Blue Oak Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Rosa, California.
- Location
- 850 Sonoma Ave, Santa Rosa, California 95404
- CMS Provider Number
- 056090
- Inspections on file
- 30
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Blue Oak Post-acute during CMS and state inspections, most recent first.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
The facility failed to complete and submit required five-day written investigation reports to CDPH for two separate, facility-reported allegations of suspected dependent adult/elder abuse involving resident-to-resident altercations. Although the initial allegations were reported to CDPH, the new ADM could not locate any investigation files or evidence that follow-up reports were sent, and the DON did not know if the investigations were completed. This occurred despite a facility policy requiring the ADM to initiate investigations and provide a follow-up report within five business days to ensure the events were investigated and safety interventions were identified.
Two residents did not receive care and monitoring consistent with professional standards and facility policy. A cognitively intact resident with multiple comorbidities reported being physically grabbed, and staff documented only general skin discoloration on the right forearm without completing a detailed skin integrity assessment at the time of the allegation; a more specific skin/wound note was not entered until several days later, despite visible bruising on later observation. Another cognitively intact resident with DM and vascular dementia exhibited increased agitation, physical aggression, and wandering, was placed on 72-hour monitoring, and had a care plan reflecting adverse behaviors and the need for such monitoring, but nursing staff failed to document required 72-hour monitoring every shift, with only two of nine expected progress notes completed.
Two residents were physically assaulted by other residents, resulting in one experiencing mild facial pain and fear. Both aggressors and victims had psychiatric diagnoses but no memory impairment. Facility staff confirmed the incidents as physical abuse, and documentation showed the facility did not prevent these occurrences, violating residents' rights to be free from abuse.
A resident with a diagnosis of Paranoid Schizophrenia was forced by a CNA and an unlicensed staff member to unclog her own toilet containing urine and feces with gloved hands, while the room door was left open despite her request for privacy. This incident caused the resident to feel embarrassed, humiliated, and victimized, constituting psychological abuse.
The facility did not follow its abuse investigation policy by failing to interview other residents who may have been affected by an alleged abuse incident. Only a single resident was interviewed, and both the DBH and Administrator confirmed that no additional resident interviews were conducted, which prevented identification of other potentially affected individuals.
A resident with a history of stroke and anxiety became agitated by another resident's noise and threw a pitcher of water at them. The incident was confirmed through interviews and documentation, and the facility's policy requires protection of residents from abuse by anyone, including other residents.
A resident experiencing pain was physically assisted from the hallway floor to bed by an LN, despite repeatedly refusing consent and asking not to be touched. The LN did not comply with the resident's requests, and other staff confirmed that this action violated the resident's rights to dignity and self-determination as outlined in facility policy.
A resident reported physical abuse by a licensed nurse, but the facility did not notify law enforcement within the required two-hour window. Staff interviews and record reviews confirmed the delay, which was not in accordance with facility policy or regulatory requirements.
A medication cart was found unlocked and unattended, with no nurse present, until a nurse returned and secured it. The nurse admitted to leaving the cart unlocked while accompanying the DON, and both the DON and another nurse confirmed that medication carts must be locked when unattended, as required by facility policy.
A resident recovering from surgery and with mobility challenges was left on a soiled bedpan for hours after multiple unanswered call light activations, due to a communication breakdown between CNAs during a shift change. Staff interviews and facility policy reviews confirmed that this failure compromised the resident's dignity and did not meet expected standards for prompt toileting assistance.
A resident alleged mistreatment by a staff member, and while the administrator investigated the claim, a required five-day follow-up investigation report was not submitted to the Department due to the administrator's lack of awareness of this reporting requirement. This failure resulted in the Department not receiving timely information about the incident.
A resident with multiple mental health diagnoses and cognitive impairment did not receive a required Level II PASRR evaluation after a positive Level I screen. Facility staff were unclear on PASRR procedures, and the absence of a specific policy led to the resident missing a comprehensive mental health assessment and access to appropriate resources.
Staff did not consistently perform or offer hand hygiene to residents after meals, nor did they perform hand hygiene before preparing medications or before and after glove use, despite facility policy requiring these actions. Staff and management interviews confirmed awareness of the policy and acknowledged the lapses during the observed incidents.
Surveyors found that the facility failed to properly dispose of discontinued and unused medications, including leaving medications for discharged residents in a medication room refrigerator, placing discontinued medications in resealable bags in disposal bins, and storing discontinued medications among active ones in a medication cart. LNs confirmed the medications were for discharged or current residents with discontinued orders, and records supported these findings. The facility's actions did not follow its own policies for medication destruction and storage.
The facility did not notify the LTC Ombudsman or provide evidence of notification for 42 residents who were discharged or transferred to the hospital by facility initiation. Staff interviews revealed that the behavioral unit had never notified the ombudsman, with some staff unaware of the requirement. Facility policy and state regulations require such notifications, but no documentation was found in the health records.
A resident with severe memory impairment and a history of stroke eloped from the facility and sustained injuries due to inadequate supervision. Despite being assessed as a low risk for wandering, the resident exhibited wandering behavior, leading to the initiation of an elopement care plan and the use of a wandering device (WMD). However, the WMD was improperly placed on the resident's wheelchair, and the resident was later found outside with injuries. The facility acknowledged a breakdown in supervision and risk assessment.
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Submit Required Five-Day Abuse Investigation Reports
Penalty
Summary
The facility failed to provide the State Survey Agency (CDPH) with written five-day investigation reports for two separate, facility-reported allegations of suspected dependent adult/elder abuse involving resident-to-resident altercations. One allegation involved an altercation between Resident 1 and Resident 2, and another involved an altercation between Resident 3 and Resident 4. Facility documents showed that both allegations were reported to CDPH on the same dates they were made, but there was no evidence that the required follow-up investigation reports were completed and submitted within five calendar days as required by facility policy and regulatory expectations. During interviews, the Administrator, whose first day in the role was 1/01/2026, stated she could not locate the facility files that would normally contain the five-day investigation reports for either abuse allegation and confirmed she could not provide evidence that the reports were sent to CDPH. The DON stated she did not know if the investigation reports for both abuse allegations were completed and acknowledged that the purpose of these reports was to ensure the facility investigated what happened and what interventions were implemented to provide resident safety, and that it was a regulatory requirement to provide the five-day investigation report to CDPH. The facility’s written policy on abuse, neglect, exploitation, or misappropriation specified that all allegations are thoroughly investigated, that the administrator initiates investigations, and that a follow-up investigation report is to be provided within five business days of the incident, which did not occur in these cases.
Failure to Complete Abuse-Related Skin Assessment and 72-Hour Monitoring per Professional Standards
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards for assessment and documentation following an abuse allegation involving Resident 1. Resident 1, who had COPD, left-sided hemiplegia, and major depressive disorder and was cognitively intact per a BIMS score of 13, reported alleged physical abuse on 12/18/25, stating that someone grabbed her right arm. An SBAR change-of-condition note documented skin discoloration on the right forearm with intact skin, no swelling, and no pain. However, no detailed skin integrity assessment was completed at that time to describe the bruising in terms of size, exact location, and characteristics, despite facility policy requiring detailed observations and the DON’s expectation that a skin integrity assessment be completed when the bruising was first reported. A skin/wound note was not entered until 12/21/25, and during a later observation on 1/05/26, two distinct bruises were noted on the lateral aspects of Resident 1’s right upper and lower arm, with specific measurements and color changes that had not been previously documented. The deficiency also involves the facility’s failure to complete ordered 72-hour monitoring every shift following a change in condition for Resident 2. Resident 2, who had DM, vascular dementia with behavioral disturbances, and major depressive disorder and was cognitively intact per a BIMS score of 13, was observed on 12/17/25 to have increased agitation, physical aggression, wandering, and entering other residents’ rooms. An SBAR change-of-condition note documented these behaviors and indicated that 72-hour monitoring was initiated, and the care plan reflected that the resident was exhibiting adverse behaviors affecting physical well-being, safety, and aggression toward staff and other residents, with 72-hour monitoring started. Facility documentation and the DON’s review showed that required 72-hour monitoring notes were not completed every shift as expected. Record review revealed that for Resident 2, there was no evidence that 72-hour monitoring was completed by nursing staff on any shift on 12/18/25, nor on AM, PM, and NOC shifts on 12/19/25, and NOC shift on 12/20/25. The DON stated that her expectation was that licensed nursing staff complete 72-hour monitoring every shift, resulting in nine progress notes over the monitoring period, but confirmed that only two notes were completed on 12/20/25. Facility policies required that all services provided to residents be documented in the medical record and that charge nurses ensure care is provided according to the care plan and that nurses’ notes reflect that the care plan is being followed. These omissions in assessment and monitoring documentation for both residents constituted failures to meet professional standards of quality and facility policy requirements.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents in two separate incidents. In the first incident, a resident with schizophrenia and no memory impairment struck another resident, also with schizophrenia and no memory impairment, several times on the back of the head while the latter was sitting on his bed. The assaulted resident reported the incident, denied pain, and had no visible injuries. The aggressor admitted to hitting the other resident, stating that the victim was making weird noises. Facility staff, including the case manager and program director, confirmed the occurrence of physical abuse. In the second incident, a resident diagnosed with schizoaffective disorder hit another resident, who also had schizophrenia and no memory impairment, several times in the head while she was lying in bed. The victim experienced mild pain to the right temple and expressed fear of the aggressor. The program director documented the incident and acknowledged it as physical abuse. Both incidents were confirmed through interviews and record reviews, and the facility's policy states that residents have the right to be free from abuse, including physical abuse.
Resident Subjected to Psychological Abuse by Staff
Penalty
Summary
A Certified Nursing Assistant (CNA) and an unlicensed staff member required a resident diagnosed with Paranoid Schizophrenia to unclog her own toilet, which contained urine and feces, using her gloved hands. The CNA instructed the resident to perform this task while the door to her room was intentionally left open, despite the resident's request for privacy. The CNA justified her actions by stating she was trying to teach the resident a lesson, and the unlicensed staff member confirmed the incident occurred as described. The resident reported feeling embarrassed, humiliated, and victimized by the incident, which negatively impacted her psychological well-being. At the time, the resident had no memory impairment, depression, hallucinations, or behavioral symptoms according to her Minimum Data Set assessment. The facility's policy prohibits all forms of abuse, including mental abuse, and commits to preventing such incidents. The actions of the CNA and unlicensed staff directly violated the resident's right to be free from psychological abuse.
Failure to Interview Other Residents During Abuse Investigation
Penalty
Summary
The facility failed to properly investigate an abuse allegation by not interviewing other residents who may have been affected. According to a review of the 5-day summary report, only one resident was interviewed in relation to the abuse allegation. During interviews, both the Director of Behavioral Health and the Administrator confirmed that no other residents were interviewed as part of the investigation, despite facility policy requiring interviews with the resident's roommate and other residents who received care from the accused employee. This omission prevented the identification of any additional residents who could have been impacted by the alleged abuse.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse when one resident threw a pitcher of water at another resident. Resident 1, who had a history of respiratory failure, hemiplegia, hemiparesis following a stroke, and major depressive disorder, was assessed as having moderately intact cognition. Resident 2, who had a history of stroke, anxiety disorder, and aphasia, was assessed as having intact cognition. According to documentation, Resident 2 became agitated by what he perceived as excessive noise from Resident 1 and responded by throwing water at him. Resident 1 was surprised by the incident and did not realize his behavior was agitating his neighbor. Interviews confirmed that Resident 2 admitted to throwing water on Resident 1 due to ongoing frustration with the noise and a perceived lack of intervention by staff. The facility's policy on abuse prevention states that residents have the right to be free from abuse, including abuse by other residents. The incident demonstrates a failure to protect Resident 1 from abuse as required by facility policy.
Resident's Right to Refuse Physical Contact Not Honored
Penalty
Summary
A deficiency occurred when a licensed nurse (LN B) physically assisted a resident who was lying on a blanket in the hallway by lifting her from the floor and placing her in bed, despite the resident's repeated verbal refusals and explicit statements that she did not consent to being touched. The resident, who was self-responsible and experiencing significant pain at the time, repeatedly told LN B not to touch her and requested that the police be called, but LN B did not comply with these requests. LN B later acknowledged that he should not have touched the resident without her consent. Interviews with other staff, including the Director of Nursing and additional licensed and unlicensed staff, confirmed that facility policy and standard practice require staff to respect residents' rights to refuse physical contact and to be treated with dignity. The facility's policy on resident rights, as well as staff statements, indicated that touching a resident without consent is a violation of those rights. The incident resulted in the resident feeling disrespected and that her rights had been violated.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse made by a resident against a licensed nurse was reported to the appropriate authorities within the required two-hour timeframe. According to documentation, the resident reported the abuse on 7/7/25 at 3:10 p.m., but the allegation was not reported to the local police department until the following day, 7/8/25. Interviews with facility staff, including the Director of Nursing, Licensed Nurse, and Director of Staff Development, confirmed that all abuse allegations should be reported to the police, ombudsman, and state licensing agency within two hours to ensure resident safety. Record reviews further verified that the reporting to law enforcement was delayed beyond the required period. A review of the facility's policy and relevant regulatory guidance indicated that abuse allegations must be reported immediately, defined as within two hours, to state licensing, the ombudsman, and law enforcement. The facility's own documentation and fax confirmation sheet confirmed the delay in reporting. This deficiency was identified for one of three sampled residents and was substantiated through interviews, record reviews, and examination of facility policies and state requirements.
Unattended Medication Cart Left Unlocked
Penalty
Summary
A medication cart was observed left unlocked and unattended in the facility, with no nurse present in the area at the time. Shortly after, a nurse returned and locked the cart, confirming that she had left it unlocked while accompanying the DON into the medication room. The nurse acknowledged that the cart should remain locked when unattended to prevent unauthorized access to medications. The DON and another nurse both confirmed the expectation that medication carts be locked at all times when not in use, in accordance with the facility's policy and procedure, which requires all compartments containing drugs and biologicals to be locked when not in use.
Resident Left on Soiled Bedpan Due to Staff Communication Breakdown
Penalty
Summary
A resident admitted for surgery aftercare following a right lower leg fracture, with a history of falls and difficulty walking, was left on a soiled bedpan for hours during the night without any response to multiple call light activations. The resident reported feeling helpless and embarrassed by the experience and notified a nurse the following morning. Staff interviews confirmed that the resident was left unattended due to a communication breakdown between two CNAs who changed assignments mid-shift, resulting in the resident's needs being overlooked. Facility staff, including a CNA, a licensed nurse, and the DON, acknowledged that the standard procedure is to respond promptly to call lights and not to leave residents on bedpans for extended periods, as this can cause discomfort and potential skin breakdown. Review of facility policies confirmed that residents should be treated with dignity and respect, with prompt toileting assistance and removal from bedpans as soon as they indicate they are finished. The failure to follow these procedures led to the resident enduring an undignified and uncomfortable situation.
Plan Of Correction
F550 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: DSD/ADSD/Nursing Supervisor In serviced 6/5/25. CNAs on 5/28/25 and 6/5/25 offering and removal of bedpans that emphasize dignity and respect for the residents during this process. One resident was affected by deficient practice. Follow-up interviews with the affected resident confirm that there have been no recurrences of deficient practice and deny any residual emotional effects. 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: DON/MDS/Nursing Supervisor identified residents who utilize bedpans. Three (3) residents have the potential to be affected by 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 recur: Therapy will track new admissions who utilize bedpans, communicate identified residents to Nursing. Identified residents who utilize bedpans will be updated in their toileting care plan. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system and includes dates when corrective action will be completed. The corrective action dates must be acceptable to the State Agency. Department heads/Interdisciplinary Team will identify resident concerns through daily Angel rounds, via review of monthly Resident Council minutes, and during quarterly care conferences. Findings will be reviewed in QAPI for three months.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to complete and provide a timely investigation report to the Department following an allegation of abuse involving a resident and a staff member. Specifically, after a resident reported not being treated with dignity and respect by a housekeeper, the administrator conducted an internal investigation but did not submit the required five-day follow-up investigation report to the Department. During an interview, the administrator stated that he was unaware of the requirement to send a follow-up report within five days after an abuse allegation, referencing guidance documents that did not indicate this obligation. A review of the facility's policy on abuse, neglect, exploitation, and misappropriation prevention confirmed that the facility is committed to investigating and reporting all allegations within federally required timeframes. However, the lack of a timely report in this instance meant that the Department did not receive necessary information to intervene or ensure protective actions for the resident involved and the other residents in the facility.
Plan Of Correction
Immediate Action Taken The Administrator reviewed the abuse investigation file involved. The alleged abuse was non-physical and was reported under California Welfare & Institutions Code 15630(a)(b)(1)(C). The code section calls for reporting to the local ombudsman or local enforcement agency. The initial report was made to the State Survey Agency, local ombudsman, and local law enforcement agency. Moving forward, results of investigation that fall under this State Law code section will be reported to the State Survey Agency under CFR Section 483.12(c)(4) within 5 working days. Action taken for other potentially affected residents The Administrator reviewed previously reported allegations, and all involved physical abuse in which both federal and state law requires reporting to the State Survey Agency, the local ombudsman, and local law enforcement agency. All initial reports were followed by a 5-day report to the State Survey Agency. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months. Prevention of recurrence Per above, the facility will report results of abuse investigations per CFR Section 483.12(c)(4) within 5 working days independent of State Law reporting provisions regardless of state law classification. Monitoring The Administrator will review open abuse investigation files to ensure compliance. System Effectiveness System effectiveness will be evaluated during monthly QAPI meetings for three (3) months.
Failure to Complete Required Level II PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosed mental illness received a required Level II PASRR (Preadmission Screening and Resident Review) evaluation. The resident, who had a history of Alzheimer's disease, non-Alzheimer's dementia, anxiety, depression, and bipolar disorder, was admitted with a positive Level I PASRR screening indicating the need for a Level II evaluation. Despite this, documentation showed that the Level II PASRR was not completed, with correspondence from the Department of Health Care Services at one point stating the evaluation could not be conducted due to the resident being isolated for health or safety reasons, and later stating the resident did not require the screening due to not having a severe mental illness. The resident's cognitive status declined over time, as evidenced by a drop in BIMS score from 11 to 3, indicating severe cognitive impairment. Interviews with facility staff revealed a lack of clarity and policy regarding the PASRR process. The Business Manager was unaware of the steps to take if the acute care hospital did not complete the PASRR accurately or if a resident developed a mental illness while in the facility. The Administrator acknowledged that a Level II PASRR should have been conducted and identified a gap in the facility's PASRR process. The facility's policy required referral for Level II evaluation when indicated, but this was not followed, resulting in the resident not receiving a complete mental health evaluation or access to appropriate mental health resources.
Plan Of Correction
On 4/25/25, the Administrator completed a revision of the facility's policy and procedure (P&P) for PASSR to 1) include the definition of a significant change and 2) address what to do when a resident is noted to have a significant change of condition. On 4/28/25, the Administrator revised the P&P with the facility's current PASSR system, authorized users, and the Interdisciplinary Team (IDT), the requirement that a Resident Review (RR) must be initiated by submitting a Level I Screening upon a resident's significant change in condition. On 4/28/25, the Administrator reviewed with the Interdisciplinary Team (IDT) the definition of a "significant change of condition." The facility's current PASSR System authorized users include the Business Office Manager, Business Office Assistant, and Admission's Director. The IDT includes the Director of Nurses, Director of Staff Development, Minimum Data Set Nurse, Social Services Director, Activities Director, Rehabilitation Director, Medical Records Designee, and Administrator. The IDT will review changes of condition as defined in the P&P during morning stand-up meetings and communicate the need to submit Level I Screening to PASSR systems users as needed. The Medical Records Designee will audit changes of conditions and for completion of the process and report findings to the IDT. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Adhere to Hand Hygiene Protocols
Penalty
Summary
Staff failed to consistently offer or perform hand hygiene (HH) for residents after meals, as observed with multiple residents who were not provided HH following lunch. Interviews with staff confirmed that facility policy requires offering HH before and after meals for infection control, and staff acknowledged not following this policy during the observed incidents. The nurse manager also confirmed that HH should be offered to residents before and after meals to prevent infection. Additionally, staff did not perform HH prior to preparing medications or before and after donning gloves, as observed with a licensed psych technician during medication pass and glove use. Staff interviews confirmed awareness of the facility's policy to perform HH in these situations, and the facility's written policy also requires HH before and after eating, before preparing medications, and after removing gloves. These lapses were directly observed and verified by staff and the nurse manager during interviews.
Plan Of Correction
On 4/7/25-4/10/25, all staff were in-serviced on Hand Washing/Hand Hygiene Policy and Procedure (P&P) by the Director of Nursing (DON), Director of Staff Development (DSD), Assistant Director of Staff Development (ADSD), and Infection Preventionist (IP). The training included: 1) Offering Hand Hygiene (HH) to residents after meals 2) Utilizing HH prior to preparation of medications 3) Utilizing HH prior to donning and doffing of gloves The IP, DSD, and ADSD will observe and monitor: (1) Staff offering HH to residents after meals (2) Utilizing HH prior to preparation of medications (3) Utilizing HH prior to donning and doffing of gloves Audits will be conducted three times a week for 3 weeks, twice weekly for 2 weeks, and then once weekly for 1 week. Additionally, random audits will be performed for one month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee for three months.
Failure to Properly Dispose of Discontinued and Unused Medications
Penalty
Summary
Surveyors identified multiple failures in the facility's handling of discontinued and unused medications. During observations, medications belonging to two discharged residents were found left inside a medication room refrigerator, despite both residents having been discharged weeks prior. Additionally, discontinued medications for two other residents were found disposed of in their original containers inside resealable plastic bags within a disposal bin, rather than being properly destroyed according to facility policy. Further, various discontinued medications, including birth control pills, were left intact and undisposed in a disposal bin, and a discontinued medication for another resident was found stored among active medications in a medication cart. Interviews with licensed nurses confirmed that the medications found belonged to residents who were no longer in the facility or whose medication orders had been discontinued. Record reviews corroborated the discharge dates and medication discontinuation orders for the affected residents. The facility's policy requires that discontinued and unused medications be destroyed in compliance with federal and state regulations, and that such medications be removed from storage areas and secured until destruction. Despite these requirements, the facility failed to properly identify, segregate, and dispose of discontinued and unused medications. The observed practices included leaving medications accessible in medication rooms and carts, and placing them in disposal bins without proper destruction. These actions were not in accordance with the facility's own policies or regulatory requirements for pharmaceutical service, labeling, and storage.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 Inservices with licensed staff regarding the facility policy and procedure titled Discarding and Destroying Medications. Licensed staff will follow the facility protocol for proper disposal and destruction of unused and discontinued medications. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medications 3 times a week for 3 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused medications 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication randomly for 1 month. System Effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three months.
Failure to Notify LTC Ombudsman of Facility-Initiated Discharges and Transfers
Penalty
Summary
The facility failed to notify and provide evidence that the LTC Ombudsman was given a copy of the transfer notice for 42 out of 42 residents who were subjected to a facility-initiated discharge or transfer to the hospital between December 2024 and March 2025. Multiple staff interviews, including those with the program director, nurse manager, licensed nurses, and the social services director, confirmed that the behavioral unit had never notified the ombudsman of any discharges or transfers to the hospital. Staff members indicated that they were either unaware of the requirement or believed it was not necessary to notify the ombudsman. A review of facility policy and the All Facilities Letter (AFL 17-27) indicated that the facility is required to send notice to the local LTC Ombudsman for any transfer or discharge initiated by the facility. The administrator acknowledged that the behavioral unit is licensed under the skilled nursing facility and is therefore required to follow state regulations, including ombudsman notification for all discharges and transfers. No evidence was found in the health records that the ombudsman had been notified for any of the affected residents.
Plan Of Correction
On 4/26/25, the Administrator reviewed the content of AFL 17-27 with the Social Services Director (SSD) and Behavioral Unit's Program Director (PD) and Nurse Manager (NM) for compliance. The Administrator stressed AB 940's requirement that the facility 1) must notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representative when a facility-initiated transfer or discharge occurs, and 2) is required to provide a copy of the notice to the LTC Ombudsman as soon as practicable if the resident is subject to a facility-initiated transfer to a general acute care hospital on an emergency basis. The SSD will maintain a binder organized by year containing 1) a list of all discharged residents to date, 2) copies of the facility-initiated transfer notices, and 3) proof of transmission of the notices to the LTC Ombudsman's office. The PD and NM will maintain the same for the Behavioral Health Unit. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who eloped and sustained injuries. The resident, who had been admitted with a diagnosis of cerebral infarction and had severe memory impairment, was assessed as being at moderate risk for falls and low risk for wandering. Despite this, an elopement care plan and a wandering device (WMD) were initiated after the resident exhibited wandering behavior and attempted to leave the facility. However, the WMD was improperly placed on the resident's wheelchair instead of on the resident, and the elopement care plan did not document the reason for this placement. On the night of the incident, the resident was found missing from the facility, and staff discovered the resident outside on the sidewalk with injuries, including a fracture to the left thumb and abrasions to the face and knees. Interviews with facility staff revealed that the resident was not adequately supervised, and there was a breakdown in the system that allowed the resident to elope without staff knowledge. The Director of Nursing acknowledged the inaccuracies in the resident's wandering risk assessment and the improper use of the WMD, confirming the facility's responsibility for ensuring resident safety.
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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