Broadway Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 605 West Broadway, Glendale, California 91204
- CMS Provider Number
- 055670
- Inspections on file
- 38
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Broadway Manor Care Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and on anticoagulant therapy experienced a significant change in condition, including altered mental status, hypotension, shortness of breath, and multiple episodes of coffee-ground emesis. Despite clear orders and care plan instructions, licensed nursing staff did not notify the physician or PA during the critical period, resulting in delayed emergency intervention. EMS was called only after the resident's condition became critical, and the resident later died at the hospital. This failure was identified as an Immediate Jeopardy deficiency.
A resident with a history of PAD, atherosclerosis, and recent stroke was readmitted from the hospital, but staff failed to include PAD in the diagnosis list, did not develop a care plan for vascular disease, and did not follow hospital recommendations for vascular assessment. Staff inconsistently monitored pedal pulses and focused on behavioral interventions for self-inflicted wounds rather than addressing underlying vascular issues. The resident's condition deteriorated, resulting in hospitalization for sepsis, gangrene, and ultimately death.
The facility failed to transmit MDS assessments to CMS within the required 14-day period for several residents, with delays ranging from 9 to 91 days. The MDS Nurse cited being overwhelmed with responsibilities as the reason for the delays, despite additional support. The Administrator and Director of Nurses acknowledged the issue, emphasizing the importance of timely submissions for accurate resident assessments and care planning.
The facility failed to follow proper sanitation and food handling practices by leaving a scoop inside a thickener container with its handle touching the contents. This was observed during a kitchen inspection, and the Dietary Supervisor confirmed that the scoop should not have been left inside, as it could lead to cross-contamination. The facility's policy requires that scoops be cleaned after each use and not left in containers.
The facility's QAPI committee failed to ensure timely transmission of MDS to CMS, affecting 11 residents. Despite hiring additional staff, the MDS Nurse was unable to submit assessments on time due to other responsibilities. The Administrator acknowledged the issue but lacked a documented plan to resolve it.
A resident with generalized anxiety disorder and muscle weakness was unable to reach the call light, which was placed on a bedside table. The resident required assistance with daily activities, and the facility's policy mandated that the call light be accessible. Both an LVN and the ADON confirmed the call light should be within reach to ensure the resident can request help, especially in emergencies.
A resident in an LTC facility was found to have five plastic bags tied together as an extension for the overhead light pull-string, creating a non-homelike and potentially hazardous environment. The resident, who was moderately cognitively impaired, expressed frustration with the setup. Facility staff acknowledged the inappropriateness of the situation, which did not align with the facility's policies for maintaining a safe and homelike environment.
A resident with Alzheimer's and diabetes was transferred to a hospital due to urgent medical needs without the facility completing the required Notice of Proposed Transfer/Discharge form. This form, which includes reasons for transfer, destination, and appeal rights, was not provided, violating the facility's policy.
The facility failed to complete the Notification of Bed-Hold and Return forms for two residents transferred to a GACH. One resident, with Alzheimer's and other conditions, had the capacity to make decisions, while the other did not. In both cases, the facility did not discuss the bed-hold policy with the residents or their representatives, and the forms were left blank.
The facility failed to follow up on PASRR evaluations for two residents, one with schizophrenia and another with depression. The first resident required a Level II mental health evaluation, which was not conducted, while the second resident needed a resubmission of a Level I screening after 30 days, which was also not done. The ADON acknowledged the oversight, emphasizing the importance of PASRR evaluations for appropriate care.
A facility failed to set a resident's low air loss (LAL) mattress according to their weight, as required by the manufacturer's guidelines, for a resident with a right heel blood-filled blister. The resident, who had conditions such as atherosclerosis, peripheral vascular disease, and diabetes, was at risk for pressure sores. Despite the care plan and Braden Scale assessment indicating the need for pressure-relieving devices, the mattress was incorrectly set at 240 pounds instead of the resident's actual weight of 184 pounds. This oversight was noted by both the LVN and ADON, highlighting the importance of correct mattress settings for effective pressure sore management.
A resident with an indwelling urinary catheter did not receive appropriate care, as the facility failed to document and report the presence of sediments in the urine and did not securely anchor the catheter tubing. This oversight was contrary to the facility's policies, which required monitoring and physician notification of urine abnormalities. The Director of Nursing confirmed the discrepancies in documentation and catheter care, highlighting a deficiency in the resident's treatment and services.
A resident with osteoarthritis experienced severe pain due to the unavailability of Norco, a prescribed pain medication. The LVN confirmed the medication was not on the cart and stated the resident usually requested acetaminophen instead. Facility policies require timely administration and adequate supply of medications, which were not adhered to in this case.
A resident with atrial fibrillation did not receive the full prescribed dose of warfarin via g-tube, as observed during medication administration. The LVN prepared the medication but left a significant residue in the dosage cup, administering only about half the dose. The incident was documented, and the physician was informed, awaiting new orders.
The facility failed to meet the nutritional needs of residents by not using preparation guides for puree diets and not providing a double portion of protein as ordered for a resident with specific dietary needs. The Dietary Supervisor missed updating the meal ticket, resulting in incorrect meal service.
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by RNs and LVNs/LPNs per shift, over a one-month period. The postings only showed hours worked by licensed nurses per shift without specifying the hours worked by each category, leading to potential misinformation about the nursing care provided. The DON acknowledged the issue, and the ADM was unaware of the inaccuracy, having used the incorrect format for some time.
The facility failed to meet the required room size of 80 square feet per resident in 30 out of 31 rooms. Despite this, residents and staff reported that the room sizes did not hinder care provision or affect comfort. A variance request was submitted, indicating no adverse effects on residents' health or safety.
A resident receiving dialysis treatments three times a week did not receive their morning medications as ordered by the physician due to the facility's standard medication administration time conflicting with the resident's dialysis schedule. The LVN responsible did not administer the medications on dialysis days and failed to seek clarification from the physician, resulting in missed doses. The DON confirmed the lack of documentation and adherence to the facility's medication administration policy.
A resident receiving dialysis treatments did not receive insulin as ordered by the physician on multiple occasions. The resident's MAR indicated insulin was held due to blood sugar levels, but there was no communication with the physician about insulin administration during dialysis days. The facility's policy requires medications to be administered as prescribed, but this was not followed, leading to a significant medication error.
A resident's privacy was compromised when an LVN inspected her G-Tube in the common dining area without enhanced PPE, contrary to the facility's practice of conducting such procedures in private. Another resident reported the incident, believing the resident was being fed publicly, which was confirmed by the facility's administration.
Failure to Notify Physician of Significant Change in Condition for Resident on Anticoagulant Therapy
Penalty
Summary
Licensed nursing staff failed to promptly notify the attending physician or physician assistant of a resident's significant change in condition, despite clear physician orders and care plan instructions to do so. The resident, who had a history of Parkinsonism, dysphagia, chronic kidney disease, hypertension, orthostatic hypotension, and was on long-term anticoagulant therapy (Eliquis), experienced multiple concerning symptoms including altered level of consciousness, shortness of breath, hypotension, and three episodes of coffee-ground emesis over a period of several hours. These symptoms were documented in the resident's records and observed by both licensed nurses and CNAs, but the physician was not notified until after emergency medical services (EMS) were called and the resident was transferred to the hospital. The facility's records and staff interviews revealed that the resident's condition deteriorated over several hours, with repeated episodes of vomiting and declining vital signs. Despite the care plan and physician orders requiring monitoring for adverse reactions to anticoagulant therapy and immediate physician notification for symptoms such as vomiting, bleeding, or changes in mental status, the licensed nurses did not contact the physician or physician assistant during the critical period. Staff interviews indicated a lack of recall regarding the specifics of the resident's symptoms and the timing of events, and documentation was incomplete or inconsistent with observed events. The failure to notify the physician in a timely manner resulted in a delay in diagnosis, care, and emergency interventions for the resident. EMS was eventually called when the resident's condition became critical, and upon arrival, EMS found the resident in respiratory failure with evidence of coffee-ground emesis. The resident was transferred to the hospital, where resuscitation efforts were unsuccessful, and the resident was pronounced dead. The deficiency was identified by surveyors as an Immediate Jeopardy situation due to the facility's noncompliance with requirements for physician notification of significant changes in condition.
Removal Plan
- The DON and Assistant DON (ADON) notified the nursing staff (all licensed nurses) of findings outlined in the IJ and conducted in-services for all nursing staff (21 licensed nurses and 42 certified nursing assistants (CNAs) regarding the Change of Condition policy. The training covered: a. Utilizing the Interact early warning toll-stop and watch technique to report any possible resident's changes in condition. b. Utilizing the SBAR form to record the change of condition to ensure accuracy and completeness that included current vital signs, detailed description of the identified situation, any drainage observed, interventions provided including physician notification. c. The anticoagulant monitoring which includes but not limited to: discolored urine, black tarry stools, nausea/vomiting or diarrhea, bruising/bleeding, abnormal vital signs, shortness of breath, and change in mental status. d. Timely physician notification for the onset of changes in condition, including the identified signs related to anticoagulant adverse reaction monitoring. The DON emphasized the importance of notifying the physician upon identification of the situation to avoid any possible delay.
- The facility pharmacist was contacted and will complete in-service to licensed nurses regarding black box warning. During the in-service, the pharmacist will educate the following areas: a. Following physician's orders/instructions for residents with medications labeled black box warning, such as specific monitoring, laboratory tests, etc., b. Creating and implementing the care plan c. Notifying the physician if any identified signs of adverse reaction
- The DON notified the staff who could not complete the in-services must receive an in-service upon their return before their shift.
- The facility notified the facility Medical Director of the IJ and the IJ Removal Plan. The Medical Director reviewed and approved the IJ removal plan.
- The ADM completed the Quality Assurance and Performance Improvement (QAPI) Plan for identifying and notifying the physician of resident change of condition. The Medical Director will review the QAPI program for change of condition/physician notification every month and assist the facility in adjusting the measures as necessary.
- LVN [1] assigned to Resident 1 received disciplinary action pending investigation. The DON provided one-to-one in-service with LVN 1 regarding physician notification prior to the suspension.
- A total of 28 current residents are receiving anticoagulant therapy. All 28 residents who have anticoagulant orders have monitoring for adverse reactions in the electronic medication administration record.
- The DON will conduct a monthly in-service for nursing staff (licensed nurses and CNAS) regarding change in condition for three months.
- The DON and/or ADON will review the change of condition daily, to ensure timely physician notification of any onset signs or symptoms.
- The DON created a change of condition monitoring log, which includes the physician notification of any changes. The DON notified nursing staff of the monitoring process and will document the findings and corrective action in the monitoring log for three months. If any issues are identified, the DON will extend the monitoring period for an addition of three months.
- The DON/RNS will make daily rounds to ensure that any resident changes in condition is being reported and addressed. The DON/RNS would provide a one-to-one inservice if any issues identified.
- The facility initiated a QAPI for physician notification of changes in condition to address the findings outlined in the IJ template. The facility will review the progress every month for 3 months and adjust the measures as needed to ensure an effective and consistent plan.
Failure to Assess, Monitor, and Care Plan for PAD and Atherosclerosis
Penalty
Summary
The facility failed to properly assess, monitor, and address a resident's diagnoses of Peripheral Arterial Disease (PAD) and atherosclerosis following the resident's recent hospitalization for an acute cerebrovascular accident (CVA), right internal carotid artery stenosis, and PAD. Upon readmission, the facility did not include PAD and atherosclerosis in the resident's cumulative diagnoses list, despite these being documented in the hospital discharge summary. This omission resulted in the lack of a comprehensive and individualized care plan for PAD/PVD and atherosclerosis, and the facility did not follow the hospital physician's recommendations for further vascular assessment and intervention. Licensed staff did not ensure that the resident was referred for an elective bilateral lower extremity arteriogram and endovascular intervention as recommended by the hospital's interventional radiologist. Additionally, the facility failed to consistently monitor and document the resident's bilateral pedal pulses as ordered by the physician, with documentation only for the left pedal pulse and not the right. The order for bilateral pedal pulse monitoring was discontinued without a documented reason. The resident's care plans focused on behavioral management of self-inflicted wounds rather than addressing the underlying vascular issues, and there was no evidence of a root cause analysis or interdisciplinary team review to determine the reason for the resident's scratching behavior. As a result of these deficiencies, the resident experienced a change in condition, including altered level of consciousness and fluctuating oxygen saturation, which led to an emergency transfer to an acute care hospital. At the hospital, the resident was found to have a suspected right lower extremity superficial femoral artery occlusion, cellulitis, gangrenous changes, and septic shock. The resident died two days after hospital admission, with diagnoses including PAD, cellulitis, gangrene, and septic shock. Interviews with facility staff confirmed that the necessary diagnoses and care plans were not established, and that communication and assessment failures contributed to the resident's decline.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system for 11 out of 13 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the MDS assessments were not submitted within the required 14-day period after completion. The delay in submission ranged from 9 to 91 days late, affecting residents with various diagnoses including dementia, hyperlipidemia, heart failure, bipolar disorder, diabetes mellitus, Parkinson's disease, schizophrenia, and chronic obstructive pulmonary disease. The MDS Nurse (MDSN) acknowledged the failure to transmit the MDS assessments timely, citing being overwhelmed with other responsibilities despite having additional support from a part-time MDSN. The MDSN admitted to not being able to fulfill her duties effectively, which resulted in the late submissions. The Administrator (ADM) and Director of Nurses (DON) were aware of the issue, emphasizing the importance of timely MDS submissions to ensure accurate resident assessments and the development of appropriate care plans. The facility's policy and procedure, as well as the CMS Long-Term Care Facility MDS 3.0 RAI User's Manual, require MDS assessments to be submitted within 14 days of completion. However, the facility did not adhere to these guidelines, leading to potential confusion regarding resident care and impacting the facility's quality of care monitoring system. The deficiency was documented for residents with significant medical conditions, highlighting the critical need for timely and accurate data submission to support effective resident care management.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices as outlined in their policy and procedure. During a kitchen observation, a scoop was found inside a thickener container with its handle touching the contents. This was observed in the presence of the Dietary Supervisor (DS), who acknowledged that the scoop should not have been left inside the container. The handle's contact with the contents could introduce bacteria or other contaminants, leading to cross-contamination. The facility's policy on the storage of canned and dry goods specifies that scoops should not be left in containers and must be cleaned after each use.
Failure to Transmit MDS Timely
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and evaluate a plan to ensure the timely transmission of the Minimum Data Set (MDS) to the Centers for Medicare and Medicaid Services (CMS) system. This deficiency was identified during a survey conducted from December 18 to December 21, 2023, and affected 11 out of 13 sampled residents. The late transmission of MDS assessments was a recurring issue from the previous annual recertification survey, indicating a persistent problem in the facility's processes. The report details several instances of late MDS submissions for residents with various medical conditions, including dementia, hyperlipidemia, heart failure, bipolar disorder, diabetes mellitus, Parkinson's disease, and others. For example, Resident 2's MDS was completed on November 26, 2024, but was not transmitted until December 19, 2024, nine days past the due date. Similarly, Resident 24's MDS was submitted 28 days late, and Resident 25's MDS was 68 days late. These delays in submission were consistent across multiple residents, with some submissions being as late as 91 days. Interviews with the MDS Nurse (MDSN) and the Director of Nurses (DON) revealed that the MDSN was aware of the issue but was unable to submit the MDS assessments on time due to being occupied with other responsibilities. Despite hiring a part-time MDS Nurse to assist, the problem persisted. The Administrator (ADM) acknowledged the deficiency and noted that while they had verbally communicated the issue and attempted to address it by hiring additional staff, there was no documented plan in the facility's QAPI to resolve the issue. The facility's policy on QAPI emphasized the importance of tracking and measuring performance, identifying deficiencies, and implementing corrective actions, but these steps were not effectively executed in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 14, by not ensuring that the call light was within reach. Resident 14, who was originally admitted on 7/31/2024 and readmitted later, had diagnoses including generalized anxiety disorder, difficulty walking, and generalized muscle weakness. The Minimum Data Set (MDS) assessment indicated that Resident 14 required varying levels of assistance with daily activities, including supervision with eating and full assistance with bathing and toileting. The resident's care plan specifically included the requirement to keep the call light within reach to attend to needs promptly. During an observation, it was noted that the call light was placed on top of the bedside table, out of reach for Resident 14, who was in bed and unable to reach it. Licensed Vocational Nurse (LVN) 1 confirmed that the resident could not access the call light in its current position and acknowledged that it should always be accessible as per the facility's policy. The Assistant Director of Nursing (ADON) also stated that the call light should be within reach to ensure the resident can request assistance, especially during emergencies. The facility's policies on answering call lights and accommodating resident needs emphasize the importance of accessibility and timely response to resident requests.
Inappropriate Use of Plastic Bags for Light Pull-String
Penalty
Summary
The facility failed to provide a safe and homelike environment for a resident, identified as Resident 50, who had five plastic bags tied together and used as an extension to pull the string to turn on and off the overhead light above the bed. This setup was observed during a survey, and it was noted that the use of plastic bags as an extension could potentially cause an accident and did not promote a homelike environment. Resident 50, who was moderately cognitively impaired and required assistance with daily activities, expressed frustration and dissatisfaction with the makeshift pull-string, stating it looked bad and was bothersome. Interviews with facility staff, including a Licensed Vocational Nurse, Maintenance Supervisor, and Assistant Director of Nurses, confirmed that the use of plastic bags as a pull-string extension was inappropriate, potentially hazardous, and not in line with the facility's policies for maintaining a homelike environment. The facility's policies emphasized the importance of providing a safe, clean, and comfortable environment, and ensuring all equipment is kept in operable condition. The deficiency was identified as a failure to adhere to these policies, resulting in a non-homelike and potentially unsafe environment for Resident 50.
Failure to Provide Proper Transfer/Discharge Notification
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for a resident's transfer or discharge. Specifically, the Notice of Proposed Transfer/Discharge form for a resident was not completed in accordance with the facility's policy and procedure. This form is crucial as it includes the reason for the transfer or discharge, the destination, contact information for the State Long Term Care Ombudsman, and details on how to appeal the transfer or discharge. The deficiency was identified during a review of the resident's records and an interview with the Director of Nursing, who confirmed that the necessary form was not completed. The resident involved had been admitted to the facility with diagnoses including Alzheimer's disease and diabetes mellitus. The resident's cognitive skills were severely impaired, requiring supervision and extensive assistance for daily activities. A Change in Condition Evaluation indicated the resident developed a cough, lung congestion, and diarrhea, leading to a transfer to a General Acute Care Hospital. Despite the urgent medical needs necessitating the transfer, the facility's policy required that the resident or their representative be notified in writing as soon as practicable, which was not done in this case.
Failure to Complete Bed-Hold Notification Forms
Penalty
Summary
The facility failed to complete the Notification of Bed-Hold and Return form for two residents who were transferred to a General Acute Care Hospital (GACH) as ordered by their physicians. Resident 38, who was admitted with Alzheimer's disease, end-stage renal disease, and heart failure, had the mental capacity to make medical decisions and was cognitively intact. Despite this, there was no indication in Resident 38's clinical record that the facility staff discussed the Notification of Bed-Hold and Return with the resident or their responsible party when the resident was transferred to the GACH. The seven-day bed hold notification form was not completed and was left blank at the time of transfer. Similarly, Resident 58, who was admitted with Alzheimer's disease and diabetes mellitus, did not have the mental capacity to make medical decisions and required supervision for daily activities. The facility also failed to discuss the Notification of Bed-Hold and Return with Resident 58 or their responsible party when the resident was transferred to the GACH. The seven-day bed hold notification form for Resident 58 was also left blank. The Director of Nursing acknowledged that the bed hold notification forms should have been completed and signed by either the resident or their responsible party, as per the facility's policy and procedure.
Failure to Follow Up on PASRR Evaluations for Two Residents
Penalty
Summary
The facility failed to follow up on the Preadmission Screening and Resident Review (PASRR) evaluations for two residents, leading to potential deficiencies in their care. Resident 49, who was admitted with diagnoses including schizophrenia, anxiety disorder, and major depressive disorder, had a positive PASRR Level I screening on April 29, 2022, indicating the need for a Level II mental health evaluation. Despite this requirement, the facility did not conduct the necessary follow-up, and the resident continued to exhibit episodes of yelling and profanity, which were managed by staff through monitoring and redirection. Resident 69, admitted with a diagnosis of depression, had a negative PASRR Level I screening on June 3, 2024, with instructions to resubmit a PASRR Level I screening if the resident remained in the facility for more than 30 days. The resident stayed in the facility for over six months without the required resubmission of the screening. The resident was observed to be dependent on staff for daily activities and exhibited signs of depression, such as a sad demeanor. The Assistant Director of Nurses (ADON) acknowledged the oversight in both cases, stating the importance of PASRR evaluations to ensure residents receive appropriate care and services. The facility's policy on PASRR, dated July 1, 2023, outlines the procedures for conducting and following up on PASRR screenings, which were not adhered to in these instances.
Incorrect LAL Mattress Setting for Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to ensure that a resident with a right heel blood-filled blister had their low air loss (LAL) mattress set according to their weight, as per the manufacturer's guidelines. The resident, who was admitted with conditions including atherosclerosis, peripheral vascular disease, and diabetes mellitus, was at risk of developing pressure sores. The resident's care plan included the use of pressure-relieving devices, and the Braden Scale assessment indicated a risk for pressure sores. However, during an observation, it was noted that the LAL mattress was set at 240 pounds, while the resident's actual weight was 184 pounds. This incorrect setting was acknowledged by the Licensed Vocational Nurse (LVN) and the Assistant Director of Nurses (ADON), who both emphasized the importance of setting the mattress correctly for effective pressure sore management. The facility's policy and procedure documents, as well as the manufacturer's guidelines, indicated that the LAL mattress should be adjusted according to the resident's weight to prevent and minimize pressure on the skin. Despite this, the mattress was not set correctly, which had the potential to delay the healing of the resident's right heel blister. Observations and interviews with the Treatment Nurse (TN) further confirmed the importance of the correct mattress setting for wound healing. The facility's failure to adhere to these guidelines and policies resulted in a deficiency that could negatively impact the resident's quality of life.
Deficiency in Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter, leading to a deficiency in care. The resident, who was admitted with diagnoses including muscle weakness and chronic kidney disease, had an indwelling catheter due to benign prostate hyperplasia. The facility's care plan for the resident included monitoring urine for sediment, cloudiness, odor, blood, and amount of urine output to reduce the risk of infection. However, observations revealed that the resident's catheter tubing contained cloudy urine and sediments, which were not documented in the Treatment Administration Record (TAR) as required. Additionally, the catheter tubing was not securely anchored, increasing the risk of dislodgement and potential trauma or infection. The facility's policies required staff to monitor and document the characteristics of the resident's urine and to notify the physician of any abnormalities. Despite these requirements, the Director of Nursing acknowledged that the TAR did not accurately reflect the resident's urine characteristics, and the nursing staff failed to report the presence of sediments to the physician. The facility's policy also mandated that the catheter tubing be securely anchored to prevent dislodgement, which was not adhered to in this case. These lapses in care had the potential to result in significant harm to the resident, including urethral and bladder trauma, pain, and untreated infection.
Failure to Maintain Adequate Supply of Pain Medication
Penalty
Summary
The facility failed to ensure an adequate supply of Norco, a pain medication, was available for a resident with an active physician order. The resident, who was diagnosed with osteoarthritis of the knee, was observed experiencing pain rated at 7/10 in both knees and the left shoulder. Despite the physician's order for Norco to be administered every four hours as needed for severe pain, the medication was unavailable during the observation. The Licensed Vocational Nurse (LVN) confirmed that the Norco was not on the medication cart and stated that the resident typically requested acetaminophen instead. The LVN acknowledged that the facility is required to have all medications available for residents with active physician orders. The facility's policy on administering medications emphasizes that medications should be administered safely, timely, and as prescribed. Additionally, the policy on ordering and receiving medications from the dispensing pharmacy requires medications to be reordered five days in advance to ensure an adequate supply. The LVN indicated that the physician should be contacted to clarify the orders if the resident uses Norco infrequently.
Incomplete Administration of Warfarin via G-Tube
Penalty
Summary
The facility failed to ensure the complete administration of a prescribed dose of warfarin to a resident via a gastrostomy tube, as observed during a medication administration. The resident, who was admitted with a diagnosis of paroxysmal atrial fibrillation, was prescribed warfarin 2.5 mg daily to prevent blood clots. During the medication pass, the Licensed Vocational Nurse (LVN) prepared the medication by crushing the tablet and mixing it with water. However, a significant amount of the medication remained in the dosage cup after administration, indicating that only approximately half of the dose was given. The LVN acknowledged the incomplete administration and noted the incident in the resident's Medication Administration Record, indicating that the physician was informed and new orders were awaited. The facility's policy on administering medications, which requires medications to be administered as prescribed, was not followed in this instance. This deficiency in medication administration could potentially increase the resident's risk of medical complications, as noted by the LVN during the interview.
Failure to Follow Dietary Orders and Preparation Guidelines
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, particularly those on puree diets and those with specific dietary orders. During observations, it was noted that dietary staff did not have access to or use preparation guides and recipes while preparing puree diets and thickened liquids for 18 residents. The Dietary Supervisor confirmed that the absence of preparation guides could lead to incorrect proportions, affecting the texture and safety of the meals for residents with swallowing difficulties. The facility's policy required standardized recipes to be accessible to dietary staff, which was not adhered to during the preparation process. Additionally, the facility did not comply with a physician's order for a resident requiring a double portion of protein at all meals. The resident, who had end-stage renal disease and diabetes mellitus, did not receive the prescribed double portion of protein during meal observations. The meal ticket did not reflect the dietary order, and the Treatment Nurse confirmed the discrepancy. The Dietary Supervisor acknowledged missing the order update, which resulted in the resident not receiving the correct meal as prescribed. The facility's policy on diet orders required nursing staff to transcribe physician orders onto a Diet Order Communication form and send it to the dietary department before meal services. However, a review of the binder containing dietary orders revealed no update for the resident's double portion of protein requirement. This oversight led to the resident not receiving the necessary nutrition as per their dietary needs.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs)/Licensed Practical Nurses (LPNs) per shift, over a one-month period from November 17, 2024, to December 17, 2024. The facility's policy, titled 'Posting Direct Care Daily Staffing Numbers,' requires that the number of nursing personnel responsible for providing direct care to residents be posted daily, including specific hours worked by RNs and LVNs/LPNs. However, the facility's postings only showed hours worked by licensed nurses per shift without specifying the hours worked by each category of nurse, which could lead to misinformation about the nursing care provided. During an interview and record review on December 17, 2024, the Director of Nurses (DON) acknowledged that the daily nursing postings did not indicate specific hours worked by RNs and LVNs/LPNs as required by the facility's policy. The Administrator (ADM) was unaware of the inaccuracy in the facility's daily nursing postings and had been using the incorrect format for some time. The facility's policy, revised in August 2022, mandates that nurse staffing data, including the type and category of nursing staff and the actual time worked during each shift, be posted in a prominent location within two hours of the beginning of each shift. The failure to adhere to this policy resulted in the posting of inaccurate nurse staffing information.
Room Size Deficiency in Resident Bedrooms
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required minimum size of 80 square feet per resident in multiple occupancy rooms. During a survey, it was found that 30 out of 31 rooms did not meet this requirement, with room sizes ranging from 138.92 to 314.27 square feet, accommodating two to four residents each. This deficiency was identified through a Client Accommodations Analysis and confirmed by observations and interviews with residents and staff. Despite the deficiency, residents and staff reported that the room sizes did not hinder the provision of care or affect residents' comfort and privacy. Interviews with residents and staff indicated that the current room sizes allowed for adequate movement and care provision. Residents expressed satisfaction with their room sizes, stating that they did not impact their comfort or care. Staff, including CNAs and LVNs, reported that they could safely maneuver equipment and provide necessary care within the existing room dimensions. The facility also submitted a variance request, indicating that the room sizes did not adversely affect residents' health, safety, or well-being.
Failure to Administer Medications as Ordered for Dialysis Resident
Penalty
Summary
The facility failed to administer morning medications as ordered by the physician for a resident who receives dialysis treatments three times a week. The resident, who was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, hyperglycemia, and hypertension, was scheduled to leave the facility for dialysis at 7:45 AM. However, the facility's standard medication administration time was 9 AM, and the resident was not present to receive the medications at that time. Licensed Vocational Nurse (LVN) 1, responsible for administering medications, stated that the resident usually left for dialysis between 6:30 AM and 7:00 AM and returned around 11:30 AM to noon. LVN 1 did not administer the 9 AM medications on dialysis days, as the resident was not present, and did not contact the attending physician to clarify whether the medications should be held or administered at a different time. This resulted in the resident not receiving their prescribed medications on multiple occasions throughout July 2024. The Director of Nursing (DON) confirmed that there was no documented evidence of the resident receiving the 9 AM medications on the specified dates and that the staff should have sought clarification from the physician. The facility's policy on medication administration emphasized the importance of administering medications as prescribed and considering resident needs and preferences. However, the staff failed to adhere to this policy, leading to the deficiency in medication administration for the resident.
Failure to Administer Insulin as Ordered for Dialysis Patient
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering insulin as ordered by the physician. The resident, who was receiving dialysis treatments three times a week, had a physician's order for Insulin Aspart to be administered subcutaneously with meals, unless the blood sugar was less than 70. However, the Medication Administration Record (MAR) for July 2024 showed that the insulin was not administered on several occasions, with codes indicating drug refusal or other reasons noted in progress notes. The resident, who had diagnoses including end-stage renal disease, hyperglycemia, and hypertension, was noted to have moderately impaired cognition. Despite this, the resident's insulin was held on multiple occasions due to blood sugar levels being above 70 but below the threshold for holding insulin. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) confirmed that there was no communication with the physician regarding whether insulin should be administered or held on dialysis days, and there was no documented evidence of insulin administration on the specified dates. The facility's policy on administering medication requires that medications be administered as prescribed and in a timely manner. However, the lack of communication with the physician and the absence of documented orders to hold insulin during dialysis treatments contributed to the medication error. The facility's policy also emphasizes the importance of ensuring that medications are administered according to prescriber orders and that any deviations are properly documented and communicated, which was not adhered to in this case.
Failure to Maintain Resident Privacy During G-Tube Inspection
Penalty
Summary
The facility failed to maintain the bodily privacy of a resident, identified as Resident 4, during an inspection of her G-Tube in the common dining area. Resident 4, who was admitted with diagnoses including dysphagia and gastro-esophageal reflux disease, requires maximum assistance for all self-care tasks and has a care plan that emphasizes maintaining privacy during enteral feeding. Despite this, an LVN checked Resident 4's G-Tube in the dining area without enhanced PPE, which was against the facility's practice of providing such care in the privacy of the resident's room. The incident was reported by another resident, Resident 1, who observed the LVN handling a container with liquid and visualizing the G-Tube, leading her to believe that Resident 4 was being fed inappropriately in a public setting. The LVN and the facility's administration, including the DON, confirmed that the G-Tube was only being checked to ensure the valve was closed, but acknowledged that the action took place in the dining area, which compromised Resident 4's privacy and dignity.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
