risk of adverse side effects. Despite care plans requiring such interventions, there was no evidence of their implementation before giving hydrocodone-acetaminophen. Interviews confirmed the lack of documentation and the importance of these interventions to potentially avoid unnecessary opioid use.
The facility failed to screen two visitors for COVID-19 symptoms, a dietary aide did not wash hands after touching a trash can lid, and several resident care items were not properly labeled or maintained, leading to potential infection risks.
A facility failed to ensure staff knocked and asked permission before entering a resident's room, violating the resident's rights to respect and dignity. The resident, with a history of muscle weakness, falls, and chronic kidney disease, had the capacity to make decisions. A nurse entered the room without knocking, acknowledging the oversight and the importance of respecting personal space. The facility's policy mandates knocking and requesting permission before entering.
A CNA failed to fully close a privacy curtain while assisting a resident with dressing, resulting in a privacy violation. The resident, who had intact cognition and required assistance with daily activities, was observed fully undressed with the curtain open. The CNA acknowledged the oversight, and the DON confirmed the expectation for full privacy during care.
A facility failed to maintain a comfortable environment in a resident room, where temperatures exceeded the acceptable range of 71 to 81 degrees Fahrenheit. Four residents, including those with end-stage renal disease and anemia, expressed discomfort due to the warm conditions. The Maintenance Supervisor and DON confirmed the importance of maintaining appropriate temperatures to prevent discomfort and dehydration.
A resident with conditions such as hypo-osmolality and kidney failure was on a strict fluid restriction of 1200 ml per day. Despite this, a water pitcher and additional cups were found at the bedside, contrary to the care plan and physician's orders. The Director of Staff Development confirmed the oversight, acknowledging the risk of fluid overload, while the DON stressed the importance of adhering to the fluid restriction to prevent electrolyte imbalance.
A facility failed to implement a scheduled toileting plan for a resident who was incontinent of bowel, despite being cognitively intact and requiring substantial assistance with walking. The care plan included regular intervals for offering a bedpan or urinal and assisting to the bathroom, but there was no documentation of scheduled bowel elimination. The facility's policy required a voiding diary, which was not maintained, as confirmed by staff interviews.
A facility failed to complete a post-dialysis assessment for a resident with end-stage renal disease, as required by their care plan. The Dialysis Assessment Form was left incomplete, and no vital signs or assessment notes were documented after the resident returned from dialysis. An LVN admitted to forgetting to fill out the necessary documentation, and the DON confirmed that licensed nurses are responsible for ensuring post-dialysis assessments are conducted to check for complications.
A facility failed to remove a lidocaine patch from a resident's knees after 12 hours as per the physician's order, leading to potential excessive dosing. The RN acknowledged the oversight, and the DON confirmed the risk of adverse effects due to prolonged application.
The facility failed to monitor side effects in two residents receiving anticoagulant therapy. One resident on apixaban for DVT prophylaxis had no documentation of monitoring for bleeding or bruising, despite the care plan's requirements. Another resident on heparin also lacked documentation of monitoring for side effects like bleeding and bruising. The facility's policy required such monitoring, which was not followed.
A facility failed to discard an expired vial of insulin lispro stored in a medication cart, which was past the 28-day usage period. A resident with diabetes mellitus had a physician's order for insulin administration, and the expired insulin posed a risk of ineffective blood glucose management. The deficiency was identified during an inspection, and the guidelines specify that opened insulin vials should be discarded after 28 days.
During a meal service, a cook failed to check the temperatures of pureed potatoes, chopped turkey, and chicken on the tray line, as required by the facility's policy. This oversight was observed and confirmed by the cook, posing a potential risk of foodborne illness to 110 medically compromised residents.
A facility failed to report an allegation of physical abuse involving a resident with COPD and respiratory failure to the State Survey Agency. The resident reported that a CNA was rough during care, causing bruises and throwing a teddy bear at them. The facility's administrator recognized this as an abuse allegation but did not report it, delaying an SSA inspection and potentially leaving other residents at risk.
The facility failed to complete Quarterly MDS assessments on time for six residents, including those with conditions like cellulitis and COPD. The assessments were not completed within the required 14-day period after the ARD, as per CMS guidelines. The delays were acknowledged by the RN, who noted potential negative impacts on residents. The DON highlighted the importance of timely assessments for effective care planning.
A resident with multiple health conditions received 13 incorrect doses of lisinopril-hydrochlorothiazide due to a transcription error by an RN. The RN used the less than symbol (<) instead of the greater than symbol (>) in the physician's order, leading to medication administration when the resident's blood pressure was below the specified threshold. The DON confirmed that the correct process involves reading back the order to the physician and avoiding the use of symbols.
Failure to Administer Ordered Atorvastatin and Insulin and Notify Physician for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide routine biologicals and pharmacy services, including administering medications as ordered, for a newly admitted resident. The resident was admitted from a general acute care hospital with diagnoses including type 2 DM, hemiplegia and hemiparesis following CVA affecting the right dominant side, and unspecified glaucoma. The resident’s MDS indicated moderately impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. On admission, the nurse practitioner and physician were notified, and the resident’s medication orders were faxed to the pharmacy. The physician’s orders included Atorvastatin 40 mg by mouth at bedtime for hyperlipidemia and Semglee (insulin glargine) 8 units subcutaneously at bedtime for DM, both with a start date of 1/6/2026. The facility’s pharmacy delivery manifest showed that these medications were delivered the following day at 3:22 a.m. Review of the resident’s January MAR revealed that the 9:00 p.m. doses of Atorvastatin and Semglee on the admission date were not administered, and code 8 (medication not available) was documented for both medications. RN 2 stated that the facility receives pharmacy deliveries three times a day and confirmed that the medications were not given at the scheduled time because they had not yet been delivered. RN 2 further stated that the charge nurse assigned to the resident should have called the physician to inform them of the missed doses and to clarify whether additional orders were needed, but review of the progress notes for that date showed no documentation that the physician was notified. The DON confirmed that for newly admitted residents, medication orders are sent to the pharmacy and that once medications are delivered, licensed nurses administer the first dose per the physician’s orders, and that the nurse should have clarified with the physician whether medications could be initiated the following day given the late admission time. Facility policies required regular and reliable pharmaceutical services, including that new medication or admission orders be available for administration of the next dose, and required documentation of services provided and changes in the resident’s condition in the medical record to facilitate communication among the interdisciplinary team.
Failure to Complete Timely Nutritional Assessment After Readmission
Penalty
Summary
The facility failed to conduct a comprehensive nutritional assessment within seven days of readmission for one resident, as required by its own policy and procedure. The resident, who had a history of diabetes mellitus, hypertension, gastrostomy, and anemia, was initially admitted and then readmitted after a hospital stay. Upon readmission, the resident's weight was recorded as unchanged from the time of transfer to the hospital, but a comprehensive nutritional assessment was not completed until the twelfth day after readmission, exceeding the facility's seven-day requirement. Interviews with the Registered Dietitian and the Director of Nursing confirmed that the nutritional assessment was delayed and not performed within the required timeframe. The facility's policies specify that a comprehensive nutritional assessment must be completed by a dietitian within seven days of admission or readmission, especially in cases of significant weight change. Despite these requirements and the resident's medical complexity, the assessment was not completed as stipulated, resulting in a deficiency.
Failure to Document Room Temperature Checks
Penalty
Summary
The facility failed to implement its policy on maintaining a homelike environment by not providing documented evidence of daily room temperature checks for residents from January 26 to January 28, 2025. The Maintenance/Housekeeping Director (MHD) stated that the facility is supposed to check and document room temperatures three times a day, with the first check by 9:00 a.m. However, during a review of the facility's Air Temperature Monitor Log, it was found that there was no documentation of temperature checks for the specified three days. Maintenance Assistant 1 (MA 1), who was responsible for checking the room temperatures, admitted to not performing the checks during this period because they forgot and were busy. The MHD emphasized the importance of daily temperature checks for residents' comfort and the necessity of documenting these checks to provide proof of compliance with the facility's policy. The facility's policy, dated May 2024, requires staff to ensure a safe, clean, comfortable, and homelike environment by maintaining comfortable room temperatures.
Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by the discovery of two unidentified and unlabeled medication tablets in one of the medication carts at Nursing Station 1. During an observation and interview with the Infection Prevention Nurse (IPN), it was noted that the medication cart contained one pink and one white tablet, both unlabeled. The IPN confirmed that all medications should be labeled with the resident's name, medication name, dose, and expiration date. This oversight was acknowledged by Licensed Vocational Nurse 1 (LVN1), who admitted forgetting to discard the unlabeled medications, which should have been removed immediately to prevent medication errors. The Director of Nursing (DON) reiterated the importance of storing medications according to the facility's policy and manufacturer's recommendations to maintain their effectiveness. A review of the facility's medication storage policy, last revised in August 2020, indicated that any outdated, contaminated, or deteriorated medications, as well as those in compromised containers, should be promptly removed and disposed of according to the established procedure. The failure to remove the unidentified tablets from the medication cart represents a breach of these protocols, potentially compromising the efficacy of medications administered to residents.
Medication Management and Fall Prevention Deficiencies
Penalty
Summary
The facility failed to ensure the safety of residents by not properly managing medication administration and fall prevention measures. For Resident 163 and Resident 164, medications were left unattended at their bedsides without a completed self-administration assessment. Resident 164, who was alert and oriented, had a Tylenol pill left at the bedside by a nurse, which was not in accordance with the facility's policy as the self-administration assessment was conducted after the incident. Similarly, Resident 163, who was severely impaired in cognition, had multiple pills left at the bedside without a prior self-administration assessment or physician's order, posing a risk of medication misuse. Additionally, the facility did not adhere to the care plan for Resident 29, who was at high risk for falls due to severe cognitive impairment and a history of falls. The care plan specified the use of bilateral floor mats to prevent injury from falls, but during an observation, no floor mats were found next to Resident 29's bed. This oversight increased the risk of injury for Resident 29, who had previously attempted to get out of bed unassisted. The facility's policies on self-administration of medications and fall prevention were not followed, leading to potential safety hazards for the residents involved. The Director of Nursing confirmed the lapses in procedure, acknowledging the importance of assessments and appropriate interventions to ensure resident safety. The failure to conduct timely assessments and implement care plan interventions contributed to the deficiencies observed.
Failure to Implement Non-Pharmacological Interventions Before Opioid Use
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering PRN opioid medication to two residents, which could increase the risk of adverse side effects from opioid use. Resident 11, admitted with diagnoses including encephalopathy, migraine headaches, and osteoarthritis, had a care plan that included non-pharmacological interventions such as maintaining proper body alignment, engaging in conversation, and using relaxation techniques. However, there was no documented evidence that these interventions were attempted before administering hydrocodone-acetaminophen on multiple occasions. Similarly, Resident 83, who was readmitted with cellulitis and had intact cognition, also had a care plan that required non-pharmacological interventions for pain management. Despite this, there was no documentation of such interventions being attempted before administering hydrocodone-acetaminophen on several occasions. Interviews with RN 4 and the DON confirmed the lack of documentation and emphasized the importance of non-pharmacological interventions to potentially avoid unnecessary opioid use. The facility's policy on pain management, last reviewed in May 2024, mandates following the resident's care plan for pain management. The DON acknowledged that non-pharmacological interventions should be attempted first, as they might suffice in managing the resident's pain without medication. The absence of documented attempts at these interventions before administering opioids represents a deficiency in the facility's adherence to its pain management policy.
Infection Control Deficiencies in Visitor Screening and Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures in several instances, leading to potential risks of infection among residents. Two visitors were not screened for COVID-19 symptoms or exposure on two separate days, contrary to the facility's policy requiring passive visitor screening. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of screening to protect residents from potential illness. In the kitchen, a dietary aide did not wash their hands after touching a trash can lid before putting on gloves, which could lead to cross-contamination and foodborne illness. The dietary aide admitted to usually washing hands after touching contaminated surfaces, and the Dietary Supervisor confirmed that handwashing is required in such situations. The facility's handwashing policy underscores the importance of washing hands after handling soiled items to prevent infection spread. Additionally, several issues were noted with resident care items. A resident's oxygen nasal cannula was not labeled with the date it was last changed, which is necessary to prevent bacterial growth and respiratory infections. Another resident's urinal was not labeled with an identifier, increasing the risk of cross-contamination. Furthermore, a resident's oxygen tubing was observed touching the floor, which should be avoided to prevent infection. These observations were verified by staff, who acknowledged the lapses in following infection control protocols.
Failure to Respect Resident's Privacy and Dignity
Penalty
Summary
The facility failed to ensure that staff knocked and asked permission before entering a resident's room, violating the resident's rights to respect and dignity. This incident involved a resident admitted with diagnoses including muscle weakness, a history of falling, and chronic kidney disease. The resident had the capacity to understand and make decisions. During an observation, a registered nurse entered the resident's room without knocking and admitted to forgetting to do so, acknowledging that knocking is a sign of respect for the resident's personal space. The facility's policy on dignity, last reviewed in May 2024, requires staff to knock and request permission before entering residents' rooms.
Privacy Violation During Resident Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, which resulted in a violation of the resident's right to privacy. The incident involved a Certified Nursing Assistant (CNA 1) who did not fully close the privacy curtain while assisting a resident, identified as Resident 96, with dressing. This oversight was observed during a survey when Resident 96 was found fully undressed and sitting on the edge of the bed with the privacy curtain open at the foot of the bed. Resident 96 had been admitted to the facility with diagnoses including difficulty in walking, generalized muscle weakness, and glaucoma. The resident's records indicated intact cognition and the ability to understand and make decisions, requiring supervision or assistance for most activities of daily living. During an interview, CNA 1 acknowledged the failure to close the privacy curtain, and the Director of Nursing confirmed the expectation for staff to provide full privacy during personal care. The facility's policy on dignity and privacy emphasized the importance of maintaining resident privacy during personal care and treatment procedures.
Room Temperature Exceeds Acceptable Range
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in Room A, as the room's temperature exceeded the acceptable range of 71 to 81 degrees Fahrenheit. This deficiency was identified through observations, interviews, and record reviews involving four residents: Resident 100, Resident 167, Resident 168, and Resident 363. The temperatures recorded in Room A were 87.1 F, 84.9 F, 83.3 F, and 82.7 F during the first measurement, and 81.3 F, 79.3 F, and 84.1 F during the second measurement. All four residents expressed discomfort due to the warm room conditions. Resident 100 was admitted with end-stage renal disease and required dialysis, while Resident 167 and Resident 168 had anemia, and Resident 363 had a urinary tract infection. The Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment among the residents, with some requiring assistance with eating. The Maintenance Supervisor and the Director of Nursing confirmed the importance of maintaining room temperatures within the specified range to prevent discomfort and potential dehydration. The facility's policy, last reviewed in May 2024, mandates daily temperature checks in multiple rooms to ensure compliance with the temperature guidelines.
Failure to Adhere to Fluid Restriction for a Resident
Penalty
Summary
The facility failed to adhere to a physician's order for a strict fluid restriction for Resident 317, who was diagnosed with conditions including hypo-osmolality, hyponatremia, hypokalemia, kidney failure, and muscle weakness. Despite the resident's care plan specifying no water pitcher at the bedside and a fluid restriction of 1200 milliliters per day, a water pitcher and additional cups were observed at the resident's bedside. This oversight occurred even though a sign above the resident's bed indicated that water pitchers should not be left at the bedside. The deficiency was identified during an observation on August 19, 2024, when the Director of Staff Development confirmed the presence of the water pitcher and acknowledged the risk of fluid overload for the resident. The Director of Nursing also emphasized the importance of following the physician's orders to prevent electrolyte imbalance and potential hospitalization. The facility's policy on fluid restriction guidelines, reviewed in May 2024, requires nursing to notify dietary services once a fluid restriction order is prescribed, ensuring the appropriate amount of fluid is managed by the nursing department.
Failure to Implement Scheduled Toileting Plan
Penalty
Summary
The facility failed to provide a scheduled toileting plan for a resident who was admitted with diagnoses including adult failure to thrive and extrarenal uremia. The resident was assessed as cognitively intact and required substantial assistance with walking. The Minimum Data Set (MDS) indicated that the resident was continent of bladder and incontinent of bowel. Despite this assessment, the facility did not implement a scheduled toileting plan as outlined in the resident's care plan, which included offering a bedpan or urinal at regular intervals and assisting the resident to the bathroom. During the review, it was found that the facility's policy required a voiding diary to be maintained and communicated among staff, but there was no documentation of scheduled bowel elimination for the resident. Interviews with the Minimum Data Set Nurse and the Director of Nurses confirmed the lack of adherence to the facility's policy. The Director of Nurses acknowledged the importance of maintaining continence or identifying reasons for incontinence to potentially place the resident on a bowel training program.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for Resident 102, who was admitted with end-stage renal disease and required dialysis. The resident's care plan specified the need to assess the dialysis access site for complications such as bleeding, and to check for bruit and thrill. However, the Dialysis Assessment Form dated 8/20/2024 was not filled out, and there was no documentation of vital signs or an assessment in the resident's electronic chart after returning from dialysis. Licensed Vocational Nurse 3 confirmed that the post-dialysis assessment section was not completed and admitted to forgetting to fill out the form or write an assessment note. The Director of Nursing stated that licensed nurses are responsible for completing the post-dialysis assessment to ensure the resident's stability and absence of complications. The facility's policy on end-stage renal disease care requires licensed nurses to look for signs of infection and complications, but this was not adhered to in this instance.
Failure to Remove Lidocaine Patch as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of quality care by not ensuring the timely removal of a lidocaine patch as per the physician's order for a resident. The resident, who was admitted with diagnoses including muscle weakness, a history of falling, and chronic kidney disease, had a physician's order for a lidocaine patch to be applied to both knees for pain management, with instructions to keep the patch on for 12 hours and then remove it for 12 hours. However, during a medication administration observation, it was noted that the patch applied the previous day was not removed after 12 hours, as it was still attached to the resident's knees when the new patch was being applied. The Registered Nurse (RN) acknowledged that the patches should have been removed the previous day according to the physician's order. The Director of Nursing (DON) confirmed that the failure to remove the patch could lead to excessive dosing and potential adverse effects, as indicated in the medication's package insert. The DON agreed that the patch should have been removed after 12 hours to prevent discomfort and potential adverse side effects due to increased absorption of lidocaine.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that licensed nurses monitored for side effects in residents receiving anticoagulant medications, specifically affecting two residents. Resident 73, who was readmitted with a diagnosis of atherosclerotic heart disease, was on apixaban for DVT prophylaxis. Despite the care plan indicating the need to monitor for bleeding or bruising, there was no documentation found to confirm that nurses were monitoring for these side effects. The Director of Nursing acknowledged the importance of monitoring for side effects due to the increased risk of bleeding associated with anticoagulants. Similarly, Resident 364, admitted with chronic obstructive pulmonary disease and other conditions, was on heparin for DVT prophylaxis. The care plan required monitoring for bleeding, bruising, and blood in the urine or stool. However, there was no documentation of such monitoring in the resident's medical record. The Licensed Vocational Nurse confirmed that side effects are usually documented on the MAR, but this was not done for Resident 364. The facility's policy on anticoagulation required monitoring for complications, which was not adhered to in these cases.
Expired Insulin Storage Deficiency
Penalty
Summary
The facility failed to ensure that a vial of insulin lispro, which was past its discard date, was not stored in one of the medication carts. This deficiency was identified during an inspection of Medication Cart A, where a vial of insulin lispro belonging to a resident with diabetes mellitus was found. The insulin vial had an open date that exceeded the 28-day usage period recommended by the manufacturer. Licensed Vocational Nurse 2 confirmed that the insulin should have been discarded after 28 days from opening, as it would lose its efficacy beyond this period. The resident involved had been admitted with a diagnosis of diabetes mellitus and required assistance for self-care. The physician's order for the resident included administering insulin lispro before meals and at bedtime. The manufacturer's guidelines and FDA recommendations specify that opened vials of insulin lispro should be discarded after 28 days, whether stored at room temperature or refrigerated. The failure to adhere to these guidelines resulted in the potential for expired insulin to be administered, which could lead to ineffective blood glucose management for the resident.
Failure to Check Food Temperatures During Meal Service
Penalty
Summary
The facility staff, specifically Cook 1, failed to check the temperature of all food items on the tray line during a mealtime service. This incident occurred on 8/21/2024 at approximately 12 p.m. when Cook 1 did not measure the temperatures of pureed potatoes, chopped turkey, and chicken. This oversight was observed during a kitchen tray line observation and later confirmed in an interview with Cook 1, who acknowledged missing the temperature checks for these specific food items. The facility's policy and procedure, titled 'Meal Service' and last reviewed on 5/22/2024, mandates that food and nutrition services staff must take food temperatures prior to meal service using a thermometer. The failure to adhere to this policy had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to 110 of the 114 medically compromised residents who received food from the kitchen.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically an allegation of physical abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an allegation of physical abuse involving a resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, to the State Survey Agency (SSA). The resident, who had the capacity to understand and make decisions, reported to a family member that a Certified Nursing Assistant (CNA) was rough while assisting them to a wheelchair, resulting in bruises on the arm and the CNA throwing the resident's teddy bear at them. The incident was documented in a grievance report, and the facility's administrator acknowledged that the rough handling should be considered an allegation of abuse. However, the facility did not report this allegation to the SSA, as required by their own Abuse Prevention Program policy. This failure resulted in a delay of an onsite inspection by the SSA to ensure the safety of other residents and had the potential to result in unidentified abuse.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that the Quarterly Minimum Data Sets (MDS) assessments for six residents were completed within the required timeframe. The residents affected included those with various medical conditions such as cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), acute embolism, and hypothyroidism. The assessments were not completed within the 14-day period following the Assessment Reference Date (ARD), as mandated by the Centers for Medicare and Medicaid Services (CMS) guidelines. During interviews and record reviews, it was revealed that the MDS assessments for these residents were completed late, ranging from several days to weeks past the deadline. For instance, Resident 83's assessment was due by July 27, 2024, but was not completed until August 12, 2024. Similarly, Resident 42's assessment was due by July 29, 2024, but was also completed on August 12, 2024. These delays were acknowledged by the Registered Nurse (RN) involved, who stated that such delays could negatively impact the residents by failing to identify significant changes in their conditions in a timely manner. The Director of Nursing (DON) emphasized the importance of timely MDS assessments to ensure that residents' specific needs are addressed promptly and that care planning is influenced by the most current assessment data. The facility's policy, last reviewed in May 2024, outlined the responsibility of the MDS Nurse/Coordinator to maintain a master schedule for MDS assessment completion and to ensure regular review by the Interdisciplinary Team (IDT). Despite these policies, the facility did not adhere to the required timelines, resulting in the identified deficiencies.
Medication Transcription Error Leads to Incorrect Doses
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) accurately transcribed a physician's order and administered the correct dose of lisinopril-hydrochlorothiazide for a resident. The resident, who had a history of cerebral infarction, acute respiratory failure, hypertension, depression, and dementia, was given 13 incorrect doses of the medication over a period of time. The physician's order specified that the medication should only be administered if the resident's systolic blood pressure (SBP) was greater than 140/80 mmHg. However, the RN mistakenly transcribed the order using the less than symbol (<) instead of the greater than symbol (>), leading to the administration of the medication when the resident's blood pressure was below the specified threshold. The resident's Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's blood pressure was below 140/80 mmHg. Specific instances included blood pressure readings such as 130/60, 129/66, and 106/74, among others. During an interview, the RN admitted to the transcription error and acknowledged that she should have used the greater than symbol as per the physician's order. The Director of Nursing (DON) confirmed that the correct process for receiving telephone orders involves reading back the order to the physician to ensure accuracy and that symbols should not be used in such orders. The facility's policy on physician's orders requires complete and accurate transcription of orders, including the resident's full name, date of the order, medication name, dosage, administration information, route of administration, and the physician's signature. The policy also mandates that staff verify the order with the physician for accuracy. The failure to follow these procedures resulted in the resident receiving incorrect doses of medication, placing them at risk for serious health complications.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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