Brentwood Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Santa Monica, California.
- Location
- 1321 Franklin Street, Santa Monica, California 90404
- CMS Provider Number
- 055711
- Inspections on file
- 45
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Brentwood Health Care Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, encephalopathy, mild cognitive impairment, and multiple stage 4 PUs did not receive care consistent with physician orders and facility policy. Care plans for impaired skin integrity were generic, using non-specific language such as “treatment as ordered” without detailing wound staging or individualized interventions, and were not updated when new DTIs developed. Turning and repositioning ordered q2h was poorly documented over many days, and a CNA reported finding the resident in the same position for up to four hours. The LAL mattress was not set according to the resident’s weight, effectively placing the resident on a hardened surface. New PUs, including DTIs on the right shoulder and left shin, were not promptly addressed with SBARs or timely assessments, and wound treatments were missed or delayed due to unclear assignment and follow-through by the treatment nurse and an LVN. These actions and omissions led to worsening existing PUs and the development of facility-acquired PUs.
A resident with Parkinson’s disease, encephalopathy, cognitive communication deficit, and multiple stage 4 PUs was dependent on staff for ADLs and had orders for specific wound care and q2h turning. Care plans for impaired skin integrity used generic language such as “treatment as ordered” without specifying treatments or individualized interventions, and CNA documentation showed many missed or undocumented repositioning times. Nursing staff failed to perform and document thorough head-to-toe skin assessments, did not promptly complete SBARs or notify the physician and family when new PUs developed on the shoulder and left shin, and the treatment nurse was unable to accurately describe the new wounds or DTPI. The resident’s LAL mattress was set at a default 400 lbs rather than near the resident’s actual weight, contrary to staff and wound care specialist statements that settings must be weight-based. These failures delayed treatment of a new unstageable PU on the shin and did not follow the facility’s own pressure ulcer assessment policy, which the report notes could have led to further deterioration, infection, sepsis, organ failure, and death.
A resident's orthopedic appointment was unnecessarily rescheduled due to the facility's failure to arrange transportation and communicate with the resident's representative. The oversight by the social service assistant led to confusion and distress, as the representative was not informed of the rescheduling despite having previously provided the appointment details.
The facility failed to ensure safe food storage by keeping expired canned food, including corned beef hash, with non-expired items in the kitchen storage area. This was confirmed by the Dietary Supervisor, who noted that expired food should be separated to prevent serving it to residents, especially given their age and medical conditions. The facility's policies require proper inspection and storage of food, but these were not followed, risking foodborne illness for 57 residents.
Two residents were not provided a dignified dining experience as CNAs stood over them while feeding, contrary to facility policy. One resident with dementia and dysphagia and another with multiple health issues were affected. The DON confirmed that feeding should occur at eye level to maintain dignity.
The facility failed to provide ongoing activities for 57 residents, as a CNA, covering for the vacationing Activities Director, was untrained in conducting activities. The DON acknowledged the importance of activities for residents' mental well-being but was unaware of the location of activity logs.
The facility failed to create comprehensive care plans for two residents, leading to deficiencies in their care. One resident, with dementia and psychotic disturbance, was prescribed psychotropic medications without a care plan addressing their use or targeted behaviors. Another resident, with major depressive disorder and atrial fibrillation, was receiving anticoagulant medication without a care plan. The absence of these care plans was confirmed by nursing staff and highlighted the facility's failure to adhere to its policies for person-centered care planning.
Two residents in the facility were not properly monitored for the effects of anticoagulants and antidepressants, leading to potential health risks. One resident on Eliquis was not monitored for bleeding, as required by their care plan, due to an oversight in carrying over orders upon readmission. Another resident on Apixaban and antidepressants lacked monitoring orders, resulting in no documentation of potential side effects or effectiveness. The facility's protocols for medication monitoring were not adhered to, as confirmed by the DON and nursing staff.
The facility failed to properly execute informed consent forms for psychotropic medications for two residents. One resident, with dementia and anxiety, received multiple medications without individual consent forms for each. Another resident, with major depressive disorder, also had medications listed on a single form. The facility's policy requires separate consent forms for each medication, specifying dosage and clinical indications.
A resident with intact cognition reported ants in their room, confirmed by observations. The facility had recently treated exterior ant activity but failed to address interior infestations promptly. The Maintenance Supervisor had to spray the room himself due to a delay in fumigation services. The DON acknowledged the facility's responsibility to ensure a pest-free environment.
A resident was found with an unlabeled medication cup containing a white powder, identified as antifungal powder, without a physician's order or assessment for self-administration capability. The resident, with intact cognition but requiring assistance for some daily activities, was not assessed for safe self-administration, and the medication was not stored securely as per facility policy. Staff were unaware of the medication's presence, and no physician order was found for its use.
The facility failed to record advanced directives for two residents, despite their intact cognitive skills and the facility's policy requiring acknowledgment forms to be signed and dated. Both residents reported that the facility did not discuss advanced directive information with them, and interviews with staff confirmed the importance of these forms in ensuring care aligns with residents' wishes.
A facility failed to accurately document a resident's use of an anticoagulant in their MDS assessment. The resident, admitted with conditions including atrial fibrillation, was prescribed Apixaban, but this was not reflected in the MDS. Interviews with staff revealed the omission was an oversight, highlighting the need for accurate assessments to coordinate care. Facility policies and CMS guidelines require comprehensive assessments, which were not followed in this instance.
A CNA was assigned to cover for the Activities Director without proper training or qualifications, affecting the well-being of 57 residents. The CNA was observed monitoring residents watching TV and admitted to being untrained. Interviews with the DSD and DON confirmed the lack of training, and the DON could not locate activity logs. The facility's job description required specific qualifications that the CNA did not meet.
A facility failed to create a care plan with measurable goals for a resident with dementia, despite the resident's severe cognitive impairment and use of medications for psychosis and anxiety. Observations and interviews confirmed the absence of a tailored care plan, contrary to the facility's policy on dementia management.
A resident was found applying antifungal powder without a physician's order, and the medication was stored improperly in an unlabeled cup at the bedside. Staff were unaware of the medication's presence, and facility policy on self-administration and secure storage was not followed.
The facility failed to document an accurate fall risk assessment for a resident with multiple diagnoses and a recent fall history, incorrectly identifying her as low risk for falls. The LVN did not review the resident's history and physical, which would have indicated a higher fall risk score. The DON confirmed that all documentation should be included in fall risk assessments.
Failure to Individualize Pressure Ulcer Care and Properly Use Support Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent the deterioration and development of pressure injuries for a resident with multiple existing pressure ulcers. The resident had diagnoses including Parkinson’s disease, encephalopathy, cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacral region and both hips. An MDS indicated mild cognitive impairment, dependence on staff for ADLs, and the presence of three stage 4 pressure ulcers with risk for additional ulcers. Physician orders included use of a pressure-relieving mattress and turning and repositioning every two hours, with refusals to be documented. However, the facility did not consistently implement and document these interventions. Care plans initiated for impaired skin integrity related to pressure injuries on the right buttocks and sacrum contained generic interventions such as “treatment as ordered” and did not specify individualized treatments, staging details, or clearly defined interventions beyond broad statements like monitoring skin and turning and repositioning. The treatment nurse stated that care plans for wounds and treatments were not updated with specific orders when wounds were reclassified or when new SBARs were generated, and that it was considered redundant to place actual treatment orders on the care plan. The treatment nurse also acknowledged that the same generic verbiage (“treatment as ordered”) was used for residents with various treatments ordered, and admitted that no SBAR was completed when a new right shoulder deep tissue injury (DTI) was discovered. A left shin DTI was discovered later, and the treatment nurse confirmed that a head-to-toe assessment could have identified this pressure ulcer earlier and prompted SBAR completion and physician and representative notification. Documentation of turning and repositioning was incomplete over multiple days, with numerous time slots lacking evidence that the resident was repositioned every two hours as ordered. A CNA reported doing her best to reposition the resident but stated there were instances when the resident was found in the same position four hours later. The CNA also reported that the resident had pressure ulcers on the buttocks, right upper arm, and a more recent ulcer on the left lower leg. The wound care specialist explained that the low air loss (LAL) mattress is weight-based and must be set close to the resident’s weight, and that setting it to 400 lbs for a resident weighing 139 lbs would be like placing the resident on a table, potentially worsening current wounds or contributing to new pressure ulcers. The medical director stated that staff must notify a physician as soon as possible for changes in condition, urgently for new pressure ulcers, and that care plans must include clear, individualized goals, and also confirmed that placing a resident on a hardened surface for a prolonged period could worsen and cause more pressure ulcers. The facility’s own policies required comprehensive, individualized care plans and detailed assessment and documentation of pressure sores, including support surfaces, which were not fully followed in this case. Additional interviews and record reviews further highlighted lapses in wound care delivery and communication. The treatment nurse initially stated he had not performed the resident’s wound care on a specific date, then later recalled that he had completed the treatments but was unable to describe the shin pressure injury and could not clearly describe what a DTI looked like. He also confirmed that lack of treatment to the left shin could result in wound deterioration, infection, sepsis, organ failure, and death. An LVN who covered as treatment nurse on one of the dates stated she had not completed the resident’s treatment because she was assigned to a different station, which was supposed to be covered by the treatment nurse. The facility’s policies on care planning and pressure ulcer/skin breakdown required comprehensive care plans prepared by the IDT and detailed assessment and documentation of pressure sores, including current treatments and support surfaces, but the practices described in the report did not align with these requirements, contributing to worsening existing pressure ulcers and the development of facility-acquired pressure ulcers for this resident.
Failure to Competently Assess and Report New Pressure Ulcers and Manage Support Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses had the competencies and skills to adequately assess, describe, and report a new pressure ulcer for a resident with multiple existing pressure injuries and significant comorbidities. The resident had Parkinson’s disease, encephalopathy, a cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacrum and both hips, and was mostly dependent on staff for ADLs. Care plans initiated for impaired skin integrity included generic interventions such as “treatment as ordered” and did not specify the actual wound treatments, staging details, or individualized interventions beyond broad statements. The resident’s MDS documented three stage 4 pressure ulcers and risk for additional PUs, and physician orders included specific wound care treatments and turning/repositioning every two hours, but these details were not clearly integrated into individualized care plans. Surveyors’ review of CNA documentation for turning and repositioning showed numerous time slots over multiple days with no documented evidence that the resident was repositioned as ordered. A CNA reported that she tried to reposition the resident but sometimes found the resident in the same position four hours later. The resident was observed with adhesive dressings on the right upper arm and left shin; the CNA stated the resident had pressure ulcers to the buttocks, right upper arm, and a more recent one to the left lower leg. The treatment nurse later stated the resident was being treated for four pressure ulcers (sacrum, left posterior trochanter, right buttocks, and right shoulder DTPI) but was initially unable to state what was under the dressings to the right upper arm and left shin, incorrectly believing those areas had healed PUs. The treatment nurse also acknowledged that head-to-toe skin assessments are supposed to be done and that SBARs and care plans must be updated for new or reclassified wounds, but admitted that treatments on care plans were documented only as “treatment as ordered” and that this same generic wording was used for multiple residents. An SBAR note dated 1/23/2026 documented a pressure injury to the left shin and right shoulder, with concern for an unstageable pressure injury on the shin and a DTPI/UTI-type injury on the shoulder, and indicated the development of pressure injury due to pillow placement. During wound care observation, the room had a foul odor, and the right upper arm ulcer was covered in black-brown jelly-like eschar, while the left shin ulcer measured approximately 7 cm by 3 cm with hard yellow-grey slough and a red halo, with no drainage. The family member reported they only learned of the left shin pressure ulcer a few days earlier during a visit and that the facility had not informed them of this new wound. The treatment nurse admitted that no SBAR had been completed when the right shoulder DTPI was discovered and that the left shin DTI had just been discovered that morning, acknowledging that a head-to-toe assessment could have identified it earlier and prompted SBAR completion and physician and representative notification. The treatment nurse initially stated he had not done the resident’s wound care on 1/21/2026, later recalled that he had, and was still unable to accurately describe the shin wound or what a DTPI looked like. Additional findings showed that the resident’s low air loss (LAL) mattress was not set according to the resident’s weight. The resident weighed 139 lbs, but the mattress was set over the maximum of 400 lbs. The DON stated that mattresses were usually set at 400 lbs to ensure tubes were inflated and should not be set lower than 152 lbs, but could not explain why, while the wound care specialist and an LVN stated that LAL mattresses are weight-based and must be set as close to the resident’s weight as possible, and that incorrect settings could lead to more or worsening pressure injuries. The facility’s pressure ulcer/skin breakdown policy required nurses to perform and document a full assessment of pressure sores, including location, stage, measurements, exudate or necrotic tissue, pain, mobility status, current treatments including support surfaces, and all active diagnoses. The survey findings showed that licensed nursing staff did not consistently perform or document comprehensive assessments, did not accurately describe and stage new wounds, did not promptly complete SBARs or notify the physician and resident representative of new pressure injuries, and did not ensure that support surfaces such as the LAL mattress were properly set, all contributing to a delay in treatment for the resident’s new unstageable pressure injury to the left shin, which the report states could have resulted in further deterioration, infection, sepsis, organ failure, and/or death.
Failure to Arrange Transportation for Resident's Appointment
Penalty
Summary
The facility failed to arrange and confirm transportation for a resident's orthopedic appointment, leading to an unnecessary change in the appointment schedule. The resident, who had multiple diagnoses including diabetes, dementia, and an artificial knee joint, required assistance with daily activities and had a surrogate decision maker. The resident's appointment was initially scheduled for the morning, but due to a lack of communication and oversight by the social service assistant (SSA), the appointment was rescheduled without notifying the resident's representative. On the day of the appointment, the certified nursing assistant (CNA) discovered the oversight and informed the SSA, who then attempted to reschedule the appointment for later in the day. The resident's representative, who had arrived to take the resident to the appointment, was not informed of the rescheduling and was upset by the lack of communication. The representative had previously informed the facility of the appointment details, but the SSA failed to document and arrange transportation as per the facility's policy. The director of nursing (DON) acknowledged the oversight but did not investigate further, assuming the issue was resolved since the resident eventually attended the appointment. The facility's policy requires the social service staff to assist residents in accessing transportation, but this was not adhered to in this instance, leading to confusion and distress for the resident's representative.
Expired Food Storage in Kitchen
Penalty
Summary
The facility failed to ensure safe food storage practices in the kitchen by storing expired canned food, specifically corned beef hash, alongside non-expired food in the food storage area. This was confirmed during an interview and observation with the Dietary Supervisor, who acknowledged that expired canned food should be separated from non-expired food to prevent serving it to residents. Additionally, some dented cans were observed, which further indicated a lapse in proper food storage practices. The Dietary Supervisor emphasized that expired food should not be served to residents, particularly because they are elderly and have medical conditions that could be exacerbated by consuming expired food. The facility's policy and procedures for food storage and handling were reviewed, revealing that all foods delivered require inspection, and damaged goods should be placed in a specified area labeled 'Return to Vendor Do Not Use.' The policy also mandates that food should be stored properly, with labels visible and arranged to permit rotation of supplies so that the oldest items are used first. Despite these guidelines, the facility did not adhere to its own procedures, as evidenced by the presence of expired and dented canned food in the storage area, posing a risk of foodborne illness to the 57 residents receiving food from the kitchen.
Failure to Maintain Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents, Resident 4 and Resident 58, by not maintaining eye-level contact during feeding. Observations revealed that Certified Nursing Assistants (CNAs) stood over the residents while feeding them, which is against the facility's policy that emphasizes the importance of feeding residents at eye level to maintain their dignity. This practice was confirmed by interviews with the CNAs and the Director of Nursing (DON), who acknowledged that feeding residents while standing diminishes their dignity. Resident 58, who was admitted with diagnoses including dementia, dysphagia, and muscle weakness, was observed being fed by CNA 1 while the CNA stood over the resident. The resident's care plan required assistance with feeding due to chewing difficulties, and the facility's policy mandated a dignified dining experience. Despite this, the CNA did not adhere to the policy, as confirmed by the CNA's own admission and the DON's statement. Similarly, Resident 4, who had diagnoses including hypertension, major depressive disorder, and congestive heart failure, was also fed by a CNA who stood over them. The resident's care plan indicated a need for assistance with feeding due to limited physical mobility. The Director of Staff Development and the DON both stated that CNAs should be seated at eye level with residents during feeding to ensure dignity, which was not followed in this case.
Deficiency in Resident Activities Due to Untrained Staff
Penalty
Summary
The facility failed to provide ongoing activities tailored to the comprehensive assessment and preferences of all 57 residents, which is essential for supporting their physical, mental, and psychosocial well-being. This deficiency was observed when a Certified Nursing Assistant (CNA 6) was found monitoring residents in the communal dining area while they watched television, instead of engaging them in activities. CNA 6 was covering for the Activities Director (AD), who was on vacation, and admitted to not having received training on conducting activities, despite being handed a guide on which activities to conduct. Further interviews revealed that the Director of Staff Development (DSD) confirmed CNA 6's lack of training in conducting activities. The Director of Nursing (DON) acknowledged the importance of activities in preventing residents' mental decline and admitted to being unaware of the location of activity logs. The facility's undated AD job description outlined the AD's responsibility for planning and directing activities to meet residents' needs, requiring specific qualifications and experience, which were not met during the AD's absence.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident 58, who was admitted with diagnoses including dementia with psychotic disturbance and anxiety disorder, was prescribed psychotropic medications Risperidone and Seroquel to manage visual hallucinations. However, the facility did not create individualized care plans addressing the use of these medications or the targeted behavior of visual hallucinations. This oversight was confirmed during interviews with the Registered Nurse Supervisor and the Director of Nursing, who acknowledged the absence of necessary care plans and the potential for untreated behaviors or side effects. Similarly, Resident 164, admitted with conditions such as major depressive disorder and atrial fibrillation, was receiving Apixaban for deep vein thrombosis prophylaxis. Despite this, there was no care plan in place for the anticoagulant medication or the resident's activities. The lack of a care plan was noted during a review of the resident's chart and confirmed by the Registered Nurse Supervisor and the Director of Nursing. The absence of a care plan was recognized as a barrier to providing individualized and appropriate care. The facility's policies and procedures, revised in March 2023, emphasize the importance of comprehensive, person-centered care plans that include measurable objectives and timeframes. These care plans are intended to ensure that residents receive services to maintain their highest practicable physical, mental, and psychosocial well-being. The failure to adhere to these policies resulted in increased risk for suboptimal care for Residents 58 and 164, as their specific medical needs were not adequately addressed through individualized care planning.
Failure to Monitor Anticoagulant and Antidepressant Use
Penalty
Summary
The facility failed to appropriately monitor the drug regimens of two residents, leading to potential complications. Resident 6, who was readmitted with diagnoses including atrial fibrillation and transient ischemic attack, was prescribed Eliquis, an anticoagulant. Despite a care plan indicating the need for monitoring for signs of bleeding, there was no documented evidence of such monitoring in the medication administration records. The MDS Nurse confirmed that the order for monitoring was not carried over upon readmission, and the Director of Nursing acknowledged that the staff should have documented monitoring for bleeding and bruising. Resident 164, admitted with major depressive disorder and atrial fibrillation, was prescribed Apixaban, another anticoagulant, and antidepressants Mirtazapine and Escitalopram. The facility's protocol required monitoring for signs of bleeding, but there was no order for such monitoring, and consequently, no documentation on the MAR. The Registered Nurse Supervisor noted that monitoring for bleeding should have been automatically ordered with the anticoagulant prescription. Additionally, there was a lack of monitoring for the effectiveness and side effects of the antidepressants, which was necessary to adjust dosing appropriately. The facility's policies and procedures for anticoagulation and antipsychotic medication use were not followed, as evidenced by the lack of monitoring and documentation for both residents. The Director of Nursing confirmed the necessity of monitoring and documenting findings for residents on anticoagulants and antidepressants to prevent unnoticed bleeding and ensure appropriate medication adjustments.
Inadequate Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the Facility Verification of Informed Consent forms were fully completed and properly executed for psychotropic medications for two residents. Resident 58, who was admitted with diagnoses including dementia with psychotic disturbance and anxiety disorder, was receiving multiple psychotropic medications such as Risperidone, Seroquel, and Ativan. However, the informed consent form for these medications was not completed correctly, as it listed all three medications on one form instead of having individual forms for each medication. The Registered Nurse Supervisor confirmed the error, stating that each medication should have its own form with the dosage and frequency clearly written. Similarly, Resident 164, who was admitted with major depressive disorder and other health issues, was prescribed Mirtazapine and Escitalopram for depression. The informed consent form for these medications was also not accurately completed, as it included both medications on one form instead of separate forms for each. The Director of Nursing confirmed that each medication should have its own consent form, including the dose, diagnosis, and behaviors to be treated. The facility's policy and procedures require that informed consent be obtained for each psychotropic medication, specifying the dosage and clinical indications. The deficient practice of not properly executing informed consent forms had the potential to leave residents unaware of the risks and benefits of the psychotropic medications they were receiving. This oversight could lead to medication errors and residents not being fully informed about their treatment, as highlighted by the facility's policy and procedures on informed consent for psychotherapeutic medications.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a deficiency related to providing a homelike environment. Resident 214, who was admitted with diagnoses including anxiety disorder and muscle weakness, was affected by this deficiency. The resident, whose cognition was intact and could make decisions for medical care, reported seeing ants on the wall and floor near the sliding glass door in their room. Observations confirmed the presence of ants in the resident's room, indicating a failure to ensure a pest-free environment. The facility had recently engaged fumigation services to address heavy ant activity outside the building, treating four ant colonies found in trees by the sidewalk. However, the fumigation company had not sprayed inside the building, and ants were discovered inside the facility, including in Resident 214's room. The Maintenance Supervisor confirmed the presence of ants and had to spray the resident's room himself, as the fumigation company would take at least 24 hours to return. The Director of Nursing acknowledged the responsibility of the facility to provide a pest-free environment for residents, as outlined in the facility's policy and procedures for maintaining a homelike environment.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team failed to ensure that a resident did not keep medications at the bedside without a physician's order and without being assessed for the capability to self-administer medications. This deficiency was identified when a resident was found with an unlabeled medication dispensing cup containing a white powder-like substance, which the resident identified as antifungal powder used for self-application under the breasts. The resident had been admitted with diagnoses including acute respiratory failure, congestive heart failure, major depressive disorder, muscle weakness, and dysphagia, and was assessed to have intact cognition but required assistance with certain activities of daily living. During observations and interviews, it was revealed that neither the Certified Nursing Assistant nor the Treatment Nurse was aware of the contents of the medication cup. The Director of Nursing confirmed that residents are only allowed to have medications at the bedside if they have been assessed as cognitively intact, have demonstrated the ability to self-administer safely, and have a physician's approval. The facility's policy requires that self-administered medications be stored securely, which was not adhered to in this case. A review of the physician orders showed no approval for the resident to apply antifungal powder, indicating a lapse in following the facility's procedures for self-administration of medication.
Failure to Record Advanced Directives for Two Residents
Penalty
Summary
The facility failed to ensure that the residents' right to formulate an advanced directive was recorded for two residents. Resident 23 was admitted with diagnoses including hyperlipidemia, hypertension, and generalized muscle weakness. Despite having intact cognitive skills, the advanced directive acknowledgment form for Resident 23 was marked as verbal, and the resident stated that the facility did not discuss advanced directive information with him. Similarly, Resident 26, who was admitted with hyperlipidemia, hypertensive chronic kidney disease, and generalized muscle weakness, also had intact cognitive skills. However, the advanced directive acknowledgment form for Resident 26 was left blank, and the resident confirmed that the facility did not discuss advanced directive information with him. Interviews with the Social Services Director (SSD), Director of Nursing (DON), and Facility Administrator (FA) revealed that the facility's policy requires the advanced directive acknowledgment form to be signed and dated by the resident to be complete and accurate. The SSD and FA acknowledged that the lack of a completed form could lead to care that does not align with the residents' wishes. The facility's policy emphasizes the importance of informing residents about their rights to formulate an advanced directive upon admission, but this was not adhered to in the cases of Residents 23 and 26.
Inaccurate Documentation of Anticoagulant Use
Penalty
Summary
The facility failed to ensure that the medical records of Resident 164 accurately documented the use of an anticoagulant medication. Resident 164 was admitted with diagnoses including major depressive disorder, atrial fibrillation, and dysphagia. The Minimum Data Set (MDS) assessment for Resident 164, dated shortly after admission, indicated cognitive impairment and dependence on staff for various activities. However, the MDS did not reflect the resident's use of Apixaban, an anticoagulant prescribed for deep vein thrombosis prophylaxis, despite this being documented in the physician's orders. Interviews with the MDS nurse and the Director of Nursing revealed that the omission of Apixaban from the MDS was an oversight. The MDS nurse acknowledged that the medication should have been included to ensure the assessment accurately reflected the care being provided. The Director of Nursing emphasized the importance of complete and accurate MDS assessments for determining the resident's level of care and coordinating a resident-specific care plan. The facility's policy and procedures, as well as CMS guidelines, require comprehensive and timely resident assessments, which were not adhered to in this case.
Unqualified Staff Assigned to Activities Program
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant 6 (CNA 6) was trained and qualified to serve as a therapeutic recreation specialist or activities professional, impacting the well-being of all 57 residents. During an observation, CNA 6 was seen monitoring residents in the communal dining area while they watched television. CNA 6 admitted to covering for the Activities Director (AD), who was on vacation, and stated it was their first day in this role. CNA 6 mentioned receiving a guide on activities but had not been trained on conducting activities with residents. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that CNA 6 had not received proper training for conducting activities. The DON acknowledged the importance of activities in maintaining residents' mental engagement and preventing decline. However, the DON was unable to locate the activity logs and could not provide specific dates when CNA 6 had worked with the AD. The facility's job description for the AD outlined the need for a qualified professional with specific educational and experiential qualifications, which CNA 6 did not meet.
Lack of Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan with measurable goals and interventions for a resident diagnosed with dementia, which is a deficiency in providing appropriate care. The resident, admitted on 9/26/2024, had a history of dementia with psychotic disturbance, anxiety disorder, and cognitive communication deficit. Despite being on medications such as Risperidone and Seroquel for psychosis and Ativan for anxiety, there was no individualized care plan addressing the resident's dementia and cognitive skills. Observations noted the resident had a flat affect and limited communication, indicating a need for a tailored care approach. The Minimum Data Set (MDS) indicated the resident had severely impaired cognition and was dependent on others, yet the facility did not have a documented care plan to address these needs. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a dementia care plan, which should have included behavioral interventions. The facility's policy on dementia management required appropriate interventions based on clinical symptoms, but this was not implemented for the resident, leading to a deficiency in care delivery.
Failure to Obtain Physician's Order for Antifungal Powder
Penalty
Summary
The facility failed to obtain a physician's order and clinical indication for the application of antifungal powder for one resident. This deficiency was identified during an observation where an unlabeled medication dispensing cup containing a white powder was found in the resident's bedside drawer. The resident confirmed that the powder was an antifungal medication applied under her breasts. However, there was no physician's order or clinical indication documented for this medication in the resident's records. Interviews with facility staff, including a CNA and the Treatment Nurse, revealed that they were unaware of the contents of the medication cup and acknowledged that it should not have been left unlabeled and accessible. The Director of Nursing stated that residents are only allowed to have medications at their bedside if they have been assessed as cognitively intact and have physician approval, which was not the case here. The facility's policy requires that self-administered medications be stored securely, which was not adhered to in this instance.
Inaccurate Fall Risk Assessment
Penalty
Summary
The facility failed to document an accurate fall risk assessment for a resident, which had the potential to place the resident at risk for falls causing injuries or even death. The resident, a [AGE] year old female, was admitted with multiple diagnoses including osteoporosis with a current pathological fracture, atherosclerotic heart disease, chronic kidney disease stage 4, sick sinus syndrome, presence of a cardiac pacemaker, hyperlipidemia, essential tremor, hearing loss, and a history of malignant neoplasms. The resident's history and physical indicated she was admitted after a fall that resulted in a T10 hyperextension fracture. Despite this, the fall risk assessment completed by the LVN did not account for the resident's fall history, incorrectly identifying her as low risk for falls. The LVN admitted to not reviewing the resident's history and physical, which would have indicated a higher fall risk score. The Director of Nursing confirmed that fall risk assessments should include all facility documentation and the physician's history and physical to determine fall risk accurately. The facility's policy and procedures for fall risk assessment were not followed, leading to the inaccurate assessment of the resident's fall risk.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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