Crystal Creek Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 9289 Branstetter Place, Stockton, California 95209
- CMS Provider Number
- 555470
- Inspections on file
- 60
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Crystal Creek Post-acute during CMS and state inspections, most recent first.
A resident with multiple orthopedic conditions and a documented moderate fall risk, who required substantial/maximal assistance with toileting/hygiene, fell from bed and sustained a distal humerus fracture while a CNA performed in‑bed incontinence care using a single‑person assist. During linen changing, the CNA released manual support so both hands could be used to pull soiled sheets while the resident was on her side, and the resident fell to the floor; there were no bed rails or fall mats in place at that time. Subsequent IDT documentation referenced low bed and landing mat interventions, but the DON later confirmed that a fall mat was not actually in place until days after the fall and that bed rails, ordered and consented to later, were not installed until two days after the order. The DON acknowledged that the resident’s injury was preventable and the physician stated that two CNAs should have been providing the in‑bed care.
A resident with hemiplegia reported to a family member that she was hit on the head by an unknown person during care. The family member informed facility staff, who documented the allegation and initiated an internal investigation, but did not report the suspected abuse to the state licensing agency as required. Multiple staff interviews confirmed the failure to report, and the incident was not reflected in the resident's care plan or progress notes.
A resident with hemiplegia reported to a family member that she was hit on the head by a staff member during care. The allegation was communicated to facility staff, but the facility did not report it to the state agency as required. Additionally, the facility's investigation did not include interviews with other residents who received care from the accused staff member, contrary to facility policy.
The facility did not consistently employ a qualified IP responsible for infection prevention and control, with gaps in both employment and documentation of required training or certification. Staff interviews and record reviews confirmed periods without a designated or properly trained IP, and missing employee files further hindered verification of compliance.
A licensed nurse failed to notify a resident's responsible party after the resident exhibited physical aggression towards another resident. Although documentation indicated the family had been informed, the nurse later admitted the notification did not occur due to being busy. This resulted in the family being unaware of the incident, in violation of facility policy requiring prompt communication of changes in condition.
A resident with a history of falls experienced multiple falls without new interventions added to their care plan. Despite hospice providing a 3-hour sitter, falls continued during evening shifts. Staff interviews indicated the sitter schedule was ineffective, and the facility's IDT did not adjust the care plan after recent falls, waiting for medication effectiveness.
The facility failed to ensure safe food storage and sanitation practices, affecting 127 residents. Observations revealed opened and expired food items in storage, wilted and moldy vegetables in the refrigerator, ice buildup in a freezer, and a dishwasher operating below the required temperature. These issues were confirmed by the Dietary Manager Assistant and Registered Dietitian, indicating potential risks of foodborne illnesses.
The facility failed to accommodate the needs of three residents, leading to deficiencies in their care. A resident with a history of stroke and contracture was unable to use a conventional call light and was not assessed for an adaptive one. Another resident with dementia and hemiplegia also struggled with a conventional call light and had a fall mat improperly positioned. A third resident experienced distress due to a lost wheelchair, which was replaced with an unsuitable one, limiting his mobility. The facility's failure to provide appropriate equipment and timely response resulted in significant deficiencies.
The facility failed to ensure safe smoking practices for eight residents, who were found with unsecured cigarettes and lighters in their rooms, despite being assessed as high risk for accidental injury. Some residents required supervision and protective equipment while smoking, but the facility did not consistently enforce these measures. Staff interviews revealed a lack of training and awareness regarding the facility's smoking policy, leading to potential fire hazards, especially for residents on oxygen.
The facility failed to prepare and serve food consistently and appetizingly, with two residents reporting cold meals and test trays found to be bland. Additionally, recipes for pureed diets were not followed, potentially affecting meal intake.
The facility failed to coordinate hospice care for three residents by not reviewing hospice visit notes, despite receiving them via email. This lack of review spanned several months, affecting the residents' care coordination. The DON emphasized the importance of having these notes in the residents' hospice binders weekly.
The facility failed to implement timely isolation precautions for a resident with C. difficile, delaying contact isolation until days after symptoms began. Additionally, glucometers were not properly sanitized according to manufacturer guidelines, risking cross-contamination. These lapses in infection control could negatively impact resident health.
A resident with obesity was upset after overhearing a CNA make negative comments about her weight and wheelchair size to an LN. The incident affected her self-worth and self-esteem, and despite her complaint, there was no follow-up from social services. The facility failed to update her care plan or adhere to policies on resident rights and care planning.
A resident with morbid obesity requested help with weight loss, and the physician recommended exercise with RNA assistance. However, the resident's inability to participate in the exercise program was not communicated to the physician, leading to a potential delay in interventions. The resident experienced significant weight gain and expressed demoralization, while the facility failed to update the physician on the resident's decline in functional abilities.
A confidentiality breach occurred when a resident's EHR contained another resident's PHI, including personal details and medical information. Interviews with the MRD and ADON confirmed the error, highlighting the importance of correct record filing to protect privacy. Facility policies emphasize the need for confidentiality in handling resident records.
The facility failed to complete accurate MDS assessments for two residents, leading to potential inaccuracies in care planning. One resident's discharge MDS was not completed, leaving their health status untracked, while another resident's MDS inaccurately indicated the use of a feeding tube. Facility staff confirmed these errors, acknowledging non-compliance with the facility's MDS Standard of Practice.
A facility failed to update the PASARR form for a resident after a significant change in her mental illness diagnosis, resulting in the resident not receiving necessary specialized mental health services. The oversight was due to a lack of communication and clarity among staff regarding the process for initiating a new PASARR when a diagnosis changes.
The facility failed to create individualized care plans for two residents, one with vision issues due to diabetic cataract and glaucoma, and another at high risk for falls. The absence of a vision care plan for the first resident and a fall care plan for the second resident was confirmed by staff, indicating non-compliance with facility policies. This oversight risked inadequate care for the residents' specific health needs.
A resident with diabetic cataract and glaucoma experienced a delay in obtaining vision services due to the facility's failure to follow up after being deemed ineligible by an outside provider. Despite the resident's repeated requests and having medical insurance, the facility did not seek alternative providers, leading to the resident's frustration and potential impact on their well-being. The facility's process for handling vision service requests was not adhered to, as confirmed by staff interviews and record reviews.
The facility failed to administer medications according to professional standards for two residents. One resident had medications, including controlled substances, left unattended at the bedside without authorization to self-administer. Another resident received medications via G-Tube instead of orally, contrary to physician orders. Staff interviews and policy reviews confirmed these practices were against facility protocols.
A medication error rate of 17.8% was identified in a facility when a resident received medications via G-Tube instead of the prescribed oral route. The error involved five medications, including Carvedilol and Losartan, and was confirmed by the physician, ADON, and Pharmacist Consultant. The facility's policy requires verification of the correct route, which was not followed.
A facility failed to store medications in a clean and sanitary environment, as a loose, unidentifiable pill was found in a medication cart. A nurse acknowledged the importance of preventing loose pills for cleanliness and accountability, while the ADON noted the infection control risk. The facility's policy requires medications to be stored in their original containers.
Two residents did not receive meals according to their documented food preferences, leading to potential health risks. One resident received a meal with disliked items, while another did not receive a necessary protein portion. The RD confirmed these discrepancies, which were against the facility's policy to honor resident food preferences.
A resident admitted with hemiplegia and hemiparesis did not receive necessary PT and OT services as indicated in their hospital discharge summary. The facility's staff failed to assess the resident for these therapies, and no orders were found in the EHR. Interviews revealed a breakdown in the process of verifying and implementing hospital discharge orders, leading to a potential decline in the resident's physical function.
The facility did not follow the planned menu for 18 residents on pureed diets during a lunch meal service, serving pureed carrots instead of the listed squash. This was due to a staff member being occupied with other tasks. The administrator confirmed the importance of menu adherence for meeting resident needs.
The facility failed to prepare pureed foods according to recipe directions, resulting in an unappetizing texture for 18 residents. Additionally, meals were served late and cold to two residents, with one resident reporting consistently cold meals. The DON confirmed the delay in meal service.
The facility failed to prepare pureed food correctly for 18 residents on a pureed diet. A staff member added unmeasured water and thickener to pureed carrots, resulting in a runny consistency. The RD confirmed water was not in the recipe, and the staff member admitted to not measuring ingredients, leading to an unsuitable texture for residents with swallowing difficulties.
The facility failed to store clean dishes according to food safety standards, affecting 144 residents. Observations revealed that food trays and plastic drinking glasses were stacked while still wet, preventing proper drying. The RD and DON confirmed the presence of moisture, identifying it as a potential environment for pathogen growth, which could lead to foodborne illnesses.
A resident with cancer and heart failure did not receive timely physician visits as required, with the last documented visit occurring months prior. Despite a system to track overdue visits, the facility failed to ensure compliance with federal regulations, resulting in a lapse in care.
A resident with multiple fractures and a contusion did not have follow-up appointments with specialists scheduled as ordered, compromising her care. The Social Services Director and Director of Nurses confirmed the lack of documentation for these appointments, which were necessary for the resident's recovery.
Failure to Ensure Safe In‑Bed Care and Timely Fall‑Prevention Measures
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe care and adequate supervision during in‑bed care for a resident, resulting in a fall and fracture. The resident was admitted in 2025 with multiple orthopedic and musculoskeletal conditions, including intervertebral disc degeneration of the lumbar region, a closed right patella fracture, an infection of an internal fixator in the right ankle, and a history of an unspecified fall. A Fall Risk Assessment dated 10/18/25 scored the resident at 25, categorized as a moderate fall risk. The resident’s MDS Section GG, dated 9/22/25, documented a need for substantial/maximum assistance with toileting and hygiene, meaning staff performed more than half the effort and held or lifted the trunk and limbs. On the morning of 1/23/26, CNA 2 provided incontinence care after finding the resident incontinent of stool in bed. CNA 2 rolled the soiled linens and tucked them under the resident while the resident was on her side. CNA 2 reported that she had one hand on the resident to steady her and one hand on the tucked linen, and then attempted to pull the soiled linen out with one hand but was unable to do so. CNA 2 stated she instructed the resident to hold onto the cabinet or bed frame so that CNA 2 could use both hands to pull the linens. CNA 2 then removed the hand that had been supporting the resident in order to use both hands on the linens. According to CNA 2, the resident indicated it was acceptable for her to let go, and CNA 2 proceeded to pull the linens; at that point, the resident fell from the bed onto the floor on her right side. The resident later reported that she had been holding the privacy curtain when she fell. At the time of the fall, there were no side rails on the bed and no fall mats on either side of the bed. Following the fall, the resident complained of right arm pain, with documentation of pain at level 7 and painful, limited ROM in the upper extremity. An x‑ray obtained that day showed a horizontal distal humerus fracture without displacement of the right elbow. The IDT Falls Progress Note dated 1/25/26 documented that the resident fell when CNA 2 was turning her and that, per the resident’s statement, she was holding onto the side of the mattress and leaning too much, resulting in loss of balance and a fall. Predisposing factors listed included a history of falls, muscle weakness, gait/balance deficit, poor safety awareness, and overestimation of limits. The same IDT note listed preventive measures such as a low, locked bed and a landing mat on the floor to reduce impact and injury of falls, but the DON later confirmed that a fall mat was not actually in place at the time of the fall and was only placed days later. The DON also confirmed that a physician’s order for quarter side rails for mobility and positioning was dated 1/26/26, with a bed rail assessment and resident consent completed that same day, but the rails were not installed until 1/28/26. The DON acknowledged that once the resident fell, a fall mat should have been placed immediately and that the resident’s injury was preventable. The resident’s treating physician stated he was not aware that only one CNA had provided incontinence care at the time of the fall and stated that there should have been two CNAs providing that care.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who had hemiplegia of her right dominant side. The resident communicated to a family member that she had been hit on the head by an unknown person while receiving care. The family member reported this allegation to facility staff, who acknowledged the report and stated they would investigate. However, the facility did not report the allegation to the state licensing and certification agency as required by policy and regulation. Interviews with facility staff, including the Social Services Director, Director of Nursing, and Director of Staff Development, confirmed that the allegation was not reported to the Department. Staff acknowledged that all allegations of abuse, regardless of whether they are believed to be factual, should be reported to the appropriate authorities, including the Department, ombudsman, and law enforcement. The facility's own policy required immediate reporting of suspected abuse, but this was not followed in this case. A review of the resident's clinical records and grievance documentation showed that the allegation was documented internally, but there were no progress notes, care plans, or social services notes addressing the abuse allegation. The facility's failure to report the incident as required by law and policy was confirmed by multiple staff members and documented in the facility's records.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state licensing and certification agency after a resident reported to a family member that she had been hit on the head by a staff member during care. The family member relayed this allegation to facility staff, but the facility did not notify the Department as required. The resident involved had a diagnosis of hemiplegia affecting her right dominant side and was admitted with significant physical limitations. A review of the facility's grievance and complaint resolution documentation showed that the investigation into the alleged abuse did not include interviews with other residents who may have had contact with the accused staff member. Interviews with the DON and Social Services Director confirmed that other residents were not interviewed, despite facility policy requiring such actions as part of a thorough investigation. The policy specifically states that all allegations are to be thoroughly investigated, including interviews with other residents to whom the accused employee provides care.
Failure to Consistently Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to consistently employ a qualified Infection Preventionist (IP) responsible for the infection prevention and control program from January 1, 2021 through December 31, 2022. During this period, there were gaps in documentation and employment records for individuals designated as IPs. Payroll and Human Resources were unable to provide information on IPs for the specified timeframe due to missing employee files, which had been sent to a previous corporation. The Administrator was only able to provide names of two individuals who served as IPs but could not initially provide their employee files or evidence of their qualifications. Upon receiving the files, it was found that one IP had no documented IP certification, and the other had a certificate but was not employed as IP for the entire period in question. Further review of employee records indicated that there was no IP employed from December 3, 2021 through May 4, 2022. Additionally, when one individual was serving as IP, there was no documented evidence of specialized training or certification required for the role. Interviews with facility staff, including the DON, confirmed the necessity of a full-time, qualified IP to ensure infection prevention protocols were followed. The lack of a qualified IP during the specified period was directly observed through record reviews and staff interviews.
Failure to Notify Responsible Party of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a licensed nurse failed to notify the responsible party (RP) of a resident's change in condition, specifically a behavioral incident involving physical aggression towards another resident. Although the nurse documented in the clinical record that the resident's son had been made aware of the incident, the nurse later admitted during an interview that she had become busy and forgot to actually notify the RP. This omission resulted in the resident's family being uninformed about the altercation. The facility's policy and procedure on change in condition, reviewed with both the Administrator and Assistant Director of Nursing, clearly required licensed nurses to assess, document, and communicate changes in a resident's condition, including notifying the responsible party. Both the Administrator and ADON confirmed the importance of promptly updating the RP regarding any changes in the resident's status or plan of care. The failure to follow this policy led to the deficiency cited in the report.
Inadequate Fall Prevention and Supervision for Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident with a history of falls. The resident experienced multiple falls on specific dates, and no new interventions were added to their fall care plan after the incidents on two of those dates. The resident was admitted with several diagnoses, including anxiety disorder, brain stem stroke syndrome, bipolar disorder, and was receiving palliative care. Despite the implementation of a 3-hour one-to-one supervision by hospice on certain days, the resident continued to fall, particularly during evening shifts and shift changes. Interviews with staff revealed that the hospice-provided sitter was not effective as it was scheduled during the day, while falls occurred in the evening. The facility's IDT met after each fall to review and adjust care plans, but no new interventions were added after the falls on two specific dates, as they were waiting for a mood stabilizing medication to reach full effectiveness. The facility's administrator acknowledged the ineffectiveness of the current sitter schedule and mentioned that one-to-one sitters are provided for residents with frequent falls or aggressive behaviors, but no adjustments were made for this resident's care plan after the recent falls.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food storage practices, affecting 127 residents who received food from the kitchen. During an inspection, it was observed that food items in the dry storage area were found in opened and unsealed containers, and some were past their use-by or best-by dates. In the walk-in refrigerator, vegetables were wilted, decomposing, and moldy, and containers of sour cream were past their best-by dates. Additionally, Freezer #2 had ice buildup on all four walls, indicating potential temperature issues. The dishwasher's water temperature was also found to be below the required range, which could compromise the sanitation of dishes. The Dietary Manager Assistant confirmed that the items past their use-by dates should not have been available for use. The Registered Dietitian stated that opened, unsealed foods should not be used, and all food items should be dated when opened and disposed of by their use-by dates. The RD also noted that the ice buildup in the freezer suggested it may have been above the temperature range at some point. The dishwasher, a low-temperature model, should maintain a temperature of 120°F to ensure proper sanitation, but it was observed to be operating below this temperature, posing a risk of foodborne illnesses to residents.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs of three residents, leading to deficiencies in their care. Resident 21, who had a history of stroke and contracture of the left hand, was unable to use a conventional push button call light due to her physical limitations. Despite being at high risk for falls, she was not assessed for an adaptive call light that would have been more suitable for her condition. Observations revealed that Resident 21 struggled to use the call light, causing her distress and increasing her risk of falls and injury. Similarly, Resident 94, who suffered from dementia and hemiplegia following a stroke, was also unable to use a conventional call light due to weakness in her hands. Her call light was found out of reach, and her fall mat was not properly positioned, further increasing her risk of falls. Despite being identified as a high fall risk, Resident 94 was not provided with an adaptive call light, and the facility's policies on fall prevention and accommodation of needs were not followed. Resident 50 experienced emotional distress and isolation due to the loss of his wheelchair, which was replaced with one that was too large and uncomfortable. This unsuitable wheelchair did not fit through his door, limiting his mobility and independence. Despite being informed of the issue, the facility delayed in providing a properly sized wheelchair, which affected Resident 50's ability to move safely and independently. The facility's failure to provide appropriate equipment and timely response to the residents' needs resulted in significant deficiencies in their care.
Unsafe Smoking Practices in Facility
Penalty
Summary
The facility failed to ensure safe smoking practices for eight residents who were identified as smokers. These residents were found to have cigarettes and lighters unsecured in their rooms, despite being assessed as high risk for accidental injury and requiring supervision while smoking. Specifically, Resident 38, who was not an independent smoker, had cigarettes and a lighter on his bedside table and in an unlocked drawer. Resident 49, who was on continuous oxygen, also kept her cigarettes and lighter unsecured in her room. Both residents were not following the facility's smoking policy, which required supervision and the use of protective equipment. Additionally, several other residents, including Residents 53, 120, 118, 112, 22, and 61, were found to have their smoking materials unsecured in their rooms. Some of these residents were assessed as safe smokers, while others required supervision and the use of a smoking apron. Despite these assessments, the facility did not ensure that smoking materials were secured, and residents were observed smoking without supervision or protective equipment. The facility's policy required staff to control the distribution of smoking materials and provide appropriate supervision, which was not consistently followed. Interviews with staff revealed a lack of training and awareness regarding the facility's smoking policy. Licensed Nurse 1 and CNA 2 confirmed that residents had access to unsecured smoking materials and were not always supervised while smoking. The Activity Director acknowledged that only a few residents had their smoking supplies locked, and none of the lockboxes had keys. The Assistant Director of Nursing highlighted the risks associated with unsecured smoking materials, especially for residents on oxygen, but confirmed that the facility's smoking policy was not being adhered to.
Inconsistent Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food in a consistent and appetizing manner, as evidenced by observations and interviews with residents and staff. Two residents reported that their meals were consistently served cold. During a test tray sampling, the Registered Dietitian (RD) confirmed that the pureed beef, rice, and potatoes were bland and not served at an appetizing temperature. The RD acknowledged that food temperatures and palatability are important for meal consumption, and there is a risk of residents not consuming their meals if they are not palatable. Additionally, the facility did not follow recipes for residents receiving pureed diets. Observations revealed that dietary staff did not add liquids or thickeners to pureed foods as required by facility recipes. The RD stated that residents on pureed diets should receive the same foods as other residents, and recipes should be followed to ensure proper consistency and taste. The facility's policy emphasized the use of standardized recipes to ensure consistent food quality, but this was not adhered to, potentially affecting the meal intake of residents.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of care with hospice services for three residents receiving hospice care. For Resident 139, there were no hospice visit notes available in the facility's binder for extended periods, despite the hospice provider's assurance that notes were left or sent to the facility. The Medical Records Director confirmed that no emails containing these notes were received, and the Assistant Director of Nursing (ADON) emphasized the importance of these notes for coordinating care and following up on hospice visits. Similarly, for Resident 121, the facility did not review hospice care provider nursing notes for several months, even though the hospice provider sent weekly emails containing these notes. The ADON confirmed that these emails were not opened or reviewed. For Resident 25, there were no hospice care provider nursing notes in the facility's binder for several months, and the ADON acknowledged that the notes were in emails that had not been opened or reviewed. The Director of Nursing stated that hospice notes should be placed in the resident's hospice binder weekly to ensure facility staff have access to the necessary clinical information.
Infection Control Lapses in Isolation Precautions and Glucometer Sanitization
Penalty
Summary
The facility failed to implement timely isolation precautions for a resident diagnosed with Clostridium difficile (C. difficile), a highly contagious infection. The resident, who had a history of diabetes mellitus and end-stage renal disease, exhibited symptoms of loose stools starting on November 4, 2024. Despite these symptoms, the resident was not placed on contact isolation precautions until November 8, 2024, after the lab results confirmed the presence of C. difficile. The Infection Preventionist (IP) acknowledged that the resident should have been placed on isolation precautions when the symptoms first appeared to prevent the potential spread of infection. Additionally, the facility did not ensure proper cleaning and sanitization of glucometers, which are used to measure blood sugar levels. During observations, it was noted that licensed nurses did not adhere to the manufacturer's guidelines for disinfecting the glucometers. The contact time between the disinfectant wipe and the glucometer was insufficient, and in some cases, the glucometer was not sanitized at all. The IP confirmed that the glucometers need to be visibly wet for two minutes to effectively kill organisms and prevent cross-contamination. These deficiencies highlight lapses in the facility's Infection Prevention and Control Program, which could lead to cross-contamination and negatively impact the health and well-being of residents. The facility's policies and procedures were not followed, and there was a lack of communication with external facilities, such as the dialysis clinic, regarding the resident's infectious status.
Resident Dignity Compromised by CNA's Negative Comments
Penalty
Summary
The facility failed to ensure that Resident 118 was treated with dignity and respect, as evidenced by an incident involving a certified nursing assistant (CNA 2) who made negative comments about the resident's weight and wheelchair size. Resident 118, who was admitted to the facility with a diagnosis of obesity, overheard CNA 2 speaking to a licensed nurse (LN 2) about the physical difficulty of pushing her wheelchair due to her size. This incident left Resident 118 feeling upset, hurt, and crying, impacting her self-worth and self-esteem. Despite Resident 118's complaint to LN 2 and the Social Services Director (SSD), there was no follow-up from the social services department to address her emotional and psychosocial needs. The facility's documentation, including the Grievance/Complaint Resolution Report, indicated that CNA 2 was aware of the resident's discomfort but did not realize she overheard the conversation. The Director of Staff Development (DSD) acknowledged that CNA 2 received a verbal in-service on professionalism and communication, but the resident's care plan was not updated to reflect the incident. The Assistant Director of Nursing (ADON) emphasized the importance of maintaining residents' dignity by preventing them from overhearing negative comments. The facility's policy on resident rights and care planning was not adhered to, as there was no episodic care plan developed for the temporary change in Resident 118's condition following the incident.
Failure to Communicate Resident's Inability to Exercise to Physician
Penalty
Summary
The facility failed to consult the physician for a resident when the resident's physician recommended exercise in response to the resident's request for help with weight loss. The resident, who was admitted in 2022 with diagnoses including morbid obesity and abnormalities of gait and mobility, had requested to try semaglutide injections for weight loss. The physician, through a Nurse Practitioner, recommended weight loss through exercise with the assistance of a Restorative Nursing Assistant (RNA). However, the order for RNA assistance with walking and exercise was discontinued and not completed, and the resident's inability to participate in the exercise program was not communicated to the physician. The resident experienced a significant weight gain and expressed feelings of demoralization due to previous failures in weight loss efforts. The Assistant Director of Nursing (ADON) acknowledged that the resident's inability to exercise should have been communicated to the physician to discuss alternative options for weight loss. The facility's failure to update the physician on the resident's decline in functional abilities and inability to follow the exercise program potentially delayed interventions to assist the resident with his weight loss goals.
Confidentiality Breach in Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for two residents. Resident 89's electronic health record (EHR) contained a clinical document titled 'Consultation Report' that belonged to Resident 95. This document included Resident 95's personal health information (PHI), such as birthdate, gender, medication details, and a recommendation for lab work. This error resulted in Resident 95's PHI being accessible to Resident 89, violating Resident 95's right to confidentiality. Interviews with the Medical Records Director (MRD) and the Assistant Director of Nursing (ADON) confirmed the presence of Resident 95's PHI in Resident 89's EHR. The MRD acknowledged the importance of correctly filing resident clinical records to protect confidentiality and privacy. The facility's policy on HIPAA Privacy Policies, reviewed in 2019, emphasized the need to remove any portion of the record relating to someone other than the resident. Additionally, the facility's Resident Rights document assured residents of confidential treatment of their health records.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two residents, leading to potential inaccuracies in care planning and tracking. Resident 51's discharge MDS was not completed for a discharge that occurred in July 2024, leaving the resident's health status untracked in the MDS system. The MDS coordinator confirmed the oversight, acknowledging the importance of the discharge assessment in reflecting the facility's true census and informing the Centers for Medicare Services (CMS) of the resident's discharge status. The facility's policy required MDS assessments to be completed and transmitted within specific timeframes, which was not adhered to in this case. For Resident 102, the MDS assessment inaccurately indicated the use of a feeding tube, despite the resident being on a pureed diet and never having received nutrition via a feeding tube. This error was confirmed during a review of the resident's electronic health record and through interviews with facility staff, including a Certified Nursing Assistant and the MDS nurse. The Director of Nursing and the Administrator acknowledged that the facility's MDS Standard of Practice, which emphasizes accurate coding and data integrity, was not followed, resulting in the incorrect documentation of the resident's nutritional status.
Failure to Update PASARR After Change in Mental Health Diagnosis
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASARR) form for one resident after a significant change in her mental illness diagnosis. Resident 43, who had a diagnosis of a serious mental illness, was initially screened with a Level I PASARR, which was positive and required a Level II screening. However, after her diagnosis was updated to include schizoaffective disorder, a new Level I screening was not completed, and consequently, a Level II evaluation was not scheduled. This oversight meant that Resident 43 did not receive an updated assessment that could have identified necessary specialized mental health services to improve her condition and quality of life. Interviews with facility staff, including the Admissions Department and the Minimum Data Set (MDS) Nurse, revealed a lack of clarity and communication regarding the process for initiating a new PASARR when a resident's mental health diagnosis changes. The Admissions Department acknowledged that they were responsible for initiating PASARRs upon receiving new diagnosis information from the MDS Nurse, but this process was not followed. The Director of Nursing and Administrator also confirmed that the facility's policy, which requires the Level I screening to reflect the resident's current condition, was not adhered to, resulting in the deficiency.
Failure to Develop Individualized Care Plans for Vision and Fall Risk
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, leading to potential unmet care needs. Resident 54, who was admitted with diagnoses of diabetic cataract and glaucoma, did not have a vision care plan addressing these conditions. Despite being legally blind and experiencing worsening vision, Resident 54's care plan lacked focus and interventions for his vision problems. Interviews with staff confirmed that the care plan was not updated to include these critical diagnoses, and the facility's policy for comprehensive care planning was not followed. Resident 94, diagnosed with dementia, hemiplegia, and hallucinations, was identified as a high fall risk. However, the facility did not develop a fall care plan despite a fall risk assessment indicating a high risk score. Observations revealed that Resident 94's call light was out of reach, and the fall mat was improperly positioned, increasing the risk of falls. The lack of a fall care plan was confirmed during interviews with staff, who acknowledged that the facility's policy for fall prevention and response was not adhered to. The facility's policies required comprehensive care plans to be developed and updated based on residents' needs and risk assessments. However, in both cases, the facility did not follow its own procedures, resulting in the absence of necessary care plans for vision and fall risk management. This oversight placed both residents at risk of not receiving adequate care to meet their specific health needs.
Failure to Assist Resident in Obtaining Vision Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident 54, in obtaining necessary vision services in a timely manner. Resident 54, who was admitted with diagnoses including diabetic cataract and glaucoma, expressed concerns about worsening vision and had requested an evaluation two months prior. Despite having medical insurance, the resident was deemed ineligible by an outside vision provider, and the facility did not follow up or attempt to find another provider. This lack of action led to Resident 54 feeling frustrated and potentially impacted their psychosocial well-being. Interviews and record reviews revealed that the Social Services Assistant (SSA) and Social Services Director (SSD) were aware of the ineligibility status but did not take further steps to secure vision services for Resident 54. The SSA was unsure of the meaning of 'ineligible' and did not document any follow-up actions. The SSD also confirmed the lack of documentation regarding attempts to arrange a vision referral. The Assistant Director of Nursing (ADON) acknowledged that the facility's process for addressing vision service requests was not followed, as there was no notification or accommodation of appointments for the resident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of practice for two residents. For Resident 111, medications, including controlled substances, were left unattended at the bedside. This occurred despite there being no physician order or care plan assessment allowing the resident to self-administer medications. During an observation, a plastic cup with medications was found on Resident 111's bedside table, and the resident confirmed they were his medications. Licensed Nurse 6 admitted to leaving the medications at the bedside upon the resident's request, acknowledging the risk that another resident could have taken them. The facility's policy clearly stated that medications should not be left unattended, and staff should observe the resident's consumption of the medication. For Resident 105, the facility did not ensure the correct route of medication administration. Although the resident's physician had clarified that medications should be administered orally (PO), they were given via a gastrostomy tube (G-Tube). During a medication pass observation, Licensed Nurse 1 administered several medications through the G-Tube, despite verbalizing that the route ordered was PO. The resident's order summary and medication administration report confirmed that the medications were ordered to be given PO. Interviews with staff, including Licensed Nurse 4 and the Assistant Director of Nursing, revealed that the medications should have been administered PO as per the physician's orders, and any issues should have been communicated to the physician. The facility's policy on medication administration required verification of the correct medication, time, and route before administration. The Pharmacist Consultant was unaware that medications were being administered via G-Tube and emphasized the importance of following physician orders. The physician confirmed that the medications should have been administered PO, especially since the resident was no longer receiving G-Tube feeding and had normal oral intake. The failure to follow the correct route of administration could affect the efficacy of the medications, particularly if they were not suitable for G-Tube administration.
Medication Administration Error Due to Incorrect Route
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 17.8% due to five errors out of 28 opportunities. These errors were identified during medication administration observations conducted over multiple days and locations within the facility. The errors involved a single resident, Resident 105, who received medications via a gastrostomy tube (G-Tube) instead of the prescribed oral (PO) route. The medications involved included Carvedilol, Losartan, Jardiance, a multivitamin with minerals, and Senna, all of which were ordered to be administered orally. During interviews, the licensed nurse (LN) responsible for the administration acknowledged the error, and both the physician and the Assistant Director of Nursing (ADON) confirmed that the medications should have been given orally as per the physician's orders. The ADON highlighted that certain medications, especially extended-release forms, should not be crushed and administered via G-Tube as it could affect their efficacy. The Pharmacist Consultant was unaware of the route change and emphasized the importance of following physician orders. The facility's policy on medication administration requires verification of the correct medication, time, and route before administration, which was not adhered to in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored in a clean and sanitary environment, as observed during a survey. A loose pill was found at the bottom of the Station 2 Medication Cart, which was not in its bubble pack, making it unidentifiable. This observation was made during an interview with a licensed nurse (LN) who acknowledged the importance of maintaining cleanliness and accountability by ensuring no loose pills were present in the medication cart drawer. The Assistant Director of Nursing (ADON) further explained that having loose pills in the medication cart posed a danger to the nurse and was an infection control issue. A review of the facility's pharmacy policy indicated that medications and biologicals should be stored in their original containers, highlighting a deviation from the established protocol.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents during lunch on November 7, 2024. Resident 28, who had documented dislikes for carrots and hamburger, received a meal tray containing both items. Similarly, Resident 101, who had significant weight loss and dietary restrictions against beef and pork, was served a meal without a protein portion, despite her need for protein to prevent muscle loss. These discrepancies were observed during a tray line observation and confirmed by the Registered Dietitian (RD), who acknowledged that the residents' dietary preferences should have been followed. On November 8, 2024, further observations revealed that Resident 101's meal tray potentially lacked a protein portion or contained a disliked item. The RD, upon reviewing a picture of the meal, could not identify the tan food item on Resident 101's plate, which could have been pork or wheat bread. The facility's policy on resident food preferences, dated November 2016, mandates that all food and dining services staff be aware of and adhere to residents' food preferences and allergies, ensuring that residents receive meals that satisfy their tastes and nutritional needs.
Failure to Initiate Rehabilitation Services for Resident
Penalty
Summary
The facility failed to provide necessary rehabilitation services to a resident, identified as Resident 94, upon their admission. Resident 94 was admitted with diagnoses of hemiplegia and hemiparesis affecting the left dominant side, as noted in the hospital discharge summary, which recommended skilled physical therapy (PT) and occupational therapy (OT). However, these services were not initiated, and the resident was not assessed for PT and OT. The Director of Rehab confirmed the absence of an order for these therapies and acknowledged that the resident depended on staff for needs due to the inability to use the left dominant side. Interviews with facility staff revealed a breakdown in the process of verifying and implementing hospital discharge orders. Licensed Nurse 8 stated that the usual procedure involved verifying orders with the Medical Director, but no PT or OT orders were found in the Electronic Health Record. The Assistant Director of Nursing (ADON) was responsible for reviewing hospital orders for new admissions, but this was not effectively carried out. The Medical Director and Director of Nursing confirmed that the expectation was for the resident to receive PT, OT, or Restorative Nurse Aide services, and if not, a note should have been entered into the resident's record. The failure to initiate these services had the potential to result in a decline in the resident's physical function.
Failure to Follow Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the planned menu for 18 residents on pureed diets during a lunch meal service. Instead of serving the squash listed on the menu, the staff member prepared and served pureed carrots. This deviation from the menu was observed during a kitchen inspection, where the staff member was seen blending cooked carrots with thickener and hot water, then serving the pureed mixture. The staff member admitted to not following the menu due to being occupied with other preparation tasks, acknowledging that the residents should have received the squash as planned. The facility's administrator confirmed the importance of following menus to meet resident preferences and needs. The administrator acknowledged that failing to serve the menu items as planned could result in unmet needs for the residents. A review of the facility's spring menu and policy indicated that the menu for the day included 'Aunties Baked Squash' for lunch, and the policy emphasized the importance of menu adherence for nutritional variety and effective dining service planning.
Deficiency in Meal Preparation and Temperature
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to recipe directions, resulting in an unappetizing texture for 18 residents on a pureed diet. During an observation, a staff member prepared pureed carrots by adding an unmeasured amount of hot water and thickening product, leading to a runny consistency that spread over the plate and mixed with other food items. The staff member admitted to not using a measuring cup for the water or thickener, confirming the carrots were not the right consistency for pureed food. The facility's policy indicated that recipes should be available and utilized, which was not followed in this instance. Additionally, the facility failed to serve meals at an appetizing temperature, as observed when the lunch meal was served late to two residents. The meal cart arrived 45 minutes after the scheduled mealtime, and residents reported that their food was cold. One resident noted that the food had been cold all week, while another resident found their meal too hard and cold to eat. The Director of Nursing confirmed that lunch was not served as scheduled on that day.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to prepare and serve pureed food at the correct texture for 18 residents who required a pureed diet. During an observation, a staff member prepared pureed carrots by placing cooked carrots into a blender, adding an unmeasured amount of hot water and a thickening product, and blending the items together. The Registered Dietitian confirmed that water was not listed in the recipe for pureed carrots, which specified using a specific amount of food thickener to achieve the correct consistency. The prepared carrots were observed to be too runny, spreading over one-third of the plate and mixing with other food items. The staff member admitted to not using a measuring cup for the water or thickener, resulting in a consistency that was not suitable for pureed food, which should resemble mashed potatoes. This improper preparation increased the risk of swallowing difficulty for residents who required a modified food texture, potentially affecting their meal intake. The staff member acknowledged that sending out food that is too runny or too thick could make it difficult for residents to eat properly.
Improper Dish Drying Practices in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety by improperly storing clean dishes, affecting 144 residents who received meals from the kitchen. During an observation, it was noted that food trays and plastic drinking glasses were stacked while still wet, preventing proper air circulation and drying. This was confirmed during interviews with the Registered Dietician (RD) and the Director of Nursing (DON), who both acknowledged the presence of moisture on the drying trays and inside the plastic cups. They identified this moisture as a potential environment for pathogen growth, which could lead to foodborne illnesses among residents.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure that a resident was examined by a physician at least every 30 to 60 days, as required. The resident, who was admitted in mid-2023 with diagnoses including rectal and intestinal cancer and heart failure, reported not having seen a doctor since a change in her physician two months prior. A review of the resident's clinical record confirmed that the last documented physician visit was in September 2023, with no subsequent visits recorded in the Electronic Health Record (EHR). Interviews with facility staff, including Health Information Management (HIM) personnel and the Director of Nurses (DON), confirmed the lack of physician visits for the resident. The HIM department had a system in place to track overdue physician visits and notify physicians, but this process did not prevent the oversight. The Medical Director acknowledged the lapse, attributing it to the sudden departure of the resident's previous physician. The facility's policy and federal regulations require physician visits every 30 days for the first 90 days after admission and at least every 60 days thereafter, which was not adhered to in this case.
Failure to Schedule Follow-Up Appointments for Resident
Penalty
Summary
The facility failed to provide medically related social services for a resident when follow-up appointments with medical specialists were not scheduled as ordered. The resident was admitted to the facility with multiple fractures and a contusion, requiring follow-up care with an orthopedist and a neurosurgeon. Despite orders for these follow-up appointments, there was no documentation in the electronic health record (EHR) or facility transport book to indicate that the appointments were scheduled or attended. Interviews with the Social Services Director (SSD) and the Director of Nurses (DON) confirmed the lack of documentation and the expectation that physician orders for follow-up appointments should be carried out. The SSD acknowledged the risk of delayed treatment if the resident did not attend the appointments, which were necessary for the resident's recovery from her injuries. The facility's policy emphasized the role of social services in addressing the well-being of residents, but the failure to schedule the appointments compromised the resident's care.
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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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