Creekside Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Yucaipa, California.
- Location
- 35253 Avenue H, Yucaipa, California 92399
- CMS Provider Number
- 055557
- Inspections on file
- 34
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Creekside Post Acute during CMS and state inspections, most recent first.
A resident with idiopathic pulmonary fibrosis and chronic respiratory failure had multiple scheduled evening medications, including antihypertensives, lipid-lowering agents, an antiplatelet, gabapentin, a supplement, and pirfenidone. On one evening, the MAR for this resident showed no nursing signatures or documentation for any of the 8:00 PM to 10:00 PM doses. The DON confirmed the absence of documentation, and an LVN later stated he had administered the medications but forgot to record them, despite facility policy requiring immediate documentation of medication administration in the MAR/EMAR.
A resident with IPF and chronic respiratory failure had a physician’s order for Pirfenidone 801 mg by mouth every 8 hours, but three scheduled doses were not administered. Review of the MAR showed the missed doses, and two LVNs reported they did not give the medication because they could not locate it in the medication cart, with one LVN also not confirming availability with the prior nurse. The DON reported that expected nurse-to-nurse communication at shift change did not occur, and the facility’s own medication administration policy requiring adherence to physician orders was not followed.
Staff without appropriate qualifications completed and signed quarterly nutrition assessments for multiple residents, with no verification by a Registered Dietitian or other qualified personnel. This resulted in inaccurate documentation, including incorrect weight ranges, and affected the nutritional evaluation process for a large group of vulnerable residents.
Multiple food items in a resident refrigerator were found unlabeled and undated, and refrigerator temperatures were not monitored or recorded for two months. A Social Worker confirmed that facility policy requiring labeling, dating, and temperature monitoring was not followed, potentially affecting 25 medically compromised residents.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
Surveyors found that medications, including a blood thinner and wound ointment, were not properly labeled with expiration dates or resident identification, and that medication carts were left unlocked and unattended by nursing staff, contrary to facility policy.
Staff did not document discussions or offers of assistance regarding advance directives for two residents, one with acute respiratory failure and tracheostomy status and another with traumatic brain injury and chronic respiratory failure. Required sections in the medical records and POLST forms were left blank, and facility policy on advance directive documentation was not followed.
A resident with a documented diagnosis of schizophrenia did not have this condition accurately coded on their quarterly MDS assessment, despite ongoing psychiatric evaluation and clear documentation in medical records. The MDS nurse and IDON confirmed the omission and acknowledged that facility policy requiring accurate assessments was not followed.
A resident admitted with multiple diagnoses, including schizophrenia, did not have their PASARR updated or re-submitted after a new psychiatric diagnosis was documented. The MDS nurse acknowledged responsibility for updating the PASARR but did not complete this task, contrary to facility policy requiring all admissions to have appropriate PASARR documentation.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not implement adequate measures to prevent new ulcers from developing.
A resident with significant physical impairments and high fall risk fell from bed while being repositioned by a CNA, who rolled the resident away from herself and did not notice the resident was too close to the bed's edge. The incident resulted in uncontrolled pain and required hospital treatment. The facility lacked a policy on bed mobility or turning residents during care.
A resident with a tracheostomy and ventilator dependence did not have an AMBU bag at the bedside as required by facility policy. Staff confirmed the absence of the device, which was supposed to be immediately available for manual ventilation in emergencies, and were unable to locate it in the resident's room.
A resident with complex respiratory needs had conflicting code status orders (DNR and Full Code) documented in the EHR. The Interim DON confirmed the EHR was incorrect and should have only indicated DNR, and stated that licensed nurses are responsible for ensuring code status accuracy.
A CNA entered a Contact Precaution room of a resident with chronic respiratory failure and Candida Auris without donning the required PPE, specifically a gown and gloves, as mandated by facility policy. The CNA performed care tasks after only donning gloves inside the room, and staff interviews confirmed this was not in accordance with infection control procedures.
A facility failed to ensure proper management of G-tubes for three residents, as an LVN did not verify tube placement before administering medications. This oversight, involving residents with complex medical conditions, was against the facility's policy and increased the risk of aspiration.
A facility failed to ensure medications were explained to three residents before administration. An LVN administered medications without explanation to residents with various medical conditions, including acute respiratory failure and cerebral infarction. The DON confirmed that the facility's policies requiring explanation of medications and resident rights were not followed.
The facility failed to secure the medication refrigerator in the medication room, as it was found unlocked during a survey. The IP acknowledged the issue, and the DON confirmed that the facility's policy requires the refrigerator to be locked at all times. The policy also mandates that controlled medications be stored separately under double lock. This deficiency posed a risk of unauthorized access and potential harm to 49 residents.
A facility failed to document the Restorative Nursing Weekly Summary for a resident with limited range of motion. The resident had diagnoses including anoxic brain damage and muscle contractures, with orders for a Restorative Nursing Assistant program to maintain range of motion. However, documentation was missing for several weeks, as confirmed by staff and the Director of Nursing, who noted that the facility's policy on range of motion exercises was not followed.
Failure to Document Evening Medication Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to follow its medication administration and documentation policies for one resident on a specific evening medication pass. The resident, admitted with idiopathic pulmonary fibrosis and chronic respiratory failure with hypoxia, had multiple scheduled medications between 8:00 PM and 10:00 PM on December 31, 2025, including antihypertensives (losartan, amlodipine, carvedilol), lipid-lowering agents (atorvastatin, ezetimibe), a nutritional supplement (Pro-Stat), an antiplatelet (ticagrelor), a neuropathic pain medication (gabapentin), and pirfenidone for respiratory failure. Review of the December 2025 MAR showed that for this date, there were no nursing signatures or documentation indicating that any of these scheduled evening medications were administered. During a concurrent telephone interview and record review, the DON confirmed that the MAR lacked documentation that the resident received the scheduled 8:00 PM to 10:00 PM medications on that date. In a separate telephone interview, the LVN assigned to administer these medications stated that he did give all of the resident’s scheduled evening medications but forgot to document them on the MAR. He acknowledged that he should have signed the MAR immediately after administering the medications rather than waiting until the end of his shift. Facility policies titled “Specific Medication Administration Procedure” and “Medication Administration” required the licensed nurse to document medication administration in the MAR/EMAR after giving the medications, which was not done in this instance.
Failure to Administer Ordered Pirfenidone Doses as Prescribed
Penalty
Summary
Surveyors identified a deficiency in medication administration when a resident with idiopathic pulmonary fibrosis (IPF) and chronic respiratory failure with hypoxia did not receive the prescribed medication Pirfenidone on three documented occasions. The resident had a physician’s order, dated December 21, 2025, for Pirfenidone 801 mg by mouth every 8 hours at 6:00 AM, 2:00 PM, and 10:00 PM. Review of the December 2025 Medication Administration Record (MAR) showed missed doses on December 26 at 2:00 PM, December 27 at 2:00 PM, and December 28 at 10:00 PM. The facility’s policy and procedure for Medication Administration required that medications be administered in accordance with written physician orders. During interviews, LVN 1 acknowledged that he did not administer the resident’s Pirfenidone on December 26 and 27 at 2:00 PM because he could not find the medication in the cart and did not check with the previous nurse to determine if the medication was available. LVN 2 stated she did not administer the Pirfenidone dose on December 28 at 10:00 PM because she was unable to locate the medication in the cart. The DON stated that her expectation was that communication between nurses should occur during shift changes and acknowledged that this communication did not occur, resulting in the resident not receiving the medication as prescribed. The facility failed to ensure that Pirfenidone was administered according to the physician’s orders and its own medication administration policy.
Unqualified Staff Conducted Nutrition Assessments Without Proper Oversight
Penalty
Summary
The facility failed to ensure that staff with the appropriate competencies and skill sets completed residents' Quarterly Nutrition Assessments. Specifically, the Dietary Service Supervisors (DSS 1 and DSS 2), who were not qualified to perform such assessments, completed and signed off on these evaluations for multiple residents over several months. Record reviews confirmed that these assessments were not verified by any other qualified personnel, such as a Registered Dietitian (RD). During interviews, both the RD and the Interim Director of Nursing (IDON) confirmed that the DSS did not have the scope of practice or qualifications to conduct these assessments, and that the process lacked oversight from appropriately credentialed staff. One resident's assessment included an incorrect Ideal Body Weight Range (IBWR), which the RD could not verify and stated was not accurate. The lack of qualified staff conducting and verifying these nutrition assessments affected a group of 52 highly vulnerable residents, as the assessments are intended to identify nutritional deficiencies or risks and guide personalized interventions. The deficiency was identified through interviews and record reviews, which revealed that the assessments were being completed solely by unqualified staff without proper verification.
Failure to Safely Store and Monitor Resident Food
Penalty
Summary
The facility failed to store resident food safely by not labeling or dating multiple food items in the resident refrigerator and by not monitoring or recording the refrigerator's temperature for the months of June and July 2025. During an observation in the dining room, it was found that food items in the resident refrigerator were not labeled with names or dates, and two thermometers were located outside the fridge. The Social Worker confirmed that food items should be labeled and dated according to facility policy. Additionally, a review of temperature logs revealed that no temperatures had been recorded for the resident refrigerator during the specified months. The facility's policy required all refrigeration units to have internal thermometers and for perishable foods to be stored in resealable containers labeled with the resident's name, the item, and the use-by date, which was not followed. These failures had the potential to affect 25 medically compromised residents who were able to store food in this refrigerator.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Labeling and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications and biologicals. Two bubble packs containing Eliquis, a blood thinner prescribed to a resident, were found in a medication cart without expiration dates. The nurse confirmed that expiration dates are typically verified upon receipt from the pharmacy, but these packs were missing the required information. Additionally, eight tubes of Santyl ointment, used for wound care, were discovered in a treatment cart without resident identification labels. The facility's policy and procedure require all prescription drugs to be properly labeled with specific information, including the resident's name and expiration date, but these requirements were not met. Further observations revealed that two medication carts were left unlocked and unattended by nursing staff for extended periods during medication administration. One cart was left unattended for ten minutes, and another for five minutes, both times without being secured as required by facility policy. Staff acknowledged that the carts should have been locked when not in use, and the facility's policy mandates that medication carts must be securely locked at all times when out of the nurse's view. These lapses in medication security and labeling were verified through interviews and policy review.
Failure to Document and Discuss Advance Directives with Residents
Penalty
Summary
The facility failed to provide evidence that staff discussed advance directives with two residents, as required by policy. For one resident with diagnoses including acute respiratory failure with hypoxia, cirrhosis of the liver, major depressive disorder, and tracheostomy status, there was no documentation in the electronic health record regarding whether the resident had an existing advance directive or had been informed of the right to formulate one. Additionally, the section of the resident's Physician’s Order for Life Sustaining Treatment (POLST) form regarding advance directives was left blank. The Corporate Medical Records Resource confirmed the absence of documentation and acknowledged the incomplete POLST form. For another resident admitted with traumatic hemorrhage of the cerebrum and chronic respiratory failure with hypoxia, the clinical record also lacked documentation that the resident or their representative was offered assistance to accept or decline the establishment of an advance directive. The Interim Director of Nursing reviewed the record and confirmed that the facility’s policy, which requires staff to offer assistance and document the resident’s decision regarding advance directives, was not followed in this case.
Failure to Accurately Code Schizophrenia Diagnosis on MDS Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately completed for a resident with a diagnosis of schizophrenia. The resident, who was admitted with multiple diagnoses including schizophrenia, had this condition documented in their admission record and in several psychiatrist assessments. However, the quarterly MDS assessment did not reflect the active diagnosis of schizophrenia, despite ongoing evaluation and monitoring for the condition by psychiatric staff. During interviews and record reviews, the MDS nurse acknowledged that the resident's schizophrenia should have been coded as an active diagnosis on the MDS assessment. The Interim Director of Nursing confirmed that the facility's policy requires assessments to accurately reflect the resident's status and stated that this policy was not followed in this instance. The omission resulted in the resident's MDS assessment not accurately representing their care and support needs.
Failure to Update PASARR Following New Diagnosis
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) was updated and re-submitted for a resident who was admitted with multiple diagnoses, including schizophrenia, respiratory failure, and hypothyroidism. Upon review, it was found that eight days after admission, a psychiatrist's assessment documented a diagnosis of schizophrenia for the resident. However, there was no evidence in the clinical record that the PASARR was updated or re-submitted to reflect this new diagnosis. During an interview and record review, the Minimum Data Set Nurse confirmed that it was her responsibility to update and re-submit the PASARR when new diagnoses were identified, but acknowledged that she did not do so in this case. The facility's policy requires that all admissions have the appropriate PASARR completed and that the administrator is accountable for monitoring this process, but this procedure was not followed for the resident in question.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not take adequate measures to prevent the development of new ulcers. This deficiency indicates that necessary interventions to manage existing pressure ulcers and prevent further skin breakdown were not implemented or maintained as required.
Resident Fall Due to Improper Bed Mobility During Care
Penalty
Summary
A resident with a history of osteomyelitis of the vertebra, ventilator dependence, and significant impairment in both upper and lower extremities on one side was identified as high risk for falls and disoriented to person, place, time, and situation at all times. While receiving care from a CNA, the resident was being repositioned in bed for a brief change. The CNA rolled the resident away from herself, contrary to expected practice, and did not notice that the resident was too close to the edge of the bed. As a result, the resident rolled off the bed, landing on her knees and coccyx, which led to uncontrolled pain and required hospital evaluation and treatment. Facility records and interviews confirmed that only one CNA was present during the incident, and the facility did not have a policy or procedure regarding bed mobility or turning residents while in bed. The root cause analysis by the interdisciplinary team identified that the CNA miscalculated the resident's roll during care, leading to the fall. The facility's policy on safety and supervision emphasized making the environment as free from accident hazards as possible, but this was not achieved in this instance.
Failure to Provide Required AMBU Bag at Bedside for Ventilator-Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and ventilator dependence, who had a history of acute respiratory failure with hypoxia, did not have an Artificial Manual Breathing Unit (AMBU) bag at the bedside as required by facility policy. During an observation, it was noted that the AMBU bag was not present in the resident's immediate vicinity. Multiple staff interviews confirmed that an AMBU bag was supposed to be at the head of the bed for all residents with a tracheostomy and ventilator, and that its absence was unacceptable. Staff searched the room but were unable to locate the required equipment. The facility's policy, dated April 17, 2025, specified that a manual resuscitator device must be placed at the bedside of each resident. Both the respiratory therapist and the respiratory therapy resource confirmed the importance of having the AMBU bag readily available for manual ventilation in case of emergency. The deficiency was identified through observation, staff interviews, and review of the facility's policy and the resident's medical record.
Inaccurate Code Status Documentation in EHR
Penalty
Summary
The facility failed to ensure that the documentation in the Electronic Health Record (EHR) was accurate for a resident reviewed for advance directives. Specifically, the resident's code status in the EHR was documented as both Do Not Resuscitate (DNR) and Full Code, which are contradictory orders regarding life-sustaining measures. This discrepancy was identified during a review of the resident's EHR, which should have accurately reflected the resident's wishes as indicated in the Physicians Orders for Life Sustaining Treatment (POLST) and other medical records. The resident involved had a medical history that included acute respiratory failure with hypoxia, tracheostomy status, and dependence on a mechanical ventilator. During interviews, the Interim Director of Nursing (IDON) confirmed that the EHR was incorrect and should have only indicated DNR status. The IDON also stated that it was the responsibility of licensed nurses to ensure the accuracy of code status documentation in the EHR. Facility policy requires that clinical records be complete and accurately documented, but this standard was not met in this instance.
Failure to Follow Contact Precaution Protocols for Infection Control
Penalty
Summary
A Certified Nurse Assistant (CNA) entered a room designated for Contact Precautions without donning the required personal protective equipment (PPE), specifically a gown and gloves, as mandated by the facility's infection control policies. The CNA performed hand hygiene, removed a lunch tray from the food cart, and entered the room, which had a visible Contact Precautions sign, without wearing PPE. Once inside, the CNA donned gloves but did not wear an isolation gown, then proceeded to reposition the resident, place a clothing protector, and open beverages, all while wearing the same pair of gloves and no gown. Upon exiting, the CNA acknowledged that she typically wears a gown and gloves before entering such rooms but could not explain the lapse on this occasion. The resident involved had been admitted with chronic respiratory failure, tracheostomy status, and gastrostomy status, and had been placed on Contact Precautions due to a diagnosis of Candida Auris. Interviews with facility staff, including a Licensed Vocational Nurse and the Infection Practitioner, confirmed that the facility's policy requires staff to perform hand hygiene and don both gown and gloves before entering any Contact Precaution room. Review of the facility's policies and procedures further supported these requirements, and the Operational Manager acknowledged that the CNA did not follow established protocols.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate treatment and management of gastrostomy tubes (G-tubes) for three residents, as observed during a survey. A Licensed Vocational Nurse (LVN) did not verify the placement of the G-tubes before administering medications to Residents 18, 19, and 6. This verification process involves listening for a gurgling sound when flushing air through the G-tube to confirm its correct position, as per the facility's policy. The failure to check the G-tube placement could potentially increase the risk of aspiration for these residents. Resident 18, who was admitted with acute respiratory failure, seizures, and chronic obstructive pulmonary disease, did not have their G-tube placement checked before medication administration. Similarly, Resident 19, with diagnoses including sepsis and cerebral infarction, and Resident 6, with anoxic brain damage and cerebral infarction, also did not have their G-tube placement verified. The Director of Nursing confirmed that the facility's policy, which requires checking tube placement every shift, was not followed by the LVN.
Failure to Explain Medications to Residents
Penalty
Summary
The facility failed to ensure that medications were explained to residents prior to administration, affecting three of the eight residents reviewed for medication administration. Specifically, the Licensed Vocational Nurse (LVN) did not inform Residents 18, 19, and 6 about the medications they were receiving during observations conducted on June 4, 2024. Resident 18, who was admitted with acute respiratory failure, seizures, and chronic obstructive pulmonary disease, was administered medications without explanation while lying in bed listening to the radio. Similarly, Resident 19, with diagnoses including sepsis and cerebral infarction, and Resident 6, with anoxic brain damage and cerebral infarction, were also given medications without being informed about them. During interviews, the LVN acknowledged the oversight, stating that explaining medications is part of the rights of medication administration. The Director of Nursing (DON) confirmed that the facility's policy and procedure, which requires explaining procedures to residents, was not followed. The facility's policy on Resident Rights also mandates that residents be informed of their medical condition and treatment, which was not adhered to in these instances. The DON expressed that the expectation was for all nurses to explain medications to their residents, indicating a lapse in following established protocols.
Medication Storage Security Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of medications in the medication room, as observed during a survey. Specifically, the medication refrigerator was found unlocked, which was acknowledged by the Infection Preventionist (IP) during an inspection. The Director of Nursing (DON) also confirmed that the facility's policy and procedure for medication storage requires that the medication refrigerator be locked at all times. The facility's policy further specifies that Schedule II, III, and IV controlled medications, including those requiring refrigeration, must be stored separately in a locked drawer or compartment under double lock. This deficiency was identified as having the potential to increase the risk of unauthorized access, misuse, and/or harm to the facility's 49 residents.
Failure to Document Restorative Nursing Weekly Summary
Penalty
Summary
The facility failed to document the Restorative Nursing Weekly Summary for a resident with limited range of motion, which was identified during an observation, interview, and record review. The resident, who was admitted with diagnoses including anoxic brain damage, cerebral infarction, and muscle contractures, was observed with a plush carrot toy in the right hand and a splint on the left hand. The resident's medical records indicated orders for a Restorative Nursing Assistant (RNA) program to maintain range of motion through various interventions, such as passive range of motion exercises and the application of orthotics and splints. However, during a review of the resident's records, it was found that there was no documentation of the RNA Weekly Summaries from April 26, 2024, to June 6, 2024. Both the Restorative Nursing Assistant and the Restorative Nursing Assistant Lead confirmed the absence of documentation for this period. The Director of Nursing also reviewed the facility's policy and procedure on range of motion exercises, which required documentation of the resident's participation, any problems or complaints, and the signature of the person recording the data. The policy was not followed, leading to the deficiency.
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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