Bethel Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Selma, California.
- Location
- 2280 Dockery Avenue, Selma, California 93662
- CMS Provider Number
- 555924
- Inspections on file
- 15
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Bethel Lutheran Home during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific actions or events involved.
A nurse attempted to obtain a urine specimen from a resident by straight catheterization without a physician's order, making two unsuccessful attempts before collecting the specimen via bedpan. The resident, who was cognitively intact and had significant medical conditions, was confused and nervous during the procedure. The nurse did not notify the physician or responsible party and was unaware that a physician's order was required, contrary to facility policy and expectations.
A male CNA violated the privacy and dignity of two residents by laying in bed with one resident, which was observed by her roommate. The incident was confirmed through interviews and video footage, revealing the CNA's inappropriate behavior. Both residents were cognitively intact and expressed discomfort, highlighting a breach of their rights to dignity and freedom from abuse.
The facility failed to ensure thorough and complete orientation and education documentation for two CNAs, as verified by the DSD. Records for both CNAs were missing signatures, dates, and other necessary information to confirm completion of required training. The Administrator confirmed these deficiencies, highlighting a lack of supervision and verification in the training process.
A facility failed to ensure a CNA received thorough education on Resident Rights, as required by its policies. The DSD did not complete or verify the necessary training, leaving the Employee Orientation document unsigned. This led to CNA 1 working without proper instruction on Resident Rights, resulting in their termination for violating these rights.
The facility failed to maintain food safety standards, with issues including freezer-burned meat, unlabeled staff food, and improperly dated yogurt in storage areas. Additionally, food items brought by family members for two residents were not labeled with dates, risking the consumption of expired food. These deficiencies were acknowledged by the Dietary Service Supervisor and Registered Dietitian, highlighting the potential for foodborne illnesses.
A facility failed to ensure privacy for two residents during medical treatments. An LVN did not pull curtains or close the door while performing a blood glucose test and administering insulin to a cognitively intact resident, exposing him to view. In another instance, the same LVN administered eye drops to a resident with severe cognitive impairment without drawing the curtains, allowing the roommate to observe. Staff interviews and facility policies confirmed the importance of maintaining privacy, which was not upheld in these cases.
A resident experienced pain and discomfort during a transfer from a wheelchair to a bed due to the improper use of a Hoyer lift sling by CNAs. The resident, with a history of muscle contracture and back surgery, was lifted in a sitting position instead of a reclined position, contrary to the manufacturer's guidelines. Staff interviews revealed a lack of awareness of the correct procedure, and the Director of Nursing confirmed the guidelines were not followed.
The facility failed to ensure proper labeling and storage of medications, with issues including missing expiration dates on pill packets, unlabeled medication containers inside boxes, and a medication refrigerator below the required temperature range. Staff acknowledged these deficiencies, and the DON emphasized the importance of correct labeling and storage to prevent harm and maintain medication potency.
The facility failed to ensure that residents received food at a safe and appetizing temperature. The Dietary Cook did not check the temperature of food on the steam table before serving, which is crucial for food safety and palatability. The absence of temperature checks was confirmed by the Dietary Services Supervisor and the Registered Dietitian, highlighting a breach in the facility's policy requiring food to be held at a minimum of 140 degrees Fahrenheit.
The facility failed to maintain the B-wing medication refrigerator at a safe temperature, risking medication safety. The refrigerator was observed at 32°F, below the acceptable range, potentially damaging medications. Staff acknowledged the issue, and the Maintenance Director noted a lack of regular checks and maintenance logs for the refrigerator.
A resident with chronic pain conditions did not receive prescribed analgesics before physical therapy sessions, as outlined in their care plan. Despite frequent complaints of pain, staff failed to administer pain medication, resulting in unmanaged pain during therapy. Interviews with staff, including an LVN and the MDS Nurse Coordinator, confirmed the oversight, highlighting a lack of adherence to the care plan.
A resident with chronic pain conditions was not given prescribed analgesia before physical therapy, leading to significant discomfort during transfers and therapy sessions. Despite a care plan specifying the need for pain management, staff failed to administer the medication, resulting in the resident experiencing unnecessary pain. The oversight was acknowledged by multiple staff members, including the DON, who confirmed the care plan was not followed.
A resident with multiple medical conditions, including diabetes and hypertension, was served an incorrect portion size due to the dietary staff using a larger scoop than prescribed. This failure to follow the physician's order for a small portion diet was observed during a tray line in the kitchen, and confirmed by both the Dietary Services Supervisor and the Registered Dietitian.
A resident with diverticulitis and malnutrition was served meals not aligned with her preferences, including chicken with skin and beets, despite her dietary restrictions. Staff interviews revealed a lack of proper checks and communication regarding meal preferences, with responsibilities shared between nurses and CNAs. The facility's policy emphasized the importance of aligning meals with residents' informed choices and treatment goals.
A resident with severe cognitive impairment was at risk due to incomplete antipsychotic consent forms, as the physician's signatures were not dated. The DON and LVN acknowledged the oversight, emphasizing the importance of dated signatures to verify informed consent before medication administration. The facility's policies and job descriptions underscored the need for accurate and complete medical records.
A contractor technician failed to wash his hands upon entering the kitchen and scooped ice from the ice machine, potentially causing cross-contamination and foodborne illnesses for 56 residents, staff, and visitors. Interviews with the DSS and RD confirmed the importance of handwashing to prevent the spread of germs, as outlined in the facility's infection control policy.
The facility failed to meet the minimum space requirement of 80 square feet per resident in multiple rooms, with 22 rooms measuring only 154 square feet for two residents each. Despite this, staff and residents reported no issues with room size, privacy, or care space. Observations confirmed adequate privacy and space for care, and a waiver continuation was recommended.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved. No further information about the circumstances, individuals affected, or specific observations is included in the report.
Urine Catheterization Performed Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) attempted to obtain a urine specimen from a resident by performing a straight catheterization without a physician's order. The resident, who was cognitively intact and had a history of hemiplegia, metabolic encephalopathy, and malignant neoplasm of the brain, recalled being confused and nervous during the procedure, as she had previously been able to provide urine specimens using a hat. The LVN made two unsuccessful attempts to insert the catheter before ultimately collecting the specimen via bedpan, without notifying the physician or the resident's responsible party. The LVN stated she was unaware that a physician's order was required for this procedure, as it had been standard practice at her previous place of employment for incontinent residents. Facility policy and procedure documents reviewed indicated that a physician's order is required for invasive procedures such as straight catheterization and for obtaining urine specimens. The Director of Nursing confirmed that the LVN had attempted the procedure without an order and acknowledged that straight catheterization is considered invasive. The facility's administrator also acknowledged that the LVN's actions were not in line with facility expectations, which require staff to follow physician orders, adhere to policy, and document all interactions and communications.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to respect the rights of two residents to a dignified private and personal space when a male CNA laid down on the bed with one of the residents, Resident 1, and took a nap. This incident was observed by Resident 1's roommate, Resident 2, leading to potential psychosocial harm such as emotional distress for both residents. The incident was confirmed through interviews and video footage review, which showed the CNA entering and remaining in the room for approximately 16 non-consecutive minutes. Resident 2, who is cognitively intact, reported the incident to the Administrator, stating that she saw the CNA in Resident 1's bed under the blankets. Resident 1, also cognitively intact, confirmed the CNA's presence in her bed and expressed discomfort about the situation. The facility's documentation and interviews with other CNAs corroborated the incident, with one CNA expressing regret for not reporting the behavior sooner. The facility's Resident Rights document emphasizes the right to dignity and freedom from abuse and neglect, which were violated in this incident. The CNA's actions were not aligned with these rights, as they compromised the residents' dignity and personal space. The facility's response included an investigation and interviews with involved staff and residents, confirming the inappropriate behavior of the CNA.
Incomplete Staff Training Documentation
Penalty
Summary
The facility failed to ensure that the orientation and education documentation for two Certified Nursing Assistants (CNAs) was thorough and completed by the Director of Staff Development (DSD). During a review of CNA 1's education records, it was found that several documents, including a training record and an employee orientation checklist, were incomplete. These documents lacked signatures, dates, and other necessary information to verify that the required training and orientation had been completed. The DSD admitted to not signing the training record, and the employee orientation checklist was entirely blank. Similarly, CNA 3's education records were reviewed and found to be incomplete. A training record was missing the name of the instructor, and the employee orientation checklist was unsigned and undated. The Administrator confirmed these findings and stated that it was expected for new hire education to be supervised and verified by the DSD. This lack of documentation and verification could potentially lead to inadequately trained staff working with residents.
Failure to Educate CNA on Resident Rights
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 1) received thorough education on Resident Rights, as required by the facility's policies and procedures. The Director of Staff Development (DSD) did not complete or verify the necessary training for CNA 1, which was evident from the incomplete Employee Orientation document. This document, which should have been signed by CNA 1 and a licensed nurse, was left blank, indicating that CNA 1 had not been properly instructed in Resident Rights before assuming direct-care responsibilities. The deficiency was further highlighted by a letter from the facility, dated November 14, 2024, which terminated CNA 1's employment due to a violation of resident rights. The Administrator confirmed that it was expected for new hires to have their in-service education supervised and precepted by the DSD. The facility's policy clearly stated that staff must receive appropriate in-service training on resident rights prior to providing direct care, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as evidenced by several observations in the kitchen and resident rooms. In the walk-in freezer, a bag of beef stew meat was found with ice crystals, indicating freezer burn, which the Dietary Service Supervisor (DSS) acknowledged should have been discarded. The Registered Dietitian (RD) confirmed that the freezer-burned meat could potentially harbor bacteria and cause food poisoning. Additionally, a foam cup with a staff member's name but no date was found in the walk-in refrigerator, improperly stored alongside resident food, which could lead to cross-contamination. Further inspection revealed an open yogurt container in the walk-in refrigerator without an open date, which the DSS and RD agreed should have been labeled to prevent serving expired food to residents. In the storage pantry, a bin of oats lacked both an opened and received date, contrary to the facility's policy, which could result in residents consuming expired oats. These lapses in labeling and storage practices were acknowledged by the DSS and RD, who emphasized the importance of proper labeling to prevent foodborne illnesses. In resident rooms, items brought by family members, such as cookies, snacks, and sodas, were found without labels indicating the date received or opened. This oversight was noted in the rooms of two residents, one with conditions including hypertension, Alzheimer's disease, and diabetes, and another with Parkinson's disease and malnutrition. Staff interviews confirmed that these items should have been labeled to prevent residents from consuming expired food, which could lead to health issues. The facility's policy requires food brought by family members to be labeled with the resident's name and a 'use by' date to ensure safety.
Failure to Ensure Resident Privacy During Medical Treatments
Penalty
Summary
The facility failed to ensure privacy and confidentiality for two residents during medical treatments. In the first instance, a Licensed Vocational Nurse (LVN) did not pull the curtains or close the door while performing a blood glucose test and administering insulin to a resident. This resident, who was cognitively intact, was exposed to the view of anyone passing by the open doorway, compromising his privacy during the procedure. In the second instance, the same LVN administered eye drops to another resident without pulling the curtains, allowing the resident's roommate to observe the procedure. This resident had severe cognitive impairment, but the lack of privacy during the medication administration was still a concern. The LVN acknowledged that the curtains should have been drawn to provide privacy. Interviews with other staff members, including another LVN, a Certified Nursing Assistant (CNA), and the Director of Nursing (DON), confirmed the importance of maintaining resident privacy during care. The facility's policies and job descriptions also emphasized the need for privacy and confidentiality, highlighting a failure to adhere to these standards during the observed incidents.
Improper Use of Hoyer Lift Sling Causes Resident Discomfort
Penalty
Summary
The facility failed to provide services that met professional standards of quality of care for a resident when a Hoyer lift sling was used incorrectly during a transfer from a wheelchair to a bed. The resident, who had conditions including muscle contracture, generalized weakness, and abdominal pain, experienced pain and discomfort during the transfer. The Certified Nursing Assistants (CNAs) used the shortest hooks near the resident's shoulders and the longest hooks near the legs, causing the resident to be lifted in a sitting position, which was contrary to the proper procedure for transferring from a chair to a bed. Interviews with the CNAs and other staff revealed a lack of awareness and adherence to the correct procedure for using the Hoyer lift sling. The Director of Staff Development and a Licensed Vocational Nurse confirmed that the staff should have positioned the resident in a more reclined position during the transfer to the bed. The Owner's Manual and Instruction Guide for the Hoyer lift also indicated the need for a reclined position during such transfers. The Director of Nursing acknowledged that the resident should not have experienced discomfort and that the manufacturer's guidelines should have been followed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure accurate labeling and storage of medications, which was observed during a survey. One of the medication carts had two out of 199 pill packets without visible expiration dates. The Licensed Vocational Nurse (LVN) acknowledged that the expiration dates should have been visible and stated that if they were not, the medication should not be administered. The Director of Nursing (DON) confirmed that labeling medications correctly was a facility policy and emphasized the importance of visible expiration dates to prevent administering expired medications, which could lose potency and be ineffective. Additionally, the facility did not label the inside containers of boxed medications with resident information. During observations, it was noted that seven boxed medications lacked labels on the medication containers inside. LVNs stated that if the medication came out of the unlabeled box, it could be given to the wrong resident, leading to medication errors. The DON reiterated the importance of labeling medication containers with the resident's name to prevent harm. The facility also failed to maintain proper storage temperatures for medications. One of the medication refrigerators was observed to be below the required temperature range, which could damage the medications and make them unsafe for use. The Minimum Data Set Nurse (MDSN) and the Assistant Director of Nursing (ADON) acknowledged the issue and stated that the pharmacist should be consulted if the temperature was out of range. The DON emphasized that maintaining the appropriate temperature range was crucial to preserving medication potency.
Failure to Ensure Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that 56 sampled residents received food at a safe and appetizing temperature. On the day of the observation, the Dietary Cook (DC) did not check the temperature of the food on the steam table before serving it to the residents. The DC placed trays of lasagna and other food items on the steam table without verifying their temperatures, which is a critical step to ensure food safety and palatability. During interviews, the DC admitted to not checking the temperatures and acknowledged the absence of temperature logs for the steam table items. The Dietary Services Supervisor (DSS) confirmed that the DC should have checked the temperatures to ensure the food was warm and safe for consumption. The Registered Dietitian (RD) also emphasized the importance of checking food temperatures to prevent bacterial growth and ensure food safety. The facility's policy on meal preparation and service, dated 2011, specifies that food items like casseroles and vegetables should be held at a minimum temperature of 140 degrees Fahrenheit. The failure to adhere to this policy had the potential to result in residents being served cold food, which could lead to decreased food intake and weight loss, as well as an increased risk of foodborne illnesses.
Failure to Maintain Safe Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition, specifically the medication refrigerator in the B-wing. During an observation, the refrigerator's temperature was recorded at 32 degrees Fahrenheit, which is below the acceptable range for storing medications. The Minimum Data Set Nurse (MDSN) confirmed that such a low temperature could damage medications, making them unsafe for resident use. The Temperature Log indicated that temperatures below 36 degrees Fahrenheit are too cold, and the MDSN acknowledged the risk of medication damage if stored at such temperatures. The Assistant Director of Nursing (ADON) stated that the Infection Prevention Nurse was responsible for monitoring the refrigerator temperatures. If the temperature was out of range, the protocol was to notify maintenance and consult the pharmacist. The Maintenance Director (MAINTD) later observed the refrigerator temperature at 41 degrees Fahrenheit after adjusting the control knob, indicating that the door being open could have caused a temporary rise in temperature. However, the MAINTD admitted that the refrigerator was not regularly checked for maintenance, and there was no maintenance log for it. Interviews with staff revealed that the B-wing medication refrigerator had issues, such as leaking water, and required defrosting. Medications were moved to another refrigerator as a precaution. The MDSN consulted with a pharmacist, who advised checking medications for crystallization before use. The facility's job descriptions for maintenance staff emphasized the importance of regular inspections and preventative maintenance, but these were not implemented for the medication refrigerators, leading to the deficiency.
Failure to Implement Pain Management Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident experiencing chronic pain, particularly in relation to pre-medicating with an analgesic before physical therapy sessions. The resident, who was admitted with conditions including generalized abdominal pain, poly-osteoarthritis, muscle weakness, and muscle contractures, reported experiencing significant pain during transfers and physical therapy. Despite the care plan specifying the administration of pain medication 30 minutes prior to treatments, this intervention was not followed, resulting in unmanaged pain for the resident. Interviews with staff revealed a lack of adherence to the care plan. A Licensed Vocational Nurse (LVN) admitted to not administering the prescribed analgesic before physical therapy, stating she was unaware of this requirement in the care plan. The Certified Nursing Assistant (CNA) confirmed that the resident frequently complained of pain, which was reported to the nursing staff. The Minimum Data Set (MDS) Nurse Coordinator acknowledged that the care plan was not followed, which could hinder the resident's participation in physical therapy due to unmanaged pain. The Director of Nursing (DON) and other staff members emphasized the importance of following care plans to ensure proper resident care. The Physical Therapy assistant also noted the resident's complaints of pain during transfers and the necessity of premedication for effective therapy sessions. The facility's policy on care plans highlighted the need for comprehensive, person-centered plans with measurable objectives, which were not adhered to in this case, leading to inadequate pain management for the resident.
Failure to Administer Pain Medication Before Physical Therapy
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 3, who was not administered analgesia as per his care plan before undergoing physical therapy. This oversight resulted in Resident 3 experiencing significant pain during transfers using a Hoyer lift and during physical therapy sessions. Resident 3, who suffers from generalized abdominal pain, poly-osteoarthritis, muscle weakness, and contractures, reported daily pain, particularly during transfers and physical therapy, which was not adequately addressed by the facility staff. Observations and interviews revealed that Resident 3 frequently expressed pain, especially during transfers and physical therapy. Despite having a care plan that specified the administration of PRN analgesia 30 minutes before treatments, this was not followed. Licensed Vocational Nurse (LVN) 1, who was responsible for Resident 3's care three days a week, admitted to not administering the PRN analgesic prior to physical therapy, as she was unaware of this requirement in the care plan. The failure to administer pain medication as outlined in the care plan was acknowledged by multiple staff members, including the MDS Nurse Coordinator and the Director of Nursing, who confirmed that the care plan was not followed. The facility's policies and procedures for pain management and care plans emphasize the importance of assessing and addressing pain to ensure residents' well-being. However, in this case, the staff did not adhere to these protocols, resulting in Resident 3 experiencing unnecessary pain. The Director of Nursing and other staff members recognized that the failure to manage Resident 3's pain according to the care plan could negatively impact his participation in physical therapy and overall condition.
Failure to Follow Physician's Dietary Order for Resident
Penalty
Summary
The facility failed to adhere to a physician's dietary order for a resident, identified as Resident 14, who was supposed to receive a small portion diet. On a specific date, during a tray line observation in the kitchen, it was noted that the dietary staff used a number 8 scoop size instead of the required number 10 scoop size for small portions. This discrepancy was confirmed by the Dietary Services Supervisor, who acknowledged that the incorrect scoop size was used, potentially leading to Resident 14 receiving more calories than prescribed. Resident 14, who was cognitively intact with a BIMS score of 15, had multiple medical diagnoses including hypertension, type 2 diabetes, anxiety disorder, gastritis, gout, and irritable bowel syndrome. The facility's policy on food preparation emphasized the importance of portion control to meet nutritional specifications, yet the dietary staff failed to follow the physician's order for a small portion, as indicated in the resident's order listing report. The Registered Dietitian also confirmed that the correct scoop size was not used, which could have resulted in weight gain for the resident.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to adhere to a resident's meal preferences, which were crucial due to her medical conditions. The resident, who had diverticulitis and protein-calorie malnutrition, was served chicken with skin and beets, despite her documented dislikes and dietary restrictions. This oversight was observed during a meal service, where the resident expressed her dissatisfaction and concern that consuming such foods could exacerbate her condition. The Registered Dietitian confirmed that the resident's preferences should have been followed to prevent malnutrition. Interviews with facility staff, including a CNA, the Director of Staff Development, an LVN, and the Director of Nursing, revealed a lack of proper checks and communication regarding meal preferences. The CNA and DSD indicated that nurses were responsible for ensuring meal accuracy, but CNAs could also verify trays. The LVN and DON acknowledged the importance of following dietary orders, especially given the resident's medical history. A review of the facility's policy on therapeutic diets emphasized the need to align meals with residents' informed choices and treatment goals.
Incomplete Antipsychotic Consent Forms for a Resident
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented in accordance with accepted professional standards of practice for a resident, identified as Resident 8. Specifically, the antipsychotic consent forms for Resident 8 were incomplete, as the physician signatures on the forms dated March 5 and September 4 were not dated. This oversight put Resident 8 at risk of receiving antipsychotic medication without being informed of the risks and benefits. The Director of Nursing (DON) acknowledged that the consent forms should have been dated by the physician and that the consents were not valid without a dated signature. The DON also stated that the Medical Records Department was responsible for verifying the completion of consents, and nurses were expected to verify consents before administering medications. During the review, it was noted that Resident 8 had a severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of three, indicating a significant need for careful consent procedures. The Licensed Vocational Nurse (LVN) confirmed that the antipsychotic consents were incomplete without the physician's dated signature, emphasizing the importance of knowing when consent was obtained. The facility's job description for the Medical Records Technician and the policy on Informed Consent both highlighted the responsibility to ensure records are accurate and complete, and that informed consent must be verified before administering psychotropic medications.
Infection Control Breach in Kitchen
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a contractor technician (CT) who did not wash his hands upon entering the kitchen. This incident was observed on 10/25/24 at 8:55 a.m. when the CT proceeded to scoop ice from the ice machine without prior handwashing. During an interview, the CT acknowledged the importance of handwashing to prevent cross-contamination and admitted that he should have washed his hands before handling the ice. This lapse in protocol had the potential to cause cross-contamination and foodborne illnesses among the 56 residents, staff, and visitors who consumed ice from the machine. Interviews with the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) further confirmed the deficiency. Both the DSS and RD stated that the CT should have washed his hands upon entering the kitchen to prevent the spread of germs and bacteria. The facility's policy and procedure on sanitation and infection control, dated 2011, also indicated that handwashing should occur before starting work in the kitchen. Additionally, a professional reference on food contamination and foodborne illness prevention highlighted inadequate handwashing as a contributing factor to foodborne illnesses. This incident underscores a failure to adhere to established infection control protocols, potentially compromising the safety and health of residents and others in the facility.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required space of at least 80 square feet per resident in multiple resident rooms. During the survey conducted from October 22 to October 28, 2024, it was observed that 22 rooms, each housing two residents, measured only 154 square feet, which is below the required space per resident. This deficiency was identified during an environmental tour with the Maintenance Supervisor, who confirmed the room measurements. Despite the deficiency, interviews with staff and residents indicated that there were no complaints or issues regarding room size, privacy, or space for care. Certified Nursing Assistant 7, who has worked at the facility for seven years, stated that room sizes had not been an issue, and there was adequate space for care and storage. Similarly, a resident interviewed expressed no concerns about room size, privacy, or storage. Observations during the survey period noted that the rooms provided reasonable privacy, adequate storage, and sufficient space for nursing care and resident ambulation. The report suggests that the waiver for room size requirements should continue, as it does not adversely affect the health and safety of residents.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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