Camden Postacute Care, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Campbell, California.
- Location
- 1331 Camden Avenue, Campbell, California 95008
- CMS Provider Number
- 555838
- Inspections on file
- 26
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Camden Postacute Care, Inc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary food storage and labeling practices, including leaving a dented can of grape juice in storage, keeping an open pack of cereal without a date, and storing various produce and frozen items without proper labeling or dating, as confirmed by the Dietary Manager.
Six residents did not have documented evidence that staff discussed, offered, or assisted them in executing advance directives, despite facility policy requiring this. Both the Social Service Director and a Registered Nurse confirmed that this process was not completed for these residents.
Six residents were found to have bed rails installed without documented assessment, attempts at alternatives, informed consent, or risk/benefit review, as required by facility policy. Nursing staff confirmed that these steps were not completed or documented prior to bed rail use, affecting residents with both intact and impaired cognition.
Staff did not consistently use required PPE, such as gowns and gloves, during wound and Foley catheter care for residents on Enhanced Barrier Precautions, and failed to perform proper hand hygiene between glove changes and resident care tasks. Additionally, respiratory and suction equipment was found unlabeled and improperly stored, increasing the risk of cross-contamination.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a board and care facility without the required 30-day written notice to the responsible party or information about appeal rights. The transfer was initiated by a CNA/AA without proper IDT involvement or documentation, and the Social Services Director did not provide written notification or advice regarding the right to appeal, resulting in a violation of the resident's rights.
A resident with severe cognitive impairment and multiple medical conditions was discharged to a board and care facility without proper IDT evaluation, responsible party involvement, or adherence to facility policy. The discharge was initiated by a staff member not authorized for the role, and critical documents were not provided to the receiving facility. The responsible party was not adequately informed or involved, and the resident subsequently eloped multiple times from the new placement.
Several deficiencies were found, including a resident with Parkinson's disease not receiving timely feeding assistance during meals, two residents with urinary catheters left with uncovered drainage bags despite care plan requirements, and staff speaking in a language other than English in the presence of a cognitively intact resident. These actions failed to uphold residents' dignity and respect as outlined in facility policy.
Two residents were found with over-the-counter medications and supplements left unattended at their bedsides, which they self-administered without an IDT assessment or physician order. Nursing staff were aware of the self-administration, but facility records lacked required documentation and authorization for these practices.
Two residents experienced unclean living conditions, including a sticky, soiled privacy curtain and a sticky floor that was not properly mopped. An LVN and the Housekeeping Supervisor confirmed these issues, and the supervisor could not provide documentation of daily or monthly cleaning, relying only on visual checks.
The facility did not complete required PASRR Level I and Level II screenings for two residents with serious mental illness. In one case, a resident with schizoaffective and major depressive disorders did not receive a Level II evaluation due to lack of staff response to the evaluating agency. In another case, a resident with delusional disorder and schizophrenia did not have a new Level I screening after updated diagnoses, as confirmed by staff and documentation review.
A resident with paraplegia, chronic kidney disease, multiple contractures, and several stage 4 pressure ulcers did not have an individualized, person-centered care plan. Instead, all pressure ulcers were combined under the same goals and interventions, despite differing measurements and treatment needs for each site. The facility did not provide relevant policy and procedure documentation.
Two residents' care plans were not updated after significant changes in their conditions: one with dementia did not have care plan revisions to address increased time in bed and the need for a charged cellphone for family contact, and another with ESRD did not have the care plan updated after the hemodialysis schedule increased from three to four times per week. These omissions were confirmed through observation, interviews, and record review.
A resident with hemiplegia and hemiparesis following a stroke was observed smoking unsupervised on the patio, despite clinical records and staff confirming the need for oversight supervision due to the resident's physical limitations. The facility did not provide a policy or procedure for smoking supervision.
The facility did not provide the required number of direct care nursing staff during weekend shifts, as confirmed by review of staffing records and staff interviews. Actual CNA and total DHPPD fell below the facility's policy minimums, affecting all residents in the facility.
The facility did not ensure that a pharmacist's medication regimen review recommendations were reviewed or acted upon for a resident with GERD and chronic pain, and failed to identify or address the lack of required lab monitoring for a resident receiving anticoagulant therapy. Facility policies requiring prompt action and documentation of pharmacist recommendations, as well as protocols for lab monitoring of anticoagulant use, were not followed.
Surveyors identified a medication error rate above 5% when two residents received medications not in accordance with physician orders: one received glipizide without regard to meal timing, and another was given hydrocortisone without food. Nursing staff did not follow prescribed administration instructions, resulting in a deficiency.
Two residents were affected when a bottle of lorazepam without a legible expiration date was stored in the medication room, and an unlabeled bottle of normal saline solution was left unattended on a bedside table. Nursing staff confirmed that both medications were not labeled or stored according to facility policy, which requires clear labeling and secure storage of all drugs and biologicals.
The facility was found to have rooms with more than four residents, with one room housing six and another five. Each resident had appropriate furnishings and there were no reported concerns from residents or staff regarding care, privacy, or safety.
Several multi-resident rooms were identified as having less than the required 80 square feet per resident, with some rooms providing as little as 64.68 square feet per individual. Despite this deficiency, interviews and observations indicated that care, privacy, and storage needs were adequately met.
The facility did not complete thorough investigations or document outcomes for alleged abuse by a CNA and physical altercations between residents. Investigation summaries lacked findings on whether the incidents occurred, and the administrator confirmed that required procedures were not followed according to facility policy.
A facility failed to assist a resident in obtaining insurance after their MediCal coverage was discontinued. The resident, admitted with heart failure, malnutrition, pressure ulcers, and sepsis, was not informed about private pay options, nor was a new MediCal application submitted. The facility's policy required admission staff to refer residents for Medicaid coverage assistance, but this was not followed.
A resident with a complex medical history was allowed to leave an LTC facility to visit a 7-Eleven store, contrary to a physician's order for therapeutic therapy. The MDSC confirmed the outing was not therapeutic and lacked documentation of physician notification, highlighting a failure to adhere to professional standards of practice.
The facility failed to protect a resident from sexual abuse when two residents were left unsupervised in the activity room, resulting in one resident touching another's inner thigh. The incident occurred due to a lack of supervision after 6 p.m., and the responsible CNA was on a delayed break.
Failure to Maintain Sanitary Food Storage and Labeling Practices
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the facility's kitchen. During a kitchen tour, a can of grape juice with a dent was found in the dry storage room and had not been removed to prevent use, despite facility policy and FDA guidance requiring removal of dented cans to prevent bacterial contamination. Additionally, an open pack of cereal was found without a date indicating when it was opened or its expiration date, which was confirmed by the Dietary Manager as not being properly labeled. Further observations revealed that various fresh produce items stored in refrigerator #2, including tomatoes, carrots, onions, lettuce, and celery, were kept in plastic bags without any labeling or dates indicating when they were delivered to the facility. In freezer #2, a pack of cauliflower and a pack of chopped spinach were also found without opened or expiration dates. These findings were in direct violation of the facility's policy requiring all food items in storage, refrigerators, and freezers to be labeled and dated.
Failure to Offer and Assist with Advance Directives
Penalty
Summary
The facility failed to follow its policy and procedure regarding advance directives (AD) for six of eight sampled residents. For each of these residents, documentation such as the face sheet and POLST forms indicated either that no advance directive was present or that it was not available. Further review of the clinical records for these residents showed no evidence that the facility discussed, offered, or assisted them in executing an advance directive, as required by facility policy. During interviews, both the Social Service Director (SSD) and a Registered Nurse (RN) confirmed that there was no documentation of AD discussions or assistance for these residents. The SSD acknowledged that she had not discussed, offered, or assisted the residents with advance directives, and the RN confirmed that the SSD was responsible for this process but had not completed it. The facility's policy states that staff must offer assistance in establishing advance directives if a resident has not already done so, but this was not carried out for the identified residents.
Failure to Follow Bed Rail Assessment and Consent Procedures
Penalty
Summary
The facility failed to follow its own policy and regulatory requirements regarding the use of bed rails for six residents. Observations revealed that multiple residents were using partial bed rails on their beds, and interviews with staff confirmed that these bed rails had been installed without proper documentation or assessment. Specifically, there was no evidence that alternatives to bed rails were attempted prior to their use, nor was there documentation of informed consent from the residents or their representatives. Additionally, the required assessment of risks and benefits, including the risk of entrapment, was not completed or documented before the installation of bed rails. Clinical record reviews for the affected residents showed that none had documentation supporting the necessary steps for bed rail use. This included the absence of a bed rail assessment, lack of documentation of alternatives attempted, no record of risk versus benefit discussions, and no informed consent obtained. The residents involved had varying levels of cognitive function, as indicated by their BIMS scores, with some having intact cognition and others having severe cognitive impairment. Despite these differences, the facility did not individualize or document the decision-making process for bed rail use as required by policy. Interviews with nursing staff confirmed the lack of documentation and adherence to policy for all residents observed with bed rails. The facility's policy clearly states that the interdisciplinary team must assess the resident, attempt alternatives, review risks and benefits, obtain informed consent, and assess for entrapment risk prior to bed rail installation. These steps were not followed or documented for the six residents identified, resulting in a failure to ensure that residents and their representatives were fully informed and protected according to facility policy and regulatory standards.
Failure to Adhere to Infection Control Protocols and PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols, specifically regarding the use of Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during resident care. Staff did not consistently wear gowns and gloves when providing wound care and Foley catheter care to residents who were on EBP, despite signage and the presence of PPE carts. Interviews with staff, including CNAs and LVNs, revealed a lack of compliance and understanding of when PPE was required, even though the Director of Nursing and Director of Staff Development confirmed that PPE should be used during these activities. Residents involved had significant medical histories, including sepsis, MRSA, indwelling catheters, and multiple wounds, increasing their risk for infection. Hand hygiene practices were also not followed as required. During wound treatment observations, an LVN failed to perform hand hygiene between glove changes and after touching various surfaces and supplies, despite acknowledging the need to do so. The facility's policy required hand hygiene to prevent the spread of infection, but this was not consistently implemented during care activities, including wound dressing changes and feeding assistance. Additionally, infection control lapses were observed in the storage and labeling of respiratory and suction equipment. A resident's nebulizer mouthpiece and suction tubing were found unlabeled and improperly stored, in contact with potentially contaminated surfaces and personal items. Staff confirmed these practices were not in line with facility policy, which required proper cleaning, labeling, and storage of such equipment. These failures in infection control practices had the potential to result in cross-contamination and the spread of infection among the facility's residents.
Improper Transfer/Discharge Without Written Notice or Appeal Rights
Penalty
Summary
The facility failed to properly manage the transfer and discharge process for a resident diagnosed with Alzheimer's disease, unspecified dementia, unsteadiness on feet, a history of falls, type 2 diabetes mellitus, hearing loss, psychotic disturbance, mood disturbance, and anxiety. The resident's cognitive status was severely impaired, and the responsible party (RP), identified as the resident's granddaughter, was not provided with the required written notice at least 30 days prior to the transfer. The RP was only verbally informed by the Social Services Director (SSD) of the impending transfer due to an alleged abuse incident, and was not given any written documentation or information about the resident's rights to appeal the transfer or discharge. Record review and interviews revealed that the transfer/discharge notice was completed by a Certified Nursing Assistant/Activity Assistant (CNA/AA) who was previously acting as Social Services (SS), rather than by the SSD or through an interdisciplinary team (IDT) discussion. The CNA/AA admitted to initiating the transfer based on her own opinion that the resident was a danger to others, without documentation or input from a medical doctor or the IDT. The administrator confirmed that the CNA/AA should not have been responsible for the transfer/discharge process and that the SSD should have coordinated the process in accordance with facility policy. Facility policy requires a 30-day written notice to the resident and/or their representative, including the reason for transfer/discharge, effective date, location, and information about the right to appeal. In this case, the required written notice and information about the appeal process were not provided to the RP. The SSD also confirmed that she did not provide written notification or advice regarding the right to appeal. As a result, the transfer/discharge was conducted improperly and in violation of the resident's rights.
Failure to Ensure Safe and Proper Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility administrator failed to provide consistent oversight to ensure that the Social Services Department and interdisciplinary team (IDT) implemented the facility's policy and procedure for safe transfer and discharge of a resident with severe cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, unsteadiness, history of falls, diabetes, hearing loss, psychotic and mood disturbances, and anxiety, was discharged to a board and care facility without proper IDT evaluation or documentation of a discharge meeting with the responsible party (RP). The responsible party, identified as the resident's granddaughter, was not given adequate notice, was not involved in the discharge planning, and did not receive necessary information such as discharge orders, medication instructions, or the opportunity to collect the resident's personal belongings. The discharge process was initiated by a staff member who was no longer serving in the Social Services Director (SSD) role, but rather as a certified nursing assistant (CNA) and activity assistant (AA). This staff member completed the notice of transfer/discharge without a documented discussion or agreement from the medical doctor or IDT, and based the decision on her own opinion that the resident was a danger to others. The current SSD and the administrator both confirmed that the proper process was not followed, and that the SSD should have been responsible for coordinating the discharge in collaboration with the IDT. Additionally, the facility failed to send critical documents, such as the POLST (physician orders for life-sustaining treatment), to the receiving board and care facility. The responsible party was not notified when the board and care staff assessed the resident, nor was she given the chance to review the new placement prior to discharge. Following the transfer, the resident eloped from the board and care facility multiple times, and the board and care facility had to implement additional safety measures. The facility's actions did not adhere to its own policy requiring a 30-day written notice and proper communication with the resident or responsible party regarding the transfer or discharge.
Failure to Maintain Resident Dignity and Timely Assistance During Care and Meals
Penalty
Summary
Multiple deficiencies were identified regarding the failure to honor residents' rights to dignity, respect, and timely assistance. One resident with Parkinson's disease, who was dependent for eating and required one-on-one feeding assistance, was observed on two separate occasions sitting alone in the dining room without staff assistance while other residents were being helped. Staff interviews confirmed that feeding assistance was delayed, and the facility's policy required immediate assistance for residents needing full help upon meal delivery. Another deficiency involved two residents with urinary catheters whose drainage bags were left uncovered. Observations showed that the catheter bags were not covered with privacy bags as required by the residents' care plans and facility policy. Staff interviews confirmed awareness of the requirement to cover catheter bags for privacy, dignity, and infection control, but this was not done for these residents. Additionally, a resident reported that housekeeping and dietary staff were speaking in a language other than English in her presence while providing care and working in the facility. This was confirmed by direct observation and staff interviews, with staff acknowledging that English should be spoken when residents are present. The facility's policy emphasized the importance of promoting dignity and respect for all residents, including communication practices and privacy measures.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) assessment and obtain physician orders for self-administration of medications for two residents. One resident had a bottle of isopropyl alcohol, which he used daily to clean his skin, left unattended on his tray table. This resident had purchased the isopropyl alcohol himself, and nursing staff were aware of his use. Review of his records showed no documentation of an IDT assessment for self-administration or a physician order for the isopropyl alcohol. The resident was cognitively intact and had a diagnosis of a non-pressure chronic ulcer of the left foot. Another resident was found with a bottle of hydrogen peroxide and a bottle of folic acid on his bedside table, both left unattended. The resident reported using the hydrogen peroxide to clean his teeth weekly and taking folic acid daily, with both items brought in by his son. Nursing staff were aware of his self-administration, but records indicated that the IDT had documented 'No' for self-medication administration and there were no physician orders for these items. This resident was also cognitively intact and had a diagnosis of anemia. Facility staff confirmed that medications should not be left at bedside unattended and that required assessments and orders were missing.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for two residents. In one instance, a resident's privacy curtain was observed to be sticky and soiled with brownish dry food particles. This was confirmed by an LVN, who stated that the curtain was dirty and should have been changed by housekeeping or janitorial staff. In another instance, a resident's room had a sticky floor, and the resident reported that housekeeping had only cleaned the room because a state surveyor was present, and that the floor was not properly mopped. The resident expressed dissatisfaction with the cleanliness of her room. The Housekeeping Supervisor stated that both daily cleaning and monthly deep cleaning of resident rooms were the responsibility of housekeeping and janitorial staff, with privacy curtains scheduled to be changed monthly or as needed. However, the supervisor was unable to provide documentation verifying that daily or monthly cleaning had been performed, as he relied solely on visual checks. Additionally, the facility was unable to provide a policy and procedure for cleaning and maintaining resident rooms.
Failure to Complete Required PASRR Screenings for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) Level I and Level II screenings were completed for two residents with serious mental illness (SMI). For one resident, who had diagnoses including schizoaffective disorder and major depressive disorder, the PASRR Level I screening indicated a Level II mental health evaluation was required. However, the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts at communication from the evaluating agency, resulting in the case being closed without the necessary follow-up or resubmission of a new Level I screening. For another resident, who had diagnoses of delusional disorder and schizophrenia, the facility did not complete a new Level I PASRR screening after the resident was diagnosed with SMI. The resident's records showed no evidence of a Level I screening following the updated diagnoses, and staff confirmed that the required screening was not performed. The facility's own policy requires timely submission and follow-up of PASRR documentation, but this was not adhered to in these cases.
Failure to Develop Individualized Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives, goals, and individualized interventions for a resident with multiple complex medical conditions. During an interview and record review with a registered nurse, it was found that the resident was admitted with diagnoses including paraplegia, chronic kidney disease, multiple contractures, and several stage 4 pressure ulcers at different anatomical sites. The care plan for pressure ulcers grouped all sites together under the same goals and interventions, rather than addressing each ulcer individually. Further review of interdisciplinary team meeting notes revealed that each pressure ulcer had different measurements, treatment changes, and status updates, confirming that individualized care planning was necessary but not implemented. The registered nurse acknowledged that each pressure ulcer site should have been care planned separately to provide person-centered care. The facility did not provide a policy and procedure related to this aspect of care planning.
Failure to Update Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to update and revise individualized and comprehensive care plans for two residents following significant changes in their conditions. For one resident with dementia, the care plan was not updated to reflect the resident's increased time spent in bed and the importance of maintaining a fully charged personal cellphone at bedside to support psychosocial well-being and facilitate communication with family members. The care plan also did not address the resident's cultural background or the need for individualized, person-centered care, despite observations and staff interviews indicating these needs. For another resident with end stage renal disease (ESRD) on hemodialysis (HD), the care plan was not revised after the resident's HD schedule increased from three to four times per week. The care plan continued to reflect the previous schedule and did not account for the change in treatment frequency, as confirmed by the DON during record review. The facility's policy required care plans to be reviewed and updated every 90 days or when there is a change in resident status or condition, but this was not followed in these cases.
Failure to Provide Required Supervision During Resident Smoking
Penalty
Summary
A resident with a history of muscle weakness, hemiplegia, hemiparesis following a stroke, and type 2 diabetes mellitus was observed smoking on the facility patio without wearing a smoking apron and without staff supervision. The resident stated that staff only provided supervision when handing over and lighting cigarettes, but not during the actual smoking period. Facility staff, including an Activity Assistant, confirmed that the resident requires oversight supervision while smoking for safety reasons. A review of the resident's clinical records and smoking safety assessments indicated that the interdisciplinary team determined the resident could smoke only with oversight supervision due to their physical limitations and medical diagnoses. The Director of Nursing confirmed that staff are expected to supervise residents during scheduled smoking times. The facility was unable to provide a policy and procedure regarding smoking supervision.
Insufficient Nursing Staff on Weekend Shifts
Penalty
Summary
The facility failed to provide sufficient direct care nursing staff to meet the needs of all residents for 24 hours a day during the weekend. Review of the facility's census and direct care service hours per patient day (DHPPD) forms showed that on two consecutive weekend days, the actual CNA DHPPD was below the required 2.4, and the total DHPPD (including CNAs and licensed nurses) was below the required 3.5. The Director of Staff Development confirmed that staffing levels did not meet the facility's own policy requirements on both days. Interviews with staff and review of facility policy further confirmed that the minimum staffing standards were not met, potentially affecting the care, health, and well-being of all 55 residents in the facility. No specific residents or their medical conditions were mentioned in relation to the deficiency, but the findings were based on record review and staff interviews confirming the shortfall in required staffing levels.
Failure to Follow Consultant Pharmacist Recommendations and Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review (MRR) and that recommendations were appropriately followed for two residents. For one resident with diagnoses including gastroesophageal reflux disease (GERD) and chronic pain, the consultant pharmacist identified issues with medication forms and dosing frequencies during the MRR. However, there was no evidence that nursing staff reviewed or acted upon these recommendations, as indicated by the absence of signatures or documentation on the MRR and confirmed by interviews with nursing staff and the Director of Nursing (DON). For another resident with a history of atrial fibrillation and pulmonary embolism who was receiving anticoagulant therapy (rivaroxaban), the facility did not order baseline or periodic laboratory work to monitor kidney function and blood levels, despite this being an intervention listed in the resident's care plan. The MRR reports for this resident did not address the lack of laboratory monitoring, and both the DON and the consultant pharmacist confirmed that this oversight occurred. The consultant pharmacist acknowledged that baseline and periodic blood work should have been recommended but was not identified during the monthly review. Facility policies required that consultant pharmacist findings be communicated to the DON or designee and that recommendations be acted upon and documented within 72 hours. Additionally, the facility's anticoagulation protocol specified that appropriate lab testing should be ordered to monitor anticoagulant therapy. These policies were not followed, resulting in missed medication clarifications and lack of necessary laboratory monitoring for residents receiving high-risk medications.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication error rate of 5.56% was identified during a medication pass, with two errors observed out of 36 opportunities involving two residents. For one resident with type 2 diabetes mellitus, a registered nurse administered glipizide 2.5 mg as ordered, but failed to ensure it was given 30 minutes prior to meals as specified in the physician's order. The medication was administered in the afternoon without confirmation of the timing in relation to meals. For another resident with a BIMS score indicating cognitive intactness and a diagnosis of low cortisol, a licensed vocational nurse administered hydrocortisone 5 mg without food, contrary to the physician's order to give the medication with food. The nurse assumed the resident had eaten a snack earlier, but the resident confirmed no food was consumed during the relevant time frame. The facility's policy requires medications to be administered according to physician orders, but this was not followed in these instances.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for two residents. In one instance, a bottle of oral liquid lorazepam, a controlled medication prescribed for anxiety, was found in the medication storage room without a legible expiration date. The medication had last been administered to the resident several months prior, and both nursing staff and the Director of Nursing acknowledged that the expiration date was unclear and should have been clarified with the pharmacy before use. Facility policy requires that each prescription medication label include an expiration date. In another instance, an unlabeled bottle of normal saline solution (NSS) was found unattended on a resident's bedside table. The resident, who was cognitively intact, reported that staff left the NSS for use in flushing a Foley catheter and for wound treatment. A nurse confirmed that the NSS should have been labeled and stored in the treatment cart, not left at the bedside. Facility policy states that any medications found at the bedside not authorized for bedside storage must be reported and given to the charge nurse.
Resident Room Overcapacity
Penalty
Summary
The facility failed to ensure that resident rooms accommodated no more than four residents, as required. During an observation, one room was found to have six beds and six residents, while another had five beds and five residents. Both rooms provided each resident with a bed, privacy curtain, nightstand, and closet, and there were no obstructions to closets, bathrooms, or exits. Interviews with residents, a CNA, and an LVN confirmed the presence of more than four residents in these rooms, though no concerns regarding care, privacy, or safety were identified by those interviewed.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
Multiple multi-resident rooms were found to be less than the required 80 square feet per resident, with specific rooms ranging from 64.68 to 78 square feet per resident. This was identified through observation, interviews with staff and residents, and record review. The facility administrator confirmed that the rooms listed did not meet the minimum space requirement. Despite the space deficiency, no care or privacy issues were observed, and both staff and residents reported that nursing care and services were not impacted. Closet and storage spaces were also found to be sufficient for residents' needs.
Failure to Complete and Document Abuse and Incident Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and provide clear outcomes for six residents involved in alleged abuse and physical altercations. Specifically, the 5-day investigation summaries for incidents involving alleged abuse by a CNA toward two residents, as well as physical altercations between two separate pairs of residents, did not indicate whether the facility determined if the alleged events occurred. The administrator acknowledged that the 5-day follow-up investigations were not completed according to the facility's abuse policy and procedure, and that he was unable to verify if the allegations were substantiated. Record reviews and interviews confirmed that the facility's investigation documentation lacked required findings and did not follow the established policy, which mandates thorough investigation, documentation, and reporting of all abuse allegations. The policy also requires that findings be reported to the appropriate authorities within five working days. The absence of documented outcomes for these incidents compromised the facility's ability to determine the circumstances surrounding the events.
Failure to Assist Resident with Insurance Coverage
Penalty
Summary
The facility failed to assist a resident with obtaining insurance coverage after their MediCal insurance was discontinued. The resident, who was admitted with diagnoses including heart failure, malnutrition, pressure ulcers, and sepsis, was removed from MediCal on July 31, 2024. The facility administrator confirmed that there was no discussion of private pay options with the resident and that the facility did not apply for MediCal on behalf of the resident. The social services staff indicated that the previous business office manager was responsible for completing the MediCal redetermination and would contact her to obtain necessary documents from the family. The facility's policy and procedure for admissions stated that admission staff should refer residents to the Social Service Director for Medicaid coverage and that the Medicaid application could be completed during the admission process.
Failure to Follow Physician's Order for Therapeutic Therapy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident when a Licensed Vocational Nurse (LVN) did not adhere to a physician's order regarding therapeutic therapy. The resident, who had a complex medical history including chronic obstructive pulmonary disease, neuralgia, neuritis, hypertensive heart, and chronic kidney disease with heart failure, was allowed to leave the facility to go to a 7-Eleven store. This action was not in line with the physician's order, which specified that the resident could go out on pass for therapeutic therapy. During an interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed that the resident signed the facility's Out on Therapeutic Pass/Leave of Absence Log to leave the premises. The MDSC stated that the resident became verbally and physically aggressive, prompting the decision to let her go out that night, and claimed to have notified the physician. However, there was no documentation in the progress notes to confirm that the physician was notified. The MDSC acknowledged that the resident's outing to the 7-Eleven store did not qualify as therapeutic therapy and was against the physician's order.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that Resident 1 was free from sexual abuse when Resident 1 and Resident 2 were left alone in the activity room, resulting in Resident 2 touching Resident 1's inner thigh. Resident 1, who has severe cognitive impairment with a BIMS score of 0, was admitted with diagnoses including vascular dementia and cognitive communication deficit. Resident 2, who also has dementia and a BIMS score of 5, was observed by Resident 3 with his hands inside Resident 1's pants. Resident 3 immediately called RN A, who confirmed the incident upon arrival at the activity room. Interviews with staff revealed that the activity room lacked supervision after 6 p.m. On the evening of the incident, CNA C, who was responsible for Resident 1, was on a delayed break and had asked other CNAs to watch her assigned residents. The facility's policy on abuse, dated 7/2025, mandates the prohibition of abuse, including sexual abuse, and requires staff to prevent such occurrences. However, the lack of supervision in the activity room after 6 p.m. contributed to the incident involving Resident 1 and Resident 2.
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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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