Crestwood Wellness And Recovery Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 3062 Churn Creek Rd., Redding, California 96002
- CMS Provider Number
- 05A371
- Inspections on file
- 25
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crestwood Wellness And Recovery Center during CMS and state inspections, most recent first.
A resident with schizoaffective and bipolar disorders, known for delusions and disruptive verbal behaviors, shared a room with another conserved resident diagnosed with schizophrenia and delirium. On the morning of the incident, a CNA heard the first resident loudly state, “I’m going to kill you,” but did not enter the room to assess safety, did not place eyes on the residents, and did not effectively report this behavioral change to the SC or an LN as required by the facility’s crisis intervention policy and CNA job description. Staff later reported that the first resident had been making daily death threats toward the roommate, yet there was no CNA documentation of such threats in the progress notes, and the DON, ADON, Wellness and Recovery Director, and LNs were unaware of them. Feeling threatened when the first resident put her fists up as if to fight, the roommate struck her in the face multiple times, causing facial and neck redness and bruising that lasted for over two weeks, demonstrating a failure to protect a resident from physical abuse by another resident.
A resident with schizoaffective disorder and bipolar type, but with intact cognition on BIMS, told an LPN that people were coming into her room and "rape her" when she was not fully awake, and a subsequent note by social services documented that a peer was having sex with her without consent. The Wellness and Recovery Director and the Administrator conducted an internal investigation after the allegation was discussed in a team meeting, and an SOC 341 later reflected that the conservator’s office was informed of non-consensual sex by a peer. Despite a facility policy requiring immediate reporting of reality-based abuse allegations to the Administrator and external authorities, and the Administrator’s own description that such allegations should be reported to police, social services, CDPH, and the Ombudsman within two hours, the allegation was not reported to these required agencies.
Surveyors found that the facility did not review or update its emergency preparedness plan within the required annual timeframe, as the last update was in 2023. Staff confirmed the absence of a current plan, affecting planning for all residents.
Surveyors identified that the facility did not update its emergency preparedness plan (EPP) policies and procedures within the required annual timeframe. Staff confirmed the last review was in 2023, resulting in a deficiency for not maintaining current EPP documentation for all residents.
Surveyors identified that the facility did not maintain an annually updated emergency preparedness communication plan, as required by regulation. Staff confirmed the last review was in 2023, resulting in the absence of a current communication plan for all residents.
Surveyors identified that the facility did not provide evidence of an annual update to its emergency preparedness plan (EPP) training and testing program. The last documented review was in 2023, and staff confirmed no subsequent update had occurred, resulting in noncompliance with regulatory requirements for emergency preparedness.
A failed water flow test revealed that the facility's sprinkler system alarm did not activate within the required timeframe, as the water flow was tested for over 90 seconds without initiating the alarm. Staff were unaware of the malfunction, and this deficiency affected all residents and smoke compartments in the facility.
A smoke detector outside a resident room failed to activate the fire alarm system during two separate tests with artificial smoke. Staff could not determine the cause at the time, but noted the proximity of an AC vent, which may have affected the detector's function. This issue impacted 14 residents in one smoke compartment.
Surveyors found a suspended power strip in a resident area, plugged into a television and positioned about one foot off the ground. Staff confirmed the power strip was accidentally suspended, indicating a failure to maintain electrical equipment according to NFPA standards.
A review of facility records and staff interviews revealed that the fire watch policy did not specify that a fire watch would be implemented within four hours of the fire alarm system being out of service, as required. This omission affected all residents in the facility.
A review of facility records and staff interviews revealed that the fire watch policy lacked required language specifying that a fire watch must be implemented if the sprinkler system is out of service for more than ten hours. This omission affected all residents and smoke compartments in the facility.
The facility did not document the results of the DON's annual TB infection screening on the required form, as confirmed by a review of personnel records and acknowledgment from Human Resources.
Two residents with schizoaffective disorder and intact cognition were permitted to self-administer oxygen per physician orders, but the MARs lacked a section for LPNs to document oxygen administration. The facility also did not formally assess the residents' ability to self-administer oxygen or provide required education, contrary to facility policy.
Surveyors observed that opened packages of frozen fried eggs, soy chicken patties, and soy beef patties were stored in the kitchen freezer without required labels or dates. The Food Service Supervisor confirmed these items had been opened and should have been labeled with an open date according to facility policy.
A resident with a history of schizoaffective disorder and anxiety was verbally and physically assaulted by another cognitively intact resident with schizophrenia and substance abuse history. The aggressor yelled derogatory names and struck the resident on the head, then chased him down the hallway before staff intervened. The incident resulted in increased anxiety and emotional distress for the victim.
A client eloped from a facility due to a malfunctioning door lock and staff oversight. The client exited through a door with a faulty magnetic lock, and a TOA, unfamiliar with residents, mistook her for an employee. Program Staff saw the client outside but assumed she was with another staff member, leading to the client being missing for eight hours.
A resident with a history of aggressive behavior physically abused two other residents in separate incidents. The first incident involved the resident striking another resident in the face, causing injuries. The second incident involved the resident choking another resident. Despite being on frequent welfare checks, the aggressive resident's behavior was unpredictable, and the facility failed to manage the situation effectively.
The facility did not label and date food containers and product bags after opening, as observed in the freezer and refrigerator. Items such as frozen breaded fish, frozen french toast, and fresh pepperoni were found open and unlabeled. A staff member acknowledged forgetting to label the items, and the Food Service Supervisor confirmed the requirement for labeling with an open date.
Failure to Intervene on Verbal Threats Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to follow its own crisis intervention and reporting policies. The facility’s Crisis Intervention Program required staff to recognize early warning signs of crisis, such as changes in behavior, mood, or thinking, and to provide early intervention when a resident exhibited increased acting-out behaviors. The CNA job description required CNAs to immediately report all changes, including agitation, to the Shift Coordinator (SC). On the day of the incident, a CNA heard one resident yelling, “I’m going to kill you,” but did not enter the room to assess the situation, ensure safety, or investigate what was happening, and did not effectively report this change in behavior to nursing staff or the SC. The resident who was later physically abused (Resident 1) had a history of schizoaffective disorder, bipolar type, and was conserved. An Annual MDS indicated this resident had delusions, verbal behavioral symptoms directed toward others, intruded on others’ privacy and activities, and significantly disrupted the care or living environment of others. Staff interviews confirmed that this resident had delusions involving being married to Elvis and yelling about wanting to kill a woman she believed was after her husband. However, review of progress notes from 5/5/25 through 12/25/25 showed no CNA documentation that any CNA had witnessed or reported verbal death threats during these recurring delusions. The resident who committed the physical abuse (Resident 2) was also conserved and had diagnoses of schizophrenia and delirium, with documented delusions. On the day of the incident, Resident 2 reported feeling threatened when Resident 1 put her fists up as if they were going to fight, and Resident 2 hit Resident 1 in the face approximately three times. Staff interviews indicated that Resident 1 had been making daily verbal death threats toward Resident 2, but the licensed nurses, DON, ADON, and Wellness and Recovery Director all confirmed they had not been notified of these threats or of the specific statement, “I’m going to kill you,” made that morning. A licensed nurse stated that if the CNA had reported the observed threat, she would have assessed the situation, determined whether the statement was related to a delusion or directed at the roommate, and attempted to redirect or separate the residents. As a result of the unreported threat and lack of timely intervention, Resident 1 sustained reddened areas and bruising on the neck and right side of the face, with bruising that persisted for 15 days.
Failure to Report Resident’s Allegation of Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident to CDPH, the police, and the local Ombudsman as required. The facility’s abuse prevention policy stated that staff must immediately report any suspicions of client abuse to the Administrator, and that all reality-based accusations must be immediately investigated and reported to officials in accordance with state law, including CDPH. The resident involved had schizoaffective disorder, bipolar type, and was conserved, with a documented history of hallucinations and delusions. However, the resident’s most recent BIMS score was 15/15, indicating intact memory, orientation, and judgment. On one occasion, a licensed nurse reported via internal communication that the resident stated people came into her room and “rape her” when she was not fully awake. This information was relayed to the Wellness and Recovery Director (WRD) and the Director of Nurses. The WRD documented in a Social Services Note that the resident told a nurse she felt a peer was coming into her room and having sex with her without her consent, and noted that the statement was similar to previous unverifiable accusations. The WRD and Administrator subsequently conducted an internal investigation after a team meeting where the allegation was discussed. An SOC 341 form later showed that the WRD had emailed the resident’s conservator’s office stating that a peer was having sex with the resident without her consent and that the facility had investigated the allegation. During interviews, the resident became visibly distressed and denied making the statements attributed to her, while the nurse involved denied that the resident had said she was raped and characterized the communication as related to the resident’s fixation on becoming pregnant. The Administrator acknowledged that, according to facility procedure, allegations of sexual abuse should trigger immediate steps to protect residents and notification of police, social services, CDPH, and the Ombudsman within two hours, and confirmed that this allegation was not reported to those authorities.
Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain its emergency preparedness plan (EPP) in accordance with federal regulations, which require the plan to be reviewed and updated at least annually. During a record review and interview with staff, surveyors requested the EPP and found that the most recent update was dated 11/15/23. Staff confirmed that the last review of the EPP occurred in 2023, and no updated version was available for the current year. This deficiency was identified during a survey on 6/9/25, where it was determined that the EPP had not been reviewed or updated within the required annual timeframe. The lack of an updated EPP could impact the facility's ability to ensure proper planning and preparation for the health and safety of all 90 residents, as the plan may not reflect current risks or procedures.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan. The facility will continue to maintain the emergency preparedness plan every year by reviewing and updating the plan annually. The facility shall update the EPP on June 26, 2025, during the QA Committee meeting. The facility shall include the EPP review and update as part of the facility's annual review for all facility Policies and Procedures, to be conducted in January 2026 and then each consecutive year in the following January. The update will be communicated to staff during the all-staff meeting scheduled for June 26, 2025, coordinated by the Administrator and facility Environmental Services Supervisor. Further issues regarding the EPP annual update and approval will be received during the QA process and brought to the QAPI Committee for review. The Environmental Services Supervisor, Administrator, and QA Manager will be responsible to ensure ongoing compliance.
Failure to Annually Update Emergency Preparedness Plan Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its emergency preparedness plan (EPP) policies and procedures as required. During a record review and interview with staff, it was found that the EPP had not been updated annually, with the last documented review occurring in November 2023. Staff confirmed that the most recent review date was in 2023, indicating that the required annual update had not been completed. This deficiency was identified during a survey in which the EPP was specifically requested and examined. The lack of an updated EPP could result in the absence of proper planning and preparation to protect the health and safety of all 90 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan (EPP). The facility shall continue to ensure the emergency preparedness plan has updated policies and procedures. The facility shall update the emergency preparedness plan policies and procedures by June 26, 2025, during the QA Committee meeting. The facility shall include the reviewed and updated emergency preparedness plan policies and procedures as part of the annual review for all facility policies and procedures to be conducted in January 2026, and then each consecutive year in the following January. Further issues regarding the facility's emergency preparedness plan's policies and procedures shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and Director of Nursing shall be responsible to ensure ongoing compliance. This page is purposefully left blank.
Failure to Annually Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring an annually reviewed and updated emergency preparedness communication plan. During a record review and interview with staff, surveyors found that the emergency preparedness plan (EPP) had not been updated since 11/15/23, and staff confirmed that the last review occurred in 2023. As a result, the facility did not have an up-to-date communication plan as required, affecting the planning and preparation for the health and safety of all 90 residents. No additional details regarding the medical history or condition of the residents at the time of the deficiency were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining an updated communication plan. The facility shall continue to maintain an updated communication plan and review it annually. The facility shall update the emergency preparedness communication plan by June 26, 2025, during the QA Committee meeting. The communication plan shall be included when the facility reviews the emergency preparedness plan annually in January 2026 and each year consecutively in the following January. Further issues regarding the facility's development of a communication plan as part of the emergency preparedness plan shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance.
Failure to Annually Update Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness requirements by not updating its emergency preparedness plan (EPP) training and testing program on an annual basis. During a record review and interview with staff, it was found that the last update to the EPP training and testing program occurred in November 2023, and no subsequent annual update was provided as required. Staff confirmed that the most recent review date was in 2023, indicating that the program had not been reviewed or updated within the required timeframe. This deficiency was identified during a survey in which the facility was unable to produce documentation of an updated EPP training and testing program. The lack of an annual update could affect the facility's ability to ensure proper planning and preparation for emergencies for all 90 residents. The findings were based solely on the absence of the required annual review and update of the emergency preparedness training and testing program.
Plan Of Correction
The facility recognizes the importance of developing and maintaining an emergency preparedness training and testing program. The facility shall continue to provide an EPP training and testing program update annually. The Emergency preparedness training and testing program shall be reviewed June 26, 2025 during the QA Committee meeting. The emergency training and testing program shall be included in the annual review of facility policy and procedures in January 2026 and then each year consecutively in the following January. Further issues regarding the training and testing program of the EPP shall be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or more frequent if necessary. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Sprinkler System Water Flow Alarm Failure
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 Life Safety Code requirements. During a tour and inspection, the water flow test was conducted at the inspector test valve located in an exterior electrical closet near the generator. The test revealed that the water flow alarm did not activate within the required 90 seconds, as the water flow was tested for over 90 seconds without initiating the alarm. The last documented water flow test was during the annual inspection on 5/16/25. Staff interviewed during the inspection were unaware that the water flow alarm was not functioning as required. This deficiency affected all 90 residents and all ten smoke compartments in the facility, as the lack of a functioning water flow alarm could delay sprinkler protection in the event of a fire. Records of system design, maintenance, inspection, and testing were maintained, but the failure to ensure the water flow alarm's proper operation led to the cited deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System, including the water flow test. The repair and retest of the Sprinkler System was conducted and completed by Environmental Services Supervisor June 9, 2025. The facility will continue to complete the Sprinkler System flow test monthly in July, August, and September—then will revert back to normal quarterly testing in October. Further issues regarding the facility Sprinkler System will be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or as necessary. The Administrator, Environmental Services Supervisor, QA Manager, and maintenance staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Smoke Detector Failed to Initiate Fire Alarm During Testing
Penalty
Summary
During a facility tour and staff interview, surveyors observed that a smoke detector located outside resident room 209 failed to initiate the fire alarm system when tested with artificial smoke. The test was conducted twice, and on both occasions, the alarm did not activate. Staff present during the testing were unable to provide an explanation for the malfunction at the time of the observation. It was noted that the air conditioning vent was approximately 36 inches from the smoke detector, and staff speculated that airflow from the vent might be interfering with the detector's ability to sense smoke. This deficiency affected 14 out of 90 residents in one of ten smoke compartments, as the non-functioning smoke detector could delay notification to emergency forces in the event of a fire.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the smoke detectors and fire alarm system. The facility contacted Sa-Fire to inspect the current locations of the smoke detectors. Facility plans to move / re-locate the 4 ceiling mount smoke detectors away from the proximity of the air registers that may have affected the smoke detectors, causing the testing issues. Sa-Fire will be placing the system on test to complete the work, and the annual fire alarm inspection is scheduled to be completed July 25, 2025. The detectors will be re-tested at that point. Further issues regarding the fire alarm system and/or the smoke detectors will be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Improper Use of Suspended Power Strip in Resident Area
Penalty
Summary
During a facility tour, surveyors observed a suspended power strip in the Trinity center, approximately one foot off the ground and plugged into a television. Staff confirmed that the power strip had been accidentally suspended by facility personnel. This observation indicated that the facility failed to maintain electrical equipment in accordance with regulatory requirements, specifically regarding the proper use and placement of power strips as outlined by NFPA standards. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining electrical equipment. The facility shall continue to properly maintain electrical equipment. Environmental Services Supervisor removed the suspended power strip in the Trinity Center June 9, 2025. In-service was provided to maintenance staff on NFPA code and to look for during room inspections, specific to power strips. Power strip audits will be conducted monthly, using the facility Monthly Maintenance Log. Further issues regarding electrical equipment shall be received during the facility QA process and brought to the QAPI Committee for review and discussion. The Environmental Services Supervisor, Administrator, maintenance staff, nursing staff, and housekeeping staff shall be responsible to monitor for ongoing compliance. This page is purposefully left blank.
Incomplete Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than four hours of the fire alarm system being out of service, as required. Staff confirmed that the policy lacked a defined time frame for initiating a fire watch. This deficiency affected all 90 residents across ten smoke compartments.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the fire alarm system, and shall update the fire watch policy. When the fire alarm system is "out of service," the facility's fire watch policy shall include language stating, "fire watch will be implemented after no more than four hours of the fire alarm system being out of service." The updated Fire Watch Policy will be reviewed, updated, and adopted June 26, 2025, during the QA Committee meeting. Further issues regarding the fire alarm system fire watch policy shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, DON, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Incomplete Fire Watch Policy for Sprinkler System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than ten hours of the sprinkler system being out of service. Staff confirmed that the required time frame was not included in the policy. This deficiency affected all 90 residents across ten smoke compartments, as the policy omission could impact the facility's response during a sprinkler system impairment.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System. When the Sprinkler System is out of service, the facility shall update the Fire Watch policy to include language indicating "fire watch will be implemented after no more than ten hours of the sprinkler system being out of service." The updated Fire Watch policy will be reviewed, updated, and approved June 26, 2025 during the QA Committee meeting. Further issues regarding the Fire Watch policy or the sprinkler system shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Incomplete Documentation of TB Screening for DON
Penalty
Summary
The facility failed to provide documented evidence of the results of the Director of Nursing Services' (DNS) annual tuberculosis (TB) infection screening on the required examination form. During a review of the DNS's personnel record, it was found that the most recent annual TB exam did not indicate whether the result was positive or negative for TB. This omission was confirmed during an interview and record review with Human Resources, who acknowledged that the TB exam documentation for the DNS was incomplete and lacked the necessary result information.
Plan Of Correction
DNS's personnel record was reviewed by DNS, Clinical Care Manager, Medical Director, and Administrator on 6/5/2025. The document was corrected and updated to reflect a negative TB result on 6/7/2025. The facility's Clinical Care Manager, DNS, Medical Director, and Administrator are responsible for the correction. Results of TB screening, examinations, and completion of forms will be conducted by the Clinical Care Manager. The Facility QA Manager will perform quarterly audits of initial health exams and annual exams to monitor for ongoing compliance. The DNS personnel file was corrected on 6/7/2025. Further issues regarding Employee Health Exams and/or Health Records will be brought to the QA/QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, and Administrator shall be responsible to monitor for ongoing compliance.
Failure to Document and Assess Oxygen Self-Administration
Penalty
Summary
The facility failed to ensure proper documentation and assessment related to oxygen administration for two patients. Specifically, the Medication Administration Records (MARs) for both patients did not include a section for licensed nursing staff to document the administration of oxygen, despite physician orders allowing the patients to use oxygen at specified rates via nasal cannula. The Director of Nursing Services confirmed that there was no place in the MARs for this documentation. Additionally, the facility did not conduct formal assessments to determine the patients' ability to safely self-administer oxygen, nor did it provide formal education to the patients regarding self-administration, as required by facility policy. Both patients involved had a diagnosis of schizoaffective disorder and were assessed as cognitively intact based on their Brief Interview for Mental Status (BIMS) scores. The facility's policies required interdisciplinary team assessments of cognitive, physical, and visual abilities for self-administration of medications, as well as patient instruction and demonstration of self-administration skills. These steps were not completed for either patient, resulting in incomplete health records and a lack of formal verification of their ability to self-administer oxygen safely.
Plan Of Correction
The facility recognizes the importance of maintaining complete and accurate health records. June 27, 2025. The facility shall continue to maintain complete and accurate health records. For Resident 3 and Resident 5, the oxygen administration was documented on MAR June 4, 2025. Formal education regarding self-administration of oxygen was completed on June 4, 2025, by the Clinical Nurse, and assessments will be performed by the Clinical Nurse Supervisor by July 15, 2025. The DNS, Clinical Care Manager, Director of Staff Development, LN Shift Supervisors, Medical Records Supervisor, and Nursing staff shall be responsible for the correction. Newly admitted patients with supplemental oxygen orders will have a self-administration evaluation assessment completed upon admission. Education on self-administration of supplemental oxygen will be provided upon admission. Residents with supplemental oxygen orders will have a self-administration evaluation assessment completed at least quarterly by licensed staff. Education on self-administration of supplemental oxygen will be provided at least quarterly, by licensed staff. Further issues regarding the content of health records and documentation of oxygen administration will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, Nurse Shift Supervisors, Nursing staff, Medical Records Supervisor, and Administrator shall be responsible to monitor for ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Failure to Label and Date Opened Frozen Food Products
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling and dating food product bags after opening them for use. During an observation in the kitchen's second freezer, open and unlabeled packages of frozen fried eggs, soy chicken patties, and soy beef patties were found. The Food Service Supervisor confirmed that these bags had been previously opened and that there was no apparent label present on any of the packages. A review of the facility's policy titled 'Labeling and Dating of Foods' indicated that newly opened food items are required to be closed and labeled with an open date and a use-by date according to guidelines. The Food Service Supervisor acknowledged that, per facility policy, products are to be labeled with an open date once the packaging is opened for use. The failure to follow this procedure was directly observed and confirmed during the survey.
Plan Of Correction
The facility recognizes the importance of storing, labeling, and dating food products in accordance with professional standards. The facility shall continue to store, label, and date food products in accordance with professional standards. The facility's Food Service Supervisor will begin utilizing a freezer-proof storage bag that works well with our permanent markers with no smearing. The Food Service Supervisor ordered for delivery on Friday, 6/13/2025. The facility will continue to utilize these to prevent labeling and dating issues in the freezer. Food Service Supervisor and the facility's Registered Dietitian have not seen any "smearing" or "smudging." The RD will include labeling, storing, and dating of food products in the freezer in the monthly audit. Further issues regarding storing, labeling, and dating of food products in accordance with professional standards will be received by the Food Service Supervisor or Registered Dietitian during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Food Service Supervisor, Registered Dietician, dietary staff, and Administrator shall be responsible for monitoring ongoing compliance. This page purposefully left blank.
Failure to Protect Resident from Verbal and Physical Abuse by Peer
Penalty
Summary
A deficiency occurred when a resident was not protected from verbal and physical abuse by another resident. Specifically, one resident with a history of schizophrenia, psychoactive substance abuse, and visual hallucinations verbally assaulted another resident by yelling and calling him derogatory names, then physically assaulted him by striking him on the head with a closed fist. The aggressor continued to chase the victim down the hallway until staff intervened and separated the two individuals. Both residents were cognitively intact according to their most recent assessments. The facility's policy required all appropriate preventative measures to ensure residents are not at risk for abuse, but this was not followed in this instance. The assaulted resident, who had a history of schizoaffective disorder, bipolar type, and self-reported anxiety, reported feeling upset and experiencing tenderness in his head following the incident. The event resulted in increased anxiety and the potential for emotional stress for the resident who was attacked.
Plan Of Correction
The facility recognizes the importance of maintaining an environment that is free from abuse and neglect. The facility will continue to maintain an environment that is free of abuse and neglect. The facility intervened immediately when the incident involving Resident 56 occurred. Resident 38, the aggressor in this incident, was transferred to a different level of care immediately after the incident. Resident 38 will not return to the facility. The facility initiated a Care Plan on 5/24/25 to monitor Resident 56 for "feelings of being unsafe through the next review date." Interventions attached to the Care Plan included "Encourage Resident 56 to inform staff if he is feeling unsafe," "Provide Resident 56 with 1:1 contacts as needed for emotional support," and "Support Resident 56 with pro-social outlets to encourage feelings of safety in the milieu." Resident 56 was placed on routine monitoring immediately after the incident, with frequent Progress Notes reflecting his comfort, levels of anxiety, and safety. 5/24/25 0239 - "Resident was counseled on staying safe and letting us know if he is being bothered" 5/24/2025 0557 - Nurse Note "Resident has not shown any s/s of emotional distress" 5/24/2025 0851 - Alert Note "Resident denies any pain or discomfort" 5/24/2025 1302 - Nurses Note "No complaints of pain or discomfort" 5/24/2025 1428 - Welfare Check "No noted issues this shift. No statements of feeling unsafe" 5/24/2025 1514 - Program Note "Resident stated he is feeling fine... The writer encouraged Resident to seek staff if he felt unsafe" 5/24/2025 1538 - Welfare Check "Feeling fine, a little better". Asked if he has concerns about safety, he stated "No I think it was a one off, he even apologized to me" 5/24/2025 - Welfare Check "Had an okay day" and felt safe in the facility 5/24/2025 2209 - Welfare Check "I am doing good and feel safe here" 5/25/2025 1356 - Nurses Note "Compliant with neuro checks... no c/o pain or discomfort and this time" 5/25/2025 1528 - Nurses Note "Stated they felt safe at this time" 5/25/2025 2145 - Asked if he is okay "Yes, I am happy here. I feel good. I am okay" 5/26/2025 0618 - Welfare Check "Client has not made any statements of distress or feeling unsafe" 5/26/2025 1407 - Welfare Check "No noted issues or statements of feeling unsafe" 5/27/2025 0939 - IDT Note "Did not wish to discuss the incident further... Did not report feeling unsafe through the weekend... Did not express any s/s of distress... will be discontinued from welfare checks due to not expressing feeling unsafe" 5/28/2025 1722 - IDT Note "Ombudsman met with Resident 58... Resident denied feeling unsafe and had no concerns at the time of the interview" Facility will continue to provide Elder and Dependent Adult Abuse education as part of the new hire orientation for newly hired staff. Facility will continue to provide Elder and Dependent Adult Abuse in-service education to staff through the year as part of the facility's annual educational calendar. Facility DSD began providing in-services to staff on 6/4/2025, including guidelines and expectations of maintaining a facility free of abuse and neglect. As part of the facility admission process, the Admission Coordinator will screen for residents with a history of abuse or assaultive behavior towards others. Further issues regarding Resident Abuse will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Administrator, Director of Nursing, DSD, Medical Director, department heads, leadership team, nursing staff, and all departments shall be responsible to monitor for ongoing compliance.
Client Elopement Due to Malfunctioning Door and Staff Oversight
Penalty
Summary
The facility failed to ensure the safety and security of a client, identified as Client 1, who eloped from the facility due to a malfunctioning security door locking system. The incident occurred when the magnetic lock on the south door intermittently malfunctioned, allowing Client 1 to exit the facility without detection. The facility's Administrator confirmed that the door could only be opened with a key, but the malfunction allowed Client 1 to push open the door and walk into the front lobby, leading to her elopement. The Temporary-Office Assistant (TOA), who was unfamiliar with the residents, did not recognize Client 1 as a client when she passed through the front lobby and exited the facility. The TOA, who had started working in August, mistook Client 1 for an employee due to the time of day when staff were coming and going. This lack of recognition contributed to the failure to prevent Client 1's elopement. Additionally, Program Staff (PS) observed Client 1 outside the facility but did not inquire about her presence or take action to ensure her safety. PS assumed that another staff member was accompanying Client 1 on an outing and did not verify this assumption. As a result, Client 1's whereabouts were unknown for eight hours, during which she was at risk for injury and exposure to cold weather.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, Resident 84, who had a history of impulsive and aggressive behavior. On June 12, 2024, Resident 84 struck Resident 82 in the face multiple times, causing bleeding injuries. This incident occurred after Resident 84 accused Resident 82 of spitting on them, which Resident 82 denied. The facility's investigation confirmed the incident, and it was noted that Resident 84's conservator was seeking a more suitable facility due to Resident 84's behavior. Earlier, on May 22, 2024, Resident 84 was involved in another incident where they placed their hands around Resident 3's throat while Resident 3 was reclined in a chair. This incident was witnessed by staff, who intervened and separated the residents. Resident 84 later claimed not to remember the incident and showed a lack of insight into their behavior during a telepsychiatry session. Despite being on welfare checks every 15 minutes for aggressive behavior, Resident 84's actions were unpredictable and sporadic. Both incidents highlight the facility's failure to adequately assess and manage Resident 84's aggressive tendencies, despite having a policy in place for abuse prevention. The facility's interdisciplinary team was expected to identify residents needing treatment planning to prevent such occurrences, but the incidents with Residents 82 and 3 indicate a lapse in effectively implementing these measures.
Failure to Label and Date Opened Food Products
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling and dating food containers and product bags after opening. During an observation and interview, it was found that multiple packages in the freezer, including frozen breaded fish, frozen french toast, frozen hashbrowns, and frozen fried eggs, were open and unlabeled. A staff member admitted to opening and using some of these items without labeling them. Additionally, in the walk-in refrigerator, a package of fresh pepperoni and a bag of peeled garlic cloves were also found open and unlabeled. The Food Service Supervisor confirmed that these products should have been labeled with an open date once the packaging was opened.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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