Courtyard Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Signal Hill, California.
- Location
- 1880 Dawson Avenue, Signal Hill, California 90806
- CMS Provider Number
- 555785
- Inspections on file
- 28
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Courtyard Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to document meal assistance three times daily for two cognitively impaired, fully dependent residents who had orders for fortified, texture-modified diets and a feeding program. Review of Minimum Data Set assessments and active diet orders showed both residents required staff support for all ADLs, including eating, yet Documentation Survey Reports for multiple days in two consecutive months lacked evidence that meals were assisted and recorded. An RN supervisor confirmed the missing documentation during interview and record review, despite a facility policy requiring provision of a nourishing, well-balanced diet that meets each resident’s nutritional and special dietary needs.
A resident with dementia, muscle weakness, and dependence on staff for all ADLs, including feeding, had orders for a fortified mechanical soft diet and participation in a restorative nursing assistant feeding program, yet there was no documented evidence of feeding assistance for multiple meals on a specific day. Resident council minutes documented that call lights were not being answered in a timely manner, and a family member reported that there were not enough nurses, especially on weekends, causing delays in care. The RN supervisor confirmed the lack of meal-assistance documentation, and the DON confirmed CNA DHPPD on several days fell below the required 2.4 hours, stating that short staffing affected resident care, contrary to the facility’s staffing policy.
Two residents did not receive medications as ordered, and required MAR documentation was missing. One resident with severe cognitive impairment and multiple chronic conditions had undocumented and unadministered doses of Alendronate, Omeprazole, and Synthroid on several mornings. Another resident with dementia, a lower extremity fracture, and muscle weakness did not receive an ordered dose of Visine eye drops. An RN supervisor confirmed the missed administrations, and the DON stated that unsigned MAR entries indicate medications were not given, contrary to the facility’s medication administration policy.
Two residents with moderately impaired cognition and significant cardiopulmonary conditions developed new respiratory symptoms, including shortness of breath, cough, and congestion, but were not promptly tested for influenza, Covid-19, or a respiratory pathogen panel, and one was not immediately placed on TBP. Documentation showed several days’ delay between onset of symptoms and diagnostic testing, and delayed initiation of TBP for one resident. The IPN confirmed that both residents should have been tested for flu and Covid-19 right away and that TBP should have been implemented immediately, contrary to the facility’s infection control P&P and LA Department of Public Health guidance requiring immediate testing and empiric TBP for symptomatic individuals.
A resident with dementia, muscle weakness, and dependence on staff for all ADLs was found with a switch adaptive call light lying on the floor and out of reach, despite the resident’s stated need to have the device positioned under the forearm to activate it. A CNA confirmed the call light was inaccessible, and the DON acknowledged that all residents must have call lights within reach. Facility policy on answering call lights also required that call lights be kept within residents’ reach, but this was not followed, resulting in a delay in care and services.
Two residents with severe cognitive impairment and significant medical conditions experienced unwitnessed falls, after which neurological checks were not completed at the required intervals according to facility policy. The DON confirmed that the neuro checks for both residents did not follow the specified protocol.
A resident with multiple serious diagnoses, including acute respiratory failure, CHF, and dementia, was transferred to a hospital and later expired. Nursing progress notes for this resident included late entries that were not properly identified as such, nor did they include the actual date and time of the events. The RN acknowledged the omission, and the DON confirmed that documentation must be accurate and complete, as required by facility policy.
Two residents with obstructive sleep apnea refused to wear their BiPAP masks, and the facility failed to notify their primary care doctors as required. Despite documentation of refusals, there was no evidence of physician notification, which is crucial for managing potential respiratory issues or sleep disturbances. Staff interviews confirmed the importance of notifying physicians, aligning with the facility's policy.
A resident with cognitive impairment and multiple diagnoses was left in a wet diaper for over five hours due to a CNA's failure to inform the charge nurse of the resident's initial refusal for a change. The CNA prioritized other tasks and a lunch break, leading to the resident's discomfort and potential risk for skin breakdown.
A resident did not receive timely refills of Norco for severe pain, leading to a gap in medication availability. Additionally, a discontinued medication was not removed from the medication cart, risking potential medication errors. The facility failed to document the refill process and adhere to policies for handling discontinued medications.
A CNA failed to perform hand hygiene between caring for two residents, using alcohol pads instead of the facility's required alcohol-based hand sanitizer. This incident involved a resident with multiple health conditions, including COPD and moderate cognitive impairment. The facility's policy mandates hand hygiene before and after resident contact to prevent infection spread.
A facility failed to ensure a safe discharge plan for a cognitively impaired resident who was taken AMA by a significant other. The resident, who required assistance with ADLs and medication, was found in a homeless encampment without necessary care. The facility did not assess the resident's condition or involve emergency services, allowing the resident to sign an AMA form without ensuring safety.
A resident with severe cognitive impairment and multiple medical conditions was taken from the facility by an unauthorized person, resulting in the resident being found in a homeless encampment two days later. The facility failed to ensure proper supervision and communication, as the significant other had previously refused to provide contact information and had expressed intentions to take the resident out against medical advice. The facility's policy on safety and supervision was not effectively followed, leading to the resident's unsafe removal.
The facility failed to maintain sanitary conditions in the kitchen, with opened food items not labeled with dates and an unclean dry storage area. Additionally, the residents' refrigerator and freezer were operating above recommended temperatures, posing a risk for food contamination.
The facility failed to assess, obtain informed consent, and secure physician orders for the use of beds against the wall as restraints for three residents with severely impaired cognition. Observations revealed that the beds restricted movement, and interviews confirmed the lack of necessary documentation and assessments as per the facility's restraint policy.
The facility failed to accurately code the MDS for two residents, leading to potential deficiencies in care planning. One resident's range of motion limitations were not correctly documented, and another resident's anxiety disorder was omitted from the MDS despite being treated for it. These inaccuracies could impact the care and services provided.
The facility failed to provide essential medications for three residents, leading to deficiencies in medication administration. A resident did not receive magnesium oxide due to stock issues, another missed lactulose for bowel management, and a third was not given gabapentin for pain due to a pharmacy delivery error. Additionally, a resident was given aspirin in a manner inconsistent with the physician's order, potentially affecting its effectiveness.
The facility failed to manage psychotropic medications properly for two residents. One resident received PRN Lorazepam without a specified duration, non-pharmacological interventions, behavior monitoring, or informed consent. Another resident was given Mirtazapine without updated informed consent for the increased dosage and changed behavior monitoring. These actions violated the facility's policies on medication management and informed consent.
A LTC facility failed to maintain a medication error rate below 5%, resulting in a 13.33% error rate. One resident did not receive magnesium oxide due to stock issues, another missed lactulose and improperly received aspirin, and a third did not receive gabapentin for pain. These errors were due to stock shortages and administrative oversights.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube, lacking physician orders and documentation. A CNA provided care without an isolation gown, despite EBP requirements. Additionally, a medication cart contained an open incinerator bin, risking contamination of medications. The facility's policies on infection prevention and medication storage were not adhered to, resulting in these deficiencies.
A facility failed to provide simultaneous feeding assistance to two residents with severe cognitive impairments, resulting in an undignified dining experience. One resident had to wait for assistance while the other was being fed due to insufficient staffing. Interviews with the DSD and DON highlighted the importance of maintaining residents' dignity during meals.
A resident with severe impairments and high fall risk was found unable to reach the call light, which was on the floor, due to impaired vision. An LVN confirmed the call light should be within reach, and the DON stated that call lights must be accessible to meet residents' needs. The facility's policy requires call lights to be within easy reach.
A resident with major depressive disorder and PTSD was inaccurately assessed in their PASARR Level I screening, which failed to indicate the presence of a mental disorder. This oversight prevented the necessary Level II PASARR evaluation, which is crucial for ensuring appropriate placement and services. The MDS nurse and DON confirmed the error, highlighting the need for accurate assessments as per the facility's PASARR policy.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and another with severe visual impairment. Resident 25, dependent on staff for all ADLs, lacked a care plan for activities. Resident 1, with cataracts and impaired vision, had no care plan addressing visual deficits, leading to difficulties in locating the call light. The facility's policy requires comprehensive care plans, but these were not implemented, resulting in deficiencies.
A resident receiving artificial nutrition through a G-tube had an outdated care plan that did not reflect the current physician's orders. The care plan indicated a discontinued feeding formula, while the resident was observed receiving a different formula as per the new order. The MDS nurse acknowledged the care plan was not updated, and the DON stressed the importance of accurate care plans for continuity of care.
A resident with ROM limitations in both legs experienced a decline in mobility due to the facility's failure to provide necessary ROM exercises. Despite recommendations for a Restorative Nursing Aide Program, staff did not perform ROM exercises, assuming others were responsible. The resident's condition worsened over time, with no additional therapy services initiated, contrary to facility policies requiring evaluations and communication for changes in ROM.
The facility failed to properly remove expired and discontinued medications, store Brimonidine tartrate ophthalmic solution at room temperature, and label an insulin Glargine pen with accurate opened dates. These deficiencies involved three residents and increased the risk of medication errors and ineffective treatments.
Failure to Document Meal Assistance for Dependent Residents on Specialized Diets
Penalty
Summary
The facility failed to ensure that two dependent residents received and had documented assistance with meals three times a day as ordered. Resident 2 was admitted with conditions including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. Orders in effect included a fortified mechanical soft diet with thin liquids and a Restorative Nursing Assistant feeding program. Review of Resident 2’s Documentation Survey Reports for February and March 2026 showed missing documentation that the resident was assisted with meals three times daily on multiple specified dates, despite the resident’s dependence on staff and specialized diet and feeding program orders. Resident 8 was admitted with COPD, kidney transplant status, dementia, anemia, and morbid obesity, with an MDS indicating severely impaired cognition and dependence on staff for all ADLs. Active orders included a fortified pureed diet with mildly thick consistency. Review of Resident 8’s Documentation Survey Reports for February and March 2026 similarly showed no documented evidence that the resident was assisted with meals three times a day on multiple specified dates. During interviews and concurrent record reviews, the RN Supervisor confirmed the lack of documentation for both residents on the identified dates and acknowledged the need to ensure meals were recorded and that residents eat at least three times a day. The facility’s Food and Nutrition Services policy stated that each resident is to be provided with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs.
Insufficient Nursing Staff Leading to Missed Feeding Assistance and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, including failure to ensure documented feeding assistance for a dependent resident and timely response to call lights. One resident was admitted with multiple diagnoses including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. This resident had orders for a fortified mechanical soft diet with thin liquids and participation in a restorative nursing assistant feeding program. However, review of the resident’s February documentation showed no documented evidence that the resident was assisted with meals three times a day on a specific date, including breakfast and lunch, despite the resident’s dependence on staff for feeding. Additional evidence of insufficient staffing came from resident council meeting minutes on two dates, which documented concerns that call lights were not being answered in a timely manner. A family member reported during a phone interview that there were not enough nurses to help residents, particularly on weekends, which delayed care and services. During interviews and record reviews, the RN supervisor confirmed the lack of documented meal assistance for the dependent resident on the identified date, and the DON confirmed that Certified Nurse Assistant DHPPD on several dates, including the date of missing meal assistance documentation, were below the required 2.4 hours per patient day. The DON stated that short staffing affected resident care. The facility’s own staffing policy indicated it would provide enough nursing staff to deliver nursing and related care services for all residents, which was not met on the identified dates.
Failure to Administer and Document Ordered Medications for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, as evidenced by missing administrations and documentation on their Medication Administration Records (MARs). One resident with severe cognitive impairment and multiple diagnoses including COPD, GERD, bilateral hip osteoarthritis, and a bone density disorder had active orders for Alendronate Sodium 70 mg once weekly on Sundays, Omeprazole 20 mg daily, and Synthroid 75 mcg every morning. Review of this resident’s March MAR showed no documented evidence that Alendronate Sodium and Omeprazole were administered at 6 a.m. on 3/1, no documented evidence that Synthroid was administered at 6:30 a.m. on 3/1 and 3/3, and no documented evidence that Omeprazole was administered at 6 a.m. on 3/3. During interview and concurrent record review, the RN Supervisor confirmed these medications were not administered as ordered, and the DON stated that if the MAR was not signed, it meant the medication was not administered. A second resident, admitted with a left tibia medial malleolus fracture, dementia with moderately impaired cognition, and muscle weakness, was dependent on staff for all ADLs and had an active order for Visine Dry Eye Relief Ophthalmic Solution 1%, one drop in both eyes three times daily. Review of this resident’s March MAR showed no documented evidence that Visine was administered at 6 a.m. on 3/3. The RN Supervisor confirmed that this medication was not administered as ordered. The facility’s 2024 “Administering Medications” policy stated that medications are to be administered as prescribed and that the individual administering the medication must document the date, time, dosage, route, and their signature and title on the MAR, which did not occur in these instances.
Delayed Respiratory Testing and TBP Implementation for Symptomatic Residents
Penalty
Summary
The deficiency involves the facility’s failure to promptly implement its infection prevention and control policies for residents who developed respiratory symptoms. One resident with chronic obstructive pulmonary disease and pulmonary fibrosis, and with moderately impaired cognition and dependence on staff for several ADLs, developed shortness of breath, coughing, and congestion as documented on an SBAR form on 2/14/2026 at 9:30 p.m. Despite these symptoms, the resident was not placed on transmission-based precautions until 2/18/2026 at 8:33 p.m., and testing for a respiratory pathogen panel was not performed until 2/19/2026 at 5 a.m. The Infection Prevention Nurse (IPN) confirmed during interview and record review that this resident should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when symptoms appeared and should have been placed on transmission-based precautions right away. Another resident, admitted with acute pulmonary edema and anemia, also had moderately impaired cognition and required set-up assistance with eating and oral hygiene and was dependent on staff for showering and toileting hygiene. This resident developed a productive cough documented on an SBAR form on 2/21/2026 at 8:29 p.m., but testing for a respiratory pathogen panel was not completed until 2/23/2026 at 3:30 a.m. The IPN confirmed that this resident likewise should have been tested for a respiratory pathogen panel or at least influenza and Covid-19 immediately when respiratory symptoms manifested. The facility’s own infection prevention and control policy stated it would maintain a safe environment to prevent and manage the spread of infections and follow current best practices, and the LA Department of Public Health toolkit specified that residents with signs or symptoms of respiratory illness should be immediately tested for Covid-19 and influenza and placed on empiric transmission-based precautions while awaiting results. The surveyors determined that these delays constituted a failure to implement infection control policies and public health guidance.
Failure to Keep Dependent Resident’s Adaptive Call Light Within Reach
Penalty
Summary
The facility failed to ensure a resident’s adaptive call light was accessible and within reach, resulting in a delay in care and services. The resident had been admitted with a fracture of the medial malleolus of the left tibia, dementia, and muscle weakness. According to the MDS dated 1/14/2026, the resident’s cognition was moderately impaired and she was dependent on staff for all activities of daily living. During an observation and interview in the resident’s room, the resident’s switch adaptive call light was found on the floor away from her, and CNA 1 confirmed that the call light was out of the resident’s reach. During the same observation, the resident stated she needed the call light positioned under her forearm so she could press it when she needed assistance from staff. In a separate interview, the DON stated that all residents must have an accessible call light within reach to ensure they can call for help. Review of the facility’s 2024 policy and procedure titled “Answering the Call Light” indicated that call lights need to be within residents’ reach. These observations, interviews, and record reviews showed that the resident’s call light was not positioned as required by facility policy or as needed by the resident, leading to the identified deficiency.
Failure to Complete Neurological Checks per Protocol After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed as indicated in their policy for two residents following unwitnessed falls. For one resident with diagnoses including acute respiratory failure, congestive heart failure, and dementia, the care plan required neuro checks after an unwitnessed fall. However, the neurological assessments were not performed at the required intervals, as the checks were completed every 30 minutes twice, every hour twice, and then every three hours three times, instead of following the specified protocol. Similarly, another resident with diagnoses of pneumonia, meningitis, and mobility abnormalities also experienced an unwitnessed fall. The neurological assessments for this resident were completed at incorrect intervals, deviating from the facility's protocol. The DON confirmed during interview and record review that the neuro checks for both residents were not completed at the correct frequencies as required by the facility's policy and procedure, which mandates specific intervals for neurological assessments following unwitnessed falls.
Inaccurate Nursing Documentation for Resident Care
Penalty
Summary
The facility failed to ensure that nursing progress notes for one resident were accurate and properly documented. Specifically, a review of the resident's admission record showed the individual was admitted with diagnoses including acute respiratory failure, congestive heart failure, and dementia with severely impaired cognition. The resident was later sent to a general acute care hospital and subsequently expired. Upon review of the resident's daily nurse notes, it was found that entries made on a certain date were actually late entries for a previous date, but the nurse did not indicate that they were late entries or specify the actual date and time the events occurred. During interviews, the registered nurse acknowledged forgetting to document the entries as late and to include the correct timing. The Director of Nursing confirmed that documentation is required to be complete and accurate. The facility's policy also states that all services and changes in a resident's condition must be documented objectively, completely, and accurately. The failure to properly document late entries resulted in an inaccurate depiction of the care and services provided to the resident.
Failure to Notify Physicians of BiPAP Refusals
Penalty
Summary
The facility failed to notify the primary care doctors of two residents when they refused to wear their BiPAP masks as ordered. Resident 1, who was admitted with obstructive sleep apnea and had intact cognition, refused to wear the BiPAP mask on multiple occasions in January 2025. Despite these refusals being documented in the Medication Administration Record, there was no evidence that the physician was notified of these refusals. Licensed Vocational Nurse 1 confirmed that the physician should have been notified and that the lack of documentation meant there was no evidence of such notification. Resident 2, who had moderately impaired cognition and required substantial assistance with activities of daily living, also refused to wear the BiPAP mask since admission. The resident expressed discomfort with the fit of the mask, stating it was not like the one used at home. Although the refusal was documented, there was no indication that the physician was notified. Licensed Vocational Nurse 2 acknowledged the importance of notifying the physician due to potential respiratory issues or sleep disturbances. The Director of Nursing confirmed that refusals should be documented and the physician notified, as per the facility's policy.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate care for a resident who was unable to perform activities of daily living, specifically in maintaining personal hygiene. The resident, who had moderate cognitive impairment and was diagnosed with bipolar disorder, COPD, and bilateral hip osteoarthritis, was left in a wet diaper for over five hours. This situation arose when the resident initially refused a diaper change at 9:30 am, requesting the CNA to return later. The CNA, after attending to other residents and taking a lunch break, did not return to check on the resident until after lunch, at which point the resident's call light was on. Upon returning, the CNA found the resident's diaper to be extremely wet, acknowledging that this could lead to skin breakdown and discomfort. The CNA admitted that she should have informed the charge nurse of the resident's refusal and arranged for another staff member to assist before going to lunch. The Director of Nursing confirmed that CNAs are expected to notify the charge nurse in such situations to prevent prolonged exposure to wet conditions, which can cause skin issues and discomfort. The facility's policy emphasizes treating residents with respect, kindness, and dignity, ensuring equal access to quality care.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure timely refilling of Norco, a controlled medication for severe pain, for a resident. The resident, who was admitted with diagnoses including bipolar disorder, COPD, and bilateral hip osteoarthritis, had an active order for Norco 7.5-325 mg to be taken every six hours as needed. However, there was a gap in availability from November 24, 2025, to December 3, 2025, during which the resident did not receive the medication. Instead, the resident was given tramadol and repositioned for comfort while waiting for authorization from the physician. The Licensed Vocational Nurse (LVN) acknowledged the importance of documenting the process in the resident's health records to ensure follow-up and continuity of care, which was not done in this case. Additionally, the facility failed to remove a discontinued medication from the medication cart. A discontinued Hydrocodone-Acetaminophen tablet for another resident was found in the cart, despite the order to discontinue it on January 27, 2025. The LVN responsible stated that discontinued medications should be removed immediately to prevent medication errors. The facility's policy requires that discontinued medications be destroyed or returned to the pharmacy, but this was not adhered to, as evidenced by the presence of the medication in the cart.
Failure in Hand Hygiene Practices by CNA
Penalty
Summary
The facility failed to implement proper infection control practices when a Certified Nursing Assistant (CNA) did not perform hand hygiene between caring for different residents. Specifically, the CNA was observed adjusting a splint for one resident and then immediately touching another resident's call light and blanket without sanitizing her hands. The CNA admitted to not using the alcohol-based hand sanitizer and instead used alcohol pads, which is not in accordance with the facility's infection control policy. Resident 1, who was involved in this incident, had been admitted to the facility with diagnoses including bipolar disorder, chronic obstructive pulmonary disease (COPD), and bilateral hip osteoarthritis. The resident also had moderate cognitive impairment as indicated by the Minimum Data Set (MDS). The facility's policy requires staff to perform hand hygiene before and after direct contact with residents to prevent the spread of infection. Interviews with the Infection Preventionist nurse and the Director of Staff Developer confirmed that all staff were educated on the importance of hand hygiene, emphasizing the 'gel in and gel out' practice.
Failure to Ensure Safe Discharge Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure a safe discharge plan for a resident with cognitive impairment and the inability to make medical decisions. The resident was taken from the facility against medical advice by a significant other, who was not authorized to make medical decisions on behalf of the resident. The facility was aware of the significant other's intention to remove the resident five days prior but did not develop a discharge plan or notify the resident's physician of the situation. As a result, the resident's whereabouts were unknown for two days, and he was later found in a homeless encampment under unsafe and unsanitary conditions. The resident, who was non-ambulatory, incontinent, and required medication for multiple medical conditions, was found without necessary care or provisions. The facility did not assess the resident's medical condition upon locating him, nor did they call emergency medical services to evaluate his need for hospitalization. Instead, the facility allowed the resident and the significant other to sign an AMA form without ensuring the resident's safety or ability to care for himself outside the facility. Interviews with facility staff revealed that they were aware of the significant other's intentions but failed to take appropriate actions to prevent the unauthorized removal. The facility's policies and procedures for discharge and AMA situations were not followed, leading to the resident being placed in a potentially life-threatening situation without proper care or support.
Removal Plan
- Facility staff went to a homeless encampment at a park, located two miles from the facility. The DON drove by the local area park again where Resident 1 and his Responsible Party were found. The DON confirmed that this was Resident 1. Resident 1 was not in any distress and had no signs of diminished cognitive response. Resident 1 was sitting in a wheelchair, his breathing was even and unlabored, he was asked his full name and date of birth, and he was able to respond appropriately. The DON called 911 and the paramedics arrived while the DON remained at the park. The paramedics asked Resident 1 if they could assess him, and he refused. The paramedics offered to take the Resident 1 to the hospital, he and the significant other refused. The paramedics informed the ADM and the DON that they could not force Resident 1 to go to the hospital against and they had a right to refuse. Resident 1 refused transport with the paramedics and refused an offer to return to the facility. The facility offered Resident 1 and the significant other supplies, but Resident 1 and the significant other told facility representatives to stop bothering them. The DON attempted to notify the Resident 1's Physician. The Physician was notified that Resident 1 refused to come back to the facility or go to the hospital to be evaluated.
- The facility reviewed Resident 1's medical records, which were available during Resident 1's admission and confirmed the significant other was listed as his Responsible Party in his previous hospital records and his facility history and physical. The facility also confirmed that Resident 1 and the significant other once resided at the same address. The significant other refused to provide any identifying information to the paramedics or facility representatives because the significant other said that information was personal. The significant other introduced herself to the paramedics as Resident 1's wife and caretaker.
- The facility Social Services Director, DON and Minimum Data Set nurse reviewed documents for all residents discharged in the past months. No deficient practices were identified. No other residents left the facility AMA in the past 3 months.
- The Continuous Quality Improvement Nurse Consultant in-serviced all licensed nurses who were present and the Interdisciplinary Team on the facility's policy and procedure pertaining to the discharge process, discharge planning, AMA, and care for residents with cognitive impairment and physical limitations. In-services were done with licensed nurses who were present on all shifts. Staff who were not present for the in-services will be in-serviced via phone and will be asked to sign the in-service form upon return to the facility. If unable to in-service via phone, staff will be in-serviced upon returning to work. Staff will not be returned to the floor until in-serviced.
- The DON and CQI Nurse Consultant reviewed all current residents' records for presence of information about the responsible party, including contact information and followed up to request information for any residents missing this information. No discrepancies were found.
- The facility will initiate discharge planning with the resident or resident's representative if the resident has no capacity to make decisions during initial social service assessment and discuss the discharge process and plan during the initial IDT care conference within one week of admission if the resident or representative agree and are available.
- When a resident or resident's representative expresses the desire to leave the facility, the social service will call for a discharge plan meeting to discuss the resident's post discharge needs unless the plan is already in place. If a resident or representative expresses the desire or intention to leave facility AMA and the physician determines the resident is not ready for discharge and will not issue a discharge order, the facility will present the resident or the representative with information regarding the risks and the consequences of leaving and request that they sign an AMA form. The Physician will be notified regarding the AMA.
- In the event that a resident leaves the facility without notice, the facility staff will assess the resident for any signs of injury or change of condition once located. The facility may transfer the resident to the emergency department for further evaluation if needed and the resident will be returned to the facility if the resident or the representative agrees. The facility will involve emergency services personnel as necessary.
Resident Removed from Facility by Unauthorized Person
Penalty
Summary
The facility failed to ensure the safety and supervision of a resident with severe cognitive impairment and multiple medical conditions, resulting in the resident being taken out of the facility by an unauthorized person. The resident, who was non-ambulatory and dependent on staff for activities of daily living, was removed by a significant other who had no documented contact information and had previously refused to sign admission documents or provide contact details. The facility was unaware of the resident's whereabouts for two days until he was found in a homeless encampment, exposed to poor weather and unsanitary conditions without necessary medications or care. The resident's medical history included metabolic encephalopathy, post-stroke hemiplegia, functional quadriplegia, hypertension, dysarthria, benign prostatic hypertrophy, urinary tract infection, hypothyroidism, generalized weakness, and a history of repeated falls. Despite these conditions, the facility did not have a responsible person listed for the resident, only a contact person with no contact information. The resident's care plan indicated a need for retraining in skills for community return, but there was no effective communication or intervention to prevent the unauthorized removal. Interviews with facility staff revealed a lack of communication and monitoring regarding the significant other's intentions to take the resident out of the facility against medical advice (AMA). The facility's weekend receptionist, who remotely opened the front door for the resident and the significant other, was not informed of the situation. The Director of Nursing acknowledged awareness of the significant other's intentions but failed to notify the resident's physician or implement a care plan to address the risk. The facility's policy on safety and supervision was not effectively followed, leading to the resident's unsafe removal and subsequent exposure to hazardous conditions.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential food contamination risks. During an observation, it was noted that several opened food items, including Simply thick easy mix, horseradish sauce, bread, and hamburger buns, were not labeled with the date they were opened. This oversight was acknowledged by a staff member, who confirmed that these items should have been dated. Additionally, the dry storage area was found to be unclean, with a banana peel observed on top of kitchen supplies, which a dietary aide agreed to remove. Further deficiencies were identified in the storage temperatures of the residents' refrigerator and freezer. The refrigerator was found to be operating at 42 degrees Fahrenheit, and the freezer at 8 degrees Fahrenheit, both above the recommended temperatures for safe food storage. The Activities Director acknowledged these issues and indicated that maintenance would be notified to address the temperature discrepancies. The facility's policies and procedures, as well as federal guidelines, emphasize the importance of maintaining proper food storage temperatures to prevent foodborne illnesses.
Failure to Obtain Consent and Physician Orders for Bed Placement as Restraints
Penalty
Summary
The facility failed to ensure that three residents were assessed for the use of physical restraints, received informed consent, and had a physician order for their beds being placed against the wall. This practice was observed for three residents, all of whom had severely impaired cognition and were dependent on staff for various activities of daily living. The placement of beds against the wall was considered a form of restraint as it restricted the residents' freedom of movement, and there was no documentation of informed consent or physician orders for this arrangement. During observations, the beds of the three residents were noted to be against the wall, and interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that this setup could be considered a restraint. The facility's policy on the use of restraints requires informed consent, a restraint assessment, and a physician order, none of which were present in the cases of these residents. The policy also emphasizes the need for a pre-restraining assessment to explore less restrictive interventions, which was not conducted for these residents.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately assess and code the Minimum Data Set (MDS) for two residents, leading to potential deficiencies in care planning and service provision. For Resident 1, the facility did not correctly code Section GG 0115 of the MDS to reflect the resident's functional limitations in the range of motion (ROM) of both arms. Despite the Occupational Therapy Joint Mobility Assessment indicating moderate to severe ROM loss in both arms, the MDS was incorrectly coded to show no ROM limitations. This discrepancy was confirmed by the MDS Nurse, who acknowledged that the incorrect coding could lead to inaccurate care planning. Resident 1 was admitted with diagnoses including cataracts, rheumatoid arthritis, and contracture of the upper arm. Observations and interviews revealed that Resident 1 had significant difficulty moving both arms, particularly the right arm, which was consistent with the findings of the Joint Mobility Assessment. The resident expressed reliance on staff for all daily care, highlighting the importance of accurate MDS coding to ensure appropriate care and services. For Resident 25, the facility failed to document the diagnosis of anxiety disorder in the MDS, despite the resident being prescribed and taking antianxiety medication. The resident's medical records, including the Order Summary Report and psychiatric visit progress reports, indicated a diagnosis of generalized anxiety disorder and the use of buspirone for treatment. Interviews with facility staff confirmed the resident's diagnoses, including anxiety, yet the MDS did not reflect this, potentially impacting the monitoring and care provided to the resident.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure the availability of essential medications for three residents, leading to deficiencies in medication administration. Resident 5 was supposed to receive magnesium oxide as per the physician's order, but the medication was not in stock, and the LVN was confused about the strength on the bottle. This oversight could potentially affect the resident's magnesium levels, leading to muscle cramps and weakness. The Director of Nursing acknowledged that missing doses could result in abnormal magnesium levels, affecting the heart and causing muscle weakness. Resident 28 did not receive lactulose solution for bowel management due to the facility running out of the medication. The LVN noted that the absence of this medication increased the risk of bowel impaction, potentially leading to emergency situations or hospitalization. Additionally, Resident 28 was administered aspirin in a manner inconsistent with the physician's order, as the chewable tablet was swallowed instead of chewed, which could delay its effectiveness in preventing heart complications. Resident 202 was not administered gabapentin for neuropathic pain because the medication was not delivered by the pharmacy. The LVN reported that the resident experienced significant pain, rated at 9 out of 10, and refused an alternative pain medication. The delay in medication delivery was attributed to an error in entering the medication as house stock. The DON confirmed that untreated pain could lead to discomfort and affect the resident's ability to perform daily activities.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for two residents, leading to deficiencies in medication administration and informed consent. For one resident, the facility did not specify a duration for the PRN Lorazepam order, failed to implement non-pharmacological interventions before administering the medication, and did not conduct behavior monitoring or obtain informed consent. This resident had a history of major depressive disorder, chronic pain syndrome, and cancer, and required significant assistance with daily activities. Another resident was administered Mirtazapine for major depressive disorder without updated informed consent reflecting the increased dosage and changed behavior monitoring. This resident, diagnosed with dementia, major depressive disorder, and anxiety, was unable to make medical decisions independently. The facility's failure to obtain new informed consent and monitor the resident's behavior for medication effectiveness was confirmed by a registered nurse supervisor. The facility's policies required monitoring for effectiveness and adverse reactions of psychotropic medications, attempting alternative behavior management before medication use, and obtaining informed consent for specific dosages. However, these policies were not followed, as evidenced by the lack of specified duration for PRN medications, absence of non-pharmacological interventions, and outdated informed consent documentation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during medication administration, resulting in a 13.33% error rate. This deficiency was observed in the cases of three residents. For one resident, the facility did not have magnesium oxide in stock, which was prescribed to treat low magnesium levels. The Licensed Vocational Nurse (LVN) was confused about the strength of the available magnesium oxide and did not administer it, potentially affecting the resident's magnesium levels and causing muscle cramps and weakness. Another resident did not receive their prescribed lactulose solution due to it being out of stock, which was necessary for bowel management. Additionally, the resident was given aspirin in a form that was not chewed as required, which could delay its effectiveness. The LVN acknowledged the error and the potential risk of heart complications due to the improper administration of aspirin. A third resident did not receive gabapentin for neuropathic pain because the medication was not available. The resident reported significant pain, and the LVN noted that the medication request was delayed due to an administrative error. This oversight left the resident in pain, which could lead to increased blood pressure and affect their mood.
Infection Control and Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube, as there were no physician orders or documentation for EBP. A Certified Nurse Assistant (CNA) was observed providing care to the resident without wearing an isolation gown, despite a sign indicating the need for gown and gloves for high-contact care. The CNA admitted to forgetting to use the gown, and the Registered Nurse Supervisor confirmed the absence of physician orders for EBP, emphasizing the need for such orders to ensure proper care under physician supervision. Additionally, the facility did not maintain a clean and sanitary environment for medication storage. A red incinerator bin with an open lid containing liquid was found in a medication cart, posing a risk of contamination to nearby medications. The Licensed Vocational Nurse (LVN) responsible for the cart was unaware of when the bin was placed there and acknowledged the risk of contamination and infection control issues. The Director of Nursing (DON) also recognized the potential for spillage and contamination due to the open bin. The facility's policies and procedures for infection prevention, physician services, and medication storage were reviewed, indicating the need for a safe and sanitary environment and proper documentation and implementation of care practices. However, these policies were not followed, leading to the deficiencies observed during the survey.
Failure to Provide Simultaneous Feeding Assistance
Penalty
Summary
The facility failed to ensure that a resident received feeding assistance at the same time as another resident, resulting in an undignified dining experience. Resident 23, who was admitted with diagnoses including age-related cataract, vision loss, hearing loss, and unspecified osteoarthritis, was dependent on staff for eating due to severely impaired cognition. The resident was on a regular diet with mechanical soft texture. During an observation, it was noted that Resident 23 was waiting for feeding assistance while Resident 17, who also had severely impaired cognition and was dependent on staff for eating, was being assisted by a Certified Nurse Assistant (CNA). Resident 17 was on a regular diet with pureed texture. The CNA stated that there was insufficient staff to assist both residents simultaneously, leading to one resident having to wait while the other was being fed. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the staff needed to be sensitive to residents requiring feeding assistance and that it was a dignity issue if residents did not eat at the same time. The facility's policy on Resident Rights emphasized treating all residents with kindness, respect, and dignity, which was not upheld in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was within reach for a resident, which had the potential to prevent the resident from receiving necessary care and services. The resident, who was admitted with diagnoses including cataracts, rheumatoid arthritis, and contracture of the upper arm, had severely impaired vision, difficulty hearing, and severely impaired cognition. The resident required assistance with various daily activities and was assessed as having a high fall risk. During an observation, the resident's call light was found on the floor, out of reach, and the resident was unable to locate it due to her impaired vision. Licensed Vocational Nurse 1 confirmed that the call light was out of reach and stated that it should always be in the resident's hands to ensure accessibility. The Director of Nursing also stated that call lights should always be accessible and within reach to allow residents to call for assistance. The facility's policy indicated that call lights should be within easy reach of residents to ensure their needs and requests are met. This deficiency was identified through observation, interview, and record review, highlighting a failure to accommodate the resident's needs and preferences effectively.
Inaccurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a mental disorder, which is a federal requirement to ensure appropriate placement and services. The resident, identified as Resident 19, was admitted with diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD). Despite these diagnoses, the PASARR Level I screening inaccurately indicated that the resident did not have a mental disorder, which should have triggered a Level II PASARR for a comprehensive evaluation. During interviews and record reviews, it was confirmed by the MDS nurse that the resident's PASARR Level I screening was incorrect and should have indicated the presence of a mental disorder, the prescription of psychotropic medications, and the experience of symptoms. The Director of Nursing also acknowledged that Level II PASARR is necessary for residents with mental disorders to ensure they receive the appropriate assistance. The facility's policy on PASARR, revised in May 2023, outlines the federal requirement to evaluate all applicants for serious mental disorders and ensure they receive the necessary services in the most appropriate setting.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to potential delays in care and services. Resident 25, who was admitted with major depressive disorder, generalized muscle weakness, and a gastrotomy tube, was found to have severely impaired cognition and was dependent on staff for all activities of daily living. However, during a review of Resident 25's care plans, it was discovered that there was no care plan addressing the resident's activities, as confirmed by the registered Nurse Supervisor. Resident 1, admitted with cataracts, rheumatoid arthritis, and contracture of the upper arm, was identified as having severely impaired vision, difficulty hearing, and severely impaired cognition. Despite these conditions, Resident 1's care plan did not address the severe visual impairments. Observations revealed that Resident 1 was unable to see the television positioned close to her face and could not locate or reach the call light due to her visual impairment. The Minimum Data Set Nurse confirmed that a care plan with specific goals and interventions should have been developed for Resident 1's visual deficits, but none was in place. The Director of Nursing acknowledged the importance of developing and implementing care plans to guide resident care and treatment, emphasizing that the absence of such plans could impede continuity of care. The facility's policy and procedure on care plans, revised in March 2022, mandates the development and implementation of comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. However, the facility failed to adhere to this policy for Residents 1 and 25, resulting in deficiencies related to their care.
Failure to Update Care Plan for Tube Feeding
Penalty
Summary
The facility failed to revise a person-centered care plan for Resident 149, who was receiving artificial nutrition through a gastrostomy tube. The care plan, created on January 5, 2024, indicated that Resident 149 was to receive Diabeticsource 1.2 at 75 ml per hour for 10 hours daily, which was discontinued on June 27, 2024. However, a new physician's order was placed on June 27, 2024, for Glucerna 1.2 at 60 ml per hour for 20 hours daily. Despite this change, the care plan was not updated to reflect the new order, leading to a discrepancy between the care plan and the current physician's orders. Resident 149, who has diagnoses of dysphagia, cerebral palsy, and unspecified abnormal physiological development, was observed on October 15, 2024, receiving Glucerna 1.2 at 60 ml per hour. The MDS nurse confirmed that the care plan was not updated with the current feeding order, and the director of nursing emphasized the importance of accurate care plans for ensuring continuity of care. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in Resident 149's case.
Failure to Provide ROM Services Leads to Decline in Resident's Mobility
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent a decline in range of motion (ROM) for a resident identified as having ROM limitations in both legs and a decline in ROM of both hips. The resident, who was admitted with diagnoses including rheumatoid arthritis and contracture of the upper arm, had been discharged from physical therapy services after reaching her highest practical level of function. However, the recommended Restorative Nursing Aide Program to apply splints was not fully implemented, as there were no orders for ROM exercises for the legs. Observations and interviews revealed that the resident was not receiving assistance with leg exercises, and staff assumed that ROM exercises were being provided by others. The Restorative Nursing Aide and Certified Nursing Assistant both confirmed that they did not perform ROM exercises, and the Director of Rehabilitation acknowledged that a therapy evaluation should have been ordered when a decline in ROM was noted. The resident's Joint Mobility Assessments indicated a worsening of ROM in both hips, knees, and ankles over time, yet no additional therapy services were initiated. The facility's policies and procedures required that any changes in ROM be addressed through evaluations and communication with the interdisciplinary team. Despite these guidelines, the resident did not receive the necessary ROM services to prevent further decline, leading to a significant reduction in mobility and potential risk for contracture development.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper removal and storage of medications, leading to several deficiencies. In the medication room, an expired bottle of Folic Acid and discontinued Inbrija capsules for a resident were found. The Director of Nursing (DON) acknowledged that the expired Folic Acid should have been removed to prevent it from being administered, and the discontinued Inbrija should have been discarded immediately after the order was placed for discontinuation. The improper storage of these medications increased the risk of medication errors and misuse. Additionally, the facility did not store Brimonidine tartrate ophthalmic solution according to manufacturer requirements. The medication was found in the refrigerator alongside another resident's Latanoprost, which requires refrigeration. However, Brimonidine should be stored at room temperature. The DON confirmed that the Brimonidine was improperly stored, which could have rendered it ineffective and unsafe for treating the resident's glaucoma. Furthermore, an insulin Glargine prefilled pen for another resident was labeled with two different opened dates, contrary to the manufacturer's requirements. This discrepancy posed a risk of administering expired insulin, potentially compromising the resident's treatment for high blood sugar levels. The DON stated that the facility staff is required to label medication containers with an opened date and follow the standard for insulin expiration, which was not adhered to in this case.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
