Brighton Place Spring Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Spring Valley, California.
- Location
- 9009 Campo Road, Spring Valley, California 91977
- CMS Provider Number
- 055685
- Inspections on file
- 44
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Brighton Place Spring Valley during CMS and state inspections, most recent first.
Three residents experienced ongoing discomfort from cold temperatures when a broken HVAC unit was not repaired, leaving them unable to control room temperature. Residents with conditions such as fibromyalgia, COPD, and mobility issues reported being cold at night and relied on extra blankets or space heaters, which were not always available. The HVAC issue persisted for weeks while awaiting corporate approval for repairs.
A resident with moderate cognitive impairment and mobility issues was found with a space heater operating in her room, which staff had provided and operated for her comfort. Facility staff confirmed that space heaters are not allowed due to burn and fire risks, and facility policy restricts unauthorized electrical appliances in resident areas. This resulted in a failure to maintain a safe environment free from accident hazards.
Three residents were discharged without receiving the required written Notice of Transfer/Discharge, as confirmed by record review and staff interviews. The DON and SSD acknowledged that notices were not provided prior to discharge, citing workload issues. Facility policy mandates that such notices be given to residents or their representatives and documented in the medical record, but this was not done in these cases.
The facility did not develop or implement timely, person-centered discharge care plans for two residents, including one with chronic kidney disease and another with pneumonia. In both cases, discharge planning was either delayed until the day of discharge or not documented at all, contrary to facility policy and staff expectations. Interviews confirmed that this lack of timely planning could lead to uncoordinated and potentially unsafe discharges.
Two residents were prescribed psychotropic medications without specific behaviors or side effects being listed or monitored, as required by facility policy. Staff and pharmacy consultant interviews confirmed the lack of documentation in physician orders and MARs, and there was no consistent evidence to support the necessity of these medications. Facility policies required such monitoring, but it was not implemented for these residents.
Two residents' rooms were found with large areas of discoloration and peeling paint on the walls near their beds, which were visible to both residents and their visitors. Nursing and maintenance staff acknowledged the poor condition but had not documented or addressed the repairs, despite facility policy requiring maintenance issues to be logged and resolved.
A resident with dementia was admitted to hospice care, but the facility did not develop or implement a hospice care plan as required. Clinical record review and staff interviews confirmed the absence of such a plan, resulting in inconsistent staff interventions. Facility policy required collaboration with hospice and timely care plan updates, but these steps were not followed.
A resident with a history of severe sepsis, UTI, and bacteremia had a PIV catheter that was not changed according to the physician's order for site rotation and dressing change every 48 hours. Multiple observations confirmed the PIV and dressing remained unchanged beyond the scheduled intervals, and both nursing staff and the DON acknowledged the lapse, which was not in accordance with facility policy.
A resident with COPD was receiving oxygen therapy without a documented rationale or indication in the medical record, despite a physician's order requiring this information. The resident used oxygen in the facility but not during trips to medical appointments, and staff confirmed the omission of the required documentation. Facility policy and staff interviews indicated that all oxygen orders should include a reason for use.
A resident with brain cancer and weight loss did not receive recommended dietary changes after the RD advised discontinuing unwanted protein shakes and substituting with a frozen supplement and peanut butter. Despite clear documentation and communication, the dietary staff delayed updating the resident's meal plan, resulting in continued provision of unwanted supplements and failure to meet the resident's nutritional preferences within the facility's required timeframe.
A resident with dementia and schizoaffective disorder, under public conservatorship, was not offered influenza or pneumococcal vaccines as required. The facility failed to document any offer, education, or consent for these vaccinations, and staff interviews confirmed that the process was not completed according to policy.
A resident with dementia and schizoaffective disorder, under public conservatorship, was not offered the COVID-19 vaccine as required. The Infection Control Nurse did not follow up with the Social Services Director or the conservator's office to obtain consent, and there was no documentation of vaccine offer, education, or consent in the clinical record, contrary to facility policy and staff expectations.
A facility failed to provide a prescribed inhaler medication to a resident with COPD for eight days due to a lack of authorization from the pharmacy. A nurse confirmed the medication's unavailability, and the DON could not explain the delay. The facility also lacked a policy for medication dispensing.
A resident with right wrist drop did not have a splint applied as ordered by a physician, potentially worsening her condition. The DON confirmed that the resident did not receive daily RNA interventions, and documentation showed range of motion exercises were provided only 10 out of 26 days.
A resident with multiple diagnoses reported feeling violated by staff members and made several attempts to report the incidents to the social worker, DON, and administrator. Despite the facility's policy requiring immediate reporting to authorities, the administrator did not report the allegations, believing them to be false without proper investigation.
The facility failed to conduct a risk assessment for legionella in its water system and did not follow aseptic techniques during a catheter insertion for a resident with cognitive impairment. The Maintenance Supervisor and Infection Preventionist confirmed the absence of a risk assessment, while an LVN acknowledged using non-sterile gloves during the procedure, contrary to facility policy.
A facility failed to ensure the accuracy of an MDS assessment for a resident with schizophrenia, not reflecting the required PASARR Level II status. Despite a completed Level II evaluation recommending specialized services, the MDS did not indicate the resident's serious mental illness. Interviews with staff revealed expectations for accurate assessments, highlighting a lapse in regulatory compliance.
A resident with moderate cognitive impairment and a history of COPD was not properly supervised according to their care plan, which included interventions for smoking and elopement risk. The resident was observed leaving the facility unsupervised while smoking and was found in a non-designated smoking area. Staff interviews revealed lapses in following the care plan, with the Administrator acknowledging documentation errors.
A resident with moderate cognitive impairment and a history of elopement risk left the facility unsupervised and smoked in a non-designated area. Despite policies requiring supervision and sign-out procedures, staff were unaware of the resident's actions, indicating a failure to adhere to safety protocols.
The facility failed to ensure that psychotropic medications were ordered with a stop date for two residents, as per policy. The report highlights that the facility's policy is to ensure that as-needed psychotropic medications are ordered for a duration of 14 days, but this was not followed. The oversight in the documentation and monitoring of psychotropic medications represents a significant deficiency in the facility's care practices.
The facility failed to discard expired medications and improperly stored medications for three residents. An LPN found expired lorazepam in the refrigerator, and the DON confirmed expired medications should not be stored. A resident with multiple sclerosis had unauthorized supplements and analgesics at their bedside, while another with COPD had an inhaler left by a nurse. A third resident with cellulitis had unauthorized supplements and numbing agents at their bedside.
The facility failed to maintain an effective training program for two LVNs, as required by its policy. LVN #7, hired in 2021, had no competency documentation, and LVN #3, hired in 2023, had only one documented training. Both LVNs reported a lack of training, and the DSD confirmed the absence of documented shadowing or competency assessments. The DON and Administrator acknowledged non-compliance with the facility's training policy.
The facility failed to ensure that call cords were within reach for five residents, potentially preventing them from obtaining needed assistance. Observations and interviews confirmed that call cords were hanging out of reach, and the facility's policy indicated that call cords should be accessible. The current call cord system did not allow for adaptive devices.
The facility failed to ensure proper respiratory care for two residents. One resident received Bi-PAP treatment without a proper setting order from the physician, and another resident's change in condition was not documented or reported to the physician in a timely manner.
Failure to Maintain Comfortable Temperatures Due to Broken HVAC
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for three of four sampled residents due to a broken HVAC unit that was not repaired in a timely manner. The HVAC malfunction affected the temperature control in several rooms, resulting in residents being unable to adjust the thermostat to a warmer setting. Observations and interviews revealed that residents consistently felt cold, especially during the night and early morning hours. Residents coped by using multiple blankets or relying on space heaters provided by staff, but these measures were insufficient or inconsistently available. Resident 1, who had fibromyalgia and moderate cognitive impairment, reported feeling extremely cold at night despite using several blankets and resorted to sleeping with her head under the covers. Resident 2, with chronic obstructive pulmonary disease and bradycardia, also experienced discomfort due to the cold and noted that the space heater was not always available for her use. Resident 3, who had difficulty walking and a history of falls, depended on a space heater to sleep comfortably. The Maintenance Supervisor confirmed that the HVAC unit had been broken for several weeks and that repairs were delayed pending corporate approval. The facility's policy emphasized the importance of maintaining comfortable temperatures for residents, which was not achieved in this instance.
Unauthorized Space Heater in Resident Room Creates Safety Hazard
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, difficulty walking, and a history of falls was found in her room with a space heater turned on. The resident reported that staff provided her with the space heater and would turn it on for her in the mornings, as she felt too cold at night without it. The space heater was observed on the floor across the room while the resident was in bed. Interviews with facility staff, including the Maintenance Supervisor and the Director of Nursing, confirmed that space heaters are not permitted in resident rooms due to the risk of burns and fire hazards. A review of the facility's policy on electrical appliances indicated that only authorized electrical appliances are allowed in resident living areas, but did not specifically address the use of space heaters. The presence and use of the space heater in the resident's room constituted a failure to provide a safe environment free from accident hazards.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to three residents and their responsible parties prior to their discharge, as required by both facility policy and federal regulations. Record reviews for three residents revealed that none had documented evidence of receiving the required written notice before being transferred or discharged to lower levels of care, such as assisted living or independent living facilities. Interviews with the Director of Nursing (DON) and the Social Service Director (SSD) confirmed that the notices were not provided, with the SSD citing being overwhelmed with workload as a reason for not issuing the notices in advance. The DON and a licensed nurse both acknowledged the importance of these notices in preparing residents and their families for discharge and reducing anxiety. The facility's own policies specify that a Notice of Proposed Transfer and Discharge must be given to the resident or their representative prior to discharge, with a copy placed in the medical record and sent to the Ombudsman. Despite these requirements, the review of clinical records and interviews with staff confirmed that the notices were not provided for the three residents in question. The absence of these notices meant that residents and their families were not formally informed in writing about the upcoming discharge, nor were they given the opportunity to appeal the decision, as required by regulation.
Failure to Develop and Implement Timely Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans related to resident discharges for two of three residents reviewed. For one resident with chronic kidney disease and a responsible party, the discharge care plan was created by the Social Service Director on the day of discharge, rather than at admission as required. The resident had a moderately impaired cognitive score, and the discharge was to an assisted living facility via medical transport. The care plan listed interventions such as establishing a pre-discharge plan and coordinating discharge, but was not developed in a timely manner. For another resident with pneumonia and intact cognition, there was no documented evidence that a discharge care plan had been developed or implemented prior to discharge to an assisted living facility. Interviews with the DON and staff confirmed that discharge care plans should be developed at admission to allow for collaboration and preparation, and that the absence or late development of such plans could result in disorganized or unsafe discharges. The facility's policy also stated that discharge planning should begin at admission and be documented by social services.
Failure to Monitor and Document Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not listing and monitoring specific behaviors for the use of psychotropic medications for two residents. For one resident with diagnoses including dementia and suicidal ideations, multiple psychotropic medications were prescribed without specific behaviors or side effects being listed for monitoring in the physician’s orders, Medication Administration Record (MAR), or care plans. Staff interviews confirmed that there was no documentation of behaviors or side effects, and the pharmacy consultant acknowledged missing this omission during the monthly medication regimen review. Another resident with diagnoses including encephalopathy and major depressive disorder was prescribed an antipsychotic medication for schizophrenia without specific behaviors being documented for staff monitoring. Interviews with staff, family, and the psychiatric nurse practitioner revealed a lack of observed or documented behaviors such as delusions, hallucinations, or violence that would justify the use of the medication. The DON and medical director both stated that there was no consistent documentation of behaviors to support the diagnosis or the use of the antipsychotic medication. Facility policies required that orders for psychoactive medications include specific behaviors to be monitored and that staff document these behaviors and any side effects. Despite these policies, the facility did not ensure that such documentation was present or that staff were monitoring and recording the necessary information to determine the continued need for psychotropic medications for the affected residents.
Failure to Maintain Clean and Homelike Resident Room Walls
Penalty
Summary
The facility failed to maintain a clean, homelike, and visually appealing environment in the rooms of two residents, as evidenced by large areas of discoloration and peeling paint on the walls near the heads of their beds. These deficiencies were observed during initial tours and confirmed by both nursing and maintenance staff, who acknowledged the poor condition of the walls and agreed that repairs were needed. The issues were visible to residents and their visitors, with one resident's family member regularly sitting in a position where the damaged wall was in clear view. Despite the facility's policy requiring staff to document maintenance needs in a log at the nurse's station, a review of the maintenance book showed no entries for the needed repairs in these rooms over a five-month period. The Director of Maintenance admitted that although repairs had been made in other units, the required repairs for these rooms had not been documented or addressed. The Director of Nursing also confirmed that all rooms were expected to be presentable and homelike, and that staff were responsible for reporting such issues.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a hospice care plan for a resident who had been admitted to hospice care, as evidenced by observation, interviews, and record review. The resident, who had a diagnosis of dementia, was admitted to the facility and subsequently had a physician's order for hospice admission. Despite this order, there was no documented evidence that a hospice care plan was created or implemented for the resident. This omission was confirmed through review of the clinical record and interviews with licensed nursing staff, who acknowledged the absence of a hospice care plan and recognized its importance for consistent and coordinated care. Further, the Director of Nursing confirmed that both the hospice agency and the facility are responsible for developing care plans to ensure staff provide consistent care, but acknowledged that this was not done for the resident in question. Facility policies reviewed also required the development and updating of comprehensive, person-centered care plans based on assessed needs, and specifically called for collaboration between the hospice and facility on care planning when a resident elects hospice care. The lack of a hospice care plan meant that staff interventions were not being implemented consistently for the resident.
Failure to Change Peripheral IV Catheter and Dressing per Physician Order
Penalty
Summary
A peripheral intravenous (PIV) catheter was inserted into a resident's left arm on 4/29/25, as documented on the dressing. The resident had a physician's order to change the PIV line and dressing every 48 hours, with scheduled changes on 5/1/25, 5/3/25, and 5/5/25. Observations conducted on 5/5/25, 5/6/25, and 5/7/25 confirmed that the PIV catheter and dressing had not been changed since the initial insertion date. Licensed nurses interviewed during these observations acknowledged that the PIV should have been changed according to the physician's order to prevent infection and ensure the line remained functional. The resident involved had been admitted with severe sepsis, urinary tract infection, and bacteremia, conditions that require careful infection control. The Director of Nursing confirmed that the facility's protocol is to follow physician orders for IV site rotation and dressing changes, and that the failure to change the PIV as ordered placed the resident at risk for further infection. Review of facility policy indicated that all IV dressing changes should be labeled and documented, and that site rotation is a required component of complete orders.
Failure to Document Rationale for Oxygen Therapy
Penalty
Summary
The facility failed to document a rationale for the use of oxygen therapy for a resident with a diagnosis of chronic obstructive pulmonary disease (COPD). The resident was observed using oxygen in bed and reported using it most of the time due to COPD, but did not use oxygen during trips outside the facility for medical appointments. The physician's order for oxygen required staff to specify a diagnosis or reason for use, but the electronic health record and Medication Administration Record did not include documentation of the indication for oxygen therapy. Oxygen saturation levels for the resident were consistently above 92% both on oxygen and on room air. Licensed nursing staff and the Director of Nursing confirmed that all oxygen orders require a rationale for use and that the omission was a mistake. Facility policy also required oxygen to be administered as prescribed, with a documented purpose. The lack of documentation for the reason for oxygen use meant that staff would not know the intended purpose of the therapy, and the resident was not provided with oxygen during transportation to appointments, contrary to the physician's order.
Failure to Implement Dietitian's Dietary Recommendations for Resident
Penalty
Summary
The facility failed to implement the Registered Dietitian's (RD) recommendations for a resident with brain cancer who was experiencing weight loss and had a low albumin level. The RD had assessed the resident and recommended discontinuing protein shakes, which the resident found too sweet and refused, and substituting them with a frozen supplement (Magic Cup) and adding peanut butter to all meals. The RD also recommended updating the resident's nighttime snack to a preferred tuna sandwich. These recommendations were documented and communicated to the Dietary Services Supervisor (DSS) via email, with the expectation that changes would be implemented within three days, as per facility policy. Despite these recommendations, observations and interviews revealed that the resident continued to receive the unwanted protein shakes and did not receive the Magic Cup supplement in a timely manner. The DSS acknowledged receiving the RD's recommendations but admitted to not entering the changes into the dietary software promptly due to being busy. As a result, the resident's dietary preferences and nutritional needs were not met as recommended by the RD, and the facility exceeded its own policy timeframe for implementing dietary changes. The resident, who had moderately impaired cognition, repeatedly expressed dissatisfaction with the provided supplements and meals, stating a preference for the frozen supplement and disliking the protein shakes. Multiple observations confirmed that the resident continued to receive the unwanted items, and staff interviews corroborated the delay in updating the dietary plan. Facility policy required dietary recommendations to be implemented within three days, but this was not followed, resulting in the resident not receiving preferred and recommended foods and supplements.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to one resident upon admission, as required by both facility policy and CDC recommendations. The resident in question had diagnoses including dementia and schizoaffective disorder and was under the legal care of a public conservator. Review of the clinical record revealed no documentation that the resident or their responsible party had been offered the vaccines, nor that the risks and benefits had been explained verbally or in writing. The Infection Control Nurse (ICN) acknowledged that she had asked the Social Services Director to assist in contacting the conservator for consent but did not follow up, resulting in no action being taken. Interviews with the ICN and the Director of Nursing confirmed that all residents should be offered these vaccines, with proper documentation of acceptance or refusal and education on risks and benefits. The facility's own policies require annual influenza vaccination offers and pneumococcal vaccination offers for eligible adults, with informed consent or refusal documented in the medical record. In this case, the process was not completed, and there was no evidence of an offer or consent for the resident, constituting a failure to follow established procedures.
Failure to Offer and Document COVID-19 Vaccination for Resident Under Conservatorship
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to one resident who was under the care of a public conservator, as required by facility policy and CDC recommendations. The resident, who had diagnoses including dementia and schizoaffective disorder, was admitted under conservatorship, with the public conservator's office acting as the responsible party for medical decisions. Upon review of the resident's clinical record, there was no documentation that the COVID-19 vaccine had been offered, nor that the risks and benefits had been explained to the resident or the responsible party. The Infection Control Nurse (ICN) acknowledged that she had asked the Social Services Director to contact the conservator's office for consent but did not follow up, resulting in no action being taken. Interviews with facility staff, including the ICN and the Director of Nursing (DON), confirmed that the expectation was for all residents to be offered the COVID-19 vaccine, with proper documentation of acceptance or refusal and education on risks and benefits. The facility's policy also required that educational materials be sent to responsible parties and that general consent be obtained. The lack of documentation and follow-up meant that the resident was not offered the vaccine, and there was no evidence that the required education or consent process occurred.
Failure to Provide Prescribed Inhaler Medication
Penalty
Summary
The facility failed to ensure that an inhaler medication ordered by a physician was available for administration to a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted with a diagnosis of COPD and was prescribed an inhaler medication to be taken once daily. However, the medication was unavailable for eight days, as indicated in the Medication Administration Record. During interviews, a Licensed Nurse confirmed the unavailability of the medication and mentioned that the pharmacy required authorization to deliver it. The Director of Nursing was unable to explain the delay in authorization and acknowledged that the resident did not receive the medication as ordered. Additionally, the facility could not provide a policy and procedure related to medication dispensing.
Failure to Apply Splint as Ordered
Penalty
Summary
The facility failed to apply a splint to a resident's right hand as ordered by a physician, which had the potential to worsen the resident's wrist drop condition. The resident was admitted with a diagnosis of right wrist drop and had a provider order for the daily application of a splint to her right wrist, except during exercise or showering. However, during an observation, the resident was found not wearing the splint, and she confirmed that it was often not applied. The Director of Nursing (DON) acknowledged that the resident did not receive the daily interventions as ordered. A review of the Restorative Nursing Assistant (RNA) documentation revealed that range of motion exercises were provided only 10 out of 26 possible days. Despite documentation indicating the splint should be applied daily, the resident was observed without it during a joint observation with the DON, who confirmed the resident was neither exercising nor showering at the time.
Failure to Report Allegations of Abuse
Penalty
Summary
The Facility failed to report allegations of abuse by staff members against a resident, despite the resident's multiple attempts to report the incidents. The resident, who had diagnoses including acute osteomyelitis, anxiety, alcohol abuse, and unspecified psychosis, reported feeling violated while in the Facility. The resident described an incident where a nurse allegedly ran her finger up the resident's inner thigh to wake them up during the night shift. The resident communicated these allegations to the social worker, Director of Nursing (DON), and the administrator, and also spoke to the ombudsman in the presence of the administrator and social worker. Despite these reports, the administrator did not take appropriate action, believing the allegations to be false without conducting a proper investigation or reporting the incidents to the authorities as required by the facility's policy. The resident provided emails as evidence of their attempts to report the abuse. In one email, the resident expressed frustration over the lack of incident reports being filed despite repeated requests. Another email detailed an incident where a nurse allegedly touched the resident inappropriately and threatened to withhold medications. The facility's policy mandates that the administrator or a designated representative notify law enforcement immediately or within two hours of the initial report and send a written report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within twenty-four hours. However, the administrator admitted to not reporting the allegations, thus failing to comply with the facility's abuse reporting and investigation policies.
Deficiencies in Water Management and Catheter Insertion Procedures
Penalty
Summary
The facility failed to implement a comprehensive water management program, as evidenced by the lack of a risk assessment to identify potential areas for legionella and other waterborne pathogens in the facility's water system. Despite having a policy in place that required the development and utilization of water management strategies, the Maintenance Supervisor admitted to not having completed a risk assessment and was unaware of the water flow through the facility. The Infection Preventionist and the Administrator also confirmed that no risk assessment had been conducted, and the water management plan had not been customized for the facility. Additionally, the facility did not adhere to proper aseptic techniques during the insertion of an indwelling catheter for a resident with moderate cognitive impairment and a history of obstructive and reflux uropathy. During the procedure, an LVN used non-sterile gloves to set up the catheter supplies, which violated the facility's policy requiring sterile equipment and techniques. The LVN acknowledged the mistake and expressed a need for further training. The DON stated that if sterile technique was compromised, the procedure should be restarted with new supplies, and the Administrator was unaware of the specific process staff should follow.
Inaccurate MDS Assessment for PASARR Level II
Penalty
Summary
The facility failed to ensure the accuracy of the annual Minimum Data Set (MDS) assessment for a resident regarding the Preadmission Screening and Resident Review (PASARR) Level II. The resident, who was admitted with a medical history of schizophrenia and schizoaffective disorder, had a Level II PASARR evaluation completed, which recommended specialized services. However, the MDS assessment conducted later did not reflect the resident's status as having a serious mental illness, as required by the PASARR process. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the MDS should have been marked for Level II PASARR, as the resident's condition had not changed. The MDS Coordinator, who was new to the facility, stated that she would have triggered the Level II PASARR on the MDS if she had been present at the time of the assessment. The DON and the Administrator both expressed that their expectation was for the MDS to be accurate, timely, and true, indicating a lapse in the facility's adherence to regulatory requirements.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident identified as an elopement risk and smoker. The resident, who had a history of chronic obstructive pulmonary disease and moderate cognitive impairment, was admitted to the facility with a care plan that required supervision while smoking and interventions for elopement risk. However, the resident was observed exiting the facility unsupervised while smoking and was later seen smoking in a non-designated area. The facility's policy required residents to sign out when leaving the premises, but there was no record of the resident signing out on one of the observed occasions. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, revealed a lack of adherence to the care plan. The Infection Preventionist indicated that the resident was allowed outside alone if signed out, while the Director of Nursing acknowledged the resident's independence but noted a failure to sign out on the observed date. The Administrator admitted that the care plans were expected to be correct but suggested that staff errors occurred due to haste. These actions and inactions led to the deficiency in implementing the resident's care plan, specifically regarding smoking supervision and elopement risk management.
Resident Elopement and Smoking Policy Violation
Penalty
Summary
The facility failed to prevent a resident from leaving the premises without staff knowledge and allowed the resident to smoke in a non-designated area. The resident, who had a history of chronic obstructive pulmonary disease and moderate cognitive impairment, was identified as an elopement risk and required supervision while smoking. Despite these precautions, the resident was observed exiting the facility in a wheelchair while smoking and proceeded down the street until out of sight. The resident later confirmed they went to a store without notifying staff or signing out, as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's departure and smoking activities. The LVN and DON were unaware of the resident's unsupervised exit, and the Infection Preventionist noted that the resident was allowed outside alone only if they signed out. The Director of Staff Development and the Administrator were not aware of any incidents of the resident smoking in non-designated areas, although the resident was observed doing so. These lapses indicate a failure to adhere to facility policies regarding resident supervision and safety measures for smoking.
Psychotropic Medication Management Deficiency
Penalty
Summary
The report identifies a deficiency in the management of psychotropic medications for two residents at the facility. The first resident, admitted on April 17, 2024, was diagnosed with schizophrenia and other mental health conditions. The care plan for this resident was initiated on April 19, 2024, and included the administration of psychotropic medications. However, the order for the medication did not include a stop date, which is a requirement for as-needed medications. The second resident, admitted on February 19, 2024, was diagnosed with anxiety and depression. The care plan for this resident also lacked a stop date for the prescribed psychotropic medication, which is a violation of the facility's policy. The report highlights that the facility's policy is to ensure that as-needed psychotropic medications are ordered for a duration of 14 days, after which the resident's condition should be re-evaluated. The report also notes that the facility's administrator expects that the use of psychotropic medications should be minimized. Despite these policies, the report identifies that the orders for the psychotropic medications were not properly documented, and the required stop dates were not included. This oversight in the documentation and monitoring of psychotropic medications represents a significant deficiency in the facility's care practices.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure expired medications were discarded and medications were properly stored, as observed in the medication storage room and involving three residents. During an observation, an LPN acknowledged the presence of expired lorazepam in the refrigerator, which should have been discarded after 90 days. The Director of Nursing confirmed that expired medications, including pantoprazole and lorazepam, should not be stored in the refrigerator. Interviews with the DON and the Administrator reiterated that expired medications should be removed and disposed of appropriately. Resident #7, admitted with a history of multiple sclerosis and pain, was found to have dietary supplements and a topical analgesic at their bedside without a care plan or physician's order to self-administer or store medications. The resident admitted to self-administering the supplement but could not reach the analgesic. An RN confirmed that the resident was not permitted to self-administer medications and removed the analgesic from the bedside. Resident #12, with a history of COPD, was observed with an inhaler at their bedside, which was left by a medication nurse from the previous shift. The resident was not care planned to self-administer medications. An RN admitted to forgetting the inhaler at the bedside. Similarly, Resident #116, admitted with cellulitis, had a supplement and a topical numbing agent at their bedside without authorization to self-administer medications. The resident was unaware of the restriction, and an LPN confirmed the resident's inability to self-administer medications.
Deficiency in Staff Training and Competency Documentation
Penalty
Summary
The facility failed to maintain an effective training program for two Licensed Vocational Nurses (LVNs) out of five staff members reviewed for training and competencies. According to the facility's policy, competency assessments should be conducted upon hire, during the first 90 days of employment, annually, or when new equipment or procedures are introduced. However, for LVN #7, who was hired on 09/16/2021, there was no competency documentation in the employee file. The Director of Staff Development (DSD) confirmed the absence of a completed orientation checklist and skills training documentation for LVN #7. LVN #7 also stated that she had not completed a competency checklist during orientation and had not received hands-on training since nursing school. Similarly, LVN #3, hired on 09/03/2023, had no documented competencies or skill checks in her personnel file, except for an in-service training on the facility's blood glucose monitoring system. LVN #3 did not recall receiving any training from the facility. The DSD acknowledged that while newly hired staff were expected to shadow other nurses, there was no evidence of this training for LVN #3. The Director of Nursing (DON) and the Administrator both confirmed that the facility was not in compliance with its policy regarding nursing competency, which requires competency forms to be completed within the first 90 days of employment and annually thereafter.
Inaccessible Call Cords for Residents
Penalty
Summary
The facility failed to ensure that call cords were within reach for five sampled residents, potentially preventing them from obtaining needed assistance from staff. Observations revealed that the call cords for Residents 1 through 5 were hanging from the wall to the floor, out of reach. Resident 1, who had diagnoses including tremor, encephalopathy, generalized weakness, and was admitted to hospice care, did not have an accessible type of call system appropriate for his functional level. Interviews with Licensed Nurses and the Director of Nursing confirmed that call cords should be within residents' reach, and the facility policy indicated that call cords should be placed within reach in residents' rooms and clipped to the bedspread for wheelchair-bound residents. On 4/3/24, observations showed that Resident 1's call cord was out of reach, and similar issues were noted for Residents 2 through 5. Interviews with Licensed Nurses 1 and 2, as well as the Director of Nursing, confirmed that call cords should be accessible to residents. The facility's policy, revised in January 2012, stated that call cords should be within residents' reach and adaptive call bells should be provided as needed. However, a telephone interview with the Administrator revealed that the current call cord system did not allow for switching to adaptive devices such as a soft touch call button.
Failure to Ensure Proper Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure proper respiratory care and treatment for two residents. For Resident 1, the licensed nurses applied a Bi-PAP machine without a proper setting order from the physician. The medical record showed an incomplete order for the Bi-PAP, and the Director of Nursing (DON) confirmed that the order should have been clarified with the physician. The facility's policy requires oxygen to be administered as prescribed, which was not followed in this case. For Resident 2, the facility failed to document a change in condition and notify the physician. The resident's oxygen saturation dropped significantly, and despite being placed on oxygen, the condition did not improve. The licensed nurse did not document the change in condition or notify the physician in a timely manner. The DON confirmed that the physician should have been notified and the event documented according to the facility's policy on change of condition.
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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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