City View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 1359 Pine Street, San Francisco, California 94109
- CMS Provider Number
- 056203
- Inspections on file
- 30
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at City View Post Acute during CMS and state inspections, most recent first.
Multiple staff and residents reported ongoing cockroach infestations in several rooms, with live and dead cockroaches observed in resident areas and food storage locations. Some rooms with reported infestations were not included in pest control or deep cleaning schedules, despite the facility's policy and pest control agreement indicating a need for ongoing and facility-wide pest management.
A resident with multiple medical and mental health conditions reported a black pouch containing cash missing after returning from the hospital. The resident had previously shown a CNA $1,000 in the pouch, but the cash was not documented in the inventory or secured as required by facility policy. The loss of the cash caused the resident significant emotional distress, including sadness and distrust toward staff.
A resident with multiple medical and mental health diagnoses reported a missing black pouch containing cash after a hospital transfer. Despite a CNA confirming the presence of $1,000 in the pouch and returning it to the resident prior to its disappearance, the facility did not document the cash in the resident's inventory or take further action after the CNA's verification. The resident experienced emotional distress, and the facility's required procedures for safeguarding and inventorying valuables were not followed.
A resident with moderate cognitive impairment and diagnoses of hypertension and pulmonary embolism was allowed to self-administer Eliquis and Metoprolol without an assessment or care plan from the interdisciplinary team, contrary to facility policy requiring such evaluation and approval.
A resident was found with visibly dirty fingernails containing black matter underneath, and reported that staff had not cleaned her nails despite her requests. An LVN confirmed the nails were dirty and noted the infection risk, while the DON stated that CNAs are responsible for daily nail care. Facility policy requires daily cleaning and regular trimming of nails to prevent infection.
Two residents experienced ongoing issues due to the facility's failure to assess, monitor, and implement care plans for sleep disturbances and behavioral symptoms. One resident with cancer and diabetes was unable to sleep because of another resident's persistent yelling, with no effective interventions or care planning provided. Another resident with dementia and encephalopathy exhibited frequent yelling, paranoia, and insomnia, but these behaviors were not addressed through care planning or accurately documented in the MDS.
The facility failed to refer two residents for a Level II PASARR evaluation after they were diagnosed with new mental illnesses. One resident, admitted in 2016, was diagnosed with a psychotic disorder with delusions in 2021, but no referral was made. Another resident, admitted in 2019, received multiple mental illness diagnoses, including psychotic disorder with hallucinations, but was not referred for evaluation. The facility's policy lacked procedures for handling new mental illness diagnoses, and the DON stated that a new PASARR would only be conducted if the mental illness caused a significant change in the resident's condition.
A facility failed to complete a new Level I PASARR screening for a resident with schizophrenia, as required by policy. The resident was admitted with a history of schizophrenia and was on antipsychotic medication, necessitating a Level II evaluation. The California DHCS could not complete the evaluation due to the facility's unresponsiveness to communication attempts. The DON admitted the facility missed calls and did not follow instructions to redo the Level I PASARR, leading to the deficiency.
A resident with severe cognitive impairment was discharged with another resident's medications due to a failure in medication reconciliation. The LVN did not verify the contents of the medication bag against the discharge list, leading to the error being discovered when the resident's sister returned the incorrect medications to the facility.
A resident with chronic pain syndrome experienced a delay in receiving an MRI due to a breakdown in communication and failure to follow facility policy. The physician's order was not promptly acted upon, leading to a re-order and delayed diagnostic imaging.
A resident with COPD did not receive their prescribed Trelegy Ellipta inhaler on multiple occasions due to the medication being out of stock. The DON confirmed that the medication was not reordered in a timely manner, despite facility policy requiring advance ordering. This created a risk for poor health outcomes for the resident.
The facility failed to ensure effective communication and proper care planning for a resident, leading to missed doctor's appointments and inadequate family communication. The resident's son reported unreturned calls and texts, and the facility mismanaged transportation arrangements, impacting the resident's clinical condition and well-being.
A resident with severe cognitive impairment and multiple diagnoses experienced significant weight loss due to being placed on a Controlled Carbohydrate Diet (CCHO) despite not being diabetic. The facility staff failed to adequately monitor and address the resident's nutritional needs, leading to a decline in the resident's health and well-being.
A resident without a diabetes diagnosis received unnecessary insulin and blood glucose monitoring. The facility's failure to follow its medication administration policy and mismanagement of the resident's drug regimen potentially compromised the resident's well-being.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and staff and resident reports of cockroach infestations in several resident rooms. During an observation, live and dead cockroaches were found in a resident's room, including on the floor, trash bin, nightstand, and inside a nightstand drawer containing food items. Food particles and brownish discolorations were also noted on the floor. Staff, including CNAs and LVNs, acknowledged the ongoing presence of cockroaches throughout the facility, with one CNA stating that every room had roaches. Housekeeping staff confirmed that some rooms had been fumigated and cleaned, but sightings persisted, and not all affected rooms were included in the cleaning or fumigation schedule. A resident reported seeing multiple cockroaches in his room and stated that his room had not been fumigated or inspected by pest control after he raised the issue during a resident council meeting. Review of pest control service reports and facility cleaning schedules confirmed that certain rooms with reported infestations were not serviced or deep cleaned. The facility's pest control agreement indicated a primary concern of active cockroach infestation with facility-wide risk, but documentation showed that only a limited number of rooms were serviced per visit, and some affected rooms were omitted. The facility's policy required ongoing pest control, but the observed and reported conditions demonstrated a failure to implement an effective program.
Failure to Safeguard Resident's Personal Property and Document Valuables
Penalty
Summary
The facility failed to safeguard the personal property of a resident who reported a black pouch containing cash missing after being readmitted from the hospital. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, stated that the pouch with $2,000 was left in his room prior to hospitalization. The resident had previously shown a CNA $1,000 in the pouch, and the CNA confirmed witnessing this amount. However, the pouch and cash were not documented in the resident's inventory of personal effects as required by facility policy. Upon the resident's return, he reported the missing pouch and cash, expressing significant emotional distress, including sadness, tearfulness, and feelings of distrust toward staff. Multiple staff interviews and record reviews confirmed that the CNA had seen the pouch and cash but failed to update the inventory or ensure the valuables were secured in the facility's safe, as per policy. The resident continued to experience emotional distress related to the loss, requiring ongoing support from the social worker and referral to a psychologist. The facility's investigation did not find evidence of wrongdoing by staff, residents, or visitors, and the missing items were not recovered. The CNA involved received in-service training on the proper process for documenting resident property and the facility's procedures for safeguarding valuables. Despite these measures, the initial failure to document and secure the resident's cash resulted in its loss and ongoing emotional impact on the resident.
Failure to Investigate and Safeguard Resident's Missing Cash
Penalty
Summary
The facility failed to thoroughly investigate a resident's report of missing personal property, specifically a black pouch containing cash. The resident, who had diagnoses including acute respiratory failure, recurrent major depressive disorder, generalized anxiety disorder, and hoarding disorder, reported that the pouch with approximately $2,000 was missing following a transfer to the hospital. The resident had previously shown a Certified Nursing Assistant (CNA) $1,000 in the pouch, and the CNA confirmed seeing and returning the pouch to the resident in the weeks prior to its disappearance. However, the pouch and cash were not documented in the resident's inventory, and the facility did not take further action after the CNA verified the presence of the cash. The investigation conducted by the facility included interviews with staff and review of documentation, but no evidence or report of wrongdoing by staff, residents, or visitors was found. The interdisciplinary team determined that the allegation was unverified, and the missing items were not recovered. The CNA involved received training on the proper process for documenting resident property and the facility's policy for safeguarding valuables, but this was after the incident had occurred. Throughout the process, the resident experienced significant emotional distress, including tearfulness, sadness, and feelings of distrust toward staff. The resident continued to express sadness and depression related to the loss of the cash, and social services provided ongoing support and referred the resident to a psychologist. The facility's policies required inventorying resident belongings and safeguarding valuables, but these procedures were not followed in this case, contributing to the loss and the resident's emotional response.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
A resident with a history of hypertension and pulmonary embolism, and documented moderate cognitive impairment, was observed self-administering medications without the required assessment and approval from the interdisciplinary care planning team. The resident had an unlabeled transparent medicine cup containing two tablets, which she identified as Eliquis and Metoprolol, on her overbed table. She reported that a nurse had left the medications for her earlier so she could take them later. Review of the resident's clinical records by the Director of Nursing confirmed that there was no documented evaluation or care plan for self-administration of medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary team have determined the resident has the decision-making capacity to do so safely. This policy was not followed in this instance.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
A deficiency was identified when a resident's fingernails were observed to be unclean, with black-colored matter present under all fingernails. The resident reported that no one had come to clean her nails despite her repeated requests, expressing dissatisfaction with the condition of her nails. During the observation, an LVN confirmed the presence of dirt under the nails and acknowledged that this could be an infection issue, emphasizing the need to keep nails clean to prevent infection. The DON stated that CNAs are responsible for daily cleaning of residents' fingernails to prevent infection. Review of the facility's policy indicated that daily cleaning and regular trimming of nails are required to prevent infections and skin problems around the nail bed.
Failure to Address Sleep Disturbances and Behavioral Symptoms
Penalty
Summary
The facility failed to provide appropriate care and treatment for two residents with significant needs. One resident, admitted with diagnoses including squamous cell carcinoma and diabetes, reported ongoing difficulty sleeping due to another resident's persistent yelling and screaming at all hours. Despite repeated complaints to nursing, social work, and management, the only intervention provided was a headphone, which was ineffective. There was no assessment, monitoring, or care plan developed to address the resident's sleep difficulties, and the grievance was not documented or addressed according to facility policy. Another resident, diagnosed with dementia and encephalopathy, exhibited ongoing behavioral disturbances including yelling, screaming, paranoia, and insomnia. Staff interviews and record reviews confirmed that these behaviors were persistent and disruptive, occurring day and night, and were documented in multiple psychiatry notes. Despite this, there was no care plan or interventions implemented to address the resident's insomnia and paranoia, and the behaviors were not accurately reflected in the Minimum Data Set (MDS) assessments. The facility's interdisciplinary team did not evaluate or monitor these behavioral symptoms as required by policy. Facility policies reviewed indicated requirements for accommodating resident needs, providing a homelike environment, addressing grievances, and developing comprehensive, person-centered care plans based on thorough assessments. However, these policies were not followed in the cases of the two residents, resulting in unaddressed sleep disturbances for one and unmanaged behavioral symptoms for the other. The lack of assessment, care planning, and intervention contributed to ongoing issues for both residents.
Failure to Refer Residents for Level II PASARR Evaluation
Penalty
Summary
The facility failed to refer two residents to the appropriate state-designated authority for a Level II PASARR evaluation after they were diagnosed with newly evident mental illnesses. Resident #56, admitted in 2016, was diagnosed with a psychotic disorder with delusions in 2021, but there was no evidence of a referral for a Level II PASARR. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the care plan included the diagnosis of psychotic disorder. Similarly, Resident #86, admitted in 2019, received multiple mental illness diagnoses, including psychotic disorder with hallucinations, psychosis, and adjustment disorder with anxiety, but was not referred for a Level II PASARR. The resident's MDS showed severe cognitive impairment, and the care plan noted the use of psychotropic medication for the psychotic disorder. The facility's policy on admissions criteria did not specify procedures for staff to follow when a resident is diagnosed with a new or possible serious mental disability. During interviews, the Director of Nursing (DON) stated that a new Level I PASARR would be conducted if a resident received a new mental illness diagnosis. However, the DON indicated that a new PASARR would only be done if the severe mental illness caused a significant change in the resident's condition, which was not the case for Residents #56 and #86. This lack of referral for a Level II PASARR evaluation represents a deficiency in the facility's compliance with regulatory requirements for preadmission screening and resident review.
Failure to Complete PASARR Screening for Resident with Schizophrenia
Penalty
Summary
The facility failed to complete a new Level I PASARR screening for a resident with a diagnosis of schizophrenia, as required by the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The facility's policy mandates that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders. If the Level I screening suggests the presence of such conditions, a referral for a Level II evaluation is necessary. The resident in question was admitted with a medical history of schizophrenia and was receiving haloperidol, an antipsychotic medication, indicating the need for a Level II evaluation. The California Department of Health Care Services (DHCS) attempted to conduct a Level II evaluation but was unable to complete it due to the facility's lack of response to multiple communication attempts. A letter from DHCS indicated that the facility staff did not respond to two or more separate attempts within 48 hours following the resident's Level I screening. The Director of Nursing acknowledged that the facility missed the calls and failed to follow the instructions in the letter to redo the Level I PASARR, resulting in the deficiency.
Medication Reconciliation Error at Discharge
Penalty
Summary
The facility failed to accurately reconcile post-discharge medications for a resident, leading to the resident being discharged with another resident's medications. This incident involved a resident with a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The discharge summary note indicated that the resident was discharged with a Post-Discharge Plan of Care form filled out and signed by the patient, with all medications and follow-up appointments reviewed. However, the Licensed Vocational Nurse (LVN) responsible for the discharge did not open the bag of medications to verify its contents against the discharge medication list. The error was discovered when the resident's sister returned to the facility with a bag of medications labeled for a different resident. The Nurse Manager confirmed that the returned medications were intended for another resident, as evidenced by the labels on the blister packs. The Director of Nursing stated that the expectation was for nursing staff to verify the medications against the discharge list before discharge, which was not done in this case.
Failure to Timely Execute Physician's Order for MRI
Penalty
Summary
The facility failed to provide necessary care and services to a resident when a physician's order for an MRI was not carried out in a timely manner. The resident, who suffers from chronic pain syndrome, expressed severe pain and a desire to understand the cause of their condition, including concerns about potential cancer. Despite the physician ordering an MRI on 3/25/24, the order was not acted upon promptly. The night nurse saw the order on 3/26/24 but did not inform the social worker responsible for outpatient referrals. This oversight led to the MRI not being scheduled, and the physician had to re-order it on 4/17/24. Interviews with the resident, LVN, SW, and DON revealed that the breakdown in communication and failure to follow the facility's policy on medication and treatment orders contributed to the delay. The DON confirmed that the physician's order should have been communicated to the appropriate staff and carried out as soon as possible. The facility's policy requires licensed nurses to record and act on physician orders immediately, but this protocol was not followed, resulting in a delay in the resident receiving the necessary diagnostic imaging.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to ensure that prescribed medication was available for administration to a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who relies on a Trelegy Ellipta inhaler to manage their condition, reported experiencing chronic shortness of breath. A review of the resident's Medication Administration Record (MAR) revealed that the inhaler was not administered on multiple occasions in February 2024 due to the medication being out of stock. The Director of Nursing (DON) confirmed that the medication was not given because it had not been reordered in a timely manner by the licensed nurses, despite the facility's policy requiring medications to be ordered in advance based on the pharmacy's lead time. During an interview, the DON acknowledged that the failure to have the Trelegy Ellipta inhaler available could worsen the resident's respiratory symptoms and emphasized the importance of communication with the doctor. The resident's progress notes indicated that the medication was out of order on several dates, and although it was reordered, it was not available for administration. This lapse in medication management created a risk for poor health outcomes for the resident.
Communication and Transportation Failures
Penalty
Summary
The facility failed to ensure effective communication and proper care planning for Resident-A, leading to significant deficiencies. Resident-A's son reported that the social worker did not return his calls or texts on five different occasions, which hindered communication about his father's care. Additionally, the facility mismanaged transportation arrangements, resulting in the cancellation of Resident-A's doctor's appointments on two separate dates. This lack of coordination and communication potentially impacted Resident-A's clinical condition and psychosocial well-being. Resident-A was admitted with multiple diagnoses, including cerebral infarction, enterocolitis due to clostridium difficile, urinary tract infection, type 2 diabetes, and frequent falls. His cognitive skills were moderately impaired, as indicated by a BIMS score of 9. Despite these complex medical needs, the facility failed to ensure that Resident-A's appointments were kept and that his family was adequately informed about his care. The social worker's failure to return calls and the facility's disorganized transportation scheduling contributed to these deficiencies. Interviews with facility staff, including the social worker and the director of nursing, revealed a lack of accountability and documentation regarding the missed appointments and communication failures. The transportation company also indicated that they were not solely responsible for the missed appointments, as the facility used multiple transportation providers and often made last-minute requests. The facility's policies on transportation and resident rights were not effectively implemented, leading to the observed deficiencies in Resident-A's care and communication with his family.
Failure to Meet Nutritional Needs of Non-Diabetic Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who was not diabetic but was placed on a Controlled Carbohydrate Diet (CCHO) since admission. This resident, who had severe cognitive impairment and multiple diagnoses including burns, hyperkalemia, and dysphagia, experienced a significant weight loss of almost 10 lbs. from September 24, 2023, to November 17, 2023. The resident's clinical record did not indicate diabetes mellitus as a diagnosis, and the CCHO diet order was carried over from the hospital without proper verification by the facility staff. The resident's poor appetite and significant weight loss were not adequately addressed by the facility's dietary and medical staff, leading to a decline in the resident's clinical health and well-being. Interviews with various staff members, including the unit managers, social worker, dietary manager, and registered dietitian, revealed a lack of awareness and coordination regarding the resident's dietary needs and weight loss. The dietary manager and registered dietitian were new to the facility and were not fully informed about the resident's condition and dietary requirements. The registered dietitian noted that the resident had a poor appetite and was on a puree texture diet with Boost supplements three times a day, but the resident's meal intake was only about 51%. The resident's daughter also confirmed that her mother was placed on a diabetic diet despite not being diabetic and that her mother's weight and appetite improved after being discharged and cared for at home. The facility's policies on weight assessment and intervention were not effectively implemented, as evidenced by the lack of timely and appropriate actions to address the resident's significant weight loss. The care plan for the resident included multiple focus areas such as nutritional risk, nausea and vomiting, dehydration, and weight loss, but the interventions were not adequately followed. The facility's failure to monitor and address the resident's nutritional needs and weight loss in a timely manner resulted in a decline in the resident's health and well-being.
Unnecessary Drug Administration and Mismanagement of Resident's Drug Regimen
Penalty
Summary
The facility failed to ensure that a resident, who had no diagnosis of diabetes mellitus, was free from unnecessary drugs and interventions. The resident was admitted with diagnoses including burns, hyperkalemia, and dysphagia, but not diabetes. Despite this, the resident had an order for a sliding scale of insulin Lispro and received it multiple times. Additionally, the resident's blood glucose was checked three times a day over a period of nearly a month, with levels ranging from 112 to 188. The resident was also placed on a Controlled Carbohydrate diet, which was later discontinued by a new registered dietitian who noted the resident's poor appetite and weight loss. The resident's daughter confirmed that her mother was not diabetic and questioned the blood sugar checks and diabetic diet. The facility's medical doctor acknowledged that the resident's hemoglobin A1C was 6, which is considered pre-diabetic according to the American Diabetes Association, and not diabetic. The MD stated that the sliding scale insulin was discontinued because the resident was well-controlled, but it was unclear who had initially ordered it. The facility's policy on administering medications emphasizes that medications should be administered as prescribed and that any concerns about inappropriate or excessive dosages should be discussed with the prescriber. However, this policy was not followed in the case of this resident. The facility's failure to adhere to its own medication administration policy and the mismanagement of the resident's drug regimen potentially compromised the resident's mental, physical, and psychosocial well-being. The care plan for the resident included a diagnosis of diabetes, which was incorrect according to the resident's daughter and the medical records. This misdiagnosis led to unnecessary interventions, including insulin administration and blood glucose monitoring, which were not clinically indicated for the resident's actual medical condition.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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