Clara Baldwin Stocker Home For Women
Inspection history, citations, penalties and survey trends for this long-term care facility in West Covina, California.
- Location
- 527 S Valinda Avenue, West Covina, California 91790
- CMS Provider Number
- 555832
- Inspections on file
- 42
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Clara Baldwin Stocker Home For Women during CMS and state inspections, most recent first.
A resident requiring moderate assistance with daily activities was discharged to an assisted living facility without being offered choices or adequate time to consider alternatives. The family was not provided with a list of options, and the only facility presented was identified shortly before discharge, contrary to facility policy and the resident's need for family support.
A resident with severe cognitive impairment and multiple health conditions was observed with new discoloration and redness on the arm after reporting that a CNA had grabbed them during a transfer, causing pain. Two LVNs noted the resident's distress and reported the incident to the DON, who recognized it as a possible abuse case. Despite facility policy requiring abuse allegations to be reported to the State Agency within two hours, the report was delayed by two days.
The facility did not follow its policy for N95 fit testing, failing to test a newly hired CNA, which is required upon hire and annually. This oversight was acknowledged by the DSD and highlighted by the IPN as crucial for preventing airborne disease transmission.
Two residents with severe cognitive impairment had their call lights out of reach, leading to delayed assistance. One resident's call light was tucked under the mattress, while another's was hooked around a dresser. A CNA and the DON confirmed the importance of accessible call lights for safety and communication, as per facility policy.
The facility failed to adhere to physician orders and document care for three residents. A resident with seizures did not have padded side rails as ordered, hospice staff did not consistently document visits for another resident, and a STAT chest x-ray was delayed for a third resident. These deficiencies highlight lapses in following care plans and ensuring timely medical interventions.
The facility failed to prevent employee beverages from being stored in a kitchen refrigerator alongside resident food items, as observed during an inspection. The Dietary Supervisor confirmed that the beverages belonged to employees and acknowledged the risk of cross contamination. This practice was against the facility's policy, which prohibits storing employee food in the kitchen refrigerator.
The facility failed to maintain its infection prevention and control program, with unlabeled urinals in shared restrooms, a lack of disinfection of a pill counting tray by an LVN, insufficient hand hygiene supplies in the laundry area, and a Housekeeping Supervisor not performing hand hygiene after touching the dumpster. These deficiencies could lead to cross-contamination and increased infection risk among residents and staff.
A facility failed to conduct a comprehensive communication assessment for a resident who primarily spoke Arabic, as required by policy. The resident, with multiple medical conditions, needed an interpreter to communicate effectively. Staff attempted to communicate using non-verbal cues without any tools, which was inadequate. A nurse confirmed the necessity of a communication assessment to provide proper care.
A facility failed to implement a person-centered care plan for a resident who only spoke Arabic, despite the resident's need for an interpreter being documented. The resident, with conditions including hemiplegia and dysphagia, was observed attempting to communicate with staff who did not use any communication tools. The absence of a communication care plan was confirmed by a Registered Nurse, highlighting a deficiency in meeting the facility's policy for effective and person-centered care.
A resident who spoke Arabic was not provided with communication tools, hindering effective communication of care needs. Despite the facility's policies on language access, staff relied on gestures and limited English, failing to use appropriate resources to assist the resident, who had multiple medical conditions requiring clear communication.
A resident receiving hemodialysis did not have an emergency kit at their bedside, which is crucial for addressing potential bleeding emergencies. The resident, with end-stage renal disease and type 2 diabetes, required dialysis thrice weekly. An LVN could not find the kit during an inspection, and the DON confirmed the facility's policy did not explicitly require it, despite its necessity for immediate response.
A resident with an indwelling foley catheter was observed with dark amber urine containing sediments, indicating a potential infection. Despite daily catheter care, the abnormal urine appearance was not reported to the physician, contrary to the facility's policy. The resident had a history of Alzheimer's, psychosis, and hypertension, and the catheter was ordered due to uropathy.
A facility failed to provide an emergency kit at the bedside of a resident requiring hemodialysis, potentially delaying emergency treatment. The resident, with end-stage renal disease and diabetes, needed dialysis thrice weekly. An LVN could not find the kit, which is crucial for addressing bleeding from the dialysis site. The DON confirmed the policy did not specify the need for a bedside kit, leading to the deficiency.
A facility failed to justify the use of fluoxetine for a resident with dementia and mild depression, lacking documentation for a gradual dose reduction (GDR) and non-pharmacological interventions. Staff interviews indicated the resident did not show depressive symptoms, and the prescriber did not document why GDR was contraindicated, contrary to facility policy.
The facility failed to properly label and discard medications in Med Cart 2, including a bottle of Geri Care Stool Softener and a box of Alka-Seltzer, which were not marked with an opened date. Staff interviews revealed inconsistencies in following the facility's protocol, which required labeling to ensure medications were not used past the recommended due date. The facility's policy required proper labeling in accordance with guidelines, indicating a lapse in adherence.
The facility failed to secure its premises, leaving the back door unlocked after dark and allowing unauthorized access. Observations showed the staff parking area gate was open, and several LVNs were unaware of how to lock the facility doors. The DON acknowledged the broken gate chain and emphasized the importance of locking doors for safety. Despite policies on safety, staff lacked training on securing the facility, putting 37 residents at risk.
The facility failed to provide adequate isolation supplies for two residents with C. diff infection, as they did not have their own package of incontinent wipes during the night shift. Staff interviews revealed a lack of sufficient wipes and uncertainty about obtaining more supplies, contrary to the facility's policy requiring dedicated equipment for isolated residents.
A resident with severe cognitive impairment was not readmitted to the first available bed at the facility after hospitalization, violating the facility's policy. Staff interviews confirmed the refusal was against policy, and the Administrator later acknowledged the error.
Failure to Ensure Resident Discharge Location Met Needs and Preferences
Penalty
Summary
The facility failed to ensure that a resident's discharge location met the resident's needs for family support and resources. The resident, who had a history of pneumonia and falls, required partial to moderate assistance with activities of daily living and mobility, as documented in the Minimum Data Set and Physical Therapy Discharge Summary. Despite these needs, the discharge planning process did not provide the resident or their family member with choices regarding potential discharge locations. The family member reported that no options were offered and that the only assisted living facility (ALF) presented was provided on the day of discharge, leaving insufficient time to evaluate alternatives or appeal the decision due to external circumstances. Interviews with facility staff, including the case manager, social services director, and director of nursing, confirmed that the resident and family were not given a list of ALFs to consider and that there was no documentation of other options being discussed. The case manager indicated that the ALF was found within 48 hours before discharge, and the family was informed that if they did not agree to the transfer, they would need to pay for additional days until a safe placement was found. The facility's policy required assisting residents in selecting a post-acute care provider relevant to their goals and preferences, but this was not followed in this case.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy by not reporting an allegation of staff-to-resident physical abuse to the State Agency within the required two-hour timeframe. A resident with severely impaired cognitive skills and multiple medical diagnoses, including hypertensive heart disease with heart failure and rheumatoid arthritis, was observed by two LVNs to have discoloration and redness on the right forearm. The resident indicated that a CNA had grabbed their arm during a transfer, causing pain and visible marks. Both LVNs noted the resident appeared upset and frustrated, and one LVN confirmed the discoloration was not present earlier that same morning. The incident was reported by the LVN to the DON on the same day it occurred, and the DON acknowledged that the situation constituted a possible case of physical abuse, which should have been reported to the State Agency within two hours according to facility policy. However, the allegation was not reported until two days later. The facility's policy, reviewed by surveyors, clearly states that all allegations of abuse must be reported within the federal requirement timeframe, which was not adhered to in this case.
Failure to Conduct N95 Fit Testing for New Staff
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding N95 fit testing, as outlined in their document titled 'N95 Fit Testing.' This policy mandates that all employees must be fit tested for an N95 respirator upon hire and annually, in accordance with OSHA's Respiratory Protection Standard. However, one of the four sampled staff members, a Certified Nurse Assistant (CNA 4), was not fit tested upon hire. CNA 4 began working at the facility on February 3, 2025, and confirmed during an interview on February 25, 2025, that they had not been fit tested for the N95 mask. The Director of Staff Development (DSD) acknowledged during a concurrent interview and record review that CNA 4 should have been fit tested before starting work, as per the facility's policy. The Director of Nursing (DON) reiterated the requirement for fit testing upon hire and annually. The Infection Prevention Nurse (IPN) emphasized the importance of fit testing to prevent the transmission of airborne diseases between employees and residents. The failure to conduct the fit testing had the potential to result in the spread of COVID-19 and other airborne diseases within the facility.
Plan Of Correction
F 880 It is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicated disease and infections. Corrective Action for Resident found to have been affected by this deficiency: No Resident was identified to have been affected by this deficiency. Identification of Other Residents having the potential to be affected by the same deficient practice and corrective action that will be taken: All Residents have the potential to be affected by this deficiency. On 2/25/2025, the IP Nurse designee completed N95 Fit Testing for CNA 4. What measures will be put into place to ensure that the deficient practice does not recur: On March 14, 2025, the DON inserviced the IP LVN Designee on the facility's policy and procedure on N95 Fit Testing; including that all new hire employees must have N95 Fit Testing upon hire and before being assigned to work with any Resident(s) and annually thereafter. On February 25, 26, and 27, 2025, the IP LVN Designee completed an N95 Fit Testing Audit on all current Employees. There were no additional employees identified as not having been N95 Fit Tested upon hire. There were 15 current employees identified as not being current with annual N95 Fit Testing. On February 28, 2025, the IP LVN Designee completed N95 Fit Testing on the identified 15 employees. On March 14, 2025, the DON gave a 1:1 inservice to the IP LVN Designee on the facility's policy and procedures on N95 Fit Testing; including that all new hires must have N95 Fit Testing upon hire and before being assigned to any Resident(s), and annually thereafter. Measures that will be implemented to ensure that solutions are sustained: The IP LVN Designee will conduct monthly audits X 3 months on all new hire employees and all employees due for the prior months' annual N95 Fit Testing to ensure that all current employees are compliant with the facility's policy and procedures on N95 Fit Testing. Results of the monthly audits will be documented on the Quality Improvement Audit Tool. The documented results will be forwarded to the QA & A Committee monthly X 3 months for review and action planning as indicated or until the QA & A Committee determines compliance.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of two residents by not ensuring that their call lights were within reach. Resident 21, who was admitted with diagnoses including anxiety disorder and failure to thrive, had severe cognitive impairment and required substantial assistance with activities of daily living. During an observation, it was noted that Resident 21's call light was tucked below the bed mattress, making it inaccessible. The resident expressed being wet and unable to call for assistance, highlighting the deficiency in care. Similarly, Resident 25, who had severe cognitive impairment and was dependent on assistance for daily activities, also had an inaccessible call light. The call light was found hooked around a small dresser drawer, out of the resident's reach. Interviews with a CNA and the DON confirmed the importance of call lights for resident safety and communication, emphasizing that they should always be within reach. The facility's policy on call lights, which mandates their accessibility, was not adhered to, resulting in delayed service provision and potential negative impacts on the residents' well-being.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and professional standards for three residents. Resident 15, who had a history of seizures, was not provided with bilateral padded side rails as ordered by the physician to prevent injury during seizure episodes. Despite the care plan and physician orders indicating the need for padded side rails, observations confirmed their absence, and staff interviews highlighted the importance of adhering to such orders for resident safety. Resident 23, who was receiving hospice care, did not have consistent documentation of hospice staff visits as required. The hospice staff were supposed to sign in during each visit, but the sign-in sheets did not reflect the frequency of visits as per the staff assignment. Interviews with facility staff emphasized the necessity of proper documentation to ensure coordinated care and communication between hospice and facility staff, which is crucial for providing end-of-life care. Resident 38, who had severe cognitive impairment and multiple health issues, did not receive a STAT chest x-ray as ordered by the physician. The x-ray was intended to address respiratory concerns, but due to delays with the diagnostic imaging company, the x-ray was not performed in a timely manner. The Director of Nursing acknowledged the issue and stressed the importance of following STAT orders promptly to allow for immediate medical interventions if necessary.
Improper Storage of Employee Beverages in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure that personal beverages for employees were not stored in one of the kitchen refrigerators, specifically Refrigerator 1. During an observation and interview with the Dietary Supervisor, two Starbucks beverages with plastic open tops were found in the refrigerator next to resident food items. The Dietary Supervisor acknowledged that the beverages belonged to employees and should not have been stored in the refrigerator due to the potential for cross contamination. A review of the facility's policy and procedure titled 'Employee Meals,' dated 2018, indicated that food brought by employees from outside the facility should not be kept in the facility's refrigerator in the kitchen.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during the survey. In shared restrooms used by residents, urinals were found unlabeled, which could lead to cross-contamination. Certified Nurse Assistant (CNA) 3 and the Infection Preventionist Nurse (IPN) confirmed that urinals should be labeled with the resident's initials and room number to prevent the spread of infectious diseases. This oversight was noted in restrooms shared by residents with severe cognitive impairments and those requiring assistance with activities of daily living. Additionally, a Licensed Vocational Nurse (LVN) did not disinfect the pill counting tray before and after use, which is a critical step in infection control. The LVN acknowledged the failure to clean the tray, which could result in drug residue and potential cross-contamination. The Infection Preventionist Nurse emphasized the importance of disinfecting the tray to prevent drug interactions and allergies. The facility also lacked sufficient hand hygiene supplies in the laundry area, which did not have a sink, soap, paper towels, or alcohol-based hand sanitizer. The Housekeeping Supervisor (HS) failed to perform hand hygiene after touching the dumpster, acknowledging the need for at least an alcohol-based hand sanitizer in the area. The facility's policy on hand hygiene stresses the importance of readily accessible supplies to prevent the spread of infections, highlighting the deficiency in the laundry area.
Failure to Conduct Communication Assessment for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a comprehensive communication assessment for a resident who primarily spoke Arabic, as required by the facility's policy and procedure. The resident was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss. The Minimum Data Set (MDS) indicated that the resident needed or wanted an interpreter to communicate with healthcare staff due to Arabic being the resident's preferred language. However, the resident was not assessed regarding their ability and preferred way of communication upon admission, which was a requirement according to the facility's policy. Observations and interviews revealed that staff members, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), attempted to communicate with the resident without using any communication tools, despite acknowledging the resident's language barrier. The staff relied on non-verbal cues such as facial expressions and pointing, which was inadequate for understanding the resident's needs. A Registered Nurse (IPN) confirmed that a communication assessment should have been conducted to address the resident's preferred language, emphasizing the importance of such an assessment for providing proper care.
Failure to Implement Person-Centered Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop or implement an individualized person-centered care plan for a resident who only spoke and understood Arabic. This deficiency was identified during a review of the resident's admission record, which indicated the resident was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss. The Minimum Data Set (MDS) assessment noted that the resident needed or wanted an interpreter to communicate with healthcare staff due to Arabic being the preferred language. Despite this, the facility did not have a communication care plan in place for the resident, which was confirmed during an interview with the Registered Nurse (IPN) who reviewed the resident's charts and acknowledged the absence of such a plan. Observations and interviews with facility staff further highlighted the communication barriers faced by the resident. A Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) both attempted to communicate with the resident without using any communication tools, relying instead on gestures and facial expressions. The LVN acknowledged the importance of providing a form of communication to understand the resident's needs and wants. The facility's policy on baseline care plans, which was revised in 2016, requires the inclusion of instructions needed to provide effective and person-centered care, yet this was not adhered to in the case of the resident in question.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool or resources for a resident who spoke Arabic, which hindered effective communication of the resident's needs. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss, was noted to require an interpreter to communicate with healthcare staff. Despite this, the facility did not provide any communication aids, and staff attempted to communicate using non-verbal cues such as facial expressions and pointing, which were inadequate for the resident's needs. Observations and interviews revealed that staff, including a CNA and an LVN, did not utilize any communication tools when interacting with the resident, relying instead on gestures and limited English. The facility's policies on language access and interpreter services were not followed, as staff did not provide the necessary resources to ensure meaningful communication. This deficiency had the potential to impact the resident's ability to convey care needs effectively, as highlighted by the staff's acknowledgment of the importance of communication in determining the resident's needs.
Failure to Provide Emergency Kit for Hemodialysis Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had an emergency kit available at their bedside, which is necessary for immediate response in case of bleeding from the dialysis site. The resident, who was admitted with end-stage renal disease and type 2 diabetes mellitus, required hemodialysis three times a week. During an observation and interview, a Licensed Vocational Nurse (LVN) was unable to locate the emergency kit in the resident's room, acknowledging that it should have been present to quickly address any potential bleeding emergencies. The Director of Nursing (DON) confirmed that the facility's policy on Hemodialysis Access Care did not specifically mention the need for an emergency kit at the bedside, but emphasized its importance due to the resident's condition. The policy outlined the steps to take in case of major bleeding, including applying pressure to the site and contacting emergency services, but did not explicitly require the presence of an emergency kit. This oversight had the potential to delay critical treatment for the resident during an emergency.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling foley catheter, which was observed to have dark amber urine with sediments. This observation was made during an interview with an LVN, who acknowledged that the presence of sediments could harm the resident and indicated a potential infection. The LVN stated that the resident's physician should have been informed to determine the cause of the abnormal urine appearance. The resident, who was admitted with diagnoses including Alzheimer's Disease, psychosis, and hypertension, had a physician's order for an indwelling foley catheter due to uropathy, with instructions to change the catheter or bag as needed. Further interviews with a Registered Nurse revealed that catheter care was performed daily, and the presence of sediments was a sign of infection. The resident's care plan aimed to prevent urinary infections and included monitoring and reporting symptoms such as pain, burning, blood-tinged urine, and cloudiness to the physician. However, the facility's policy on catheter care, which was intended to prevent catheter-associated urinary tract infections, was not adequately followed, as the abnormal urine appearance was not reported to the physician or supervisor immediately.
Failure to Provide Emergency Kit for Dialysis Resident
Penalty
Summary
The facility failed to provide an emergency kit at the bedside of a resident who required hemodialysis, which could potentially delay treatment during an emergency. The resident, who was admitted with end-stage renal disease and type 2 diabetes mellitus, required hemodialysis three times a week. During an observation, a Licensed Vocational Nurse (LVN) was unable to locate the emergency kit in the resident's room, which is necessary to quickly address any bleeding from the dialysis site. The Director of Nursing (DON) confirmed that the facility's policy did not specifically mention the need for an emergency kit at the bedside, but acknowledged its importance in case of major bleeding post-dialysis. The policy outlined the steps to take in the event of major bleeding, including applying pressure to the site and contacting emergency services, but did not explicitly require an emergency kit to be readily available. This oversight in policy and practice led to the deficiency noted by the surveyors.
Lack of Clinical Justification for Fluoxetine Use in Resident
Penalty
Summary
The facility failed to ensure that a resident's use of fluoxetine, a medication for depression, was clinically justified and that a gradual dose reduction (GDR) was not contraindicated. The resident, who was diagnosed with dementia and mild, recurrent major depressive disorder, was receiving fluoxetine without clear documentation of the necessity for its continued use or evidence of non-pharmacological interventions prior to its initiation. The resident's care plan indicated interventions for resistance to care due to dementia, but there was no documentation of depressive symptoms or behaviors that would justify the use of fluoxetine. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that the resident did not exhibit signs of depression, such as sadness or crying, and often complied with care after initial refusal. The consultant pharmacist recommended a GDR, but the prescriber did not provide documentation to justify why a reduction was contraindicated. The facility's policy required determining the cause of behaviors before using psychotropic medications, but this was not documented in the resident's case.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure that all drugs and medications used were labeled properly and discarded according to professional standards. During an observation, it was found that Med Cart 2 contained multiple opened house supply medications, including a bottle of Geri Care Stool Softener and a box of Alka-Seltzer Buffered aspirin, which were not marked with an opened date. This was contrary to the facility's protocol, which required labeling with an opened date to ensure medications were not used past the recommended due date, typically ninety days from opening. Interviews with staff revealed inconsistencies in the application of the facility's protocol. LVN 2 indicated that staff followed the manufacturer's expiration date rather than labeling with an opened date, while the Director of Nursing emphasized the importance of labeling to ensure medication effectiveness. LVN 6 acknowledged that the opened pouch of Alka-Seltzer should have been discarded for infection control. The facility's policy, revised in April 2019, required all medications to be properly labeled in accordance with state and federal guidelines, highlighting a lapse in adherence to these standards.
Facility Security Lapses Lead to Safety Risks
Penalty
Summary
The facility failed to ensure that unauthorized individuals did not enter the premises undetected, as the back door remained unlocked after dark. Observations revealed that the gate to the staff parking area was wide open, providing easy access to the facility's back door, which was also unlocked. Interviews with several Licensed Vocational Nurses (LVNs) indicated that they were unaware of how to lock the facility doors, and the back door had been left unlocked consistently during the night shifts for weeks. The Director of Nursing (DON) acknowledged that the chain to the gate of the staff parking area had broken, and the gate was supposed to be locked with a passcode. However, the DON was unaware of the exact date when the chain broke. The DON emphasized the importance of locking the facility doors for the safety of the property, residents, and employees. Despite this, the LVNs and Certified Nursing Assistants (CNAs) interviewed did not know how to lock the facility doors, and some were not shown how to do so when they started working at the facility. The facility's policy and procedure on safety and supervision of residents highlighted the importance of making the environment free from accident hazards and ensuring resident safety through employee training and monitoring. However, the lack of knowledge among staff about locking the facility doors and the broken gate chain indicated a failure to adhere to these policies. The facility's failure to secure the premises placed all 37 residents at risk for accident hazards and harm.
Failure to Provide Adequate Isolation Supplies for C. diff Patients
Penalty
Summary
The facility failed to implement its policy and procedure for isolation and transmission-based precautions, specifically for two residents diagnosed with Clostridium difficile (C. diff) infection. Both residents were placed on contact isolation, but during the night shift, they did not have their own package of incontinent wipes in their isolation rooms. This oversight was identified during interviews with staff, including CNAs and LVNs, who reported a lack of sufficient wipes for the entire shift and uncertainty about how to obtain more supplies during the night shift. The facility's policy required that non-critical resident-care equipment be dedicated to a single resident when possible, which was not adhered to in this case. Interviews revealed that the housekeeper typically provided one package of wipes per shift and placed one package in each isolation room in the morning. However, during the night shift, there was no clear process for obtaining additional wipes, leading to a potential risk of infection spread. The Director of Nursing and the Infection Prevention Nurse confirmed the necessity of having dedicated wipes in isolation rooms to prevent cross-contamination.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident to the first available bed after hospitalization, as required by their policy. The resident, who had severe cognitive impairment and was initially admitted with diagnoses including Parkinson's Disease and hyperlipidemia, was transferred to a General Acute Care Hospital (GACH) due to refusal of all oral intake. Upon being ready for discharge from the GACH, the facility's case manager refused to accept the resident back, citing the absence of a bed hold, despite the facility's policy allowing for readmission to the first available bed. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and Director of Staff Development (DSD), confirmed that the refusal to readmit the resident was against the facility's policy. The DON and DSD both stated that the facility should not refuse readmission unless the resident's condition is severe and imminently dangerous or if the resident poses a threat to themselves or others. The Administrator acknowledged the error and instructed the case manager to accept the resident back, but the initial refusal constituted a violation of the resident's rights to resume residency at the facility.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
