Claremont Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Claremont, California.
- Location
- 621 W Bonita Ave, Claremont, California 91711
- CMS Provider Number
- 555085
- Inspections on file
- 36
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Claremont Manor Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to perform and/or document the required 20-year testing of quick-response sprinkler heads throughout all smoke compartments, as required by NFPA 25. During review of Life Safety records with the Director of Environmental Services, no documentation of a 20-year sprinkler test was available, despite the sprinklers being original to the building. Spare sprinkler heads in stock showed manufacturing dates from the late 1990s, and the outside testing company could not provide historical records to confirm that the mandated 20-year testing had ever been completed.
Surveyors found that the facility did not activate or transmit the fire alarm signal during multiple fire drills conducted during daytime and evening hours, as required by NFPA 101. Documentation showed that three drills held during non-nocturnal hours were recorded as having no alarm activation. In an interview, the DES stated that staff may have avoided pulling the alarm during a drill held around dinner time and also suggested there might have been documentation errors, but could not clearly explain the discrepancies. This practice was cited as having the potential to negatively affect the health and safety of residents, staff, and visitors.
Surveyors observed that an electrical outlet in Nursing Station 1's med room was installed 18 inches from a sink and was not equipped with a required ground-fault circuit interrupter (GFCI), as mandated by NFPA 70, National Electrical Code. The DES confirmed during the survey that this outlet lacked GFCI protection, resulting in a cited deficiency related to utilities and electrical safety in one of the facility’s smoke compartments.
A resident with intact cognition and independence in daily activities was verbally abused by another resident with cognitive impairment and a history of verbal aggression. The incident, which involved yelling, cursing, and threats, was witnessed by staff including an LVN, the Activities Director, and the DON. The affected resident was left scared and unusually quiet, indicating emotional distress. The facility's policy prohibits all forms of abuse, including resident-to-resident verbal abuse, but the event was not prevented.
A resident with severe cognitive impairment and multiple medical conditions made an allegation of sexual abuse to a CNA, who promptly informed an LVN and the DON. Although the police and Ombudsman were notified within the required two-hour window, the facility failed to report the allegation to the Department of Public Health within the mandated timeframe, as required by facility policy.
A resident with severe cognitive impairment was subjected to repeated loud instructions by an LVN, which staff perceived as verbal abuse. Multiple CNAs witnessed or were informed of the incident, but the allegation was not reported to the administrator or authorities within the required two-hour window. The delay in reporting was confirmed through staff interviews and documentation, in violation of facility policy and state regulations.
The facility failed to maintain an effective pest control program, resulting in cockroaches in the kitchen. Grease and dirt buildup were observed, and the kitchen had not been deep cleaned recently. The Infection Preventionist confirmed a 48-hour kitchen closure due to the issue. The facility lacked a pest control policy, and recommendations to address pest entry points had been pending. The facility's policies did not adequately address pest control, leading to the deficiency.
A resident with dementia and a history of falls was left unsupervised in their room, leading to a fall and injuries. Despite increased agitation and confusion, the resident's physician was not notified, and the resident was not adequately monitored. This failure to follow facility policies on dementia care and fall prevention resulted in the resident sustaining a laceration, bruising, and abrasions.
The facility failed to develop and implement individualized care plans for four residents, leading to potential unmet needs and incorrect care. A resident with a change in skin condition did not have a care plan for monitoring and intervention. Another resident on Eliquis lacked a care plan for anticoagulant use, and a resident on Quetiapine had no care plan for antipsychotic use. Additionally, a resident with dementia did not have a care plan addressing cognitive impairment and specific behaviors.
Two residents at a facility experienced inadequate pressure ulcer care and prevention. One resident's low air loss mattress was improperly set, reducing its effectiveness. Another resident did not receive documented repositioning, weekly skin assessments, or timely treatment for a pressure injury. The facility failed to follow its policy for skin and wound assessment, leading to potential worsening of pressure injuries.
The facility failed to document drug allergies accurately for two residents, leading to the administration of contraindicated medications. One resident received Ambien despite it being an allergy, and another had incorrect allergy documentation in their EMR. The discrepancies were not communicated to the pharmacy, posing a risk of adverse reactions.
The facility failed to follow infection prevention guidelines, including improper PPE use during peri-care for a resident under enhanced precautions, lack of a HEPA filtration system for a COVID-19 positive resident, and incorrect PPE use by a visitor. Additionally, a laundry aide prefilled disinfection logs, contrary to policy.
A facility failed to update a resident's code status in the EMR, leading to a discrepancy between a full code MD order and a signed DNR form. Staff interviews revealed that the inconsistency was noted but not corrected, risking incorrect emergency services for the resident.
A resident with Alzheimer's and psychosis showed increased agitation and confusion, attempting to stand unassisted from a wheelchair. The RN failed to notify the physician of this change, contrary to facility policy. Interviews confirmed this was a change in condition requiring immediate notification, which was not done.
A facility failed to ensure the SNFABN form was signed for a resident with severe cognitive impairment, potentially leading to uninformed decisions about denied medical coverage. The resident, diagnosed with dementia, hearing loss, and visual loss, lacked the capacity to make decisions. The Social Services Designee confirmed the absence of signatures could result in billing disputes.
The facility failed to update care plans for two residents, one with Alzheimer's and increased confusion, and another with depression and a change in Trazadone dosage. Staff observations and interviews confirmed the need for care plan revisions to ensure appropriate interventions and medication management, as per facility policies.
A resident with chronic respiratory failure and asthma was found with their nasal cannula disconnected from the oxygen concentrator, and the humidifier bottle was not labeled or dated as per facility policy. The resident expressed uncertainty about receiving oxygen, and staff interviews confirmed the oversight, highlighting the risk of infection and inadequate oxygen delivery.
A resident with a fracture requiring scheduled pain medication did not receive a Lidocaine patch as it was not delivered by the pharmacy on time. The facility's policy required medications to be administered within 60 minutes of the scheduled time, but this was not met, leading to a deficiency in pharmaceutical services.
A resident was prescribed Quetiapine without a documented diagnosis to support its use, despite having severe cognitive impairment and dependency on daily activities. Interviews with the PMHNP and DON confirmed the lack of a clear medical indication for the medication, which was contrary to the facility's policy requiring a thorough evaluation and documented diagnosis before administering psychotropic drugs.
The facility's kitchen failed to maintain sanitary conditions, risking foodborne illness for residents. Observations revealed a cook preparing food without a hairnet, expired food items stored improperly, and dented cans in the dry food area. Interviews with staff confirmed these practices violated facility policies on food safety and sanitation.
A resident with limited mobility and medical decision-making capacity was found with an inaccessible call light, contrary to facility policy. Staff interviews confirmed the call light should have been within reach, as per the facility's procedures.
A facility failed to report an alleged abuse incident involving a CNA and a resident within the required two-hour timeframe. The resident, with conditions like encephalopathy and heart failure, was allegedly subjected to inappropriate touching. The incident was reported to authorities three days late, violating the facility's abuse prevention policy.
A facility failed to remove a CNA from duties during an investigation into alleged inappropriate conduct with a resident. Despite a report of the CNA squeezing a resident's brief inappropriately, the CNA continued working their regular schedule. The resident involved had a history of encephalopathy and other conditions, and the facility's investigation could not substantiate the complaint.
A verbal altercation between two residents during a Cinco de Mayo celebration was not reported to the necessary authorities within the required timeframe. Despite being witnessed by the Activities Director, the incident involving threats and profane language was not communicated to the State Survey Agency, Long-Term Ombudsman, or local law enforcement until over 24 hours later, contrary to facility policy.
Failure to Perform and Document Required 20-Year Sprinkler Head Testing
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct the required 20-year testing of quick-response sprinkler heads in accordance with NFPA 25. During an interview and record review with the Director of Environmental Services (DES), the facility’s Life Safety materials binder was found to lack any record of a 20-year sprinkler test for the quick-response sprinkler heads installed throughout all four smoke compartments. The DES reported that the sprinklers were original to the building, which was constructed in 1999, and stated that the required testing may have been done in 2009, but there was no documentation on site to verify that the test had occurred. Further observation and interview showed that spare quick-response sprinkler heads in the facility’s stock had manufacturing dates such as 1996 and 1999 printed on them, confirming the age of the system components. The DES indicated that the outside testing company was unable to locate records from that time period to confirm whether the 20-year sprinkler testing had been performed. As a result, there was no evidence available to demonstrate that the required 20-year sprinkler head testing had been completed for the sprinkler system serving all four smoke compartments, as required by NFPA 25 and related Life Safety Code provisions.
Plan Of Correction
K353 – Sprinkler System Maintenance and Testing (NFPA 25) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately contacted a licensed fire protection vendor to schedule the required 20-year sprinkler head testing. The sprinkler system remains fully operational and monitored, ensuring continued fire protection coverage while corrective actions are implemented. 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 3/13/2026, the Director of Environmental Services (DES) conducted a review of all available Life Safety documentation to confirm the absence of records for the 20-year sprinkler testing across all smoke compartments. The contracted licensed vendor has been engaged and performed testing on representative sprinkler heads throughout the facility in accordance with NFPA 25 standards on 3/19/2026. Response time, response time index and water seal release all passed. The report is dated 3/20/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a Life Safety compliance tracking system that includes all required inspection, testing, and maintenance schedules in accordance with NFPA 25. On 3/13/2026, the DES re-educated staff on regulatory requirements for sprinkler system testing, including 20-year testing requirements for quick-response sprinkler heads. The facility will maintain all Life Safety documentation in a centralized, secure, and readily accessible binder and electronic file. Additionally, the facility will contract with a licensed fire protection vendor to ensure ongoing compliance with all inspection and testing requirements. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will track all required Life Safety inspections and testing through a compliance calendar and conduct monthly audits to ensure all required documentation is current and on file. Results of these audits will be reported to the Administrator and reviewed quarterly in the Quality Assurance and Performance Improvement (QAPI) committee meeting. Any identified gaps will be addressed immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency.
Failure to Activate Fire Alarm System During Day and Evening Fire Drills
Penalty
Summary
Surveyors identified a deficiency in the facility’s conduct of fire drills, specifically the failure to activate and transmit the fire alarm signal during drills that occurred between 6:00 a.m. and 9:00 p.m., as required by NFPA 101, 2012 Edition, Section 19.7.1. Review of the Life Safety materials binder on 3/12/2026 showed that three of twelve documented fire drills—held at 9:30 a.m. on 4/8/2025, 5:30 p.m. on 5/2/2025, and 8:30 p.m. on 8/19/2025—were conducted outside the nocturnal hours of 9:00 p.m. to 6:00 a.m., yet the records indicated that the fire alarms were not activated during these drills. During an interview, the DES reported that for the 5:30 p.m. drill, staff may have chosen not to pull the alarm because it occurred around dinner time, and also suggested that the technician might have mistakenly documented that alarms were not activated, but the DES could not explain why the records were marked that way. This deficient practice was cited as having the potential to negatively affect staff response during an actual fire emergency, potentially affecting the health and safety of residents, staff, and visitors.
Plan Of Correction
K712 – Fire Drills (NFPA 101) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the Director of Environmental Services (DES) immediately re-educated staff responsible for conducting fire drills on requirements to activate and transmit the fire alarm signal during all drills conducted between 6:00 a.m. and 9:00 p.m. Fire drill procedures were reinforced to ensure compliance with NFPA 101 standards. 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 3/13/2026, the DES conducted a review of all fire drill documentation for the past 12 months to ensure compliance with required alarm activation and documentation standards. Any identified discrepancies were reviewed, and staff involved were re-educated on proper fire drill procedures. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has revised its fire drill policy to clearly require activation of the fire alarm system during all drills conducted between 6:00 a.m. and 9:00 p.m. On 3/12/2026, the DES contacted the company responsible for fire drills to ensure understanding of regulatory requirements, proper documentation, and expectations. On 3/31/2026 the DES in-serviced staff on compliance with required alarm activation and documentation standards. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will review all fire drill documentation monthly for 3 months to ensure compliance with alarm activation requirements and proper documentation. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any identified issues will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Non-GFCI Electrical Outlet Near Sink in Medication Room
Penalty
Summary
Surveyors found that the facility failed to ensure electrical safety in accordance with NFPA 70, National Electrical Code, 2011 Edition, Section 210.8. During an observation in Nursing Station 1's medication room, an electrical outlet was identified 18 inches from a sink that was not equipped with the required ground-fault circuit interrupter (GFCI). The Director of Environmental Services (DES) was present during the observation and confirmed that the outlet, located near the sink, did not have a GFCI. This deficiency affected one of four smoke compartments and was cited as noncompliance with NFPA 101 requirements for utilities, gas, and electric systems. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on the physical environment and the noncompliant electrical installation near the sink in the medication room.
Plan Of Correction
K511 - Utilities - Gas and Electric (NFPA 70) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. There were no residents identified as directly affected by this deficient practice. Upon identification on 3/12/2026, the facility immediately removed the outlet from use and implemented interim safety measures. A licensed electrician was contacted to install a GFCI-protected outlet at Nursing Station 1 medication room sink area. The GFCI outlet was installed on 3/12/2026 to ensure compliance with NFPA 70 requirements and reduce risk of electrical shock. 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 3/12/2026, the Director of Environmental Services (DES) conducted a facility-wide audit of all electrical outlets located within proximity to water sources, including medication rooms, kitchen areas, and resident care areas. Any outlets identified as not GFCI-protected were immediately removed from service and scheduled for correction by a licensed electrician. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. To prevent recurrence, the facility has implemented a preventive maintenance program that includes routine inspection of all electrical outlets near water sources for GFCI compliance. On 3/13/2026, the DES re-educated staff on NFPA 70 requirements, specifically related to GFCI installation near sinks and wet locations. The facility will ensure that all future electrical work is reviewed for compliance with applicable codes and completed by licensed professionals. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The DES or designee will conduct weekly environmental rounds for 3 months to ensure all outlets near water sources are GFCI-protected and functioning properly. Findings will be reported to the Administrator and included in the quarterly QAPI meeting. Any deficiencies will be corrected immediately. The QAPI committee will monitor compliance until sustained. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. 4/1/2026
Failure to Prevent Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent verbal abuse when one resident verbally threatened, cursed, and yelled at another resident in the activities room. The resident who was verbally abused had intact cognitive skills and was generally independent in daily activities, while the resident who initiated the verbal aggression had moderately impaired cognitive skills and a history of verbal aggression. Multiple staff members, including an LVN, the Activities Director, and the Director of Nursing, directly observed or were made aware of the incident, which involved one resident yelling, cursing, and threatening to physically harm another resident. Following the incident, the affected resident was observed to be scared, upset, and unusually quiet for the remainder of the shift. The facility's policy explicitly states a zero-tolerance approach to any form of abuse, including resident-to-resident abuse, and defines verbal abuse as yelling, cursing, and threatening another resident. Despite this policy, the incident occurred and was witnessed by staff, with the affected resident experiencing emotional distress as a result. The report documents that the facility did not prevent the occurrence of verbal abuse between residents, as required by their own policy and regulatory standards.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the California Department of Public Health within the required two-hour timeframe, as specified in the facility's policy and procedure. The resident, who was admitted with diagnoses including urinary tract infection, metabolic encephalopathy, and hypertension, was assessed as severely impaired in cognitive skills and required significant assistance with daily activities. On the morning of the incident, the resident reported an allegation of sexual abuse to a CNA, who then informed an LVN. The LVN subsequently notified the Director of Nursing (DON) and stated that all allegations of abuse must be reported within two hours to the police, Ombudsman, and the Department. Despite the internal notifications, the facility did not report the allegation to the Department within the required two-hour window. The administrator confirmed that the report to the Department was faxed more than three hours after the initial allegation was made, although notifications to the police and Ombudsman were made within the required timeframe. The facility's policy, revised in April 2018, clearly states that any observed, suspected, or known abuse must be reported to the Department, Ombudsman, law enforcement, and the administrator immediately, but not later than two hours.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving a resident with severe cognitive impairment was reported immediately, but no later than two hours after the allegation was made, as required by facility policy and state regulations. The resident, who had diagnoses including Alzheimer's disease and unspecified psychosis, was observed by staff attempting to get up from a wheelchair. During this event, a Licensed Vocational Nurse (LVN) was reported by multiple Certified Nursing Assistants (CNAs) to have repeatedly and loudly instructed the resident to sit down, which was perceived as yelling and considered by staff to be a form of verbal abuse. Despite the incident occurring on the same day as a documented fall, the allegation of abuse was not reported to the facility administrator or other required authorities within the mandated two-hour timeframe. Interviews with staff, including the Director of Staff Development (DSD), revealed that the administrator was not notified until the day after the incident, and the official report to the State Agency was not completed until over a month later. Facility policy and in-service training materials clearly stated that all suspected abuse must be reported immediately to the administrator and appropriate authorities. Documentation reviewed included progress notes, staff statements, and the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), all of which confirmed the delay in reporting. The failure to promptly notify the administrator and external agencies as required resulted in a delay in initiating protective measures and investigation for the resident involved.
Facility Lacks Effective Pest Control Program, Leading to Cockroach Infestation in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in the kitchen of a 59-bed facility. During an inspection, grease and dirt buildup were observed on the pipes and kitchen exhaust hood, and cockroaches were found near the dishwashing area. The kitchen had not undergone a deep cleaning recently, and the head chef, who was new to the facility, was unaware of the last deep cleaning date. The kitchen staff performed daily cleaning, but it was insufficient to prevent pest infestation. The Infection Preventionist (IP) confirmed that the kitchen had been closed for 48 hours due to the cockroach issue, and no food from the kitchen would be served to residents after lunch on the day of the inspection. The Director of Environmental Services (DES) and Housekeeping Supervisor (HKS) stated that a professional deep cleaning was conducted twice a year, with the last one completed several months prior. However, the housekeeping department did not clean the kitchen area, leaving it to the kitchen staff. The facility lacked a pest control policy, and the Administrator, who was also new, relied on vendor recommendations for pest control services. A review of vendor receipts revealed that recommendations to remove debris and seal entry points for pests had been pending since the previous year. The facility's policies did not include specific cleaning protocols for the kitchen, and the Infection Prevention & Control Program did not adequately address pest control measures. The U.S. Food & Drug Administration Food Code requires effective measures to eliminate pests in food establishments, which the facility failed to implement, leading to the observed deficiency.
Failure to Prevent Fall in Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident diagnosed with dementia, leading to a fall and subsequent injuries. The resident, who had a history of Alzheimer's Disease and psychosis, was admitted to the facility with an unsteady gait and poor balance, making them at risk for falls. Despite these known risks, the facility did not ensure that the resident received adequate supervision or that their physician was notified of changes in their condition, such as increased agitation and confusion. On the day of the incident, the resident attempted to stand up unassisted from their wheelchair multiple times, indicating a change in condition that required immediate attention. However, the registered nurse failed to notify the resident's physician about these changes, as required by the facility's policy. Additionally, a certified nurse assistant took the resident to their room and left them unsupervised in bed, despite the resident's increased confusion and agitation. This lack of supervision resulted in the resident falling out of bed, sustaining a laceration, bruising, and abrasions. Interviews with staff revealed that the resident was known to be at risk for falls and required constant monitoring. However, there was a breakdown in communication and supervision, as the resident was left unsupervised in their room, leading to the fall. The facility's policies on dementia care, change in resident condition, and fall prevention were not followed, contributing to the incident and the resident's injuries.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for four residents, leading to potential unmet needs and incorrect care. Resident 37 experienced a change in skin condition on 1/11/2025, but a care plan was not developed to address this change. The resident's records indicated a new order for Optifoam dressing for protection, but no care plan was created to monitor and implement specific interventions for the unstageable pressure injury or deep tissue injury identified. Resident 27 was receiving Eliquis for atrial fibrillation, but there was no care plan for anticoagulant use. This omission meant there was no identification of the resident as high risk for bleeding or bruising, which could guide staff in implementing necessary interventions. Similarly, Resident 6 was on Quetiapine for poor impulse control, but no care plan was developed for antipsychotic use, leaving staff without guidance on monitoring the drug, its goals, and specific interventions for the resident's behavior. Resident 5, diagnosed with dementia, did not have a care plan addressing cognitive impairment and specific behaviors related to dementia. The absence of a care plan for this resident meant that their needs and continuity of care, especially concerning behavioral issues, were not adequately addressed. The facility's policy and procedure required comprehensive care plans to be developed within 14 days and updated quarterly or upon a change of condition, but these requirements were not met for the residents in question.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, Resident 32 and Resident 37, who were at risk for skin breakdown and pressure injuries. For Resident 32, the low air loss (LAL) mattress was improperly set at 550 pounds, despite the resident weighing only 138 pounds. This incorrect setting reduced the mattress's effectiveness in redistributing pressure and managing moisture, which are critical for preventing skin damage and pressure injuries. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the mattress setting was too high and emphasized the importance of adjusting it according to the resident's weight to ensure effective pressure relief and prevent skin damage. Resident 37 experienced multiple deficiencies in care related to pressure ulcer prevention and treatment. The facility failed to document evidence of repositioning every two hours during the night shift over a month-long period, as required by the resident's care plan. Additionally, weekly skin assessments were not performed as indicated, and treatment for an unstageable pressure injury on the coccyx was missed on one occasion. The facility also delayed the initiation of pressure-relieving devices when the pressure injury was discovered. The Infection Prevention Nurse (IPN) and Registered Nurse (RN) acknowledged these lapses, noting that the lack of documentation and missed treatments could lead to worsening of the pressure injury. The facility's policy and procedure for skin and wound assessment and treatment were not followed, as evidenced by the lack of a change of condition documentation and the failure to implement a low air loss mattress promptly for Resident 37. The Director of Nursing and other staff members recognized the importance of creating a change of condition to inform the care team and ensure proper monitoring and treatment of pressure injuries. The deficiencies in care for both residents had the potential to result in the development of new pressure injuries and the worsening of existing ones.
Failure to Document Drug Allergies Accurately
Penalty
Summary
The facility failed to implement its policy on ordering and receiving non-controlled medications for two residents, leading to incorrect documentation of drug allergies in their electronic medical records (EMR). Resident 28, who had 12 documented drug allergies, received Ambien nine times in December 2024, despite it being listed as an allergy. Additionally, Resident 27's EMR did not reflect allergies to clindamycin and Norco, and incorrectly listed allergies to prednisone and prednisolone. Resident 28 was admitted with diagnoses including major depressive disorder, muscle weakness, and atrial fibrillation. Despite having intact cognitive abilities, Resident 28's EMR failed to accurately reflect their drug allergies, leading to the administration of Ambien, which was known to cause anxiety in this resident. Similarly, Resident 27, who had chronic systolic heart failure and hyperlipidemia, reported allergies to penicillin, sulfa, Norco, and some antibiotics, which were not accurately documented in their EMR. Interviews with staff and record reviews revealed that the discrepancies in allergy documentation were not communicated to the pharmacy, which could lead to the administration of contraindicated medications. The Director of Nursing acknowledged that the EMR's failure to trigger alerts for drug allergies posed a risk of adverse reactions, including anaphylaxis, due to incorrect allergy documentation.
Infection Control Lapses in PPE Use and Environmental Measures
Penalty
Summary
The facility failed to adhere to its infection prevention guidelines in several instances, leading to potential risks of infection transmission. In one case, a Certified Nursing Assistant (CNA) entered a resident's room without donning the required gown, despite the room being under enhanced barrier precautions due to the resident's medical condition. The CNA proceeded to perform peri-care without the appropriate personal protective equipment (PPE), which was acknowledged as a necessary measure to prevent the spread of multidrug-resistant organisms (MDROs). The Infection Prevention Nurse confirmed that proper PPE, including gowns and gloves, should have been used during such high-contact activities. In another instance, the facility did not follow its policy regarding the use of a portable HEPA filtration system for a resident who tested positive for COVID-19. The resident's door was left open to monitor for fall risks, but no air purifier was placed in the room, contrary to the facility's infection control policy. This oversight was acknowledged by both the Licensed Vocational Nurse and the Infection Prevention Nurse, who noted that the absence of an air purifier increased the risk of COVID-19 transmission to other residents, staff, and visitors. Additionally, a family member visiting the COVID-19 positive resident was observed not wearing the correct PPE, including gloves, a face shield, and a properly fitted N95 mask. The Infection Prevention Nurse noted that visitors are required to don all necessary PPE to prevent the spread of infection. Furthermore, a laundry aide prefilled disinfection logs, indicating tasks were completed before they were actually done, which was against the facility's policy. This practice was confirmed by the Environmental Services Director, who emphasized that logs should only be signed after tasks are completed to ensure proper infection control measures are followed.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to implement its policy on Advance Directives by not ensuring the correct code status for a resident, referred to as Resident 27. Resident 27 had a Medical Doctor (MD) order for full code status, which indicates that all lifesaving procedures should be performed if the resident's heart stops or they stop breathing. However, there was also an Emergency Medical Services Prehospital Do Not Resuscitate (EMSPDNR) form signed, indicating a DNR status, which means no cardiopulmonary resuscitation should be performed. This inconsistency in documentation could lead to Resident 27 receiving incorrect emergency services. Interviews with staff, including a Licensed Vocational Nurse (LVN 1), the Social Services Designee (SSD), and the Director of Nursing (DON), revealed that the discrepancy was noted but not corrected in the electronic medical record (EMR). The SSD confirmed that the responsible party for Resident 27 had signed the DNR form, but the EMR still reflected a full code status. The DON acknowledged that the nursing staff should have updated the code status in the EMR upon seeing the signed EMSPDNR form. The facility's policy on Advance Directives requires staff to verify and update code statuses, which was not followed in this case.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse (RN 1) notified the physician (MD 1) regarding a change in condition for a resident (Resident 92). On 1/20/2025, Resident 92, who was diagnosed with Alzheimer's Disease and psychosis, exhibited increased agitation and confusion, attempting to stand unassisted from a wheelchair multiple times. Despite these changes, RN 1 did not inform MD 1 about the resident's altered condition, which was against the facility's policy and procedure for notifying physicians of changes in resident conditions. Interviews with the Director of Nursing (DON) and the RN Consultant (RNC) confirmed that the increased confusion and attempts to stand unassisted were considered a change in condition, requiring immediate notification to the physician. The hospice registered nurse (HRN 1) also indicated that the hospice agency was not informed of the resident's increased confusion, which would have prompted further assessment and potential intervention. The facility's policy, revised in 2016, mandates timely communication of any sudden or serious change in a resident's condition to the physician, which was not adhered to in this case.
Failure to Obtain Signed SNFABN Form for Resident
Penalty
Summary
The facility failed to ensure that the Advance Beneficiary Notice of Non-coverage (SNFABN) form was signed for a resident, identified as Resident 26. This form is crucial as it informs residents or their responsible parties about potential non-coverage of certain services by Medicare. The deficiency was identified during a review of Resident 26's records, which showed that the SNFABN form was not signed by either the resident or their responsible party. The Social Services Designee (SSD) confirmed that the absence of signatures on the SNFABN form could lead to disputes over billing and costs, as it indicates that the resident or their responsible party was not informed about the services and associated costs after the last covered date. Resident 26 was originally admitted to the facility with diagnoses including dementia, hearing loss, and visual loss, and was readmitted later. The resident's cognitive abilities were severely impaired, as indicated by the Minimum Data Set (MDS) and the History and Physical (H&P) documents, which noted that Resident 26 lacked the capacity to understand and make decisions. The facility's failure to have the SNFABN form signed meant that the resident or their responsible party might not have been able to make informed decisions regarding potential denied medical coverage.
Failure to Update Care Plans for Residents with Cognitive and Depressive Disorders
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident 92, diagnosed with Alzheimer's Disease and psychosis, experienced increased confusion and agitation, as observed by staff on multiple occasions. Despite these changes, the resident's care plan was not updated to reflect the need for increased monitoring and interventions. Interviews with staff confirmed that the care plan should have been revised to address the resident's altered cognitive function and ensure appropriate care. Similarly, Resident 5, who has dementia and a depressive disorder, was prescribed Trazadone 100 mg for depression, but the care plan was not updated to reflect this change in medication dosage. The care plan still indicated a previous dosage of 50 mg, which did not align with the current physician's order. Staff interviews highlighted the importance of updating care plans to ensure that all staff are aware of the current treatment regimen and can provide proper care. The facility's policies on care planning and changes in resident condition emphasize the need for timely updates to care plans, which were not adhered to in these cases.
Failure to Implement Oxygen Therapy Policy
Penalty
Summary
The facility failed to adhere to its policy on Oxygen Therapy, resulting in a deficiency related to the care of a resident requiring supplemental oxygen. During an observation, it was noted that the resident's nasal cannula tubing was disconnected from the oxygen concentrator machine and was found on the floor, while the machine was still running at 3 liters. Additionally, the humidifier bottle attached to the oxygen concentrator was not labeled or dated as required by the facility's policy. The resident, who was admitted with chronic respiratory failure, asthma, and a dependence on supplemental oxygen, expressed uncertainty about receiving oxygen through the nasal cannula. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the staff is responsible for dating the humidifier bottle, which should be changed weekly, and ensuring the nasal cannula is properly connected. The LVN acknowledged that the disconnection might have occurred accidentally during repositioning and emphasized the risk of infection from the nasal cannula touching the floor. The DON confirmed that the humidifier bottle should be dated to track its usage duration and reiterated the importance of connecting the nasal cannula to ensure the resident receives the necessary oxygen therapy.
Failure to Provide Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a routine pain medication was available for a resident, leading to a deficiency in pharmaceutical services. The resident, who was admitted with a diagnosis of an unspecified fracture of the lower end of the left humerus, was on a scheduled pain medication regimen that included a Lidocaine external patch for pain relief. The Minimum Data Set indicated that the resident had frequent pain and required both scheduled and as-needed pain medication. However, during a medication administration observation, it was noted that the Lidocaine patch was not applied as scheduled because it was not available at the facility. Interviews with the Licensed Vocational Nurses (LVNs) revealed that the patch was not delivered by the pharmacy in time for the scheduled administration. The facility's Medication Administration Policy and Procedure required medications to be administered within 60 minutes of the scheduled time, but this was not adhered to due to the unavailability of the medication. The resident expressed the need for the Lidocaine patch to manage pain in the right shoulder, which was used more frequently than the left. The delay in medication delivery and administration was documented in the resident's Medication Administration Record and Progress Notes.
Inappropriate Use of Psychotropic Medication Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic drugs were not used unnecessarily for one of the sampled residents, identified as Resident 32. The resident was prescribed Quetiapine, a medication used to treat bipolar disorder and schizophrenia, without a clear, documented diagnosis in the medical record to support its use. The resident's Admission Record indicated diagnoses of hemiplegia/hemiparesis, muscle weakness, and a need for assistance with personal care. The Minimum Data Set showed severe cognitive impairment and dependency on activities of daily living and mobility. Despite these conditions, there was no documented diagnosis justifying the use of Quetiapine for the resident's impulse control disorder, which was manifested by constantly calling for help. Interviews with the Psychiatric-Mental Health Nurse Practitioner and the Director of Nursing revealed that the prescription of Quetiapine was inappropriate due to the lack of a documented diagnosis. The facility's policy on psychotherapeutic medication use emphasized the need for a thorough clinical evaluation and a clear diagnosis before administering such medications. The policy also required gradual dose reductions and behavioral interventions unless clinically contraindicated. The failure to adhere to these guidelines resulted in the potential for unnecessary use of psychotropic drugs, which could lead to side effects and adverse consequences for Resident 32.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that the dietary staff stored and prepared food under sanitary conditions in the kitchen, which placed residents at risk for foodborne illness. During an observation, a cook was seen preparing rice while wearing a ball cap without a hairnet underneath, which is against the facility's policy for proper hair containment during food preparation. Additionally, expired food items, including cottage cheese containers and a cake mix, were found stored in the refrigerator and dry food area, respectively. Dented cans of marinara sauce were also stored in the dry food area, which could compromise the safety and integrity of the food. Interviews with the Sous-Chef and the Director of Dining Services confirmed that these practices were not in line with the facility's policies and procedures. Both staff members acknowledged that expired food should not be stored and that dented cans should be discarded due to the risk of contamination and potential for foodborne illness. They also emphasized the importance of wearing hairnets to prevent food contamination. The facility's policy on Food-Nutrition Services requires adherence to professional standards for food service safety, including proper sanitation and food handling practices to prevent foodborne illness.
Call Light Inaccessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for Resident 4, who was observed lying in bed with the mechanical pad call button tucked and hanging on the backside of the bed between the wall and the headboard, making it inaccessible. Resident 4 had been admitted with diagnoses including contracture of muscle, hemiplegia/hemiparesis, and age-related osteoporosis, and was dependent on assistance for activities of daily living and mobility. The resident could make needs known but could not make medical decisions, highlighting the importance of having the call light within reach. Interviews with staff, including a CNA and the DON, confirmed that the call light should have been clipped to the resident's gown or side rail for easy accessibility. The facility's policy and procedure on the call system, revised in 2009, stated that call cords should be placed within the resident's reach at all times. The failure to adhere to this policy had the potential to delay or prevent Resident 4 from obtaining necessary care and services.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the California Department of Public Health (CDPH) and law enforcement within the required two-hour timeframe. The incident involved a Certified Nursing Assistant (CNA) who allegedly squeezed the resident's brief around the genitalia area to check if it was wet. The facility's investigation commenced on September 13, 2024, after receiving a complaint through the corporate compliance department. However, the incident was not reported to the CDPH, local police, and Ombudsman until September 16, 2024, which was beyond the mandated reporting period. The resident involved had been admitted to the facility with diagnoses including encephalopathy, muscle weakness, hypertensive heart disease, and acute diastolic heart failure. The resident was capable of making needs known but unable to make medical decisions. The facility's abuse prevention policy and procedure required immediate reporting of suspected abuse resulting in serious bodily injury within two hours. The delay in reporting this incident resulted in a deficiency, as it had the potential to subject residents to further abuse.
Failure to Remove CNA During Abuse Investigation
Penalty
Summary
The facility failed to immediately remove a potential threat to a resident after receiving a report of alleged inappropriate conduct by a Certified Nursing Assistant (CNA). The incident involved CNA 1, who was reported to have squeezed a resident's brief around the genitalia area to check if it was wet. Despite the report, the facility did not suspend CNA 1 from resident care duties during the investigation, which is contrary to the facility's abuse prevention policy that mandates making every attempt to prevent further potential abuse while an investigation is in progress. Resident 2, who was involved in the incident, had a medical history including encephalopathy, muscle weakness, hypertensive heart disease, and acute diastolic heart failure. The resident was capable of making needs known but could not make medical decisions. The facility's investigation report, which commenced on the same day the complaint was received, was unable to substantiate the complaint of inappropriate touching. However, CNA 1 continued to work their regular schedule throughout the investigation period, indicating a failure to adhere to the facility's policy of non-tolerance towards any form of behavior that might be construed as abuse.
Delayed Reporting of Verbal Abuse Incident
Penalty
Summary
The facility failed to report an alleged verbal abuse incident involving two residents within the required timeframe to the State Survey Agency, Long-Term Ombudsman, and local law enforcement. The incident occurred in the dining room during a Cinco de Mayo celebration, where one resident verbally threatened another. Despite the altercation being witnessed by the Activities Director, it was not reported immediately to the appropriate authorities or facility staff, leading to a delay in addressing the situation. Resident 2, who was admitted with multiple diagnoses including hypertensive heart disease and moderate cognitive impairment, was involved in a verbal altercation with Resident 3. Resident 3, also with multiple diagnoses and moderate cognitive impairment, was reported to have used profane language and threatened Resident 2. The altercation was documented by a Licensed Vocational Nurse and later communicated to the Director of Nursing, who notified the Primary Care Provider. However, the incident was not reported to the necessary external agencies until more than 24 hours later. The facility's policy requires immediate reporting of any suspected abuse to the relevant authorities within two hours. Interviews with staff revealed a lack of immediate action and communication regarding the incident, contributing to the delay in reporting. The Administrator confirmed the late reporting, which was contrary to the facility's established procedures for handling abuse allegations.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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