Creekside Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 3580 Payne Avenue, San Jose, California 95117
- CMS Provider Number
- 055884
- Inspections on file
- 32
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Creekside Post-acute during CMS and state inspections, most recent first.
A resident with chronic venous ulcers did not have a wound care order transcribed onto the TAR, as confirmed by a treatment nurse during review. This omission meant the prescribed wound care might not have been administered as ordered.
A CNA assisted a resident with repositioning an ice wrap on the knee, removed gloves, and exited the room without performing hand hygiene. The CNA acknowledged the lapse, and facility policy requires hand sanitizing after glove removal and resident contact, as confirmed by the infection preventionist.
A resident with a history of heart failure had a change in code status from Full Code to DNR, but the facility failed to promptly communicate and document this change in the EMR. During a medical emergency, staff and EMS found conflicting POLST forms, leading EMS to perform CPR based on outdated information, contrary to the resident's wishes. Staff interviews confirmed lapses in communication, documentation, and record management.
A resident admitted after a surgical amputation experienced a decline in mental status, but the nurse did not notify the physician as required, instead leaving a message in a communication binder. Additionally, a wound care order for daily dressing changes from the hospital was not transcribed into facility orders, resulting in no dressing changes for two days.
A resident with a history of a humerus fracture and muscle weakness was discharged home with a family member and a home health agency referral. However, the MDS inaccurately indicated discharge to a hospital. Interviews with staff confirmed the coding error, with expectations for accurate MDS coding expressed by the DON and Administrator.
The facility failed to ensure accurate and timely PASRR screenings for two residents. One resident's Level I screening did not reflect a diagnosis of paranoid schizophrenia, while another resident's screening was not updated after their stay exceeded 30 days. Staff interviews revealed lapses in verifying and updating PASRR screenings.
A resident at moderate risk for falls was left unattended in a shower room, resulting in a fall, while another resident with cognitive impairment had unsecured bed rails, posing a safety hazard. Staff failed to provide necessary supervision and did not identify or report the loose bed rails, leading to deficiencies in maintaining a safe environment.
The facility failed to complete and submit the Discharge MDS for three residents within the required timeframes, resulting in non-compliance with CMS regulations. The MDS coordinator confirmed the oversight, acknowledging that the assessments were overdue and not submitted as required by federal guidelines.
A resident with multiple wounds did not receive consistent weekly wound assessments as required by the facility's policy. Despite having serious conditions like sepsis and diabetes, the resident's wounds on the toes, knee, mid spine, and perianal area were not assessed for several weeks. The DON confirmed these lapses, which could affect wound healing progress.
The facility was found to have unsafe flooring conditions, with multiple holes in the hallway and rehabilitation area. Maintenance staff acknowledged the unsafe condition, which contradicts the facility's policy requiring floors to be maintained in a clean, safe, and sanitary manner.
A resident with end-stage renal disease fell from a wheelchair due to improper positioning by a CNA, who failed to notify a nurse for assessment before transferring the resident back. The facility also did not document the incident correctly, violating its policies.
The facility failed to conduct a criminal background check for a re-hired CNA before they began working with residents, contrary to its policy. The CNA returned to work without the required check, which was completed over nine months later, potentially compromising resident safety.
A resident with peripheral vascular disease and osteoarthritis experienced recurrent skin tears during transfers due to inadequate investigation and documentation by the facility. Despite multiple incidents, the facility failed to determine the exact causes, leading to repeated injuries. The DON confirmed the lack of follow-up investigations, and the facility's policies requiring thorough investigations were not adhered to.
A resident with peripheral vascular disease and osteoarthritis frequently refused the RNA program, but the facility failed to notify her physician in a timely manner and did not update her care plan to address these refusals. Despite the refusals being reported to an LVN, there was no documentation of physician notification or a revised care plan, as confirmed by the DON.
A resident with cognitive impairment was found with another resident's hands inside her diaper due to inadequate monitoring of the latter's wandering behavior. Despite a history of entering other residents' rooms, there was no specific care plan or monitoring in place for the resident with wandering behavior, leading to a violation of the facility's abuse prevention policy.
Failure to Transcribe Wound Care Order to Treatment Record
Penalty
Summary
A resident with a diagnosis of chronic venous hypertension and bilateral lower extremity ulcers was admitted to the facility. The resident received a treatment order from the wound physician to cleanse a venous ulcer on the right lower lateral leg with normal saline, apply Xeroform, and cover with a dry dressing and Kerlix. However, review of the Treatment Administration Record (TAR) for the relevant month showed that this treatment order was not transcribed onto the TAR. During an interview, the treatment nurse confirmed that the wound care order was not present on the TAR, acknowledging that the wound might not receive the prescribed treatment if the order was not documented for licensed nurses to follow. The facility's policy requires that drug and biological orders be recorded on the physician's order sheet in the resident's chart, but this was not done for the resident's wound care order.
Failure to Perform Hand Hygiene After Resident Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow infection control practices after assisting a resident who had a physician's order for ice therapy to the knee. The CNA entered the resident's room, donned gloves, and repositioned the ice wrap on the resident's knee as requested. After completing the task, the CNA removed her gloves and exited the resident's room into the hallway without performing hand hygiene. During an interview, the CNA acknowledged that she should have sanitized her hands upon leaving the room. The facility's infection control policy requires staff to use alcohol-based hand rub or soap and water after direct resident contact and after removing gloves, and specifies that glove use does not replace hand hygiene. The infection preventionist confirmed that staff are expected to sanitize their hands when leaving residents' rooms.
Failure to Communicate and Document Resident Code Status Results in Inappropriate CPR
Penalty
Summary
The facility failed to ensure proper communication and documentation of a resident's code status, resulting in confusion among staff regarding whether to perform resuscitation efforts. The case manager did not immediately communicate the change in the resident's code status from Full Code to Do Not Resuscitate (DNR) after receiving a new POLST form from the resident's daughter, which was signed by both the resident and her attending physician. Additionally, the previous POLST indicating Full Code was not promptly removed from the electronic medical record (EMR), and the change in code status was not immediately documented in the EMR after verification with the resident and her daughter. This lack of timely communication and documentation led to conflicting information in the resident's medical records. When the resident became unresponsive, staff and emergency medical services (EMS) encountered two different POLST forms: one indicating DNR and another indicating Full Code. The EMS team questioned the validity of the DNR POLST due to a missing back page and ultimately relied on the Full Code POLST found in the EMR, leading them to initiate CPR, which was inconsistent with the resident's confirmed wishes. Interviews with facility staff revealed that the case manager acknowledged the failure to remove the outdated POLST from the EMR and to document the confirmed DNR status in a timely manner. Nursing staff were unaware of the voided status of the Full Code POLST and could not provide clear guidance to EMS during the emergency. The director of nursing also confirmed that the updated POLST had not been uploaded to the EMR. The facility's own performance improvement project identified root causes including dual POLST forms, incomplete documentation, and lack of clear workflow for verifying POLST accuracy during emergencies.
Failure to Notify Physician and Implement Wound Care Orders
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the physician after a resident experienced a significant change in mental status. The resident, who was admitted following an orthopedic surgical amputation, was initially alert and oriented to person, place, and time. However, nursing progress notes documented a decline to being alert and oriented to person only. Instead of directly notifying the physician as required by facility policy and the hospital discharge instructions, the nurse left a message in the facility's communication binder regarding the change in condition. Additionally, the facility failed to transcribe and implement a wound care order from the resident's hospital discharge instructions. The discharge orders specified daily dressing changes for the surgical site, but this order was not entered into the SNF physician orders or the Treatment Administration Record. As a result, the wound dressing was not changed for two days. Both the wound care nurse and the DON confirmed that the wound care order was missing from the resident's SNF orders, and the wound care nurse was unaware of the need for dressing changes during that period.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident, specifically regarding the discharge status. The resident, who had a medical history including a humerus fracture, history of falling, and muscle weakness, was admitted to the facility and later discharged home with a family member and a referral to a home health agency. However, the discharge-return not anticipated MDS inaccurately indicated that the resident was discharged to a short-term general hospital. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the error in coding. The MDS Coordinator acknowledged the incorrect coding, stating that the resident was discharged home, not to a hospital. Both the DON and the Administrator expressed their expectation for accurate MDS coding, highlighting the discrepancy between the documented discharge plan and the MDS coding.
Deficiencies in PASRR Screening for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy and timely submission of Level I Preadmission Screening and Resident Reviews (PASRRs) for two residents. Resident #41 was admitted with a diagnosis of paranoid schizophrenia, which was not reflected in the Level I PASRR screening completed by the hospital prior to admission. The screening inaccurately indicated that the resident did not have a serious mental disorder and was not prescribed psychotropic medication, leading to the conclusion that a Level II evaluation was not required. Both the MDS Coordinator and the Director of Nursing acknowledged the oversight in not verifying the accuracy of the hospital-completed screening. For Resident #70, the facility did not submit a Level I PASRR screening after the resident remained in the facility longer than 30 days, despite the initial screening indicating a serious mental disorder and the use of psychotropic medications. The resident was initially considered exempt from the PASRR process due to an expected stay of less than 30 days following a hospital discharge. However, the MDS Coordinator admitted that the facility failed to review and update the PASRR screening when the resident's stay extended beyond the 30-day exemption period. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed a lack of adherence to the PASRR process and a failure to ensure the accuracy and completeness of the screenings. The Administrator was not involved in the PASRR process but expected compliance with the guidelines. These deficiencies highlight lapses in the facility's procedures for managing PASRR requirements, particularly in verifying and updating screenings as necessary.
Inadequate Supervision and Hazardous Environment in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who was at moderate risk for falling. The resident, who had a medical history of muscle weakness, difficulty in walking, spinal stenosis, and muscle spasms, required partial/moderate assistance with bathing and supervision during transfers. Despite this, a CNA left the resident alone in the shower room to obtain linens, resulting in the resident sliding out of the shower chair and falling to the floor. The CNA acknowledged awareness of the need for supervision but left the resident unattended due to the inconvenience of wet towels. In another incident, the facility failed to ensure the environment was free of accident hazards for a resident with a history of falls and cognitive impairment. The resident, who was totally dependent on staff for bed mobility and transfers, had bed rails that were not secure. Observations revealed a loose bed rail with a gap between the bed and the rail, which could pose a risk of falling. Staff members, including CNAs and LVNs, were unaware of the loose bed rail, and the issue was not reported to maintenance. The facility's policy required periodic checks for bed rail safety, but there was no documentation of these checks. The Director of Nursing and the Administrator both stated that staff should identify and report hazards, such as loose bed rails, to ensure resident safety. However, the loose bed rail was not brought to their attention, and the facility did not have a documented process for checking the bed rails regularly. The lack of supervision and failure to maintain a hazard-free environment contributed to the deficiencies identified in the report.
Failure to Timely Submit Discharge MDS for Residents
Penalty
Summary
The facility failed to complete and submit the Discharge Minimum Data Set (MDS) for three residents within the required timeframes, resulting in non-compliance with CMS regulatory requirements. Resident 1 was discharged on 9/14/24, Resident 2 on 9/13/24, and Resident 3 on 9/17/24. As of 11/6/24, the discharge MDS for all three residents were overdue, still in progress, and not submitted to CMS. This was confirmed during an interview with the MDS coordinator, who acknowledged that the discharge MDS should have been completed within 14 days and submitted within 28 days post-discharge. The facility's policy, dated 7/2017, assigns the responsibility of ensuring timely submission of resident assessments to the assessment coordinator or designee, in accordance with federal and state guidelines. The CMS's Resident Assessment Instrument (RAI) Manual specifies that the discharge MDS Completion Date should be no later than 14 days after discharge, and the Transmission Date should be no later than 14 days after the Completion Date. The failure to adhere to these guidelines led to the deficiency noted in the report.
Inconsistent Wound Assessments for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services as required, specifically in the consistent completion of weekly wound assessments. The resident, who was admitted with serious conditions including sepsis, atelectasis, and diabetes, had multiple wounds on various parts of the body, including the toes, knee, mid spine, and perianal area. Despite the requirement for weekly assessments, the wounds on the resident's toes, knee, and mid spine were not assessed for several weeks at different intervals, and the perianal wound was not assessed until several months after the order was given. The Director of Nursing confirmed the lapses in the wound assessments during an interview, acknowledging that the assessments were not conducted as required by the facility's policy. The facility's policy mandates a comprehensive skin assessment with every risk assessment, and documentation of findings on a facility-approved skin assessment tool. The failure to conduct these assessments resulted in an undetermined wound status, which could potentially affect the progress of wound healing for the resident.
Unsafe Flooring Conditions in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for residents and staff due to the presence of multiple holes in the flooring. During an observation, it was noted that the hallway in front of nursing station 3 had a hole measuring 6 x 3 x 0.5 inches below the handrail. Additionally, the rehabilitation area contained eight holes, each measuring 5 3/4 x 3/4 x 0.5 inches. During a concurrent interview, maintenance staff acknowledged that the condition of the floor was not good and not safe. The facility's policy from December 2009 requires that floors be maintained in a clean, safe, and sanitary manner.
Failure to Ensure Resident Safety and Proper Documentation
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 1, who was at risk due to improper positioning in a wheelchair by a Certified Nursing Assistant (CNA A). The resident, who had end-stage renal disease and was dependent on staff for transfers, was not positioned correctly in the wheelchair, with her buttocks only halfway in. This improper positioning led to the resident sliding off the wheelchair and falling to the bathroom floor. Despite the fall, CNA A did not immediately notify a Licensed Nurse (LN) to assess the resident for possible injuries before transferring her back to the wheelchair and then to bed. Interviews with various staff members, including Licensed Vocational Nurses (LVN B and LVN D), other CNAs, and the Director of Staff Development (DSD), confirmed that the standard procedure was not followed. The staff emphasized the importance of ensuring that a resident's buttocks are fully positioned in the wheelchair to prevent falls and the necessity of notifying a Charge Nurse immediately after any fall, whether witnessed or unwitnessed, for an assessment of possible injuries. The CNA A admitted to not following these procedures, which are outlined in the facility's policies and procedures. Additionally, the facility failed to document the correct information regarding the fall incident in Resident 1's medical records. Despite interviews conducted by the Director of Nursing (DON) and the DSD with CNA A, the accurate details of the incident were not recorded. The facility's policies require thorough documentation of fall incidents, including the cause and details of how the fall occurred, but this was not adhered to in this case.
Failure to Conduct Timely Background Check for Re-hired CNA
Penalty
Summary
The facility failed to implement its policy and procedure related to staff screening procedures for hiring direct access employees. Specifically, the facility did not conduct a criminal background check for a Certified Nursing Assistant (CNA A) prior to re-employment. CNA A had gone on vacation and did not return for over 90 days. Upon re-hiring CNA A, the facility allowed them to start working with residents the day after re-employment without completing the required criminal background check. This oversight was confirmed during an interview and record review with the Director of Staff Development (DSD), who admitted to forgetting to complete the background check before rehiring CNA A. The facility's policy, revised in March 2019, mandates that background checks, including criminal conviction investigations, be conducted on all applicants for positions with direct access to residents. These checks are to be initiated within two days of an employment offer and completed before employment begins. However, in this case, the criminal background check for CNA A was not completed until more than nine months after they were re-hired. This lapse in following the established procedure had the potential to compromise resident safety.
Failure to Investigate Recurrent Skin Tear Incidents
Penalty
Summary
The facility failed to ensure the safety of a resident by not thoroughly investigating the root causes of recurrent skin tear incidents during transfers from bed to wheelchair and after using the bathroom. The resident, who had peripheral vascular disease, osteoarthritis, muscle weakness, and moderately impaired cognition, experienced four skin tear incidents on her lower legs over several months. Despite these incidents, there was no comprehensive investigation or documentation to determine the exact causes of the skin tears. The resident's medical records and care plans indicated that she required partial/moderate assistance during transfers and had no impairment in her extremities. However, interviews with staff revealed that the resident's legs were repeatedly caught in the wheelchair during transfers, leading to skin tears. The facility's Director of Nursing confirmed the lack of documentation and follow-up investigations for these incidents, acknowledging that they should have been investigated and documented. The facility's policies and procedures required complete investigations of resident injuries and documentation of findings, but these were not followed in the case of the resident's skin tears. The interdisciplinary team records also lacked detailed discussions of the incidents, and care plan interventions did not adequately address the underlying causes of the skin tears. This lack of thorough investigation and documentation contributed to the recurrence of the incidents.
Failure to Notify Physician and Update Care Plan for RNA Program Refusals
Penalty
Summary
The facility failed to provide adequate care and services for a resident by not notifying the resident's physician about her repeated refusals to participate in the Restorative Nursing Assistant (RNA) program in a timely manner. The resident, who was admitted with diagnoses including peripheral vascular disease, osteoarthritis, muscle weakness, and gait abnormalities, frequently refused the RNA ambulation and omni cycle programs. Despite these refusals being reported to a Licensed Vocational Nurse (LVN), there was no documentation of physician notification during May 2024, as confirmed by the LVN and the Director of Nursing (DON). Additionally, the facility did not update the resident's care plan to address her frequent refusals of the RNA program. The resident's care plan initially included participation in the RNA program to maintain gait function and strength, but her refusals were not incorporated into a revised nursing care plan. The DON acknowledged that the licensed nurses should have notified the physician within seven days of the refusals and initiated a nursing care plan to address the issue, as per the facility's policies and procedures.
Failure to Prevent Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from unwanted touching, resulting in a deficiency related to abuse prevention. A receptionist discovered a resident with cognitive decline and wandering behavior inside another resident's room, with his hands inside her diaper. The resident who was touched had severe cognitive impairment due to late-onset Alzheimer's disease and was unable to respond verbally or make eye contact during observations. The incident occurred because the facility did not have adequate monitoring in place for the resident with wandering behavior, despite his history of entering other residents' rooms and taking their belongings. The facility's staff, including a licensed vocational nurse and a certified nursing assistant, confirmed the incident and noted that the resident who wandered had previously been known to enter other residents' rooms. However, there was no specific care plan addressing his wandering behavior, and monitoring of his whereabouts was not implemented until after the incident. The facility's policy on abuse prevention was not effectively followed, as the resident's right to be free from abuse was compromised. Interviews with staff and a review of the facility's policy highlighted the lack of a specific plan to monitor the resident's wandering behavior. The facility's failure to implement appropriate monitoring measures and address the resident's behavior led to the incident, which was a violation of the resident's rights and the facility's abuse prevention policy.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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