Bishop Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bishop, California.
- Location
- 151 Pioneer Ln, Bishop, California 93514
- CMS Provider Number
- 555777
- Inspections on file
- 54
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bishop Care Center during CMS and state inspections, most recent first.
The facility did not provide a timely written response to a grievance submitted by the Family Council, despite a policy requiring written responses within 14 days. Family Council minutes, submitted by the LTC Ombudsman to the former Administrator, documented concerns such as residents waiting two hours for incontinence pad changes and not being checked every two hours by staff. As confirmed by the DON, no written response was issued within the required timeframe, which was attributed to a change in Administrators, affecting all residents in the facility.
The facility did not provide the required minimum direct care service hours per patient day over a six-day period, resulting in insufficient nursing staff to meet resident needs. The DON confirmed ongoing staffing shortages, particularly on night shifts, due to recent CNA resignations and reliance on temporary staff. Facility records showed multiple days with DHPPD below regulatory requirements, affecting the care and safety of all residents.
The facility did not meet the required 3.5 direct care service hours per patient day on several occasions, as confirmed by staffing records and leadership interviews. On one occasion, a call light was left unanswered for 40 minutes due to lack of CNA coverage, highlighting the impact of insufficient staffing on resident care and safety.
A resident with Alzheimer's and other conditions was found with unexplained facial injuries. Staff observed and documented the injuries, and the DON and administrator were notified, but the required report to the state agency and ombudsman was delayed. The SOC341 form was submitted several days after the incident, and the facility could not provide the mandated 5-day investigation report, resulting in a deficiency for failure to follow reporting and investigation protocols.
The facility did not provide the required minimum direct care service hours per patient day on multiple occasions, as confirmed by staff interviews and record reviews. Staff shortages, discontinuation of registry and travelers, and unfilled vacancies led to insufficient staffing, preventing adequate care and supervision for residents, including those with wandering behaviors. Leadership acknowledged awareness of the issue and that facility policy and waiver requirements were not met.
The facility failed to maintain RN coverage for eight consecutive hours, seven days a week, as required by policy. On multiple occasions, no RN was scheduled, and the DON was only on-call, not physically present. Staff interviews confirmed the necessity of RN presence for certain treatments, highlighting a scheduling issue that led to this deficiency.
The facility failed to provide sufficient staffing on three sampled days, with direct care service hours per patient day falling below the required 3.5 DHPPD. This deficiency was confirmed through interviews and record reviews with the Administrator and DON, who acknowledged the staffing issues and the failure to adhere to the facility's staffing waiver. The deficiency had the potential to impact the psychosocial and physical needs of 93 residents.
The facility failed to provide adequate hydration to three residents, leading to potential health risks. Residents reported delays in receiving assistance and inconsistent water distribution. Staff interviews revealed confusion about responsibilities for hydration, and the Director of Nursing acknowledged the issue. Facility policies on hydration were not adhered to, as evidenced by empty water pitchers and resident complaints.
Three residents experienced significant delays in receiving assistance, with one resident left soiled for hours and others waiting over an hour for help after using call lights. The facility's staffing issues contributed to these deficiencies, as confirmed by staff interviews.
The facility failed to serve meals at an appetizing temperature to three residents, as required by its food and nutrition services policy. The residents reported receiving cold meals, and the DON acknowledged that staffing challenges and improper handling of meal carts might be contributing factors.
The facility failed to follow its garbage disposal policy by leaving four outdoor dumpsters open, as observed during an inspection with the Maintenance Director. The DON acknowledged the risk of attracting rodents, which could pose a health risk to the 89 residents. The facility's policy and the FDA Federal Food Code require dumpsters to be kept closed to prevent attracting pests.
The facility failed to maintain its pest control program, leading to a reported sighting of mice, affecting 89 residents. A resident reported seeing a mouse inside the facility, which was confirmed by the Maintenance Director. The DON acknowledged the presence of mice and stated that the pest control program had been discontinued due to budget reasons. The facility's policy indicated an ongoing pest control program was required.
The facility failed to follow its policy for timely call light response, affecting four residents with various medical conditions, including difficulty walking and muscle weakness. Residents reported long wait times for assistance, with one noting delays of up to 45 minutes. The DON acknowledged the issue, which contradicts the facility's policy requiring prompt response to call lights.
A resident reported inappropriate conduct by a CNA, who was hired before completing a background check, to the facility Administrator. The Administrator failed to initiate an investigation or report the incident to the relevant agencies within the required timeframe, only addressing the issue after it was brought to attention by the ombudsman a week later. This failure to follow the facility's abuse prevention and reporting policies placed the resident and others at risk.
A resident reported inappropriate touching by a CNA, but the facility failed to suspend the CNA immediately as per policy. The CNA continued to work for two days, maintaining contact with the resident and others. The Administrator admitted forgetting to place the CNA on leave, and HR was unaware of the need for removal from the schedule.
A facility failed to administer medications timely to a resident with peripheral vascular disease, missing several doses due to a breakdown in communication and procedure adherence. Additionally, three residents experienced significant delays in call light responses, particularly during nighttime hours, due to insufficient staffing. These deficiencies posed potential risks to the residents' health and safety.
A CNA failed to report suspected abuse of a resident within the required timeframe, delaying the facility's investigation. The resident, with moderate cognitive impairment, was allegedly abused by another staff member. Facility policy mandates immediate reporting of such incidents.
Failure to Provide Timely Written Response to Family Council Grievance
Penalty
Summary
The facility failed to provide a timely written response to a grievance submitted by the Family Council, as required by its own policy. According to the facility’s undated Family Council policy, the facility must respond in writing to written requests, concerns, or recommendations of the Family Council within 14 calendar days. The Long-Term Care Ombudsman submitted the Family Council minutes from an October 17, 2025 meeting to the former Administrator on November 9, 2025. As of an interview conducted on December 29, 2026, the facility was unable to provide any written response addressing the concerns raised in those minutes, and the DON acknowledged that no written response had been issued within the 14-day timeframe. Review of the Resident Council Town Hall Minutes dated November 20, 2025, showed that new concerns were discussed, including residents waiting two hours for an incontinence pad change and residents not being checked every two hours by staff. These concerns were part of the issues brought forward through the Family Council process. During the December 29, 2026 interview, the DON confirmed that a change in Administrators occurred during this period and stated that, due to this change, the facility did not provide the required written response within the policy’s 14-day requirement. The lack of timely written response affected all 99 residents residing in the facility, who are described as highly vulnerable.
Failure to Maintain Sufficient Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as required by federal and state regulations. Over a six-day period, the facility did not meet the minimum required 3.5 direct care service hours per patient day (DHPPD), with documented shortfalls on each day. The Director of Nursing (DON) confirmed that the facility was short-staffed, particularly on the night shift, due to the recent resignation of three Certified Nursing Assistants (CNAs) and reliance on temporary staff. Facility records showed that on several days, the DHPPD fell significantly below the required threshold, with the lowest being 2.22 DHPPD. The facility's own policy, which mandates sufficient and competent staffing in accordance with resident care plans and facility assessment, was not followed during this period. This staffing deficiency had the potential to result in unmet psychosocial and physical needs, as well as safety concerns, for all 95 residents in the facility. The DON acknowledged awareness of the staffing shortfalls and confirmed that the required staffing levels were not maintained on the specified dates. The deficiency was identified during an unannounced complaint investigation related to quality of care, and the findings were corroborated through interviews and review of facility documentation.
Failure to Meet Required Nursing Staff Hours
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the required 3.5 direct care service hours per patient day (DHPPD) as mandated by regulation and the conditions of their staffing waiver. On multiple dates, including May 18, June 6, June 7, June 8, and June 9, 2025, the actual DHPPD fell below the required threshold, with the lowest recorded at 2.50 hours. This shortfall was confirmed through review of staffing assignments and acknowledged by both the Director of Staff Development (DSD) and the Director of Nursing (DON). During the investigation, it was reported by an LVN that a call light was left activated for 40 minutes without a Certified Nursing Assistant (CNA) present to respond, indicating a delay in addressing resident needs due to insufficient staffing. The DSD and DON both acknowledged the facility's failure to meet staffing requirements on the specified dates and recognized the importance of adequate staffing for resident safety and care. The deficiency had the potential to result in unmet psychosocial and physical needs, as well as safety concerns, for the facility's 95 residents. The facility's staffing waiver required a minimum of 3.5 DHPPD, and the failure to meet this standard was documented and confirmed by facility leadership during interviews and record reviews.
Plan Of Correction
3. We are scheduling registry CNAs to help with staffing requirements and pay for housing for staff. 4. Staffing coordinator & DSD will obtain availability schedule for staff to work during days off. 5. DSD and Administrator reiterated our attendance policy during our all staff meeting on June 5, 2025. D) How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. 1. The staffing coordinator/DSD will report during stand-up meetings the projected PPD for the day and the PPD calculation from the previous day and adjust staffing according to admission and discharge and if there are absences. 2. DSD will report findings during the monthly QA meeting if there are days that fall below the required PPD staffing levels and monitor for trends. 3. We will continue to reward and employee recognition for attendance and morale. We scheduled a shaved ice truck for all staff meetings as well as other local vendors to boost employee satisfaction/attendance. The Director of Nursing will report monitoring results to the Quality Assurance Performance Improvement (QAPI) Committee monthly for three months or until substantial compliance is achieved and maintained. The QAPI Committee will make recommendations for additional interventions or modifications as needed. All corrective actions will be completed by 6/29/25.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of suspected abuse or injury of unknown origin for one resident in accordance with its policy and regulatory requirements. The resident, who had diagnoses including Alzheimer's disease, osteoarthritis, benign prostatic hyperplasia, and lack of coordination, was found with redness and scratches on the face. Nursing notes documented a 1cm area of redness above the eyebrow, and the resident's power of attorney raised concerns about additional discoloration and marks, requesting an investigation. The incident was observed and discussed among staff, with the Director of Nursing (DON) and administrator being notified. Interviews with staff revealed that the certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) noticed the injuries during their shifts, but there was uncertainty about how the injuries occurred. The LVN documented the findings and notified the DON, but did not believe the incident required immediate reporting or investigation, as the injuries did not appear intentional. The Director of Staff Development (DSD) collected statements from staff and communicated with the resident's sister, but the source of the injuries remained unknown. The facility's policy required immediate reporting of all suspected abuse or injuries of unknown origin to the state agency and local ombudsman, but this was not done within the required timeframe. The SOC341 form, which is used to report suspected abuse, was not submitted to the state agency until several days after the incident, and the facility was unable to provide the required 5-day investigation report. Interviews with the administrator and DSD confirmed that the reporting was delayed and that the investigation documentation was incomplete. The facility's failure to promptly report and thoroughly investigate the incident as required by policy and regulation constituted a deficiency.
Failure to Maintain Minimum Direct Care Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by 52 sampled days between October 2024 and March 2025 where the direct care service hours per patient day (DHPPD) fell below the required minimum of 3.5 hours. Interviews with CNAs revealed that staff shortages prevented them from providing necessary care, including 1:1 supervision for residents who wander, and that recent staff resignations had not been replaced. Management had discontinued the use of registry and travelers, further exacerbating staffing shortages, and both the Acting DON and DSD acknowledged ongoing difficulties in maintaining adequate staffing, particularly during sick calls and in the context of being in a rural area. Record reviews confirmed multiple dates with DHPPD below the required threshold, and the facility's own policy, which mandates adequate staffing to meet resident needs, was not followed. The Administrator and other leadership were aware of the staffing shortfalls and acknowledged that the facility did not meet the minimum required hours, despite having a staffing waiver that still required at least 3.5 DHPPD. The deficiency had the potential to result in unmet psychosocial, physical, and safety needs for the facility's 97 residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure registered nurse (RN) coverage for eight consecutive hours, seven days a week, as required by their policy and regulatory standards. This deficiency was observed on multiple occasions during Fiscal Year 2025, Quarter 1, and in the timeframe from February 11, 2025, through March 11, 2025. Specifically, there was no RN scheduled on several Sundays, and on one occasion, an RN was scheduled for only four hours. The facility's policy, revised in August 2022, mandates that an RN provides services at least eight consecutive hours every 24 hours, seven days a week. However, the facility's schedules and staffing reports revealed gaps in RN coverage, with the Director of Nursing (DON) being on-call rather than physically present on some of these days. Interviews with facility staff, including RN #3 and the DON, confirmed the lack of RN coverage and the necessity of having RNs present to administer certain treatments that licensed vocational nurses (LVNs) are not trained to perform. The DON acknowledged the facility's failure to meet the regulatory requirement and noted that being on-call did not equate to being physically present in the facility. Acting Administrators also confirmed the need for RN presence in the building for the required hours and suggested that the issue could be resolved with better scheduling. The absence of RNs during these times indicates a failure to adhere to staffing requirements, potentially impacting the quality of care provided to residents.
Staffing Deficiency Due to Insufficient Direct Care Hours
Penalty
Summary
The facility failed to provide sufficient numbers of staff on three out of five sampled days, resulting in less than 3.5 direct care service hours per patient day (DHPPD). Specifically, on January 9, 11, and 12, 2025, the facility recorded DHPPD of 3.33, 3.31, and 3.15, respectively, which were below the required 3.5 DHPPD. This deficiency was identified through interviews and record reviews with the Administrator and the Director of Nursing (DON). The Administrator acknowledged the staffing issues and mentioned that they have refused to admit residents due to staffing concerns, while the DON confirmed that the facility's staffing policy was not followed. The facility had a staffing waiver in place, valid from July 1, 2024, to June 30, 2025, which required a minimum of 3.5 DHPPD. However, the waiver was not adhered to on the specified dates, as confirmed by the DON. The failure to meet the required staffing levels had the potential to result in unmet psychosocial, physical needs, and safety concerns for 93 residents. The DON emphasized the importance of having enough staff to ensure patient care is not affected and to provide adequate support for the working staff.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure that three residents received or were offered adequate fluids during the day and night, which could potentially compromise their health and safety. Resident 1, who has multiple diagnoses including contracture of the lower legs, thyrotoxicosis, and blindness in one eye, reported being left in soiled diapers and not having their urinal emptied. The resident also mentioned that requests for water refills were often ignored. Observations confirmed that the resident's water pitcher was empty, and the urinal was half full. Resident 2, diagnosed with hemiplegia, hypertension, and diabetes, expressed that it often took an hour or more to receive assistance after pulling the call cord. The resident stated that water was not regularly provided and had to be requested repeatedly. Similarly, Resident 3, who has congestive heart failure, hypertension, and muscle weakness, reported delays in receiving assistance and needing to call for water refills, as they were not automatically provided. Interviews with CNAs and the Kitchen Supervisor revealed inconsistencies in the water distribution process, with some staff members unaware of who was responsible for passing out water pitchers. The Director of Nursing acknowledged the issue, noting that the water pitchers should have been a specific color to indicate the shift responsible for hydration. The facility's policies on activities of daily living and hydration were reviewed, indicating a commitment to providing adequate hydration, which was not met in these instances.
Inadequate Response to Call Lights and Resident Care
Penalty
Summary
The facility failed to adhere to its Activities of Daily Living (ADLs) policy and procedure, resulting in inadequate care for three residents. Resident 1, who suffers from chronic pulmonary disease, idiopathic peripheral autonomic neuropathy, and cachexia, reported using the call light to request assistance but had to wait over an hour for help. This delay occurred during a time when the facility was short-staffed, and the resident was too weak to assist themselves. Resident 2, diagnosed with contractures, thyrotoxicosis, and blindness in one eye, was left in soiled diapers on multiple occasions. The resident reported that a CNA promised to return to change them but failed to do so, leaving them soiled from 2:00 AM until the morning shift at 9:00 AM. Additionally, the resident's urinal was not emptied, and requests for water were ignored, indicating a pattern of neglect in meeting basic care needs. Resident 3, who has hemiplegia and hemiparesis following a cerebral infarction, hypertension, and diabetes type II, also experienced significant delays in receiving assistance, often waiting over an hour after using the call light. The resident, along with their roommate, had to repeatedly request water, which was not provided consistently. Interviews with staff, including CNAs and the Director of Staff Development, confirmed issues with staffing and acknowledged that residents were left without timely care, which is considered neglect and a violation of the facility's policies.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to adhere to its food and nutrition services policy by serving meals that were not at an appetizing temperature to three sampled residents. Resident 1, who was admitted with a diagnosis of hyperlipidemia, reported that the food was not always served warm. Resident 2, diagnosed with bipolar disorder, stated that breakfast was often cold. Resident 3, admitted with muscle weakness, mentioned that the food was sometimes cold and barely warm on certain days. All three residents had no mental impairment as indicated by their Brief Interview for Mental Status (BIMS) scores. The Director of Nursing (DON) acknowledged that the issue of cold food might be related to staffing challenges, which can cause delays in food delivery. Additionally, it was noted that staff might not be closing the meal cart properly when delivering trays, leading to other trays getting cold too quickly. The facility's policy, dated October 2017, requires that food trays be inspected to ensure meals are provided at a safe and appetizing temperature, which was not adhered to in these instances.
Improper Garbage Disposal in Facility
Penalty
Summary
The facility failed to adhere to its food-related garbage disposal policy when four outdoor dumpsters were left open. This was observed during a concurrent observation and interview with the Maintenance Director, where it was noted that some dumpsters outside the facility were not closed. The Director of Nursing was later shown pictures of the open dumpsters and acknowledged the risk they posed as potential breeding grounds for rodents. The facility's policy, dated April 2006, requires that outside dumpsters be kept closed and free of surrounding litter. Additionally, the FDA Federal Food Code, 2022, emphasizes the importance of proper storage and disposal of garbage to prevent it from becoming an attractant and breeding place for insects. This failure had the potential to attract vermin, posing a significant health risk to the 89 clinically compromised residents residing in the facility.
Pest Control Deficiency Due to Discontinued Program
Penalty
Summary
The facility failed to adhere to its pest control policy, which resulted in a reported sighting of mice within the facility, affecting 89 residents. A resident reported seeing a mouse, described as a kangaroo mouse, inside the facility two days prior to the survey. This incident was reported to the maintenance staff. The Maintenance Director confirmed a recent occurrence of mice at the nursing station. The Director of Nursing acknowledged the presence of mice and stated that the facility's pest control program had been discontinued due to budget reasons. A review of the facility's pest control policy, dated May 2008, indicated that the facility was supposed to maintain an ongoing pest control program to keep the building free of insects and rodents.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing care and services to residents, specifically in ensuring that call lights are answered promptly. This deficiency was observed in the cases of four residents who experienced delays in receiving assistance with activities of daily living. Resident 1, who has a history of falling and difficulty walking, reported long wait times for call light responses. Similarly, Resident 2, diagnosed with muscle weakness, expressed concerns about staff availability and unresponsiveness to call lights. Resident 3, with osteoarthritis and walking difficulties, reported waiting up to 45 minutes for assistance and noted issues with meal service, including cold and delayed meals. Resident 4, also experiencing walking difficulties and weakness, reported waiting times of 20 to 45 minutes for staff response. During an interview, the Director of Nursing acknowledged the problem with call light response times, agreeing that residents should not have to wait 45 minutes for assistance. The facility's policy, dated October 2010, mandates that call lights should be answered as soon as possible. The failure to comply with this policy has the potential to jeopardize the health and safety of clinically compromised residents, as their requests for assistance were not addressed in a timely manner.
Failure to Follow Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to adhere to its policies and procedures in preventing, reporting, and investigating an allegation of suspected physical abuse involving a resident. The incident involved a Certified Nursing Assistant (CNA 1) who was employed before the completion of her background check. The background check was initiated two days after her hire date, contrary to the facility's policy that requires background checks to be completed before employment. This oversight was acknowledged by the Human Resources/Payroll department, the Director of Staff Development, and the Director of Nursing, all of whom were unaware of the premature hiring. The deficiency was further compounded by the facility Administrator's failure to respond promptly to an abuse allegation reported by the resident. The resident, who had a cognitive functioning score indicating full mental capacity, reported the inappropriate conduct by CNA 1 to the Administrator. However, the Administrator did not initiate an investigation or report the incident to the relevant state and local agencies within the required timeframe. The delay in action was attributed to the Administrator forgetting about the report, which was only addressed after being brought to attention by the ombudsman a week later. The facility's policies on abuse reporting and investigation were not followed, as confirmed by the Administrator and the Director of Nursing. The policies require immediate investigation and reporting of abuse allegations to local, state, and federal agencies. The failure to act promptly on the resident's report of abuse placed the resident and other vulnerable individuals at risk, highlighting significant lapses in the facility's adherence to its own procedures.
Failure to Suspend CNA After Alleged Abuse
Penalty
Summary
The facility failed to implement immediate protective measures following an alleged abuse incident involving a resident and a Certified Nurse Assistant (CNA). The incident was reported on April 24, 2024, when the resident informed the Administrator that the CNA had inappropriately touched her. Despite the facility's policy requiring immediate suspension of the accused staff member to protect residents, the Administrator admitted to forgetting to place the CNA on administrative leave. As a result, the CNA continued to have access to the resident and other vulnerable individuals in the facility for two consecutive days. The Human Resources/Payroll department was unaware of the need to remove the CNA from the schedule due to the ongoing investigation. This oversight allowed the CNA to work regular hours, maintaining contact with the resident and other residents, which was against the facility's policy. The facility's policy, as reviewed with the Director of Nursing and the Administrator, clearly states that any employee accused of abuse should be placed on leave with no resident contact until the investigation is complete. The Administrator acknowledged that the facility did not adhere to this policy, which posed a risk of further abuse, neglect, exploitation, or mistreatment of the residents.
Medication Administration and Call Light Response Deficiencies
Penalty
Summary
The facility failed to administer medications to Resident 1 in a timely manner as prescribed by the physician. Resident 1, who was admitted with a diagnosis of unspecified peripheral vascular disease, reported a decrease in the quantity of pills taken in the morning. An error occurred at the pharmacy, and although the medications were delivered to the facility, they were not placed in the medication cart drawer for administration. This resulted in missed doses of Apixaban, Tamsulosin, Diltiazem HCL, Furosemide, and Digoxin over several days in May 2024. Interviews with the nursing staff revealed a breakdown in communication and procedure adherence, leading to the failure to administer the medications as per the Medication Administration Record (MAR). Additionally, the facility did not respond promptly to call lights for three residents, including Resident 1, Resident 2, and Resident 3. Resident 1 reported waiting times of up to 16 hours for assistance during the night, while Resident 2 and Resident 3 experienced delays of up to two hours. These delays were particularly problematic during nighttime hours, from 8:00 PM to early morning. The Director of Nursing acknowledged the poor response times, attributing them to insufficient staffing levels, with only four Certified Nursing Assistants (CNAs) available during the night shift. The facility's policy and procedure documents for administering medications and answering call lights were not followed, leading to these deficiencies. The failure to administer medications as prescribed and the delayed response to call lights posed potential risks to the health and safety of the residents involved, who were clinically compromised due to their medical conditions.
Delayed Reporting of Suspected Abuse by CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 1) reported an allegation of suspected physical abuse towards a resident (Resident 1) within the timeframe specified by their policy and procedures. CNA 1 was aware of the alleged abuse on April 2, 2024, but did not report it to the facility administration until April 4, 2024. This delay hindered the facility's ability to promptly investigate the allegation and potentially exposed Resident 1 to continued risk of abuse. The incident involved CNA 1 overhearing a conversation about another staff member allegedly abusing Resident 1 by splashing water in her face, pulling her hair, and hitting her in unnoticeable areas while laughing at her distress. Resident 1 was admitted with diagnoses including unspecified dementia and adjustment disorder with mixed anxiety and depressed mood. The resident had a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. The facility's policy required immediate reporting of suspected abuse to the administrator and other authorities, defining 'immediately' as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. The Director of Nursing confirmed that CNA 1 should have reported the incident immediately, as per the facility's policy.
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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