California Post-acute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Lynwood, California.
- Location
- 3615 E. Imperial Hiwy, Lynwood, California 90262
- CMS Provider Number
- 055052
- Inspections on file
- 74
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at California Post-acute Care during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in the kitchen utility room, including dirty, standing water and debris under the manual dishwashing and sanitizing stations. A dietary aide reported that the sanitizing station had been leaking for weeks and that the utility room was dirty and cluttered, without having been cleaned or organized. A dietary cook confirmed ongoing pooling of dirty water and debris under the sanitizing station and stated staff were expected to remove food waste from sink strainers after dishwashing. Review of the facility’s sanitation policy showed requirements for maintaining equipment in working order, maintenance support for Food & Nutrition Services, and a cleaning schedule designated by the FNS Director.
Surveyors found that multiple closets and resident rooms were not maintained in a clean, safe, and sanitary condition. The Maintenance Director acknowledged broken and detached baseboards, cluttered and dirty floors, debris, and employee files and boxes stored on dirty floors in several closets, and could not state when some rooms were last cleaned. A resident with muscle weakness and HTN, who had decision-making capacity and required assistance with ADLs, reported that her room and bathroom had not been cleaned for several days, were dirty, and had ants present, and she felt dehumanized by these conditions. Observations showed stained furniture where she stored clothes, moldy food in a dresser drawer, and multiple cups left in the room. A shared restroom for two rooms contained multiple basins with pooled dirty water and yellowing towels under the sink. The IP stated that moldy food could cause infections and attract pests and that housekeeping should clean storage areas daily, while a CNA acknowledged the dirty basins and towels should have been removed and cleaned, contrary to facility sanitation and homelike environment policies.
The facility failed to maintain an effective pest control program and adequate sanitation, as shown by a pest control report noting damaged, peeling baseboards at an entry door that could harbor roaches and recommending sealing and improved sanitation. The Maintenance Director acknowledged detached baseboards and cracks in a shared restroom that could allow roach entry. A resident reported that her room and bathroom had not been cleaned for several days, described them as dirty, and pointed out ants crawling on a drawer, stating she felt dehumanized by the conditions, despite a written pest control policy requiring the building be kept free of insects and rodents.
Surveyors found that multiple resident rooms and adjacent hallways were not kept clean or sanitary, including dirty hallway floors with food crumbs and trash, dirty towels on bathroom floors, towels and trash on a resident room floor, a bedpan with smeared feces placed on a vanity, and smeared feces on a toilet flush handle. During observation, the DON acknowledged that these conditions could attract pests, spread germs, cause infections, make residents uncomfortable, and create tripping hazards. Review of the facility’s cleaning and disinfection policy showed that environmental and housekeeping surfaces, including floors, furniture, and bed rails, were required to be regularly cleaned when visibly soiled and disinfected with an EPA-registered hospital disinfectant, but these practices were not followed in Rooms A, B, C, D, E, F, and G.
A resident with muscle weakness, difficulty walking, and fluctuating decision-making capacity, but generally able to communicate, required varying levels of assistance with ADLs per the MDS. The resident’s attorney requested the resident’s medical records from the MRD by phone and email, but the records were not released within the timeframe required by facility policy, which specified provision as soon as practicable within 5 days, up to 30 days from a written request. The MRD delayed sending the records while awaiting corporate review and supervisor verification, resulting in the request exceeding 30 days and violating the resident’s and representative’s rights to access the medical record.
A resident with muscle weakness and cellulitis had a sacral skin tear documented on an SBAR form, but this wound was not recorded on the Transfer Sheet when the resident was sent to a GACH for fever. In addition, the required weekly skin assessment for the sacral skin tear was not completed during the week it was due because no wound care provider was available, despite facility policies requiring skin condition documentation at discharge and comprehensive weekly skin assessments.
A resident with paraplegia and major depressive disorder, who was dependent on staff for transfers and most ADLs, had his wheelchair, ice chest, and other personal belongings removed from his room for fumigation and not returned in a timely manner. Staff, including CNAs, cleared the room and stored the items; afterward, the resident reported feeling harassed and controlled and stated that his wheelchair and ice chest were taken and not brought back. CNAs and an LVN confirmed the removal of the property, and the DON indicated the SW was responsible for returning it, while the ADM stated he had instructed staff to return the items after cleaning. This handling of the resident’s belongings conflicted with facility policy that residents be provided a homelike environment and encouraged to use their personal possessions.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing required gowns and gloves during high-contact care for three residents with indwelling devices or a colostomy. One resident with quadriplegia and a Foley catheter received mobility assistance from a CNA whose hands, arms, and uniform contacted the resident and linens without PPE. Another resident with quadriplegia and a suprapubic catheter was fed by a CNA who did not wear a gown, despite EBP orders. A third resident with a colostomy and severe cognitive impairment was repositioned and fed by CNAs who did not wear gowns or gloves, even though posted EBP signage and facility policy required PPE for high-contact activities such as feeding, turning, and repositioning, as confirmed by an LVN and the DON.
A resident with hypertension and legal blindness was involved in a verbal altercation with a CNA, during which inappropriate language was exchanged and the CNA allegedly yelled at the resident. Although staff witnessed or were aware of the incident, it was not reported to CDPH as required by facility policy, resulting in a delay in investigation.
A resident with hypertension and legal blindness was involved in a verbal altercation with a CNA, during which both parties used inappropriate language and the CNA yelled at the resident. Although the incident was documented in progress notes, no investigation was initiated within the required 24-hour period due to a delay in reporting the event to the ADM, contrary to the facility's abuse policy.
A resident who was dependent on staff for all care and incontinent of bowel was readmitted without a documented skin assessment, contrary to facility policy. Wounds including deep tissue injuries and abrasions were not identified or treated until days later, resulting in delayed wound care.
A resident with a history of verbal aggression and legal blindness, who required supervision for some activities, was involved in a verbal altercation with a CNA at the nurse's station. Both the resident and CNA used inappropriate language, and there were conflicting accounts about whether the CNA yelled or made inappropriate remarks. The incident occurred despite a care plan outlining interventions to manage the resident's behavior, and staff did not consistently follow professional communication standards.
Staff were not adequately trained on abuse reporting requirements, resulting in a delay in reporting and investigating an alleged verbal abuse incident between a resident with bipolar disorder and a CNA. Documentation was made in the resident's record, but the incident was not reported to administration or regulatory authorities, and staff interviews revealed gaps in knowledge about reporting procedures and training frequency.
A resident with severe physical and cognitive limitations was found without access to a call light, as it was stuck under the mattress and not within reach. Both an LVN and a CNA confirmed the oversight, which left the resident unable to request assistance for basic needs. Facility policy requires call lights to be accessible, but this was not followed in this case.
A resident with quadriplegia and intact cognitive skills was repeatedly assigned a CNA he had previously refused due to a traumatic care experience, despite his documented and verbal preferences. The facility also imposed a strict shower time limit that did not accommodate the resident's extensive physical needs, and staff failed to consistently document or communicate his care preferences, resulting in repeated violations of his expressed wishes.
A resident with quadriplegia and a history of trauma related to care provided by a specific CNA had a documented care plan specifying CNA preferences. Despite this, the resident was repeatedly assigned to the same CNA, contrary to the care plan interventions. Facility staff interviews confirmed that the care plan was not followed, resulting in the resident's dissatisfaction and distress.
The facility did not ensure a clean and homelike environment for several residents, as evidenced by dirty walls behind headboards, soiled feeding pumps, and stained privacy curtains with dried formula. Some residents had significant medical needs and were dependent on staff for daily care. Staff interviews confirmed awareness of the cleanliness issues and the facility's responsibility to maintain sanitary conditions, in line with facility policies.
Surveyors observed that the kitchen's grill food waste receptacle was not emptied or cleaned, and that empty soda cans and a cell phone were stored on a shelf with resident food items. Dietary staff confirmed the grill waste should be cleaned daily and that personal items should not be stored with food. The DON stated that kitchen cleanliness is necessary to prevent pest infestation. Facility policies and job descriptions required safe food handling and regular cleaning, but these were not followed, resulting in unsanitary conditions.
A resident with legal blindness and depression was verbally abused by a CNA after repeatedly requesting not to be assigned to that caregiver. Despite the resident's clear preferences, staff failed to adjust assignments, resulting in an altercation where the CNA yelled and used derogatory language. This incident violated facility policies on abuse prevention and resident dignity, and negatively affected the resident's psychosocial well-being.
Staff did not follow care plan interventions for three residents, including failing to separate two individuals after an alleged abuse incident and not monitoring another resident identified as an elopement risk. As a result, the residents continued to interact despite care plan directives, and one resident left the facility without staff knowledge. Interviews and record reviews confirmed that required interventions were not communicated or enforced by staff.
A resident with a history of inappropriate touching was observed repeating the behavior, but the care plan was not updated with new interventions after the incident. Despite existing interventions and facility policy requiring care plan revisions when behaviors change, staff did not develop additional strategies to address the recurrence.
A resident with schizophrenia and epilepsy was allowed to leave and return from therapeutic passes without the required completion of Out On Therapeutic Pass/Leave of Absence forms by a licensed nurse. The forms were missing nurse signatures, return times, and verification of the resident's condition, contrary to facility policy. Staff interviews confirmed that these documentation steps are necessary to ensure resident safety and proper communication.
Following an allegation of abuse between two residents, the facility did not ensure that the Social Services Designee assessed or documented the psychosocial needs of those involved. Despite one resident having significant cognitive and physical impairments and the other having medical conditions, there was no evidence of timely psychosocial evaluation or care planning after the incident, as required by facility policy and job descriptions.
A licensed nurse did not document the administration of insulin for a resident with diabetes on the MAR and also failed to record a change of condition involving agitation and a verbal altercation in the nursing progress notes. Facility policies and job descriptions required accurate and timely documentation of medication administration and resident condition, but these were not followed in this case.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on each shift, as required.
A resident with severe cognitive impairment and multiple diagnoses did not have their oral intake documented for several meals, as required by care plans and facility policy. A CNA failed to record this information, citing lack of access to the charting system, and multiple staff confirmed that such documentation is essential for monitoring nutrition and health. Review of records showed missing documentation on several days, resulting in incomplete medical records.
A dietary aide was observed handling food in the kitchen without wearing a hairnet, contrary to facility policy and food safety standards. The aide admitted to forgetting the hairnet, and the dietary supervisor confirmed that hair restraints are required for all kitchen staff. This lapse had the potential to contaminate food and preparation areas for all residents.
The Administrator was not involved in the facility's pest control program, resulting in an ongoing cockroach infestation in the kitchen. Multiple staff members observed and reported cockroaches, but the issue persisted due to lack of oversight and documentation. The kitchen was ultimately closed by Environmental Health Services after numerous live cockroaches were found, and the Administrator was unaware of the severity of the problem.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident with hemiplegia and COPD, who was dependent on staff for daily activities, was served a salad containing tomatoes despite documented dislikes. The resident attempted to remove the tomatoes and expressed dissatisfaction. Staff interviews and facility policy confirmed that food preferences should be honored, but the failure to do so resulted in the resident not eating the meal.
A resident with Alzheimer's disease, anxiety disorder, and muscle weakness was admitted and required moderate staff assistance for ADLs, but the facility did not initiate care plans addressing the resident's Alzheimer's and anxiety diagnoses. A nurse confirmed the absence of these care plans, despite facility policy requiring comprehensive, measurable care plans for all identified needs.
A resident with paraplegia and other medical conditions, who required maximal assistance and was cognitively intact, was not routinely offered showers or bed baths as scheduled. Staff documentation and interviews confirmed that the resident was not given the opportunity to choose or refuse bathing, contrary to the care plan and facility policy, resulting in missed personal hygiene care.
A CNA provided feeding assistance to a resident with severe cognitive impairment and dysphagia while standing beside the bed rather than at eye-level, contrary to facility policy and staff expectations. Interviews with staff confirmed that feeding at eye-level is necessary to maintain resident dignity and comfort, and the facility's policies emphasize supporting resident self-esteem and self-worth during care activities.
A resident with hemiplegia and urogenital implants, requiring maximal assistance, was left undressed and exposed on a shower chair in their room without the privacy curtain drawn or the door closed. Staff acknowledged the lapse in privacy and confirmed that facility policy requires shielding residents during personal care to maintain dignity.
A resident with depression, anxiety, moderate cognitive impairment, and significant physical limitations expressed a preference for female CNAs to provide shower assistance, which was communicated to staff and documented in records. Despite this, the facility did not develop a care plan to address the resident's preference, resulting in a missed shower and potential delays in care, contrary to facility policy requiring care plans to reflect resident choices.
A resident with dementia, dysphagia, and type 2 diabetes was readmitted but did not have a diet order entered into the eHR or a diet slip sent to the kitchen, resulting in a two-hour delay in receiving a breakfast tray. Staff interviews and record review confirmed that the required process for timely meal delivery was not followed, leading to the resident eating much later than scheduled.
Two residents were not protected from accident hazards when staff failed to provide feeding assistance at eye-level to a resident with dysphagia and did not ensure another resident at high risk for falls wore non-skid socks while ambulating. These actions were not consistent with the residents' care plans and facility policies, as confirmed by staff interviews and direct observation.
A resident with chronic kidney disease and other comorbidities missed multiple scheduled hemodialysis sessions, but the physician was only notified of one missed treatment. Nursing staff failed to communicate and document the refusals appropriately, and the dialysis clinic was unable to obtain information from facility staff. Facility policy required prompt physician notification and documentation for such events, but these procedures were not consistently followed.
A resident with severe dementia and behavioral disturbances, who frequently refused prescribed medications and wandered unsupervised, entered another resident's room and engaged in inappropriate sexual contact. Staff failed to follow abuse prevention and wandering management policies, did not adequately supervise or intervene, and did not notify the physician about repeated medication refusals, resulting in a violation of the resident's right to be free from sexual abuse.
A resident with severe dementia, schizophrenia, and other behavioral health diagnoses repeatedly refused multiple prescribed medications, including donezepril, quetiapine, depakote, and trazodone. Despite documentation of these refusals and increased wandering behavior, nursing staff did not promptly notify the physician or document the refusals as a change in condition, as required by facility policy. This resulted in delayed treatment and increased risk of harm for the resident.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was observed and documented to wander the facility daily, yet the MDS assessment failed to reflect this behavior. Staff interviews confirmed the inaccuracy, and facility policy required accurate coding of resident status during the assessment period.
Surveyors found that clinical records for four residents were incomplete or inaccurate, including missing documentation of 72-hour monitoring after altercations, blank MARs indicating possible missed medication administration, and lack of required notes after dialysis. Nursing staff confirmed these omissions, which were not in line with facility policy and professional standards.
The facility did not develop or implement care plans for two residents with specific behavioral issues: one with Alzheimer's disease who wandered into other residents' rooms, and another with depression and chronic kidney disease who repeatedly called 911 without notifying staff. Despite documented patterns of these behaviors and staff awareness, no care plans were in place to address or manage them, contrary to facility policy.
A resident with diagnoses of schizophrenia, psychosis, and anxiety disorder, who was prescribed multiple psychotropic medications, was admitted without an accurate Level I PASRR screening. The screening failed to document the resident's mental health conditions and medication use, resulting in the omission of a required Level II evaluation. The DON confirmed the oversight during a review of records and policies.
The facility did not post daily nurse staffing information in accordance with state requirements and facility policy, as the postings lacked the facility name, were not on the State-specific NHPPD form, and did not specify whether hours were projected or actual direct care hours. Payroll staff and the DON confirmed these omissions, and all observed postings at nursing stations were non-compliant.
A resident with multiple serious mental illness diagnoses and prescribed psychotropic medications was admitted without accurate documentation of these conditions in the PASRR screening, resulting in the absence of a required Level II evaluation. The facility did not develop individualized care plans for the resident's mental health diagnoses or psychotropic medication use, nor did it implement behavioral monitoring as required by policy. These deficiencies were confirmed by the DON and were inconsistent with facility procedures for behavioral health care.
A resident with a history of stroke and cognitive intactness was struck on the head by another resident, but neurological checks were not initiated until seven hours after the incident, despite facility policy requiring immediate assessment after head trauma. Staff interviews and record review confirmed the delay and the failure to follow established protocols.
The facility failed to serve omelets as specified on the menu, instead providing scrambled eggs to 124 residents. A dietary staff member mistakenly served scrambled eggs, believing it was on the menu. The Dietary Manager was unaware of the change and emphasized the need for menu adherence to meet nutritional requirements. Facility policy requires menu changes to be approved by the DM and dietician, which was not followed.
The facility failed to maintain proper food storage and handling practices, affecting all residents. Observations revealed unlabeled food items in the refrigerator, freezer, and dry storage, and improper glove use by a dietary aide. The facility also lacked pasteurized eggs and sufficient fresh fruits, impacting residents' dietary preferences and satisfaction.
Unsanitary Kitchen Utility Room and Dishwashing/Sanitizing Areas
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the facility’s kitchen, specifically in the kitchen utility room and around the manual dishwashing and sanitizing stations. During observation with a dietary aide, there was dirty, standing water and debris under the manual washing station and sanitizing station. The dietary aide reported that the sanitizing station had been leaking for several weeks, that maintenance had checked and fixed it, but water continued to spill due to water pressure. The aide also stated the kitchen utility room was dirty and cluttered, and that they had not had the chance to clean and organize it, despite acknowledging that the utility room should always be kept clean. In a separate observation and interview with the dietary cook later the same day, surveyors again noted dirty, standing water and debris under the sanitizing station. The dietary cook stated there was no point in cleaning under the sanitizing station because water kept pooling, and although the sanitizing station had already been cleaned, they did not know the source of the standing water. The cook also stated that staff were supposed to remove all food waste from the sink strainer after washing dishes to keep the area clean. Review of the facility’s sanitation policy indicated that all equipment must be maintained and kept in working order, that the Maintenance Department assists Food & Nutrition Services with equipment and janitorial duties as needed, and that the Food & Nutrition Services Director is responsible for writing a cleaning schedule designating who performs cleaning tasks.
Failure to Maintain Clean, Safe, and Sanitary Resident Areas and Storage Spaces
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, and sanitary environment in multiple areas, including three closets and several resident rooms. The Maintenance Director acknowledged that Closets A, B, and C had broken or detached baseboards, cluttered and dirty floors, debris, and a dirty sink, and that employee files and boxes were stored directly on dirty floors. He stated he did not know when certain rooms were last cleaned and confirmed that files should not be on the floor and that he had not obtained authorization for a cabinet to organize documents. Observations of specific resident rooms showed dirty floors, a dirty restroom with towels on the floor, and a shared restroom for two rooms with dirty basins containing pooled dirty water and yellowing towels stored under the sink. Baseboards in these areas were detached, and the Maintenance Director stated that detached baseboards and cracks could be an entry point for roaches. Resident 1’s records showed admission with muscle weakness and hypertension, with assessments indicating she had decision-making capacity, could understand and be understood, and required varying levels of assistance and supervision for ADLs such as eating, hygiene, dressing, transfers, and mobility. During interviews and observations, Resident 1 reported that her room and restroom had not been cleaned for four days, were dirty, and had bugs present, pointing out ants on a drawer. She stated she felt dehumanized by the condition of her room. Further observation revealed stains in her armoire where she placed clothes, a tray of old food (hamburger and moldy fries) in a dresser drawer, and multiple cups left in the room because staff did not want to pick them up. The Infection Prevention Nurse stated that old moldy food in drawers could lead to infections, sickness, and pests, and that housekeeping should check and clean armoires and dressers daily. A CNA acknowledged that nine piled basins with dirty water and yellowing towels under the shared restroom sink should have been removed and cleaned. Facility policies on sanitation and homelike environment required a safe, clean, comfortable environment and outlined responsibilities for cleaning schedules and maintenance support, which were not followed in these instances.
Failure to Maintain Effective Pest Control and Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by unresolved structural issues and inadequate sanitation contributing to the presence of pests. A pest control service report dated 3/4/2026 documented that the baseboard on the right side of the entry door was peeling and damaged, creating a potential entry point and harborage area for roaches, and recommended sealing the peeling baseboards and maintaining high sanitation standards, including preventing food particles and water leaks around kitchen appliances and in patient rooms. On 3/10/2026, the Maintenance Director confirmed that the shared restroom for Rooms 2 and 3 had detached baseboards and acknowledged that cracks could serve as entrance points for roaches. During the same survey, a resident reported that her room and restroom had not been cleaned in four days, described them as dirty, and pointed out ants crawling on a drawer, stating she felt dehumanized being in such a dirty room. These conditions occurred despite a written pest control policy dated 1/2026 stating the facility should maintain an ongoing pest control program to keep the building free of insects and rodents.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
Surveyors identified a deficiency in maintaining a safe, clean, comfortable, and homelike environment when multiple resident rooms and adjacent hallways were found to be unsanitary. During observation with the DON, the hallway floors by Rooms A, B, and E were noted to be dirty with food crumbs and pieces of trash. The shared bathroom for Rooms A and B had dirty towels surrounding the toilet floor, and Room C had three towels and trash on the floor, creating clutter. In Room D, a bedpan with smeared feces was observed placed on top of the vanity. In the shared bathroom for Rooms F and G, the toilet tank flush handle had smeared feces. The DON acknowledged that dirty floors with food crumbs and trash could attract pests and be a source of germs leading to infections, that dirty towels on the bathroom floor could cause residents to feel uncomfortable, that towels and trash on the floor could cause residents or others to trip and fall, and that feces on the toilet handle could lead to cross-contamination and infections. Review of the facility’s “Cleaning and Disinfection of Environmental Surfaces” policy dated 1/2018 showed that environmental and housekeeping surfaces, including floors, furniture, and bed rails, were to be cleaned regularly when visibly soiled and disinfected with an EPA-registered hospital disinfectant according to label directions. These observations demonstrated that the facility did not follow its own cleaning and disinfection policy for environmental surfaces in Rooms A, B, C, D, E, F, and G and their shared bathrooms and hallways, resulting in an environment that was not clean, sanitary, or home-like for the affected residents.
Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident’s medical records as required by its policy and procedure titled Access to Personal and Medical Records. One resident, originally admitted and later readmitted to the facility, had diagnoses including muscle weakness and difficulty walking. A History and Physical dated 1/9/2026 documented that the resident had fluctuating capacity to understand and make decisions, while a Minimum Data Set (MDS) dated 10/14/2025 indicated the resident was usually able to understand and be understood by others. The MDS further showed the resident required supervision for eating and oral hygiene, was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear, required maximal assistance for upper body dressing, and moderate assistance for personal hygiene. On 12/23/2025 at 11:15 a.m., the resident’s attorney’s office contacted the Medical Records Director (MRD) to request the resident’s medical records, followed by an email at 4:10 p.m. the same day, for which no confirmation was received. The attorney later spoke with the MRD on 1/8/2026 and was informed that the MRD was waiting for supervisor verification before releasing the records. In a subsequent interview, the MRD stated she received the written request on 12/23/2025 after 4:00 p.m. but did not send the records because the corporate office had to review them first and had told her she had a month to send them. On 1/26/2026, the MRD acknowledged that more than 30 days had passed since the request and confirmed that the facility’s policy required that requested medical records be provided as soon as practicable within 5 days, up to 30 days from the date of the written request. This delay resulted in the facility’s failure to release the resident’s medical records within 30 days, violating the resident’s and resident representative’s rights to access records.
Failure to Document Sacral Skin Tear and Complete Weekly Skin Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident by omitting documented skin issues from transfer documentation and not completing required weekly skin assessments. The resident was admitted with diagnoses including muscle weakness and cellulitis of the left lower limb and had an H&P indicating lack of capacity to understand and make decisions, while an MDS assessment indicated the resident could understand and be understood and required varying levels of assistance with ADLs. On 12/26/2025, an SBAR form documented a sacral skin tear measuring 3 cm by 0.5 cm by 0.5 cm. However, when the resident was transferred to a general acute care hospital on 1/4/2026 for fever, the Transfer Sheet completed at 5:02 p.m. did not include the resident’s sacral skin tear or skin condition, contrary to the facility’s discharge policy requiring assessment and documentation of the resident’s condition at discharge, including skin assessment. The facility also failed to complete the weekly skin assessment for the sacral skin tear that was due during the week of 12/28/2025 to 1/3/2026. Review with the DON showed there was no weekly skin assessment documented for the sacral skin tear identified on 12/26/2025, and the DON stated this was because there was no wound care provider available that week. This omission was inconsistent with the facility’s policy on prevention of pressure injuries, which required a comprehensive skin assessment with each weekly risk assessment and upon changes in condition according to the resident’s risk factors.
Failure to Timely Return Resident’s Wheelchair and Personal Belongings After Room Fumigation
Penalty
Summary
The facility failed to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions when the resident's wheelchair and ice chest were not returned in a timely manner after his room was fumigated. The resident, who had paraplegia, neuromuscular bladder dysfunction, benign prostatic hyperplasia, and major depressive disorder, was dependent on staff for toileting, transfers, and most ADLs. His history and physical indicated he had capacity to understand and make decisions. On the day of fumigation, staff, including CNAs, cleared his room and removed his wheelchair, ice chest, and other personal property for storage. The LVN reported that CNAs helped clear the room and that he did not know where the resident's property was, and also noted that the resident did not like people touching his property. Following the fumigation, the resident reported that his wheelchair and ice chest were not returned and stated he felt harassed, bullied, and controlled, and that he did not trust the facility with his belongings because items had previously gone missing or been broken. He stated he requested the return of his wheelchair and ice cooler from the Administrator the day after fumigation, and the Administrator told him he would look into it. CNAs confirmed that the resident said the social worker took his wheelchair and ice cooler and did not bring them back, and one CNA stated the items were removed from the bedside to fumigate the room. The DON stated the social worker was responsible for returning residents' property, and the Administrator stated he had instructed staff, including the social worker, to return the resident's wheelchair and ice chest after the room was cleaned, and acknowledged that if they had told the resident to place his property in storage, he would have become upset. The facility's policy on a homelike environment indicated residents are to be provided a safe, comfortable, homelike environment and encouraged to use their personal belongings to the extent possible, which was not followed in this instance.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) and infection prevention and control measures for three residents who required gown and glove use during high-contact care. Facility records showed that Residents 1 and 2 had quadriplegia and neuromuscular dysfunction of the bladder, with indwelling urinary catheters (a Foley catheter for Resident 1 and a suprapubic catheter for Resident 2). Their care plans and order summaries directed staff to follow EBP and to use gowns and gloves during high-contact activities to prevent MDRO infection. Resident 3 had a colostomy, cellulitis, diabetes mellitus, and severe cognitive impairment, with orders indicating EBP due to the colostomy. The facility’s EBP policy stated that gowns and gloves were required prior to high-contact care activities for residents with indwelling medical devices or wounds. Surveyors observed multiple instances where staff did not follow these requirements. In Resident 1’s room, CNA 1 was observed providing mobility assistance without wearing a gown or gloves, while their uniform, hands, and arms came into direct contact with the resident and the resident’s linens. For Resident 2, CNA 4 was observed feeding the resident breakfast without wearing a gown, despite the resident’s EBP status related to a suprapubic catheter and care plan instructions for gown and glove use during high-contact activities. These observations occurred even though both residents had documented orders and care plans specifying EBP and the need for PPE during high-contact care. For Resident 3, who had an order for EBP due to a colostomy, CNA 1 and CNA 3 were observed repositioning and moving the resident without wearing gowns and gloves, with their uniforms and hands touching the resident and linens. In a concurrent observation, CNA 3 was also seen feeding Resident 3 without a gown and gloves. The EBP informational sign posted for Resident 3 indicated that staff were required to wear gowns and gloves for all high-contact activities, including feeding and repositioning. During interviews, CNA 3, LVN 1, and the DON all confirmed that high-contact activities such as feeding, turning, and repositioning required gown and glove use under the facility’s EBP policy, and acknowledged that staff should have been wearing this PPE when providing care to these residents.
Failure to Timely Report Alleged Verbal Abuse to Authorities
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving a certified nurse assistant (CNA) and a resident to the California Department of Public Health (CDPH) as required. The incident occurred when a resident, who had diagnoses including hypertension and legal blindness and was assessed as having the capacity to understand and make decisions, was involved in a verbal altercation with CNA 1 at the nurse's station. According to progress notes and interviews, both the resident and CNA 1 exchanged inappropriate language, and the resident alleged that CNA 1 yelled and made an unprofessional remark. Multiple staff members, including a registered nurse (RN 1) and a licensed vocational nurse (LVN 1), witnessed or were aware of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse to supervisors and the appropriate authorities, the incident was not reported to the CDPH. RN 1, who witnessed the event, acknowledged that yelling at a resident could be considered abuse and recognized the need to file a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), but only reported the incident to the incoming RN on the next shift. RN 2, the incoming RN, stated that no such report was made to him, and LVN 1 did not escalate the incident further, assuming the supervisor was already aware. The facility's policy clearly outlines the requirement for anyone witnessing suspected abuse to report it immediately to a supervisor and for the administrator or designee to submit a written report to the Licensing and Certification Program District Office. The failure to follow these procedures resulted in a delay in notifying the CDPH and investigating the alleged abuse, as the incident was not reported through the proper channels as required.
Failure to Timely Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal abuse involving a resident and a Certified Nurse Assistant (CNA) within 24 hours, as required by its Abuse and Neglect Prohibition Policy. The incident occurred when the resident, who had diagnoses including hypertension and legal blindness and was assessed as having the capacity to understand and make decisions, had an argument with the CNA at the nurses' station. Both the resident and the CNA used indecent language toward each other, and the resident reported that the CNA yelled and made an inappropriate comment. The progress notes documented the altercation but did not indicate that an investigation was initiated. Interviews revealed that the Registered Nurse (RN) present during the incident recognized that yelling at residents could be considered abuse and acknowledged that the incident should have been reported immediately to the Administrator (ADM) for investigation. However, the ADM was not informed of the incident until the following day, resulting in a delay in starting the investigation beyond the 24-hour requirement outlined in the facility's policy. This delay was acknowledged by both the RN and the ADM, and it was noted that the lack of timely investigation could have led to further incidents.
Failure to Perform Timely Skin Assessment on Readmission
Penalty
Summary
The facility failed to perform a skin assessment for a resident upon readmission, as required by facility policy. The resident, who had diagnoses including urinary tract infection and muscle weakness, was dependent on staff for all activities of daily living and was always incontinent of bowel. Upon review of the clinical record, there was no documentation of a skin assessment being conducted at the time of readmission. Orders for wound care were initiated after wounds were identified days later, including deep tissue injuries to both feet, abrasions on the left medial ankle and right hip, and a stage 2 pressure injury on the left hip. A licensed vocational nurse confirmed that no wound or skin assessment was performed at the time of readmission, and that the physician did not assess the resident until six days later. The facility's policy required a comprehensive skin assessment within eight hours of admission or readmission, but this was not completed. As a result, there was a delay in identifying wounds and initiating appropriate wound care for the resident.
Failure to Maintain Professional Communication Standards with Resident
Penalty
Summary
The facility failed to follow professional standards of care by not ensuring staff communicated appropriately with a resident who had a history of verbal aggression and legal blindness. The resident, who was able to understand and make decisions, required supervision and setup assistance for some activities of daily living but was otherwise independent in mobility. The care plan documented multiple prior episodes of verbal aggression and outlined interventions such as assessing the resident's understanding, allowing time for expression, encouraging communication, and respecting privacy. Despite these interventions, an incident occurred in which the resident and a Certified Nurse Assistant (CNA) engaged in a verbal altercation at the nurse's station. Progress notes indicated both parties used inappropriate language, and interviews revealed conflicting accounts regarding whether the CNA yelled at the resident or made inappropriate remarks. The incident was further complicated by the resident's request to switch CNAs based on personal preference, which escalated into an argument involving both the CNA and a Registered Nurse (RN). The RN acknowledged that yelling at residents could be considered a form of abuse, and both the resident and CNA reported feeling disrespected during the exchange. The facility's failure to ensure staff maintained professional communication standards contributed to a situation where verbal aggression occurred, contrary to the resident's care plan and professional standards of quality.
Failure to Train Staff on Abuse Reporting Requirements
Penalty
Summary
The facility failed to ensure that staff were adequately trained regarding the reporting requirements for alleged resident abuse, as outlined in its Abuse and Neglect Prohibition Policy. A review of a resident's records revealed that after an incident involving verbal aggression between a resident and a Certified Nurse Assistant (CNA), the event was documented in the progress notes but was not reported to the Administrator or to the appropriate licensing and certification authorities. Interviews with staff indicated a lack of awareness about the proper procedures and timelines for reporting alleged abuse, particularly among night shift staff. One Licensed Vocational Nurse (LVN) stated he had not received abuse prevention training in a long time and was unsure of the reporting process. The resident involved had a history of aggressive behavior related to bipolar disorder and legal blindness, and was able to understand and communicate with others. The care plan for this resident included interventions for managing aggressive behavior, but during the incident, both the resident and the CNA exchanged inappropriate language. The facility's policy required ongoing training for all employees on abuse prevention and reporting, but the Administrator could not recall when the last training was conducted, and acknowledged that not training all staff, including night shift, could result in failures to report and investigate alleged abuse in a timely manner.
Call Light Not Accessible to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with significant physical and cognitive impairments did not have access to a working call light within reach. The resident, who was dependent on staff for all activities of daily living due to muscle wasting, atrophy, and muscle weakness, was observed to be unable to locate her call light and expressed distress over not being able to call for assistance. The resident required supervision or full assistance for eating, dressing, hygiene, toileting, and transfers, and was always incontinent of urine. During interviews, both a Licensed Vocational Nurse and a Certified Nurse Assistant confirmed that the call light was stuck under the mattress and not accessible to the resident. The CNA stated that the resident had recently been moved to the room and the call light's placement was overlooked. Facility policy requires that call lights be placed within easy reach of residents, but this was not followed in this instance, resulting in the resident being unable to request help when needed.
Failure to Honor Resident Care Preferences and Shower Needs
Penalty
Summary
The facility failed to honor a resident's documented and verbal preferences regarding care assignments and shower routines. The resident, who is quadriplegic and entirely dependent on staff for activities of daily living, had previously experienced a traumatic incident with a specific CNA during a shower. Despite the resident's clear and repeated refusals to receive care from this CNA, the facility continued to assign her to his care on multiple occasions. The resident had communicated his preferences to the Quality Assurance Nurse (QAN) and provided a CNA preference list, but these preferences were not consistently documented or communicated among staff, leading to repeated assignments against his wishes. Additionally, the facility imposed a 15- to 30-minute shower time limit on the resident, despite his need for longer showers due to his extensive physical limitations and medical diagnoses. Staff interviews confirmed that the time restriction was implemented without the resident's agreement and that the resident's preferences for longer showers were not honored. The Director of Nursing (DON) acknowledged that a dependent resident would typically require at least 45 minutes for a proper shower and that the imposed time limit was not respectful of the resident's dignity or individual needs. Record reviews and staff interviews revealed that the facility's care plan and interdisciplinary team (IDT) notes included interventions to document and honor the resident's CNA preferences and to monitor his satisfaction with care. However, these interventions were not effectively implemented. The lack of a consistent schedule coordinator and inadequate communication among staff contributed to the failure to follow the resident's care plan, resulting in repeated assignments of the unwanted CNA and the enforcement of a shower time limit that did not accommodate the resident's needs.
Failure to Implement Resident Care Plan Preferences for CNA Assignment
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions developed by the Interdisciplinary Team (IDT) for a resident with quadriplegia, spinal stenosis, spastic diplegic cerebral palsy, muscle weakness, and anxiety. The resident was entirely dependent on staff for activities of daily living and had intact cognitive skills, with the capacity to make and understand medical decisions. The resident had previously experienced a traumatic incident during care provided by a specific CNA and had clearly expressed a preference not to be assigned to that CNA again, providing a preference list to facility staff. Despite these documented preferences and care plan interventions, the resident was assigned to the same CNA on multiple occasions, including a recent incident where the CNA was assigned to provide care and entered the resident's room to perform tasks. The care plan required communication among nursing staff and scheduling coordinators regarding the resident's CNA preferences, review of assignments before each shift, daily monitoring of the resident's satisfaction, and immediate documentation of any deviations from the preference. However, these interventions were not followed, and the resident's preferences were not honored, resulting in repeated assignments of the CNA to the resident. Interviews with facility staff, including the QAN, MDS nurse, and DON, confirmed that the care plan interventions were not effectively implemented. The QAN acknowledged assigning the CNA to the resident due to staffing limitations and did not notify the resident beforehand. The MDS nurse and DON both stated that the interventions identified in the IDT meeting were not followed, which led to the resident's dissatisfaction and distress. The facility's policy required the development and implementation of a comprehensive, person-centered care plan, which was not adhered to in this case.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for four out of six sampled residents by not ensuring the cleanliness of walls, feeding pumps, and privacy curtains. Observations revealed that the walls behind the headboards of two residents were stained with black spots, which appeared to be dried feeding tube formula. Additionally, feeding pumps used by two residents were found with black and brown spots, also resembling dried formula. Privacy curtains in the rooms of three residents were similarly soiled with black and brown dried spots. Resident records indicated that several of the affected individuals had significant medical needs, including diagnoses such as dysphagia, cerebral infarction, dementia, and gastrostomy status. Some residents were noted to have severe cognitive impairment and were totally dependent on staff for activities of daily living, while others required supervision or assistance. One resident without cognitive impairment specifically stated that his privacy curtain was dirty and had not been changed, expressing a desire for a clean living space. Interviews with staff, including a Licensed Vocational Nurse, housekeeping personnel, the housekeeping supervisor, and the Director of Nursing, confirmed that it was the facility's responsibility to keep feeding pumps, curtains, and walls clean. Staff acknowledged the presence of visible dirt and dried formula on these surfaces and recognized the importance of maintaining cleanliness to provide a safe and homelike environment. Review of facility policies indicated that curtains should be cleaned when visibly soiled and that wall washing was part of the housekeeping schedule.
Unsanitary Kitchen Practices and Improper Food Storage
Penalty
Summary
The facility failed to maintain safe and sanitary practices in the kitchen, as observed during a survey. Specifically, the grill food waste receptacle was found full of oil and food waste, and had not been emptied or cleaned as required. Additionally, empty, crushed soda cans and a cell phone were discovered on a shelf designated for resident food storage, next to boxes of powdered sugar. The Dietary staff member present confirmed that the grill had not been used that morning and that the receptacle should be cleaned daily, but was unsure if it had been cleaned during her absence. She also acknowledged that it was the cook's responsibility to clean the grill after each use and that personal items and trash should not be stored with resident food items. The Director of Nursing confirmed that staff are expected to keep the kitchen clean and prevent food or dirty items from being left out to avoid pest infestations. Review of the cook's job description and facility policies indicated clear expectations for safe food handling, proper storage, and cleaning of equipment and surfaces after use. The failure to follow these procedures resulted in unsanitary conditions with the potential to attract pests and cause cross-contamination.
Failure to Prevent Verbal Abuse and Honor Resident Care Preferences
Penalty
Summary
A deficiency occurred when a resident, who was legally blind and had a history of major depressive disorder, was subjected to verbal abuse by a Certified Nursing Assistant (CNA). The resident had previously communicated to both the Licensed Vocational Nurse (LVN) and the Administrator that he did not want this CNA assigned to his care, due to a history of not getting along. Despite these requests, the CNA was assigned to the resident, and an altercation ensued in which the CNA yelled at the resident, used curse words, and called him names. The incident escalated to the point where a Registered Nurse (RN) had to intervene to separate the CNA and the resident. The facility failed to follow its own policies and procedures regarding abuse prevention and resident dignity. The policies required staff to identify, correct, and intervene in situations where abuse was more likely to occur, and to honor residents' preferences regarding their caregivers. Staff interviews confirmed that the resident's preferences were known but not consistently communicated or honored in the assignment process. The CNA and other staff acknowledged that the resident had expressed a desire not to be cared for by this particular CNA, but the assignment was not changed, leading to the incident. The failure to accommodate the resident's preferences and to prevent the assignment of the CNA resulted in the resident experiencing verbal abuse and a negative impact on his psychosocial well-being. The incident was recognized by the Director of Nursing and other staff as a violation of the resident's rights and facility policy, specifically regarding the expectation that residents be treated with dignity and respect at all times.
Failure to Implement Care Plan Interventions for Resident Safety and Supervision
Penalty
Summary
Staff failed to implement care plan interventions for three residents, resulting in deficiencies related to resident safety and supervision. For two residents, after an alleged incident of sexual abuse where one resident touched another's legs, care plans were updated to require separation and increased supervision. However, observations showed that these two residents continued to sit together and interact in the lobby, with one resident placing a pillow under the other's legs. Interviews with staff revealed a lack of awareness and enforcement of the separation intervention, and the residents themselves were not informed that they should not be together. The Director of Nursing confirmed that staff did not follow the care plan interventions to keep the residents separated after the abuse allegation. Another resident, identified as an elopement risk due to a history of leaving the facility without authorization, had a care plan requiring monitoring of her location and documentation of wandering behavior. Despite this, the resident left the facility without notifying staff or signing out, and her absence was not noticed until several hours later. Staff interviews indicated that monitoring was not performed as required by the care plan, and the Director of Nursing acknowledged that the failure to monitor allowed the resident to leave unsupervised. Record reviews and staff interviews confirmed that the facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables to be developed and implemented for each resident. In these cases, the interventions specified in the care plans were not carried out, resulting in lapses in resident safety and supervision. The deficiencies were directly related to staff not being aware of, or not following, the care plan interventions for separation after an abuse allegation and for monitoring a resident at risk for elopement.
Failure to Revise Care Plan After Inappropriate Resident Behavior
Penalty
Summary
The facility failed to revise the care plan for a resident after an incident of inappropriate touching was observed. Specifically, a resident with intact cognitive skills and independence in most activities of daily living was noted to have touched the legs of another resident. The care plan addressing inappropriate statements and touching had previously included interventions such as increased supervision and resident education. However, after the new incident, the care plan was only noted as revised, with no new goals or interventions developed to address the recurrence of the behavior. Record review and staff interviews confirmed that the care plan was not updated with new interventions following the incident, despite facility policy requiring care plan revisions when there is a significant change in a resident's condition or behavior. The DON stated that a revision should include new interventions when previous ones are ineffective, and failure to do so results in an outdated plan of care. The facility's policy also emphasized the need for ongoing assessment and timely updates to care plans as resident conditions change.
Failure to Complete Therapeutic Pass Documentation for Resident
Penalty
Summary
The facility failed to follow its policy and procedure regarding residents leaving and returning from therapeutic passes for one of three sampled residents. Specifically, for a resident with diagnoses of schizophrenia and epilepsy, the required Out On Therapeutic Pass/Leave of Absence forms were not properly completed on multiple occasions. The forms lacked the signature of a licensed nurse, did not indicate the date and time of the resident's return, and did not include the name of the person signing the resident back into the facility. This failure meant there was no documentation that a licensed nurse had assessed the resident's stability before leaving or upon return, as required by facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy mandates a licensed nurse to sign the form both when a resident leaves and returns, to verify the resident's condition and ensure their safety. The incomplete forms did not provide a system to ensure the resident's safe release or return, and staff acknowledged that without proper documentation, there was no proof of assessment or verification of the resident's whereabouts. The facility's policy review further confirmed that all residents leaving the premises must be signed out and in, with expected times of return documented.
Failure to Address Psychosocial Needs After Abuse Allegation
Penalty
Summary
The facility failed to address the psychosocial needs of two residents following an allegation of abuse. After an incident in which one resident reported being touched inappropriately by another during lunch, there was no evidence that the Social Services Designee (SSD) assessed the affected residents or documented any follow-up. Record reviews showed that neither resident had a social services note or care plan addressing their psychosocial needs after the alleged abuse incident. One resident involved had diagnoses including Tourette's syndrome and psychosis, with moderate cognitive impairment and significant dependence on staff for daily activities. The other resident had a history of cerebral infarction and diabetes, with intact cognitive skills and some independence in daily activities. Despite these vulnerabilities, there was no documentation of psychosocial assessment or intervention by the SSD after the incident. Interviews with facility staff confirmed that the SSD did not promptly visit or assess the residents following the alleged abuse. The SSD acknowledged that it was his responsibility to develop care plans and provide psychosocial support, especially after such incidents, but admitted he did not remember seeing the residents immediately and did not develop care plans for them. The facility's policies and job descriptions require the SSD to monitor and address residents' psychosocial needs, particularly after abuse allegations, but these actions were not taken.
Failure to Document Insulin Administration and Change of Condition
Penalty
Summary
A licensed vocational nurse failed to document the administration of insulin Aspart, 35 units, for a resident with diabetes mellitus on the Medication Administration Record (MAR) for a specified morning dose. The MAR review showed no indication that the insulin was administered as ordered, and the nurse did not record the medication administration. The nurse acknowledged the importance of following physician orders and documenting medication administration to ensure resident safety and to provide proof of care. The resident's care plan required insulin administration before meals, and the nurse did not implement this intervention as outlined. Additionally, the same resident experienced a change of condition (COC) involving agitation and a verbal altercation with a certified nursing assistant. Although an SBAR form documented the incident, there was no corresponding documentation in the nursing progress notes for the evening shift on the day of the event. Facility staff confirmed that documentation of COC should occur every shift for 72 hours following such incidents, as part of the nursing care plan. The lack of documentation meant that staff would not be aware of the resident's emotional and psychosocial status, potentially delaying necessary care. Facility policies and job descriptions reviewed indicated that licensed vocational nurses are responsible for implementing care plans, administering medications per physician orders, and documenting accurately and thoroughly. The facility's policies required prompt, complete, and factual documentation of resident conditions, changes, and all medication administrations. The failure to document both the insulin administration and the resident's change of condition was inconsistent with these requirements.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the lack of adequate staffing and the absence of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Document Resident Oral Intake
Penalty
Summary
The facility failed to ensure that nursing records were completely and accurately documented by not recording the oral intake for a resident with significant cognitive impairment and multiple diagnoses, including Alzheimer's disease, dementia, and anemia. The resident required varying levels of assistance with daily activities and had care plans in place to monitor nutritional status and address unplanned weight changes. The care plans specifically required staff to monitor, record, and report oral intake at each meal to maintain adequate nutrition and identify potential issues. On at least one occasion, a Certified Nursing Assistant (CNA) did not document the resident's oral intake for breakfast and lunch, citing lack of access to the charting system as the reason. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Staff Development (DSD), and the Assistant Director of Nursing (ADON), confirmed that CNAs were expected to document meal percentages after each meal as part of their responsibilities. The ADON reviewed the resident's Nutrition Report and found missing documentation of oral intake for multiple days, emphasizing that lack of access to the charting system was not an acceptable reason for failing to document. Review of the CNA job description and facility policies further confirmed that recording residents' oral intake is a required duty. Facility policies also stated that documentation should be complete, factual, and promptly recorded to accurately reflect services provided. The failure to document oral intake as required resulted in incomplete medical records and had the potential to disrupt communication among staff and delay necessary care for the resident.
Plan Of Correction
A. How corrective actions will be accomplished for those residents found to be affected by the deficient practice? a) On 7/25/25, CNA 1's access to PointClickCare (PCC) was reviewed, and CNA1 PCC password was reset by the Administrator to ensure proper access to the electronic documentation system. b) On 7/28/25, CNA 1 documented Resident 5's food intake for all meals to ensure that current data was recorded. c) On 7/26/25, the Director of Nursing (DON) reviewed Resident 5's weights and there was no impact as a result of the documentation failure. d) On 7/25/2025, CNA 1 received a 1:1 in-service training on the importance of timely and accurate documentation of resident food intake after each meal. The training also emphasized the requirement to immediately notify a supervisor, the Director of Staff Development (DSD), or the Administrator if there are any access issues with the PCC system. 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? a) All residents who were identified as having nutritional or weight related issues are at risk due to this deficient practice. b) The DON or Medical Records Director (MRD) conducted a facility-wide audit of oral intake documentation for all residents with nutritional risk or weight-related care plans was initiated on 7/25/25 and completed by 7/28/25. c) There were no additional residents identified with deficiencies related to the documentation of food intake. C. What measures will be put in place or what systematic changes the facility will make to ensure that the deficient practice does not recur? a) On 7/28/25, mandatory re-education was provided to all CNAs, LVNs, and RNs on: The importance of accurate, timely documentation of oral intake. The requirement to report immediately if PCC access is unavailable or not functioning. b) On 7/28/25, the Director of Staff Development (DSD) reviewed the PCC access status of all CNAs to identify and resolve any issues with login credentials or system access. c) The DON or Medical Records Director will perform random daily audits of oral intake documentation using audit tools for 10 residents daily x3 days, then weekly for 4 weeks, and monthly thereafter for 3 months. Any staff found not documenting resident food intake were immediately re-educated by the DSD or DON. D. How the facility plans to monitor its performance to make sure the solutions are sustained? a) All audit findings related to oral intake documentation and identified trends will be presented during the monthly QAPI meetings by the Facility Administrator, Director of Nursing (DON), and Medical Records. b) Any patterns of non-compliance will result in immediate corrective actions, including individual coaching, counseling, and re-training of involved staff. c) The QAPI Committee will continue to monitor oral intake documentation compliance for a period of 3 months, or until sustained compliance is achieved.
Failure to Ensure Kitchen Staff Wore Hair Restraints During Food Service
Penalty
Summary
A deficiency was identified when a dietary aide was observed in the kitchen emptying food from residents' plates without wearing a hairnet. The aide admitted to forgetting to put on a hairnet and acknowledged that it should have been worn to prevent hair from contaminating the food. This observation was made during a survey and was confirmed through an interview with the dietary supervisor, who stated that all kitchen staff are required to wear hairnets while in the kitchen to prevent hair from landing on food. A review of the facility's policy and procedure on food handling practices indicated that staff are expected to practice good personal hygiene, including the use of appropriate hair restraints during any food service activities such as cooking, preparing, and assembling food. The failure to follow these sanitary requirements had the potential to contaminate clean surfaces, food preparation areas, and food served to all 117 residents in the facility.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On July 10, 2025, a hairnet was immediately provided to Dietary Aide (DA) 1, who resumed duties only after becoming compliant with the facility's hairnets policy. On the same day, DA 1 was given a 1:1 re-education regarding the requirement to wear hairnets while in the kitchen. How the facility will identify other residents having the potential to be affected by the same deficient practice: All residents who received meals prepared in the facility's kitchen were identified as potentially at risk due to this deficient practice. On July 11, 2025, a full observation of kitchen staff was conducted by the Registered Dietitian (RD) to ensure that all staff were wearing appropriate hairnets. No additional non-compliance was noted. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: On July 11, 2025, all dietary staff received mandatory in-service training on proper personal hygiene and sanitation practices, including the importance of wearing hair restraints and following infection control procedures during all aspects of food preparation. Ongoing Observations: The Dietary Supervisor or designee will conduct observations of kitchen staff for compliance with hairnet use: daily for 3 consecutive days, then weekly for 2 weeks, then monthly thereafter. How the facility plans to monitor its performance to make sure that solutions are sustained: The Dietary Supervisor and Facility Administrator will review results from ongoing kitchen staff observations to ensure adherence to food safety protocols. Kitchen staff observation results and compliance trends will be reported to the QAPI committee monthly. The QAPI Committee will monitor and evaluate compliance for a minimum of 3 months, or until 100% compliance is achieved and sustained. How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Immediate Action: On 7/10/25, cease all kitchen operations and food preparation. Facility leadership and the infection control team were promptly notified on 07/10/2025. On 7/10/25, posted visible signage: KITCHEN CLOSED for SANITATION. Starting on 7/10/25, all resident meals were catered from outside services.
Administrator Failed to Oversee Effective Pest Control, Leading to Kitchen Closure
Penalty
Summary
The facility failed to ensure effective and efficient administration, as the Administrator was not involved in maintaining an effective pest control program. During multiple observations, live cockroaches were seen in the kitchen, including one immediately upon entry and at least ten under a handwash sink. Staff interviews revealed that the issue had been ongoing, with dietary staff reporting sightings to the Dietary Supervisor, who in turn reported the problem to the Administrator and the previous Maintenance Supervisor. However, the Administrator was not present at the facility during the survey, being on vacation, and was unaware of the severity of the infestation. The Vice President of Clinical Reimbursement, who was covering for the Administrator, was also unaware of any pest or maintenance issues. The facility did not have documentation of pest control services, as the previous Maintenance Supervisor, who had been the main contact with the exterminator, was no longer employed and the Administrator was not included in related communications. The lack of oversight and documentation led to the Environmental Health Services Officer mandating the closure of the kitchen due to the cockroach infestation. The Administrator's job description indicated responsibility for all facility operations, including physical operations, but this responsibility was not fulfilled in relation to pest control.
Plan Of Correction
A comprehensive inspection of the kitchen was conducted, followed by pest control services and treatment on 07/10/2025. The entire kitchen was thoroughly cleaned and disinfected by the dietary manager and housekeeping staff on 07/10/2025. On 7/10/25, a pest control log was created and is actively maintained by the acting Administrator for tracking ongoing pest management. On 7/14/25, the Facility Administrator was given a 1:1 in-service by the Regional Administrator on leadership responsibilities, including environmental services oversight. On 7/11/25, the Dietary Manager was provided with a 1:1 in-service by the facility's Registered Dietitian (RD), with emphasis on proper kitchen sanitation standards and infection control protocols. All kitchen staff received in-service training by the Registered Dietitian (RD) on 7/11/25, reinforcing sanitation procedures and safe food handling practices. How the facility will identify other residents having the potential to be affected by the same deficient practice: All 117 residents were considered at risk due to the potential health hazards related to pest infestation and the temporary closure of the kitchen. On 7/11/25, residents were monitored for any signs of gastrointestinal or allergic reactions during the affected period; no related health incidents were identified. No adverse effects were reported among residents. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: At random times, the Administrator and Registered Dietitian will conduct Kitchen Sanitation Reviews daily for 5 days, twice a week for 2 weeks, and weekly thereafter. They will use kitchen sanitation audit tools to review the kitchen and high-risk areas twice a month for three months. Any findings will be reviewed with the Dietary Manager and Administrator for further actions. The pest control vendor will provide treatments and is required to submit a written service report after each visit, which will be signed off by the administrator to confirm it has been reviewed. A comprehensive inspection of the kitchen was conducted, followed by pest control services and treatment on 07/10/2025. The entire kitchen was thoroughly cleaned and disinfected by the dietary manager and housekeeping staff on 07/10/2025. On 7/10/25, a pest control log was created and is actively maintained by the acting Administrator for tracking ongoing pest management. On 7/11/25, all staff were given an in-service on the importance of timely reporting of pest sightings as shown on lesson plan titled, "Know the Enemy: Identifying Pests for Better Control in Healthcare," under the objective: "Report and document pest sightings accurately." The in-service was completed by the clinical consultant. The facility plans to monitor its performance to ensure that solutions are sustained: Pest control reports and Kitchen Sanitation will be standing agenda items at the facility's monthly QA Committee meeting. Kitchen inspections at random times and pest control documentation will be reviewed monthly by the Facility Administrator and Maintenance Supervisor and reported to the QAPI Committee. The QAPI Committee will monitor and evaluate compliance for a minimum of three months or until 100% compliance is achieved and maintained.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice Immediate Action: On 07/10/2025, the facility immediately ceased all kitchen operations and posted visible signage stating "KITCHEN CLOSED FOR SANITATION." On 07/10/2025, residents and their responsible parties were notified of the kitchen closure and the interim meal service plan. The Maintenance staff, Vice President of Clinical Reimbursement, and the Registered Dietitian conducted a full inspection of the kitchen on 07/10/2025. Pest control services were contacted immediately, and treatment was performed the same day. On 07/11/2025, the facility obtained a written pest control report and recommendations based on the 07/10/2025 treatment. On 07/10/2025, the entire kitchen was thoroughly deep cleaned and disinfected by the Dietary Manager and housekeeping staff. On 07/11/2025, the Dietary Manager, Registered Dietitian (RD), and Infection Control Preventionist conducted sanitation rounds in the kitchen to verify cleanliness following the deep cleaning. All infested materials were removed and properly disposed of by kitchen staff and environmental services on 07/11/2025. Beginning 07/11/2025, the Maintenance Director scheduled and completed repairs to seal all visible gaps and crevices within 24-48 hours following the pest control treatment. Pest control services were increased to twice-weekly treatments, with services performed on 07/11/2025, 07/12/2025, 07/14/2025, 07/15/2025, and 07/18/2025. Royalty Commercial Cleaning was contracted to complete additional deep cleaning of the kitchen on 07/12/2025, 07/13/2025, 07/15/2025, and 07/16/2025. On 07/10/25 and 07/11/2025, all facility staff received in-service training from Clinical Nursing Consultants on pest prevention protocols, environmental sanitation, and identifying pest-related risks. On 07/11/2025, all kitchen staff received an in-service from the Registered Dietitian to ensure adequate knowledge of food safety practices and vermin infestation prevention. Interim Meal Service Plan During Kitchen Closure Effective 07/10/2025 On 07/10/2025, meal planning, menu modifications, and dietary adjustments were immediately implemented by the Dietary Manager in response to the kitchen closure. All residents' meals are being catered by a licensed and verified outside food vendor. A Registered Dietitian (RD) reviews and approves all catered menus in advance to ensure the following: - Menus align with individual dietary orders and resident care plans - Meals accommodate resident preferences, allergies, and cultural or religious dietary needs - Delivered meals are received, logged, and checked for appropriate holding temperatures - Meals are served by facility staff in a designated clean area using disposable service ware - Nursing staff continue to monitor and document meal intake, weight changes, hydration status, and any adverse reactions or concerns related to food quality - Mechanically altered diets (e.g., chopped, ground, pureed) and thickened liquids are prepared by the off-site kitchen in accordance with physician orders and resident care plans On 07/11/2025, all infested materials were removed and properly disposed of by kitchen staff and environmental services. Beginning 07/11/2025, the Maintenance Director scheduled and completed repairs to seal all visible gaps and crevices within 24-48 hours following the pest control treatment. Pest control services were increased to twice-weekly treatments, with services performed on 07/11/2025, 07/12/2025, 07/14/2025, 07/15/2025, and 07/18/2025. Royalty Commercial Cleaning was contracted to complete additional deep cleaning of the kitchen on 07/12/2025, 07/13/2025, 07/15/2025, and 07/16/2025. On 07/10/25 and 07/11/2025, all facility staff received in-service training from Clinical Nursing Consultants on pest prevention protocols, environmental sanitation, and identifying pest-related risks. On 07/11/2025, all kitchen staff received an in-service from the Registered Dietitian to ensure adequate knowledge of food safety practices and vermin infestation prevention. Interim Meal Service Plan During Kitchen Closure Effective 07/10/2025 On 07/10/2025, the facility dining room was converted into a temporary food service area. Housekeeping staff are responsible for cleaning and disinfecting the area before and after each meal service. Residents are not permitted to stay in the dining room at any time during this period. Signage was posted stating: "STAFF ONLY -- DO NOT ENTER" and "DINING ROOM CLOSED." All food is served using disposable kitchenware, and this practice will remain in place until kitchen operations resume. Dietary staff from California Post Acute are responsible for preparing mechanically altered meals and thickened liquids at the off-site kitchen and transporting them safely back to the facility. How facility will identify other residents having the potential to be affected by the same deficient practice All residents were considered at risk due to the potential health hazards related to pest infestation and the temporary closure of the kitchen. On 07/11/2025, the Social Services department conducted interviews with a representative sample of residents, specifically, at least 20% of cognitively intact residents, to assess satisfaction with the interim meal service and identify any related concerns. No concerns were reported. On 07/11/2025, residents were monitored for any signs of gastrointestinal or allergic reactions during the affected period; no related health incidents were identified. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: At random times, the Administrator/Registered Dietitian will conduct Kitchen Sanitation inspections daily for 5 days, twice a week for 2 weeks, and weekly thereafter. Using kitchen sanitation audit tools, inspections of the kitchen and high-risk areas will be conducted twice a month for three months. Any findings will be reviewed with the Dietary Manager and Administrator for further actions. The pest control vendor will provide biweekly treatments and is required to submit a written service report after each visit, which will be signed off by the administrator to confirm it has been reviewed. On 07/10/2025, the facility dining room was converted into a temporary food service area. Housekeeping staff are responsible for cleaning and disinfecting the area before and after each meal service. Residents are not permitted to stay in the dining room at any time during this period. Signage was posted stating: "STAFF ONLY -- DO NOT ENTER" and "DINING ROOM CLOSED." All food is served using disposable kitchenware, and this practice will remain in place until kitchen operations resume. Dietary staff from California Post Acute are responsible for preparing mechanically altered meals and thickened liquids at the off-site kitchen and transporting them safely back to the facility. How the facility plans to monitor its performance to make sure that solutions are sustained: Pest control service logs and kitchen sanitation audit results will be standing agenda items for review at the facility's monthly Quality Assurance (QA) Committee meetings. The Facility Administrator, Maintenance Supervisor, and Registered Dietitian will present their findings and feedback regarding pest control logs and kitchen sanitation audits to the QAPI Committee during scheduled reviews. The QAPI Committee will monitor and evaluate compliance for a minimum of three months, or until 100% compliance is achieved and sustained.
Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when dietary staff failed to honor a resident's documented food dislikes, resulting in the resident being served a salad containing tomatoes, which she disliked. The resident's admission record and meal slip clearly indicated a dislike for tomatoes and carrots, yet her lunch tray included tomatoes. The resident, who had left side hemiplegia and COPD, was observed attempting to remove the tomatoes from her salad and expressed her dissatisfaction, stating she wanted to eat the salad but not with tomatoes. The resident was dependent on staff for most activities of daily living and required setup assistance for eating. Interviews with the Dietary Supervisor, Assistant Director of Nursing, and Director of Nursing confirmed that resident food preferences should be followed and that it was the responsibility of dietary aides and licensed nurses to check food trays for accuracy. The facility's policy stated that residents would receive the correct diet with preferences accommodated as feasible, and that nursing personnel were responsible for ensuring residents were served the correct food tray. Despite these policies and procedures, the resident's food preferences were not honored, resulting in her not eating the provided meal.
Plan Of Correction
A. How corrective actions will be accomplished for those residents found to have been affected by the deficient practice 1. On 7/9/2025, Resident #1's dietary preference card and tray ticket were reviewed by the Director of Nursing (DON) and the Dietary Manager. 2. On 7/9/2025, the Assistant Director of Nursing (ADON) met with the resident to provide reassurance that the facility is honoring their documented food preferences. 3. A 1:1 in-service was provided to the Dietary Manager by the Registered Dietitian on 07/10/2025. B. How facility will identify other residents having the potential to be affected by the same deficient practice 1. All residents with food preferences have the potential to be affected by this deficient practice. 2. Beginning on 7/10/2025, a full audit of all residents' dietary preference meal tickets and meal trays was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) to ensure that all food dislikes and preferences were accurately reflected on each resident's meal tray. 3. No other deficiencies were identified. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: 1. On 7/10/2025, in-service training was provided to all dietary staff and dietary aides on reviewing tray tickets before each meal service and cross-checking meals with residents' documented food preferences and dislikes. 2. On 7/10/25, all licensed nursing staff and CNAs received in-service training focused on the importance of honoring resident food preferences, confirming the accuracy of meal tray contents, and ensuring alignment with documented food preferences before delivery to residents. 3. Resident food preferences will be added into each resident's care plan, and all food dislikes will be included in the resident's diet orders to ensure consistency and accuracy in meal preparation. 4. An audit tool was developed for the RN Supervisor / Licensed Designee to cross-check tray tickets and meal trays to ensure that meals are served according to each resident's documented food preferences. Audits will be conducted daily for three days, then weekly for two weeks, and monthly for three months. 5. Any inconsistencies found during audits comparing meal trays with documented food preferences will be promptly reported to the Director of Nursing (DON) and the Dietary Manager and will be addressed immediately upon identification. D. How the facility plans to monitor its performance to make sure that solutions are sustained: 1. The DON/Facility administrator and dietary manager will monitor corrective actions through ongoing compliance and audit results from comparisons of meal trays to documented food preferences completed by the RN supervisor/designee. 2. The DON/Administrator will report the findings and trends of meal trays to documented food preferences audits to the QAPI Committee monthly for review and recommendations. 3. The QAPI Committee will monitor the process for 3 months or until 100% compliance is achieved.
Failure to Develop Person-Centered Care Plan for Resident with Alzheimer's and Anxiety
Penalty
Summary
The facility failed to develop a person-centered care plan for one of five sampled residents who was diagnosed with Alzheimer's disease and anxiety disorder. The resident was admitted with these diagnoses, as well as muscle weakness, and required moderate assistance from staff for activities of daily living such as bathing, dressing, and toileting. Despite these needs, a review of the resident's care plans over a one-year period revealed that no care plans had been initiated to address the resident's Alzheimer's and anxiety diagnoses. During an interview and record review, a registered nurse confirmed that there were no care plans in place for these conditions and acknowledged that care plans are essential communication tools for staff to provide quality care. The facility's own policy required comprehensive care plans with measurable objectives and timetables to meet residents' medical, nursing, mental, and psychosocial needs, but this was not followed for the resident in question.
Failure to Offer Scheduled Showers and Honor Resident Preferences
Penalty
Summary
The facility failed to offer showers to one resident, who had diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and major depressive disorder. The resident was cognitively intact and required maximal assistance with bathing and personal hygiene. According to the care plan, the resident was to be provided with opportunities for choice regarding shower times, and staff were to negotiate shower times to allow the resident to participate in decision-making. Despite this, the resident reported not being offered showers or bed baths and could not recall the last time he received such care. The facility's shower schedule indicated specific days for showers, and staff confirmed that the resident could request showers on other days as well. Record review and staff interviews revealed that on multiple occasions, the resident was not offered a shower or bed bath, as indicated by documentation of "Not Applicable" in the electronic health record, which staff explained meant the resident was not asked or offered the option. Staff acknowledged that the resident should have been routinely offered showers and that failing to do so denied the resident the opportunity to make his own decisions regarding personal hygiene. The facility's policy required providing the preferred method of personal hygiene, but this was not followed, resulting in the resident not receiving showers as scheduled.
Failure to Provide Eye-Level Feeding Assistance Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide feeding assistance at eye-level to a resident with severe cognitive impairment, dysphagia, and diabetes who required a mechanically altered diet and assistance with eating. During observation, the CNA was seen standing to the side of the resident's bed while feeding, rather than being at eye-level as required by facility policy and staff expectations. The resident's bed was elevated at the head but positioned low to the floor, and the CNA did not adjust her position to be at eye-level with the resident. Interviews with the CNA, a licensed vocational nurse (LVN), and the assistant director of nursing (ADON) confirmed that staff are expected to provide feeding assistance at eye-level to maintain resident dignity and comfort. Facility policies reviewed also emphasized the importance of maintaining resident self-esteem and self-worth during care activities, including meal assistance. The failure to provide feeding assistance at eye-level was noted as a lapse in upholding the resident's right to dignity and could affect the resident's self-esteem and self-worth.
Resident Privacy Not Maintained During Post-Shower Care
Penalty
Summary
A deficiency occurred when a resident, who had hemiplegia, urogenital implants, and required maximal assistance with personal care, was left undressed and sitting on a shower chair in their room without the privacy curtain drawn or the door closed. This was observed during a survey, with one CNA present in the room and another CNA outside. The staff acknowledged that the resident had just come from the shower and was not covered, and both CNAs stated that the door should have been closed and the resident covered for privacy and dignity. Further interviews with staff confirmed that the facility's policy required maintaining resident privacy during personal care by using a closed door or drawn curtain. The RN interviewed also confirmed that the resident's rights to privacy and dignity were violated by exposing the undressed resident. The facility's policy, reviewed by surveyors, emphasized the importance of shielding residents during all personal care and treatment procedures.
Failure to Develop Care Plan Addressing Resident's Shower Preference
Penalty
Summary
The facility failed to develop a care plan addressing a resident's expressed preference for female CNAs to provide shower assistance. Despite documentation in the psychosocial progress note and direct communication from the resident to staff, this preference was not incorporated into the resident's care plan. The resident, who had diagnoses of depression, anxiety, moderate cognitive impairment, and physical limitations requiring maximal to total assistance with activities of daily living, communicated his preference to staff after moving rooms and refused a shower when a male CNA was assigned. Multiple staff members, including a CNA and an LVN, were aware of the resident's preference, and the LVN acknowledged that a care plan should have been created to address it. A review of the resident's records confirmed the absence of a care plan reflecting this preference, even though the facility's policies require care plans to address resident choices and preferences. The failure to document and implement the resident's care preference had the potential to delay and negatively affect the delivery of care for the resident's overall wellbeing, as noted by staff during interviews.
Delayed Diet Order Entry Resulted in Late Meal Service for Readmitted Resident
Penalty
Summary
The facility failed to timely input a resident's diet order upon readmission, resulting in a delay in meal service. Specifically, a resident with diagnoses including dementia, dysphagia, and type 2 diabetes mellitus was readmitted to the facility, but the licensed nurse did not enter the required diet order into the electronic health record or submit a diet slip to the kitchen. As a result, the kitchen was unaware of the resident's dietary needs, and the resident did not receive a breakfast tray at the scheduled time. The resident ultimately received breakfast two hours after the scheduled mealtime, as observed by staff and confirmed through interviews and record review. The resident's medical records indicated a need for a mechanically altered, consistent carbohydrate, no added salt diet due to diabetes and swallowing difficulties. Staff interviews revealed that the process for ensuring timely meal delivery was not followed, as the admitting nurse did not input the diet order or notify the kitchen. The delay was only identified during morning rounds, after which the diet order was entered and the meal provided. Facility policy required regular meal times and prompt communication of dietary needs, which was not adhered to in this instance.
Failure to Prevent Accident Hazards During Feeding and Ambulation
Penalty
Summary
Two deficiencies were identified regarding accident hazards and supervision for two residents. For one resident with dementia, dysphagia, and diabetes, staff failed to provide feeding assistance at eye-level. Observations showed a CNA feeding the resident while standing to the side of the bed, rather than at eye-level, despite the resident's care plan and facility policy requiring close monitoring for signs of choking due to swallowing difficulties. Interviews with staff confirmed that being at eye-level is necessary to observe swallowing and prevent choking, and that this protocol was not followed during the observed feeding. For another resident with ataxia, a history of falls, and dementia, staff failed to ensure the use of non-skid socks while the resident was ambulating. The resident was observed propelling himself in a wheelchair and then walking in the hallway wearing regular socks without grips, contrary to the care plan and facility policy, which specified non-skid socks as a fall prevention measure. Staff interviews confirmed that the resident was at high risk for falls and should always wear non-skid socks or shoes when out of bed. Both deficiencies were supported by record reviews, staff interviews, and direct observations. Facility policies and care plans for both residents outlined the required safety measures, but these were not followed during the survey, resulting in the residents being exposed to potential accident hazards.
Failure to Notify Physician of Missed Hemodialysis Treatments
Penalty
Summary
The facility failed to notify a resident's physician when the resident refused to attend scheduled hemodialysis treatments on multiple occasions. The resident, who had diagnoses including diabetes mellitus, congestive heart failure, and chronic kidney disease, was admitted with an order for hemodialysis three times a week. Documentation and interviews revealed that the resident missed dialysis sessions on three separate dates, but the physician was only notified of one of these missed treatments. There was no evidence that the physician was informed about the other two missed sessions. Interviews with nursing staff indicated lapses in communication and documentation. One LVN was unaware that the resident had missed dialysis and was not informed by the previous shift, while another LVN admitted to forgetting to endorse the refusal to the oncoming nurse and did not notify the dialysis clinic or the physician. The dialysis clinic nurse also reported difficulty obtaining information from facility staff regarding the resident's absences and ultimately reported the incident to the California Department of Public Health. The facility's policy and procedure required prompt notification of the attending physician and documentation of any change in the resident's condition, including missed treatments, using the SBAR tool. The Assistant Director of Nursing confirmed that staff were expected to notify both the dialysis clinic and the physician, document the event, and monitor the resident for complications. However, these steps were not consistently followed, resulting in a failure to provide appropriate notification and care according to physician orders and facility policy.
Failure to Prevent Sexual Abuse Due to Inadequate Supervision and Medication Management
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a resident with a history of wandering and behavioral disturbances entered another resident's room and engaged in inappropriate sexual contact. The facility did not follow its Abuse and Neglect Prohibition Policy, which required identifying, correcting, and intervening in situations where abuse was more likely to occur. Staff were aware that the resident with behavioral issues frequently wandered into the same room and required frequent redirection, but adequate supervision and intervention were not provided to prevent the incident. The resident who committed the abuse had diagnoses of severe dementia with behavioral disturbance, schizophrenia, and bipolar disorder, and was known to have fluctuating capacity for decision-making. This resident had a documented history of refusing prescribed medications, including donezepril and quetiapine, which were intended to manage dementia-related behaviors and wandering. Despite repeated refusals, there was no documentation that the physician was notified, nor were alternative interventions or changes to the care plan implemented. Staff interviews confirmed that medication refusals were not properly communicated or addressed, and that the resident's wandering and behavioral episodes increased during the period of non-compliance. Observations and interviews revealed that the resident was frequently unsupervised while wandering the facility in a wheelchair, and staff had previously observed the resident entering the same room multiple times. The roommate of the abused resident also reported that the resident had been coming into the room repeatedly for several months. The facility's policies on wandering behavior management and abuse prevention were not followed, as interventions and supervision were insufficient to prevent the incident of sexual abuse.
Failure to Notify Physician of Medication Refusals in Resident with Dementia and Behavioral Disturbances
Penalty
Summary
The facility failed to promptly notify the physician of a change in condition for a resident who repeatedly refused multiple prescribed medications. The resident, who had diagnoses including severe dementia with behavioral disturbances, schizophrenia, major depressive disorder, and bipolar disorder, exhibited daily episodes of roaming and had a history of rejecting necessary care. Despite clear documentation in the Medication Administration Record (MAR) that the resident refused significant numbers of doses of donezepril, quetiapine, depakote, and trazodone throughout the month, there was no evidence that the physician was notified in a timely manner as required by facility policy. Interviews with facility staff, including a CNA, LVN, RN, and the ADON, confirmed that the resident was non-compliant with care, frequently wandered, and required frequent redirection. Staff acknowledged that the resident's medication refusals should have been documented as a change of condition, and that the physician and responsible party should have been notified. The MAR showed that the resident refused donezepril for six consecutive shifts and had increased episodes of roaming, but these refusals were not documented in the nursing progress notes, nor was there evidence of physician notification. The nurse practitioner responsible for the resident stated that he expected to be notified of medication refusals to prevent withdrawal and manage the resident's behavior. He indicated that lack of notification may have contributed to increased wandering and hypersexual behaviors, which ultimately led to an incident involving another resident. Facility policies reviewed indicated that medication refusals must be reported to the prescriber after three doses are refused, and that the attending physician should be promptly informed of any change in condition. The failure to follow these policies resulted in delayed treatment and placed the resident at risk of harm.
Inaccurate MDS Coding for Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for a resident was accurately coded to reflect the resident's wandering behavior. The resident, who had diagnoses including severe dementia with behavioral disturbance, schizophrenia, major depressive disorder, and bipolar disorder, was observed multiple times roaming the facility in a wheelchair. The resident's Medical Administration Record indicated at least ten episodes of roaming daily, and both Certified Nursing Assistant and Licensed Vocational Nurse interviews confirmed that the resident wandered around the facility and required frequent redirection. Despite these observations and documentation, the MDS assessment did not indicate that the resident exhibited wandering behavior. Both the LVN and Registered Nurse acknowledged during interviews that the MDS assessment was inaccurate and should have been coded as occurring daily. The Assistant Director of Nursing confirmed that the MDS nurse was responsible for completing and auditing the MDS assessments, and the facility's policy required that assessments accurately reflect the resident's status during the observation period.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records for four of six reviewed residents were complete and accurate, as required by professional standards. For one resident with severe cognitive impairment and a history of Alzheimer’s disease and seizures, documentation was missing for two shifts during a 72-hour monitoring period following a physical altercation. The responsible LVN confirmed that the absence of progress notes meant staff would not be aware of any changes in the resident’s condition during those times. Another resident with mild cognitive impairment and multiple chronic conditions, including hypertension and chronic kidney disease, had a blank Medication Administration Record (MAR) for one shift, indicating that medications may not have been administered or documented. The RN acknowledged that licensed nurses are responsible for ensuring MARs are completed. Similarly, a third resident with severe cognitive impairment and chronic kidney disease was missing documentation for the final shift of a 72-hour monitoring period after a physical altercation, as confirmed by the LVN. A fourth resident, who was dependent on hemodialysis and had no cognitive impairment, had a blank MAR for one shift, suggesting medications were not given, and lacked documentation in the progress notes upon return from dialysis. The RN stated that documentation is required to note any changes in the resident’s status after dialysis, and the facility’s policy mandates recording pre- and post-dialysis information. The facility’s documentation guidelines require prompt, complete, and accurate recording of resident care, which was not followed in these instances.
Failure to Develop Resident-Centered Care Plans for Behavioral Needs
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for two residents with specific behavioral needs. For one resident with Alzheimer's disease and a history of wandering, documentation showed the resident had severely impaired cognitive skills and was at moderate risk for elopement, with a pattern of wandering into other residents' rooms. Despite staff observations and assessments indicating this ongoing behavior, there was no care plan in place to address or manage the wandering, as confirmed by both a CNA and an LVN during interviews and record reviews. Another resident, diagnosed with depression and chronic kidney disease, had intact cognitive skills but repeatedly called 911 for medical concerns without notifying facility staff. Nursing progress notes documented multiple instances where the resident called emergency services and was transferred to a hospital without staff being informed beforehand. Despite these repeated incidents, there was no care plan developed to address this behavior, as confirmed by both an RN and the Quality Assurance Nurse during interviews and record reviews. Facility policy required that care plans be developed for changes in condition and that a comprehensive care plan be created within seven days of the resident assessment. However, in both cases, the required care plans addressing the residents' specific behaviors were not present, contrary to facility policy and staff expectations. This lack of care planning was identified through observation, interviews, and record reviews.
Failure to Accurately Complete PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Level I Preadmission Screening and Resident Review (PASRR) for one resident. Upon admission, the resident had documented diagnoses of schizophrenia, psychosis, and anxiety disorder, and was prescribed multiple psychotropic medications, including Ativan and Chlordiazepoxide. The nursing admission assessment noted the resident was disoriented and had communication difficulties. However, the Level I PASRR completed did not reflect the resident's serious mental illness diagnoses or the use of psychotropic medications. As a result, the Notice of PASRR Level I Screening Results indicated that a Level II Mental Health Evaluation was not required, based on the inaccurate information provided in the Level I PASRR. During an interview and record review, the DON confirmed that the resident's diagnoses and medication orders were not included in the PASRR, acknowledging that this inaccuracy could affect the resident's access to necessary behavioral health services. Facility policies reviewed indicated requirements for individualized care planning and behavioral health services, including accurate PASRR screening and ongoing monitoring.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in accordance with both state requirements and the facility's own policy and procedure. Observations revealed that the posted nurse staffing document was untitled, did not include the facility's name, and was not printed on the State-specific Nursing Hours Per Patient Day (NHPPD) form. Additionally, the posting did not specify whether the hours listed were projected or actual direct care hours provided. Payroll staff responsible for updating the posting confirmed these omissions and could not recall if the required information had ever been included. Further review with the Director of Nursing (DON) and examination of the facility's policy confirmed that the postings did not meet the stated requirements, which include listing the facility name, actual direct care hours, and use of the State-specific NHPPD form. Observations at all three nursing stations showed that none of the postings were compliant, and there were no alternative postings available to provide the missing information to residents or visitors. The DON acknowledged that the postings were not in accordance with policy and that residents and their families have the right to know the staffing levels.
Failure to Provide Behavioral Health Services and Accurate PASRR Screening
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident with multiple serious mental illness diagnoses, including schizophrenia, psychosis, and anxiety disorder. Upon admission, the resident's records indicated these diagnoses and active prescriptions for psychotropic medications such as lorazepam and chlordiazepoxide. However, the Level I PASRR screening completed for the resident did not document these serious mental illnesses or the use of psychotropic medications, resulting in a determination that a Level II Mental Health Evaluation was not required. Further review revealed that the resident did not have individualized care plans addressing the diagnoses of schizophrenia, psychosis, or anxiety disorder, nor were there care plans for the administration of psychotropic medications. The facility also lacked orders for monitoring the behavioral manifestations associated with these diagnoses while administering the medications. The DON confirmed that behavioral monitoring and care plans were absent, despite facility policy requiring individualized care plans and ongoing behavioral monitoring for residents receiving psychotropic medications. Facility policies reviewed indicated that residents with behavioral health needs and those on psychotropic medications should have individualized care plans, including non-drug interventions and regular monitoring of behaviors. The failure to accurately complete the PASRR, develop and implement appropriate care plans, and monitor behavioral manifestations while administering psychotropic medications constituted deficient practices in providing necessary behavioral health care and services.
Delayed Neurological Checks After Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to promptly initiate a 72-hour neurological check for a resident who was struck on the back of the head by another resident. The incident was witnessed by a CNA, and the resident who was hit had a medical history including schizophrenia, major depressive disorder, hemiplegia, and hemiparesis following a stroke, but was cognitively intact and able to make decisions. Despite facility policy requiring neurological assessments after any head trauma, the neurological checks for this resident were not started until approximately seven hours after the altercation. Interviews with staff revealed that the licensed nurse assigned to the resident did not immediately begin the neurological checks and was waiting for direction from the DON, who later confirmed that such checks should have been initiated immediately after the incident. The delay in starting the neurological checks was acknowledged by both the nurse and the DON, and facility records confirmed the late initiation. The facility's policy clearly indicated that neurological assessments are required following any accident involving head trauma.
Failure to Serve Menu-Specified Omelets
Penalty
Summary
The facility failed to ensure that dietary staff served omelets as indicated on the menu for 124 residents, resulting in the residents being served scrambled eggs instead. On the morning of the incident, a dietary staff member, referred to as DC 2, was observed serving scrambled eggs with salsa instead of the omelet that was listed on the menu. During an interview, DC 2 stated that she prepared meals based on the facility's dietary menus and believed scrambled eggs were on the menu for that day. Upon review of the menu dated for the day of the incident, it was confirmed that an omelet was supposed to be served. The Dietary Manager (DM) was unaware of the substitution and emphasized the importance of following the menu to ensure nutritional value for residents. The facility's policy required that any menu changes be noted and approved by the DM and dietician, which did not occur in this instance. The DM stated that she must be informed of all food changes to notify the dietician and residents, ensuring the nutritional needs are met.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices, affecting all 146 residents. During a kitchen tour, it was observed that food items in the refrigerator and freezer were not labeled with 'in' dates or 'use by' dates. Additionally, the dry storage room contained food items without 'use by' dates, and there were empty cans and cracker packages on the food rack. The Dietary Manager confirmed that all food items should be labeled with received, open, and use by dates to ensure proper food management and prevent infection. The facility also failed to provide pasteurized eggs for residents, as only liquid pasteurized eggs were available. Residents who requested fried eggs were only given scrambled eggs due to the lack of shelled eggs. The Dietary Manager acknowledged the importance of having shelled eggs available to meet residents' food preferences and enhance their satisfaction. Furthermore, improper glove use by a dietary aide was observed, as the aide did not change gloves when switching tasks, potentially leading to cross-contamination. Additionally, the facility did not have the required amount of fresh fruits, such as apples and oranges, available for residents. The Dietary Manager stated that having fresh fruits is essential for residents' satisfaction and well-being. These deficiencies were in violation of the facility's policies and procedures regarding food labeling, storage, and glove use.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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