Claremont Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pomona, California.
- Location
- 219 E. Foothill Blvd, Pomona, California 91767
- CMS Provider Number
- 055394
- Inspections on file
- 40
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Claremont Care Center during CMS and state inspections, most recent first.
Nursing staff failed to assess and document blood pressure immediately before administering antihypertensive medications to two residents, despite physician orders and facility policy requiring this step. In one case, a resident received blood pressure medications without a current BP check, and in another, a resident was given isosorbide mononitrate even though their systolic BP was below the hold parameter. Staff interviews confirmed that previous BP readings were sometimes used instead of obtaining a current measurement, leading to improper medication administration.
A resident with a history of heart failure, COPD, and diabetes, who was cognitively intact and required moderate ADL assistance, disclosed a past sexual assault to the ADM following recent abuse allegations involving a CNA. The facility created a care plan for emotional distress related to the new allegations but did not promptly develop a trauma-informed care plan addressing the resident's prior trauma, as required by policy. Staff confirmed the delay in care planning, resulting in unmet individualized needs.
A resident with a history of right femur fracture, dementia, and impaired mobility did not receive appropriate pain assessment and management when reporting persistent pain. Nursing staff failed to document the pain location and did not administer or record pain medication as required by the care plan and facility policy, resulting in incomplete pain management and documentation.
A facility failed to maintain accurate and complete medical records for a resident by not properly documenting pain location in therapy and nursing notes, and by omitting the rationale for a room transfer. Physical therapists and an LVN did not accurately record the site of pain, and the MAR lacked this information during pain medication administration. Additionally, the reason for a room change was not documented, despite facility policy requiring such documentation.
A resident with a history of falls, cognitive impairment, and significant mobility limitations had multiple episodes of attempting to get up unassisted from a wheelchair. Despite these incidents, the care plan was not updated to include new interventions or increased monitoring, contrary to facility policy and regulatory requirements. Staff interviews confirmed the care plan remained unchanged after the events.
The facility failed to maintain a clean and homelike environment for several residents, with issues such as peeling paint, cracked drywall, and raised floor tiles observed in their rooms and bathrooms. Interviews revealed a lack of effective reporting and maintenance, with no entries in the maintenance logs for necessary repairs, despite the facility's policy for monthly environmental rounds.
A resident with type 2 diabetes did not receive insulin as scheduled, with doses often administered hours late or early. Staff interviews revealed that insulin should be given within an hour of the scheduled time, but the MAR showed significant deviations. The facility's policy stresses timely administration according to physician orders.
The facility failed to handle and store milk properly, leading to expired milk being found in the kitchen and served to residents. The DSS acknowledged the expired milk and disposed of it, but was unsure how it reached the residents. The facility's policy requires proper labeling and daily inspections, which were not followed.
The facility failed to adhere to its infection prevention and control program for two residents, leading to potential infection risks. A CNA entered a resident's room under contact isolation for MRSA without a gown, and housekeeping staff cleaned another resident's room under enhanced barrier precautions without a gown. Both instances violated the facility's PPE protocols, increasing the risk of infection transmission.
A facility failed to accurately document a resident's discharge status on the MDS. The resident, diagnosed with dementia and emphysema, was discharged against medical advice to their family, but the MDS incorrectly recorded the discharge as to a General Acute Care Hospital. This discrepancy was confirmed by the MDS Nurse and contradicted the facility's policy on accurate resident assessments.
A resident with a language barrier was not provided with a communication board as required by their care plan, hindering their ability to communicate needs. The resident, who only spoke Mandarin, was admitted with conditions affecting mobility and cognition. Despite facility policies mandating the availability of communication tools, staff interviews confirmed the absence of the board, which was crucial for the resident's communication.
A resident at risk for pressure injuries had their low air loss (LAL) mattress incorrectly set at 180 lbs, despite weighing 117 lbs. This setting did not comply with the physician's order to adjust the mattress based on the resident's weight, potentially worsening the resident's existing pressure ulcers. The resident was admitted with conditions including urinary tract infection and reduced mobility, and was dependent on assistance for daily activities.
A resident with cognitive impairment and multiple health conditions was at risk of falling due to staff failing to activate a pressure pad alarm and not lowering the bed as per the care plan. Observations and staff interviews confirmed these oversights, which were contrary to the facility's Fall Management System policy.
Failure to Assess and Document Blood Pressure Prior to Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to accurately administer blood pressure (BP) medications to two residents by not following physician orders and facility policy regarding assessment and documentation of vital signs prior to medication administration. For one resident with hypertensive heart disease, heart failure, and chronic kidney disease, multiple nurses did not assess or document BP immediately prior to administering carvedilol and nifedipine, as required by the medication orders which specified to hold the medication if systolic BP was less than 100 or heart rate was less than 60. Instead, nurses often relied on BP readings taken hours earlier or for unrelated assessments, such as COVID-19 screening, rather than obtaining a current BP immediately before giving the medication. Interviews with nursing staff confirmed that they sometimes used previous BP readings rather than checking at the time of administration, acknowledging the risk of adverse reactions if the resident's BP had changed since the last measurement. Another resident, with a history of hypotension, hypertensive heart disease, and end stage renal disease, was administered isosorbide mononitrate despite a BP reading of 92/54, which was below the ordered hold parameter of systolic BP less than 100. The nurse responsible for administering the medication stated that BP and heart rate should be checked prior to giving BP medications and that medications should be held if the parameters are not met. The Director of Nursing confirmed that the purpose of hold parameters is to prevent injury or hospitalization due to hypotension and that BP should be checked within a couple of minutes, but not more than an hour before or after medication administration. Review of the facility's policy and procedure on medication administration indicated that vital signs must be taken and medications held if indicated by the order. Despite this, documentation and interviews revealed that nurses did not consistently follow these requirements, resulting in medications being given without proper assessment or documentation of BP immediately prior to administration. This failure to follow established protocols and physician orders had the potential to cause harm to residents with complex medical conditions.
Failure to Timely Develop Trauma-Informed Care Plan After Resident Disclosure
Penalty
Summary
The facility failed to develop an individualized, person-centered care plan with measurable objectives and timeframes to address a resident's reported history of past trauma. After the resident disclosed a previous rape to the administrator, this information was not promptly incorporated into the resident's care plan. Although a care plan addressing emotional distress related to recent abuse allegations was created, a trauma-informed care plan specific to the resident's history of sexual assault was not initiated on the same day as the disclosure. Interviews with facility staff, including the Social Services Director and Director of Nursing, confirmed that the trauma-related care plan was not developed in a timely manner, despite the recognition that such planning is essential for addressing emotional and psychological needs. The resident, who had diagnoses including heart failure, COPD, and diabetes mellitus, was cognitively intact and required partial to moderate assistance with activities of daily living. The resident reported never having shared the history of sexual assault with the facility prior to the recent abuse allegation involving a staff member. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to meet identified needs. However, the lack of timely trauma-informed care planning resulted in a deficiency in meeting the resident's individualized needs.
Failure to Assess and Document Pain Management for Resident with Fracture and Dementia
Penalty
Summary
A deficiency occurred when the facility failed to properly assess and manage pain for a resident with a history of right femur fracture, dementia, osteoarthritis, and impaired mobility. The resident's care plan required staff to administer analgesic medication as ordered, anticipate pain relief needs, and respond immediately to any complaints of pain. Physician orders specified that licensed staff should monitor the resident's pain level using a 0-10 scale every shift and administer Hydrocodone-Acetaminophen as needed for moderate to severe pain. On one occasion, the resident complained of persistent pain in the right lower extremity during a physical therapy session. The physical therapist documented the complaint and informed the licensed nurse, who agreed to monitor the resident. However, there was no evidence in the Medication Administration Record (MAR) that the resident received pain medication before or after the therapy session, nor was there documentation of a pain assessment on that day. Additionally, when pain medication was administered on subsequent dates for moderate to severe pain, the location of the pain was not documented by the licensed nurse, contrary to facility policy and care plan requirements. Interviews with nursing staff confirmed that pain location and assessment details were not consistently documented, and the responsible nurse acknowledged failing to record the pain location when administering medication. The facility's policies required thorough pain assessment, including location, intensity, and onset, as well as documentation and follow-up. The lack of assessment and documentation had the potential to result in unrelieved or uncontrolled pain for the resident.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident by not ensuring that physical therapists and nursing staff accurately documented the resident's pain location in both physical therapy encounter notes and the medical record. Specifically, two physical therapists documented the resident's pain as being in the left lower extremity, but later clarified that the pain was actually in the right lower extremity. Additionally, the licensed vocational nurse did not assess or document the pain location when administering pain medication on multiple occasions, and the medication administration record lacked this critical information. Further, the facility did not document the rationale for a room transfer for the resident. While the social services director and admissions coordinator acknowledged that the resident was moved to another room and that the family was notified, neither could recall or provide documentation of the reason for the transfer. The facility's policy required comprehensive documentation of social service assessments and interventions, including reasons for room changes, but this was not followed in this instance. The resident involved had a complex medical history, including a recent right femur fracture, dementia, osteoarthritis, and generalized muscle weakness. The resident required significant assistance with activities of daily living and had a history of falls and pain management needs. The lack of accurate and complete documentation in the resident's medical record resulted in incomplete information that could affect the resident's care, as noted by staff during interviews and record reviews.
Failure to Update Care Plan After Unassisted Transfer Attempts in High Fall Risk Resident
Penalty
Summary
The facility failed to revise the care plan for a resident at high risk for falls after the resident experienced episodes of attempting to get up unassisted. The resident, who had a history of falling, a right femur fracture, dementia, osteoarthritis, abnormal gait, and generalized muscle weakness, was admitted with significant mobility and cognitive impairments. The Minimum Data Set assessment indicated the resident required varying levels of assistance for daily activities and had not attempted transfers or walking due to safety concerns. Despite these risks and a documented fall prior to admission, the care plan, which included interventions such as call light accessibility, low bed, floor mats, and pressure pad alarms, was not updated after the resident attempted to get up unassisted from a wheelchair on two occasions. Interviews with facility staff confirmed that the care plan had not been revised following these incidents to include additional interventions, such as more frequent monitoring. The facility's policy required individualized care plans for residents at high risk for falls, with updates as new issues arose. However, the lack of timely care plan revision after the resident's unassisted transfer attempts represented a failure to address the resident's changing needs and risk factors as required by facility policy and regulatory standards.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for ten sampled residents, as observed during a survey. The deficiencies included peeling paint, cracked drywall, and loosely fitting pipe escutcheons in the bathrooms of several residents' rooms. Additionally, cracked caulking, chipped paint, and raised floor tiles were noted, which could potentially expose residents to dirt, mold, and drywall dust. These conditions were observed in the bathrooms and rooms of the residents, indicating a lack of maintenance and repair. Interviews with the housekeeping staff and the Maintenance Director (MD) revealed that there was a process for reporting maintenance issues, but it was not effectively utilized. The MD acknowledged the need for repairs in the affected rooms and bathrooms, citing potential health risks from dust and the risk of falls due to cracked tiles. A review of the facility's maintenance logs showed no entries for the necessary repairs in the affected rooms, despite the facility's policy requiring monthly environmental rounds to ensure a safe and comfortable environment.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with multiple diagnoses, including type 2 diabetes, dementia, and adult failure to thrive. The resident's Medication Administration Record (MAR) indicated that insulin was not administered at the scheduled times on numerous occasions throughout November and December 2024. The insulin was often given several hours past the scheduled time, and in one instance, it was administered before the scheduled time. This failure to adhere to the prescribed schedule for insulin administration could lead to inaccurate blood sugar readings and inappropriate insulin dosing. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), revealed that the staff generally administers medication within an hour before or after the scheduled time. However, the MAR showed significant deviations from this practice. The LVN highlighted the importance of checking blood sugar levels before meals to ensure accurate insulin dosing, while the DON acknowledged that administering insulin without a meal or snack could result in hypoglycemia. The facility's policy on medication administration emphasizes the necessity of accurate and timely administration according to physician orders.
Expired Milk Handling Deficiency
Penalty
Summary
The facility failed to ensure proper handling, preparation, and storage of food, specifically milk, which could lead to foodborne illness. During an initial kitchen tour, eleven cartons of 2% fat milk with expired dates were found in the reach-in refrigerator. The Dietetic Service Supervisor (DSS) acknowledged the expired milk and disposed of it. Additionally, during a tray line observation, seven more expired milk cartons were found on a tray of drinks intended for residents. The DSS, upon being informed, discarded these cartons as well, although he was unsure of their origin since he had previously checked the tray in the refrigerator. Furthermore, a Certified Nursing Assistant (CNA) was observed returning a food tray to the kitchen with a half-empty milk carton that was also expired. This milk was intended for a specific resident, and the DSS expressed uncertainty about how the expired milk reached the resident. The facility's policy and procedure on labeling and dating foods require that all food items be labeled and dated, with perishable items discarded according to the manufacturer expiration date or seven days after opening. The policy also mandates daily inspections of refrigerators to ensure food safety, which was evidently not adhered to in this instance.
Failure to Follow Infection Control Protocols for Two Residents
Penalty
Summary
The facility failed to adhere to its infection prevention and control program for two residents, leading to potential risks of infection transmission. For Resident 78, who was on contact isolation due to Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine, a Certified Nursing Assistant (CNA) entered the resident's room without donning a gown, which is a requirement under contact precautions. The CNA acknowledged the mistake and stated that proper personal protective equipment (PPE) should have been worn to prevent cross-contamination and ensure safety. The Infection Preventionist Nurse (IPN) confirmed that the expectation was for staff to always don and doff appropriate PPE, including gowns and gloves, when entering rooms under contact isolation. In another instance, the facility did not follow enhanced barrier precautions for Resident 20, who required PPE for high-contact care activities. A housekeeping staff member was observed cleaning Resident 20's room while wearing only a surgical mask and gloves, without a protective gown, despite signage indicating the need for gown and gloves due to enhanced standard precautions. The housekeeping staff admitted to forgetting to wear a gown, and the Maintenance Director emphasized the importance of wearing a gown to prevent the spread of germs, as it is not always known if residents have infections or what they have touched in the room. The facility's policy and procedure documents, revised in October 2024, outlined the necessity of using PPE based on predicted staff interaction with residents and potential exposure to pathogens. The policy specified that for enhanced barrier precautions, signage should clearly indicate the high-contact resident care activities requiring gown and gloves. The failure to follow these protocols for both residents had the potential to transmit infectious microorganisms and increase the risk of infection for all residents and staff in the facility.
Inaccurate MDS Documentation of Resident Discharge Status
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, resulting in an inaccurate assessment of the resident's discharge status. The resident, who had been diagnosed with dementia, emphysema, and a history of falling, was discharged against medical advice (AMA) to their family. However, the MDS inaccurately recorded the discharge as being to a General Acute Care Hospital (GACH) instead of to the resident's home. This discrepancy was identified during a review of the resident's records, including the Admission Record, Physician's Discharge Summary, and Progress Notes, which all indicated the resident left AMA to go home. During an interview with the Minimum Data Set Nurse (MDSN 1), it was confirmed that the MDS should have been marked as a discharge to home rather than to a GACH. The facility's policy on Resident Assessment: Accuracy of Assessment (MDS 3.0) requires that assessments accurately reflect the resident's status, which was not adhered to in this case. This oversight led to the inaccurate documentation of the resident's discharge status on the MDS.
Failure to Provide Communication Board for Resident with Language Barrier
Penalty
Summary
The facility failed to provide a communication board for a resident who had a language barrier, as indicated in the resident's care plan. The resident, who was admitted with diagnoses including metabolic encephalopathy and reduced mobility, was unable to communicate effectively due to a language barrier, as they only spoke Mandarin. The care plan specified the need for a communication board in Mandarin to help the resident communicate basic needs to the staff. However, during an observation, it was noted that no communication board was present in the resident's room, which was confirmed by a family member who stated the resident might have difficulty communicating their needs. Interviews with facility staff, including an LVN and the Social Services Director (SSD), revealed that the communication board was not easily accessible as required. The LVN acknowledged the importance of the communication board for residents with language barriers and noted its absence in the resident's environment. The SSD admitted that communication boards could be misplaced and emphasized the need for them to be within the resident's line of sight to facilitate effective communication. The facility's policies and procedures indicated that communication tools should be provided and kept at the resident's bedside, but this was not adhered to in this case.
Incorrect LAL Mattress Setting for Resident
Penalty
Summary
The facility failed to ensure that a resident at risk for skin breakdown and pressure injuries received appropriate treatment and services to prevent skin breakdown. The deficiency was identified when it was observed that the low air loss (LAL) mattress for a resident was incorrectly set at 180 pounds, while the resident's actual weight was 117 pounds. This incorrect setting was not in accordance with the physician's order, which specified that the LAL mattress should be set based on the resident's weight. The incorrect setting of the LAL mattress could lead to increased pressure on the resident's existing pressure ulcers, potentially worsening their condition. The resident in question was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, and reduced mobility, and was dependent on assistance for activities of daily living. The resident's care plan indicated the use of a LAL mattress with bolsters for tissue load management due to the presence of pressure ulcers and the potential for further development. The facility's policy on pressure ulcers emphasized the need for necessary treatment and services to promote healing and prevent new sores. However, the failure to adjust the LAL mattress according to the resident's weight compromised the therapeutic benefits intended by the mattress, placing the resident at higher risk for further skin breakdown.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to its Fall Management System policy and Resident 1's care plan, which aimed to prevent falls. Specifically, the staff did not activate Resident 1's pressure pad alarm and did not return the bed to its lowest position after providing care. These actions were contrary to the care plan interventions designed to alert staff if Resident 1 attempted to get up unassisted, thereby increasing the risk of falls. Resident 1, who was admitted with conditions including type 2 diabetes mellitus, heart failure, and acute cerebrovascular insufficiency, was moderately impaired in cognitive skills and dependent on staff for daily activities. During observations, it was noted that the bed was not in the lowest position, and the pad alarm was turned off, despite the care plan's requirements. Staff interviews confirmed these oversights, acknowledging the potential risk of injury if Resident 1 were to fall.
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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