Delano District Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Delano, California.
- Location
- 1509 Tokay Street, Delano, California 93215
- CMS Provider Number
- 555479
- Inspections on file
- 60
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Delano District Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, bipolar type, anxiety, major depressive disorder, and urinary retention requiring a Foley catheter twice attempted suicide in her room, first by wrapping a call light cord around her neck and shortly afterward by removing her Foley catheter and wrapping the tubing around her neck, during a period when staff had removed cords but had not clearly assigned continuous supervision. Nursing staff acknowledged knowing the resident was a danger to herself but left the room after the first attempt, each assuming another staff member would monitor her, and the DON later reported not knowing there had been two separate attempts. The resident was placed on q30‑minute visual checks rather than 1:1 monitoring until days later, and review of suicide‑observation documentation showed missed q30‑minute checks at multiple times despite an order for such monitoring, in contrast to the facility’s Suicide Prevention Guidelines policy requiring close monitoring and documented 30‑minute checks after suicidal ideation or attempts.
The facility failed to ensure a CNA received required annual abuse prevention training, as confirmed by training records, staff interviews, and facility policy. A resident’s responsible party reported that the resident complained a night-shift CNA was rude and mean. Review of the CNA’s file showed her last abuse training was completed more than three years earlier, despite the Administrator, DSD, and written policy all stating that abuse and resident rights training must be provided annually and as needed.
The facility did not complete the required 5-day abuse investigation report after a CNA reported overhearing an argument and alleged verbal abuse by a resident’s daughter during a meal pass. The incident was documented on an SBAR form, and facility policy required that a final investigation report be faxed to the appropriate agency within five working days. The Administrator stated the DON was responsible for this report, and the DON acknowledged that the 5-day report was not completed, despite more than a week having passed since the allegation.
A resident experienced a verbal altercation with her daughter that was reported by a CNA via an SBAR form after staff overheard an argument in the resident’s room during meal pass. The resident’s care plan was updated to address an alteration in well-being related to this incident and included an intervention for the Social Service Designee to conduct wellness checks for 72 hours. During later review, the SSD could not provide documentation that these wellness checks were completed, and both the Administrator and DON acknowledged that Social Services should have monitored the resident as care-planned, resulting in a failure to implement the care plan intervention.
The facility failed to ensure staff who operated the resident transport van were assessed and documented as competent, despite using the vehicle to take residents to medical appointments and activity outings. A staff member and the AD reported routinely transporting residents, including wheelchair-bound individuals, using a van equipped with a hydraulic lift and wheelchair restraints, without ever being required to demonstrate driving competency or safety. The DSD confirmed there was no process to verify driver competency, and the DON acknowledged that no competencies had been completed for staff who drive the van, contrary to the facility’s own competency evaluation policy requiring staff providing care, treatment, or services to be competent.
The facility did not follow its Abuse Prevention Program policy for an agency CNA. The DON and DSD could not provide a clear hire date for the CNA, who had been working intermittently at the facility for about a year. The DSD reported that the staffing agency, not the facility, handled all background and reference checks and ensured required training, and confirmed the facility did not perform its own reference checks or provide resident-rights and abuse-prevention training to agency staff. Policy required reference checks for potential employees and mandated that all new employees receive resident-rights and abuse-prevention in-service training during orientation within 60 days of employment and annually, but these steps were not completed for this CNA.
A resident lying in bed with the head of the bed elevated reported that CNAs did not provide their call light and was later heard repeatedly calling out for a CNA, stating they did not have a call button. When a CNA entered the room, the call light was found looped to the bed rail but hanging behind the top side of the mattress, out of the resident’s reach; the CNA confirmed it was not reachable and that call lights should be easily accessible. Facility policy required that all residents have a call light in place at all times as the primary means to alert nursing staff to their needs, but this was not followed for this resident.
A cognitively intact resident sustained a skin tear to the hand during ADL care provided by two CNAs and immediately stated, "you hit me," while one CNA reportedly gripped the resident and commented on the resident screaming. Both CNAs documented and later confirmed that the resident alleged they hit her but asserted she struck the siderail, and neither reported the abuse allegation at the time it occurred. An SOC 341 abuse report was not completed until two days later, and the DON confirmed the allegation was not promptly reported, contrary to facility policy requiring immediate reporting and protective measures during abuse investigations.
A resident sustained a skin tear during care, after which a CNA obtained triple antibiotic ointment and a bandage from the treatment nurse, then cleaned the wound and applied the ointment and bandage herself. The DON stated that CNAs are not permitted to perform wound treatments. Facility documentation reflected that the CNA recorded applying antibiotic ointment and a bandage after the resident was accidentally hit against a side rail. Review of the facility’s medication administration policy showed that medications are to be prepared and administered only by licensed nurses, pharmacy, or other personnel authorized by state regulations, which was not followed in this case.
Surveyors determined that the facility did not follow its abuse prevention screening policy when hiring two CNAs. Review of personnel files with the DON and Human Resource Assistant showed that one CNA was hired without any reference checks or required exclusion/OIG background check, and another CNA was hired without any reference checks. The facility’s Abuse Prevention Program required pre-employment screening for abuse, neglect, or mistreatment history, including reference checks and multiple background checks (e.g., CA courts, Megan’s Law, exclusion lists, and L&C verification), but these procedures were not completed before these CNAs began employment.
Two CNAs were hired without documented evidence of completed criminal background checks prior to their start dates. Although HR stated that checks were performed, no proof with dates was available, resulting in noncompliance with the facility's hiring policy.
The facility did not provide a written discharge notice to a resident and their responsible party prior to discharge, instead giving the notice on the day of discharge. Additionally, discharge notices were not sent to the State LTC Ombudsman for twelve discharged residents, despite facility policy and prior written notification from the Ombudsman requiring this action.
A resident with significant physical limitations was discharged home without the physician-ordered home health PT/OT/ST services due to lack of available providers and insurance network issues. The discharge summary lacked a documented post-discharge care plan, and the resident's family member reported being unable to provide the necessary care.
A resident with multiple health conditions, including anxiety disorder and legal blindness, alleged that staff were hitting and kicking him. The administrator, who was also the abuse coordinator, was informed of the allegation but did not report it to CDPH as required by facility policy and state law.
The facility failed to promptly answer call lights for several residents, leading to unmet needs and frustration. A resident's call light was ignored by staff, including a new CNA unsure of her assignment, resulting in a delay in changing a dirty brief. Other residents reported feeling desperate and frustrated due to routine delays exceeding 15 minutes. The facility's policy requires prompt response to call lights, but this was not followed, as acknowledged by the administrator.
The facility failed to meet pharmaceutical service needs for three residents. A resident's Lidocaine patch was not removed as prescribed, another received a crushed Nifedipine ER tablet instead of whole, and discrepancies were found in the accounting of controlled drugs for a third resident. Additionally, a nurse signed the narcotic count sheet prematurely, violating policy.
The facility failed to maintain food safety and sanitation standards, as dented tomato soup cans were found in storage and a container of lentil beans was left open. The Dietary Manager acknowledged these issues, which violated the facility's policies on canned and dry goods storage, posing a potential risk of foodborne illness to residents.
The facility failed to maintain infection control standards, with soiled laundry cart covers and a dirty linen closet floor potentially contaminating clean linen. Additionally, two RNs did not properly disinfect glucometers after use, risking exposure to bloodborne pathogens. The Infection Preventionist confirmed the need for proper disinfection procedures.
The facility failed to document the COVID-19 vaccination status of nine employees, including a PM worker, a housekeeper, CNAs, an RN, an LVN, and NAs, hired between July 2024 and January 2025. The Infection Preventionist Nurse did not record their vaccination status, as it was not mandatory at the time of hiring, despite the facility's policy requiring such documentation. This oversight had the potential to spread COVID-19 within the facility.
A facility failed to ensure the accuracy of the MDS for a resident, leading to an incorrect record of the resident's discharge location. The MDS indicated a discharge to a hospital, while Nurse's Notes showed the resident was discharged home. The MDSC acknowledged the error, noting the lack of a specific policy for MDS accuracy and admitted to not verifying the information against the medical record.
A resident at risk for dehydration due to diarrhea did not have fluids accessible at the bedside. The water pitcher and cup were placed out of reach, and no straw was available, hindering the resident's ability to drink independently. A nurse confirmed the need for the bedside table to be within reach, aligning with the facility's hydration policy.
The facility failed to monitor the oxygen saturations of two residents as per physician orders. One resident was observed without oxygen despite an order for oxygen inhalation when saturation was below 93%, and their oxygen levels were not documented. Another resident's oxygen saturations were missing from records for several shifts, despite an order for continuous oxygen inhalation for low saturation. Staff confirmed the lack of documentation and monitoring, which was against the facility's process to follow physician orders.
A registered nurse at the facility was found to lack current CPR certification, a requirement stated in the job description. The nurse's certification had expired the previous year, and both the nurse and the Human Resource Manager acknowledged the deficiency. This lapse in certification could impact the nurse's ability to respond to medical emergencies.
A resident who required adaptive eating equipment due to coordination issues was not provided with the necessary utensils during meals, as observed during a survey. Despite a physician's order and care plan indicating the need for build-up foam utensils, the resident was seen using regular utensils. RN 2 confirmed the oversight and noted that the kitchen was responsible for providing the adaptive equipment, as per the facility's policy.
The facility failed to maintain clean and sanitary conditions in resident shower rooms, affecting multiple residents. Observations revealed discolored grout, dirty shower chairs, and a bowel movement on the wall. The Facility Director and Administrator acknowledged the issues, which were contrary to the facility's housekeeping policy.
A resident with moderately impaired cognition was subjected to undignified treatment when an RNA placed her hand over the resident's mouth to quiet her. This incident, observed by a CNA and confirmed by security footage, violated the facility's policy on dignity and respect. The DON verified the incident, leading to the termination of the involved RNAs.
A facility failed to follow its Abuse Prevention Program when a CNA observed an RNA placing her hand over a resident's mouth to stop her from screaming. Despite the immediate report of the incident, the RNA continued working for several hours before being sent home, contrary to the policy requiring accused employees to be placed on administrative leave during investigations.
The facility failed to follow its safety policy when tools were left unattended on the floor, posing a potential injury risk. Nine screws were found in a hallway, and a screwdriver with repair parts was left in an open office. The Maintenance Assistant admitted to leaving the tools, and both the Administrator and DON expressed safety concerns. The Director of Maintenance emphasized the need to clear hazards and block off work areas.
The facility failed to position two high-risk residents near the nurse's station as required by their care plans, leading to multiple falls. One resident, with a history of falls and conditions like dementia and osteoporosis, was placed far from the nurse's station, resulting in a hip fracture after an unwitnessed fall. Another resident, also at high risk, fell while trying to get up from a wheelchair, despite having an alarm. Staff confirmed the residents' rooms were not close enough for effective monitoring.
The facility failed to report multiple allegations of abuse involving residents, including physical altercations and sexual misconduct. Despite being informed of these incidents, the facility did not report them to the state agency as required. The incidents involved residents with varying cognitive abilities, and staff were aware of the situations but did not take appropriate action to ensure resident safety.
The facility failed to provide timely dental services for two residents, resulting in potential oral health issues. One resident experienced severe pain due to delayed referrals for recommended extractions, while another faced delays in receiving oral surgery. The facility's policy emphasized prompt dental care, but the lack of follow-up and delayed referrals highlighted a failure to adhere to these guidelines.
The facility failed to process complaints from four cognitively intact residents regarding medication administration issues by registry nurses (RNNs) according to their policy. Residents reported issues such as medications not being passed on time or not at all during night shifts. The Facility Scheduler acknowledged complaints but did not verify RNN competency, and the Director of Staff Development confirmed medication errors without identifying affected residents. The facility's grievance policy was not followed, as complaints were not documented or resolved.
A new LVN at an LTC facility administered medications without completing the required competency evaluation, leading to a medication error. The LVN placed medications into a resident's tube feeding bag, which was against protocol. The resident, who was cognitively intact, noted forgetfulness in night shift medication administration. The DON confirmed this as a medication error, highlighting a lapse in ensuring staff competency.
A resident with hemiplegia, hemiparesis, and a history of falls experienced an unwitnessed fall resulting in a laceration and fracture of the right pinky finger. The facility failed to document required two-hour checks and interactions, as per their fall prevention protocol, contributing to the incident.
The facility failed to label tube feeding bags with dates and times for two residents, as required by its policy. Both residents, who had diagnoses related to gastrostomy and were on Jevity 1.5, had unlabeled feeding bags. This oversight was confirmed by nursing staff and had the potential to result in the residents consuming contaminated feeding formula.
A resident's room was found to be 84.4°F, exceeding the facility's policy of 71-81°F, verified by the Facility Director. The resident had multiple medical conditions and was unable to participate in cognitive assessments. The facility's policy emphasized maintaining safe temperatures to minimize health risks, but this was not adhered to.
A resident reported an altercation with a CNA, alleging abuse, but the CNA did not report the incident to management and continued working. The facility's policy requires immediate reporting and removal of the accused staff, which was not followed, potentially delaying the investigation.
A resident with a history of walking difficulties and high fall risk fell and sustained a shoulder injury due to inadequate assistance during ambulation. The Director of Rehabilitation was holding a cellphone and a wheelchair, failing to provide necessary hand support or use a gait belt, contrary to facility policy. This resulted in the resident losing balance and falling, leading to severe pain and hospitalization.
The facility failed to maintain an effective pest control program, as observed in the resident patio area where two residents reported seeing black widow spiders and cockroaches. Despite daily cleaning by maintenance staff, thick webs and egg sacs were present, indicating inadequate pest control measures. The facility had recently changed pest control services, but lacked proper tracking of the new company's activities.
A resident was moved to the dining room to sleep for one night after a late admission tested positive for COVID-19 and no other rooms were available. The resident felt scared and rushed, and the resident's representative stated there was no consent given for the move, describing it as humiliating. The facility's policy on Resident Rights was not upheld in this situation.
A resident with a history of seizures experienced multiple, prolonged seizures that were not promptly addressed by the RN, leading to a significant decline in the resident's condition. Despite staff urging, the RN did not send the resident to the hospital and left unqualified CNA students to monitor the resident.
The facility failed to treat four residents with dignity and respect, as evidenced by multiple incidents involving a registered nurse (RN). The RN dismissed a resident's concerns about another resident's seizures, displayed a bad attitude, and was intimidating. The RN had a history of similar complaints and disciplinary actions.
Failure to Adequately Supervise and Monitor Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and monitor a resident after suicide attempts, and failure to follow its Suicide Prevention Guidelines policy. The resident was admitted with schizoaffective disorder, bipolar type, cognitive communication deficit, anxiety disorder, and major depressive disorder, and had a BIMS score of 14, indicating cognitively intact status. The resident required a Foley catheter for urinary retention. On one day in March, the resident attempted to commit suicide in her room by wrapping her call light cord around her neck. Staff removed the call light and other cords from the room, but there was no clear assignment or confirmation of continuous supervision at that time. Later that same day, the resident made a second suicide attempt by removing her Foley catheter and wrapping the tubing around her neck. CNA 1 reported first finding the resident with the call light around her neck and then, about 10 minutes after leaving the room at the request of nursing staff, finding the resident again with the Foley catheter around her neck while no staff were present. LVN 1 confirmed she knew the resident was a danger to herself and needed monitoring, but she left the room after the first attempt assuming that either RN 1 or CNA 1 would stay with the resident, and did not obtain confirmation of who would supervise. The DON later stated she was not aware that the resident had made two separate suicide attempts that day and believed the call light and Foley catheter were used at the same time. Following these events, the resident was placed on every 30‑minute visual checks rather than one‑to‑one monitoring. LVN 2, who worked the night shift after the attempts, stated the resident was on 30‑minute checks and questioned why one‑to‑one monitoring was not implemented given the suicide attempts. The DON stated the resident was not placed on one‑to‑one monitoring until two days after the attempts. Review of the facility’s Observation of Resident: Suicidal Ideation/Suicidal Attempts documentation showed that on a later date, the resident, who was ordered to be monitored every 30 minutes, was not monitored at 11:00 a.m., 3:00 p.m., and 3:30 p.m. The DON acknowledged the resident should have been monitored at those times. The facility’s Suicide Prevention Guidelines policy required immediate attention, close monitoring, and 30‑minute checks with documentation and room inspection when residents threaten or attempt self‑harm, but the monitoring ordered and the documentation of checks were not consistently carried out as required.
Failure to Ensure Annual Abuse Prevention Training for CNA
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA 1) completed required annual abuse training, as identified through interviews and record review. Resident 1’s interdisciplinary team (IDT) note documented that the responsible party reported the resident complained that a night-shift CNA was rude and mean. During review of CNA 1’s training records with the Human Resource Assistant, it was confirmed that CNA 1’s last abuse training occurred on 2/7/23, more than three years prior to the survey, and no more recent abuse training could be produced. In separate interviews, the Administrator and the Director of Staff Development both stated that abuse training was required to be completed annually, and CNA 1 also confirmed that her last abuse training before the allegation was on 2/7/23. The facility’s Abuse Prevention Program policy dated 7/22/2021 stated that all new employees must attend resident rights and abuse prevention training during orientation and that such training shall be provided on an annual basis and as needed, which was not followed in the case of CNA 1. This deficiency centers on the facility’s failure to adhere to its own policy and procedure requiring annual in-service training on resident rights and abuse prevention, resulting in CNA 1 not receiving the mandated annual abuse training for more than three years prior to the reported complaint about her behavior toward Resident 1.
Failure to Complete 5-Day Abuse Investigation Report for Verbal Abuse Allegation
Penalty
Summary
The facility failed to complete and submit a final abuse investigation report within five working days for an allegation of verbal abuse involving one of three sampled residents (Resident 1). On 2/21/26 at 5:30 p.m., a CNA overheard an argument coming from the resident’s room during the meal pass and reported verbal abuse by the resident’s daughter, which was documented on an SBAR communication form and progress note at 6:54 p.m. the same day. The facility’s policy, “Abuse Prevention Program” dated 7/29/2020, requires that the final investigation report be faxed and confirmed to the appropriate agency within five working days from the time the incident occurred. During interviews on 3/5/26, the Administrator stated that the DON was responsible for completing the five-day report, and the DON acknowledged that the five-day report for this allegation was not completed, nine working days after the incident, contrary to facility policy. No additional medical history or clinical condition details for the resident at the time of the incident are provided in the report.
Failure to Implement Care Plan Wellness Checks After Verbal Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident following a reported verbal altercation with her daughter. On 2/21/26 at 6:54 p.m., an SBAR (Situation, Background, Appearance, Review and report) communication form and progress note documented that a CNA reported verbal abuse from the resident’s daughter after overhearing an argument from the resident’s room during meal pass. In response, the resident’s care plan, dated 2/23/26, identified an alteration in well-being related to the verbal altercation between the resident and her daughter and included an intervention for the Social Service Designee to conduct wellness checks for 72 hours. During a concurrent interview and record review on 3/5/26 at 11:35 a.m., the Social Service Director was unable to provide documentation that the wellness checks had been completed for the resident. In separate interviews on 3/5/26, both the Administrator and the DON stated that Social Services should have monitored the resident and completed the 72-hour wellness checks after the incident. Review of the facility’s Comprehensive Care Plans policy dated 11/2017 indicated that the comprehensive care plan should be updated to reflect changes in condition and that interventions are instructions to disciplines to perform direct care or provide assistance so residents may strive to achieve their established goals. Despite the care plan intervention specifying wellness checks, there was no documented evidence that these checks were carried out.
Failure to Ensure Driver Competency for Resident Transport Vehicle
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff members who drive the facility’s transport vehicle were assessed and documented as competent to do so. During interviews, one facility staff member stated he had transported residents in the facility vehicle when asked by leadership, and employee file review showed another staff member also used the transport vehicle to transport residents. The DON confirmed that the facility provides transportation for residents to and from appointments and for activity outings. The DSD reported that facility staff, including two identified staff and activities staff, use the facility van for these purposes but stated there was no process in place to verify that these staff were competent and safe to operate the transport vehicle. The AD, who had worked at the facility for 15 years, stated that transporting residents on outings is part of her job and described the facility van as accommodating nine residents, including wheelchair-bound residents, with a hydraulic lift and wheelchair securement straps. She reported she had not been required to demonstrate competency or safety in driving the van. A concurrent observation with the DON confirmed the presence of a hydraulic lift and capacity for nine residents, including those who must remain in wheelchairs. The DON acknowledged that the facility had not completed competencies for staff who drive the transport vehicle. This practice was inconsistent with the facility’s written Competency Evaluation policy, which requires that all staff who provide care, treatment, or services be competent to perform their duties, with competency defined as the demonstrated knowledge and skill necessary to perform a task or job safely, successfully, and efficiently.
Failure to Screen and Train Agency CNA per Abuse Prevention Policy
Penalty
Summary
The facility failed to follow its Abuse Prevention Program policy regarding screening and training of staff, specifically for one CNA obtained through an agency (CNA 1). During interviews and record reviews with the DON and DSD, it was determined that the facility could not provide a hire date for CNA 1, who had been working at the facility approximately once or twice a week for about a year. The DSD stated that the staffing agency was responsible for ensuring CNA 1 had all required training and for performing background and reference checks, and confirmed that the facility did not conduct its own reference checks or provide abuse-prevention or resident-rights training for agency staff. Review of the facility’s Abuse Prevention Program policy, revised 7/22/21, showed that potential employees were to be screened for a history of abuse, neglect, or mistreatment through reference checks with previous or current employers, and that all new employees were required to attend resident rights and abuse prevention in-service training during orientation within 60 days of employment and annually thereafter. These policy requirements were not followed for CNA 1.
Failure to Keep Call Light Within Resident’s Reach
Penalty
Summary
The facility failed to ensure a resident’s call light was placed within reach, as required by its policy that all residents have a call light in place at all times to alert nursing personnel to their needs. During an observation and interview in the resident’s room, the resident was lying in bed with the head of the bed elevated and stated that CNAs did not give them their call light. Later, while outside the room, the resident was heard repeatedly yelling for a CNA and stating they did not have a call button, continuing to call out for several minutes. A subsequent observation with a CNA in the room showed the resident still in bed with the head of bed elevated, and the call button looped to the bed rail but hanging behind the top right-hand side of the mattress, out of the resident’s reach. The CNA confirmed the resident could not reach the call light and acknowledged that the call light should be within easy reach for residents. A review of the facility’s “Call Light – Answering” policy, last reviewed on 4/25/14, indicated that the call light system is the only mechanism at the bedside for residents to alert nursing personnel to their needs, that each resident receives directions on its use and positioning upon admission, and that all residents will have a call light in place at all times. The observations and interviews showed that this policy was not followed for this resident, resulting in the resident not having ready access to the call light while in bed.
Failure to Timely Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting and investigation of an allegation of abuse involving one cognitively intact resident. The resident’s MDS dated 10/28/25 showed a BIMS score of 15, indicating intact cognition. On 12/21/25, documentation on an SBAR form indicated the resident sustained a skin tear while being changed and performing ADLs, with a note that the resident was accidentally bumped on the side rail. A Special Problems entry the same day, signed by CNA 3, documented that the resident screamed an expletive and said, "you hit me," and that CNA 3 responded that she did not hit the resident and that the resident hit herself on the siderail. A nurse’s note dated 12/23/25 indicated that an SOC 341 was completed because the resident claimed she was hit on the right hand and sustained a skin tear during ADLs, showing a delay between the allegation and formal reporting. During interviews, the resident stated that on 12/21/25 two CNAs provided care, that one CNA was gripping her and told her she screamed too much and should say please and thank you, and that her hand was injured during care, prompting her to tell the CNAs, "you hit me." On observation, a scab the size of a dime was noted over the pinky finger knuckle of the resident’s right hand. CNA 2 and CNA 3 both confirmed that during care on 12/21/25 the resident was injured, that they believed she hit herself on the bedrail, and that the resident told them, "you hit me." Both CNAs acknowledged they did not report the resident’s allegation of being hit. The DON confirmed that the resident made allegations to CNA 2 and CNA 3 that they hit her and that these allegations were not reported, despite the CNAs having been trained on reporting abuse. The facility’s Abuse Prevention Program policy required that alleged or suspected abuse be reported to specified parties and agencies within 24 hours and that residents be protected from harm by ensuring the accused perpetrator was not near the resident, measures that were not followed in this case.
Unlicensed Staff Performed Wound Treatment Using Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wound was treated by a licensed nurse, as required by facility policy. During care, Resident 1 sustained a skin tear, described as an acute, traumatic wound where the top layers of skin separate from the underlying tissue. Certified Nursing Assistant (CNA) 2 reported that after the skin tear occurred, CNA 3 went to the treatment nurse and obtained triple antibiotic ointment, a pad to clean the wound, and a bandage. CNA 2 stated that CNA 3 cleaned Resident 1’s skin tear, applied the triple antibiotic ointment, and then placed the bandage on the wound. The Director of Nursing (DON) stated that CNAs are not allowed to perform wound treatments. Review of Resident 1’s Special Problems documentation dated 12/21/25 showed an entry indicating that after accidentally hitting the resident against the side rail, CNA 3 went to get a bandage and some antibiotic ointment and applied it to the resident, with the note signed by CNA 3. In a separate interview, CNA 3 confirmed that Resident 1 received a skin tear during care, that she informed the treatment nurse, and that the treatment nurse gave her ointment and a bandage, which she then applied to the resident’s skin tear. Review of the facility’s Medication Administration Schedule policy, revised 10/19/22, indicated that medications are to be administered only by persons legally authorized to do so and prepared only by licensed nurses, pharmacy, or other personnel authorized by state regulations, which was not followed in this instance.
Failure to Complete Required Abuse-Prevention Screening for CNAs Prior to Hire
Penalty
Summary
Surveyors found that the facility failed to follow its abuse prevention screening policies by not completing required reference and background checks for two certified nursing assistants (CNAs) prior to their employment. During an interview and concurrent record review with the DON and Human Resource Assistant, CNA 1’s personnel file showed a hire date of 3/25/25 with no reference checks and no exclusion (Office of Inspector General) background check completed before employment, despite facility policy requiring these screenings. In the same review, CNA 2’s file, with a hire date of 1/9/23, showed no reference checks completed prior to employment, again contrary to facility policy. The facility’s written Abuse Prevention Program policy dated 7/22/21 stated that potential employees would be screened for a history of abuse, neglect, or mistreatment using reference checks with previous and/or current employers and additional hiring procedures, and that all applicants must have checks completed through CA courts (including supreme and 5th appellate district), Megan’s Law website, exclusion lists, and L&C verification searches. DON and HRA both acknowledged during the interviews that, per facility policy, reference checks and background checks were required to be completed prior to employment for these CNAs, but this was not done in these two cases.
Failure to Document Criminal Background Checks Prior to Hire
Penalty
Summary
The facility failed to ensure that two certified nursing assistants (CNAs) had completed and documented criminal background checks prior to their dates of hire. During a review of employee files, it was found that there were no documented dates on the criminal background checks for both CNAs. The Director of Nursing confirmed the hire dates and the absence of documentation, while Human Resources stated that background checks were performed before hiring but could not provide evidence, as the screen grabs taken did not include dates. The facility's policy requires that all applicants be screened for criminal background, fraud, and sex offender status before employment, and that any applicant with documented actions against them would not be considered for hire. However, the lack of documented dates on the background checks meant there was no verifiable proof that these checks were completed prior to employment, resulting in noncompliance with the facility's own hiring procedures.
Failure to Provide Timely Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written discharge notice to a resident and their responsible party prior to discharge, as required. The discharge order for the resident was written by the physician, and the resident was discharged two days later. However, the Notice of Proposed Transfer/Discharge was only provided to the responsible party on the day of discharge, rather than in advance. The responsible party was verbally informed of the discharge, but the written notice, which included the reason for discharge, was not given until the day the resident left the facility. Additionally, the facility did not send copies of discharge notices to the State Long-Term Care Ombudsman for twelve residents who were discharged during the review period. The Ombudsman confirmed that they did not receive the required notices, only a list of discharged residents with basic information. The facility's policy requires that a copy of the discharge notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, but this was not done. The Ombudsman had previously notified the facility in writing of this requirement.
Failure to Arrange Ordered Home Health Services and Document Discharge Plan
Penalty
Summary
The facility failed to implement an effective discharge plan for a resident who was discharged home without the home health services ordered by the physician. The resident, who had diagnoses including generalized muscle weakness, difficulty walking, and unsteadiness on feet, required assistance with ambulation, transfers, toileting, dressing, bathing, and grooming. The discharge summary indicated the need for physical, occupational, and speech therapy at home, but did not provide information on how these services would be obtained. Additionally, the section of the discharge summary designated for the discharge planning or post-discharge care plan was left blank. Facility staff documented that no home health agency was available to provide services in the resident's area, and the resident's insurance did not have in-network agencies nearby. The social services assistant informed the responsible party that out-of-network services would be needed, but there was uncertainty about whether this was understood. As a result, the resident was discharged to the care of a family member without any home health services in place, despite being physically weak and unable to independently perform activities of daily living.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a male resident with a history of anxiety disorder, muscle weakness, legal blindness, history of falling, and need for assistance with personal care. The resident was admitted to the facility and, during an emergency department visit, reported that facility staff were abusing him. The resident specifically told the facility's administrator, who also served as the abuse coordinator, that staff were hitting and kicking him. This allegation was made directly to the administrator after staff called him to the resident's room due to the resident's behavior, which included kneeling on the floor, refusing food and medication, and requesting to be sent to the hospital. Despite the resident's clear allegation of abuse, the administrator did not submit a report to the California Department of Public Health (CDPH) as required by the facility's policy and state law. The facility's policy states that all alleged or suspected violations and substantiated incidents of abuse must be promptly reported to the Ombudsman, law enforcement, and CDPH within 24 hours if no serious bodily injury occurred. As of the date of the survey, no report had been made to CDPH regarding this incident.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for five of the 72 sampled residents, leading to unmet needs. Observations and interviews revealed that Resident 47's call light was on for an extended period without being addressed, despite multiple staff members passing by. CNA 4, who was new to the facility, was unsure of her assignment and did not assist Resident 47, who needed a brief change. Resident 47 expressed that CNAs had told her she was too needy, which discouraged her from using the call light. Other residents, such as Resident 105 and Resident 92, reported feeling desperate and frustrated due to delays in call light responses, with waits often exceeding 15 minutes. The facility's policy on call light answering, dated 4/25/14, emphasizes the importance of meeting residents' needs promptly, yet this was not adhered to. The administrator acknowledged that a 15-minute delay is not prompt and that staff should answer call lights regardless of whose resident it is. Resident 96 experienced a 15-minute wait after pressing the call light for assistance, and Resident 86 confirmed that such delays were routine. These findings indicate a systemic issue with the facility's response to call lights, impacting residents' ability to have their needs met in a timely manner.
Pharmaceutical Service Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents. For Resident 93, staff did not adhere to the physician's order to remove a Lidocaine patch after 12 hours of application. This oversight resulted in the patch being left on longer than prescribed, as observed when a nurse removed the previous day's patch before applying a new one. The facility's policy requires medications to be administered according to physician orders, which was not followed in this instance. Resident 128 was administered a Nifedipine Extended Release tablet in a crushed form, contrary to the physician's order and FDA guidelines, which specify that such tablets should be swallowed whole to ensure the medication is released slowly over time. The Licensed Vocational Nurse crushed the tablet and mixed it with food, leading to the resident receiving a higher dose than intended. The facility's policy states that only medications that can be crushed should be crushed, which was not adhered to in this case. For Resident 96, there were discrepancies in the documentation and accounting of controlled drugs, specifically Morphine and Methadone. The Narcotic Logs did not match the actual amounts of medication left in the vials, indicating a failure to properly account for these controlled substances. Additionally, the outgoing nurse signed the end-of-shift narcotic count sheet before the end of her shift and without the incoming nurse present, which is against the facility's policy requiring both nurses to verify and sign the controlled drug count together at shift change.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary kitchen conditions, as observed during a survey. In the dry food storage room, multiple dented 50-ounce tomato soup cans were found, which the Dietary Manager (DM) acknowledged should not have been there and needed to be removed. The facility's policy and procedure (P&P) on canned and dry goods storage, dated 2018, required that dented cans be set aside for return to the vendor or proper disposal. The DM admitted that the policy was not followed, and the designated area for dented cans was in their office. Additionally, a 22-quart container of dry lentil beans was found with its lid open, which the DM confirmed should have been closed to prevent food contamination or insect intrusion. The facility's P&P specified that metal or plastic containers with tight-fitting lids should be used for storage. The DM stated that kitchen staff were expected to follow this policy, but it was not adhered to in this instance. These lapses in following established procedures had the potential to cause foodborne illness among the vulnerable residents.
Infection Control Deficiencies in Laundry and Glucometer Disinfection
Penalty
Summary
The facility failed to implement proper infection control practices in several areas. Three personal laundry cart covers were observed to be soiled and discolored, which could potentially contaminate clean linen. The Housekeeping and Laundry Aide acknowledged the discoloration, and the Housekeeping and Laundry Supervisor confirmed that the covers needed replacement to protect clean laundry from dust during transport. Additionally, a clean linen closet was found with a dark discolored floor and debris, which had not been cleaned in a while, contrary to the facility's policy requiring daily cleaning with a detergent germicide. Furthermore, two Registered Nurses failed to properly disinfect glucometers after use, as per the facility's policy and manufacturer's guidelines. RN 1 used a Super Sani-Cloth wipe but did not allow the glucometer to remain wet for the required two minutes. RN 3 used an alcohol prep pad, which is not in line with the facility's policy or the manufacturer's instructions. The Infection Preventionist Nurse confirmed that the glucometers should be disinfected for at least three minutes with Sani-Wipes to prevent the risk of transmission-based infections.
Failure to Document Employee COVID-19 Vaccination Status
Penalty
Summary
The facility failed to track and record the COVID-19 vaccination status of nine employees, including a Plant and Maintenance worker, a Housekeeper, two Certified Nursing Assistants, a Registered Nurse, a Licensed Vocational Nurse, and three Nursing Assistants. These employees were hired between July 2024 and January 2025, and their vaccination statuses were not documented in the facility's Employee COVID-19 Vaccination Log. This oversight was identified during a review of the log, which was undated, and confirmed through interviews with the Infection Preventionist Nurse and Scheduler Personnel. The Infection Preventionist Nurse stated that the vaccination status of recently hired staff was not recorded because COVID-19 vaccination was not mandatory at the time of their hiring, and the nurse no longer inquired about it. The facility's policy, dated January 1, 2022, required all employees to report their vaccination status and provide proof to the infection prevention team or human resources. The policy also mandated that employees provide truthful and accurate information about their COVID-19 vaccination status. Despite this policy, the failure to document the vaccination status of these employees had the potential to spread COVID-19 to residents, staff, and visitors.
Inaccurate MDS Documentation of Resident Discharge Location
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, resulting in an inaccurate medical record regarding the resident's discharge location. During an interview and record review, it was found that the MDS indicated the resident was discharged to a short-term general hospital for acute care. However, the Nurse's Notes documented that the resident was actually discharged to home in stable condition. The MDS Coordinator (MDSC) acknowledged the discrepancy and stated that the MDS should have been accurate. The MDS was completed by the Social Services Director, and the MDSC had attested to its accuracy without reviewing the relevant section for correctness. The facility did not have a specific policy and procedure for ensuring MDS accuracy but followed the CMS RAI Manual. The MDSC admitted to not verifying the information in the MDS Section A2105 against the medical record, leading to the inaccurate documentation of the resident's discharge location.
Inaccessible Fluids for Resident at Risk of Dehydration
Penalty
Summary
The facility failed to ensure that fluids were accessible at the bedside for one of the sampled residents, identified as Resident 47. During an observation and interview, it was noted that the bedside table with a water pitcher and cup was placed next to the window, away from the resident's reach, and no straw was available. Resident 47 expressed that she could drink water independently if a straw was provided and mentioned experiencing diarrhea. A registered nurse confirmed that the bedside table should be within the resident's reach and acknowledged the resident's risk for dehydration due to diarrhea. The resident's care plan indicated a potential fluid deficit, and the facility's policy on hydration required that fresh water and a clean cup be available near the bedside at all times.
Failure to Monitor Oxygen Saturations
Penalty
Summary
The facility failed to monitor the oxygen saturations of two residents, Resident 18 and Resident 41, as per their physician orders. Resident 18 was observed on multiple occasions without wearing oxygen, despite having an order for oxygen inhalation at 2 liters per minute via nasal cannula as needed for oxygen saturation less than 93%. The Registered Nurse (RN) confirmed that Resident 18's oxygen saturations were not documented in the Electronic Medication Administration Record (EMAR), which should have been done according to the order. The Director of Nursing (DON) acknowledged that Resident 18 should have had oxygen saturation monitoring to determine when oxygen needed to be applied. Similarly, Resident 41's oxygen saturations were missing from the electronic medical record (eMR) for several shifts, despite having a physician order for continuous oxygen inhalation at 2-3 liters per minute via nasal cannula for shortness of breath or if oxygen saturation was less than 92%. The Licensed Vocational Nurse (LVN) confirmed the absence of documentation, and the DON stated that the facility's process was to follow physician orders, which included monitoring oxygen saturations. The Respiratory Therapist (RT) indicated that in a nursing home, oxygen saturations are typically monitored once a shift, and other assessments should be performed for residents with oxygen orders.
RN Lacks Current CPR Certification
Penalty
Summary
The facility failed to ensure that a registered nurse (RN 1) maintained current cardiopulmonary resuscitation (CPR) certification, as required by the facility's job description for registered nurses. During a review of RN 1's employee file, it was found that RN 1's CPR certification had expired the previous year, and the Human Resource Manager confirmed that RN 1 did not meet the employment requirement for CPR certification. RN 1, who was observed working in the facility's East wing, acknowledged the lapse in certification and recognized its importance in responding to medical emergencies involving residents. The job description for registered nurses at the facility explicitly stated the necessity of having a CPR license, which RN 1 did not possess at the time of the review.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to a resident, identified as Resident 18, who required such equipment during meals. According to the resident's Order Summary Report dated February 5, 2025, and a physician's order from November 3, 2023, Resident 18 was to use build-up foam utensils with all meals due to a lack of coordination. The resident's care plan also indicated a risk for nutritional decline related to the need for adaptive equipment. However, during an observation on February 5, 2025, Resident 18 was seen eating lunch with regular utensils, contrary to the prescribed adaptive equipment. During an interview with RN 2, it was confirmed that the resident was using regular utensils and that the adaptive equipment was not provided as required. RN 2 acknowledged the oversight and stated that it was the kitchen's responsibility to ensure the provision of the necessary adaptive utensils. The facility's policy on Nutrition Care, dated 2018, mandates that adaptive eating devices should be readily available during meal times for residents assessed to need them, with the Department of Food and Nutrition Services responsible for their provision. This failure to provide the necessary adaptive equipment had the potential to result in nutritional decline for Resident 18.
Facility Fails to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the resident shower rooms, affecting five sampled residents. During an observation and interview with the Facility Director, it was noted that the East Wing Shower Room had blackish discoloration on the grout in the shower stalls, and the grout around the toilet was discolored and damaged. The storage area for shower chairs and gurneys had black spots on the ceiling and floor tiles, and the shower chairs had a thick, slimy black substance under the seat. Similar issues were observed in the [NAME] Wing Shower Room, where the grout and shower chairs were also discolored and dirty. In the North Wing Shower Room, a brown discoloration on the wall was identified as a bowel movement. The Facility Director acknowledged that the housekeeping staff were responsible for cleaning these areas during the day, while janitors were responsible in the evening. The Administrator stated that high-touch surfaces should be cleaned daily and acknowledged the need for cleaning and maintenance in the shower rooms. The facility's housekeeping policy, dated 5/1/12, outlined the responsibility of maintaining a clean and safe environment, but the observations indicated a failure to adhere to these standards, potentially leading to the spread of infection or negative health outcomes.
Violation of Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Restorative Nurse Assistant (RNA) who placed her hand over the resident's mouth to quiet her down. This incident was observed by a Certified Nursing Assistant (CNA) and was later confirmed through security camera footage. The resident, who has moderately impaired cognition as indicated by a BIMS score of 9, was seen wheeling herself out of her room and screaming for help. The RNA was observed on camera placing her hand over the resident's mouth, which the resident then slapped away. The RNA subsequently touched the resident's head and shoulder. The Director of Nursing (DON) verified the observations from the security footage and confirmed that the facility's investigation had been completed. The facility's policy on dignity and respect, which emphasizes a zero-tolerance stance on harassment and requires employees to maintain professional conduct, was not adhered to in this instance. The actions of the RNA were in direct violation of this policy, leading to the decision to terminate both RNA 1 and RNA 2 involved in the incident.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its Abuse Prevention Program policy and procedure for a resident, leading to a potential risk of further abuse. On a specific date, a Certified Nursing Assistant (CNA) observed a Restorative Nurse Assistant (RNA) placing her hand over a resident's mouth to stop her from screaming. The resident was in her wheelchair, coming out of her room, and was heard screaming for help. The CNA reported this incident immediately to her supervisor. Security camera footage confirmed the incident, showing the RNA placing her hand over the resident's mouth and the resident slapping the hand away. Despite the immediate report of the abuse, the RNA continued to work with residents for several hours before being sent home. The facility's policy required that accused employees be placed on administrative leave during investigations to ensure resident safety, which was not followed in this case.
Unattended Tools Pose Safety Risk
Penalty
Summary
The facility failed to adhere to its policy and procedure on safety for residents when tools were found unattended on the floor, posing a potential risk of injury. During an observation and interview, nine one-inch screws were discovered on the floor in the hallway near the Director of Nursing's office, which the Administrator confirmed. Additionally, a screwdriver and repair parts were found on the floor of an office with the door left open. The Maintenance Assistant admitted to leaving the tools and parts unattended and acknowledged that it was unsafe to do so. The Administrator and Director of Nursing both expressed concerns about the safety implications of leaving tools unattended, especially with the office door open, allowing residents access. The Director of Maintenance and Housekeeping emphasized that all potential hazards should be cleared and work areas should be blocked off. The facility's policy, dated January 28, 2018, clearly states that tools and equipment should not be left unattended in resident areas.
Failure to Position High-Risk Residents Near Nurse's Station
Penalty
Summary
The facility failed to ensure that two residents, who were at high risk for falls, were positioned near the nurse's station as specified in their care plans. Resident 1, who had a history of repeated falls and was diagnosed with conditions such as dementia, muscle weakness, osteoporosis, and difficulty walking, was observed to have their bed placed by the window, far from the nurse's station. Despite interventions in the care plan to keep Resident 1 close to the nurse's station for closer monitoring, the resident experienced multiple falls, including an unwitnessed fall that resulted in a hip fracture. Interviews with the Director of Nursing and staff confirmed that Resident 1's room was not close enough to the nurse's station, which hindered timely response to the resident's bed alarm. Similarly, Resident 3, who also had a history of falls and was diagnosed with muscle weakness and unsteadiness on feet, was found to have their bed positioned by the entrance door, away from the nurse's station. The care plan for Resident 3 also included an intervention to keep the resident close to the nurse's station for monitoring. However, Resident 3 experienced an unwitnessed fall while attempting to get up from their wheelchair, which was equipped with an alarm. The facility's policy on resident falls emphasized the need for prompt intervention and monitoring to prevent further falls, but the failure to position these high-risk residents near the nurse's station as planned contributed to the deficiency.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency for five of eight sampled residents. Resident 1 reported multiple incidents of physical altercation with another resident, Resident 2. Despite Resident 1 being cognitively intact and reporting these incidents to the Social Services Department, the facility did not report the allegations to the California Department of Public Health (CDPH) because they found no evidence of the altercations on security cameras. Staff interviews revealed that Resident 2 had a fixation on Resident 1, and there were multiple instances where staff had to intervene to prevent altercations. Resident 3 reported multiple incidents of sexual allegations against Resident 4, who had severe cognitive impairment and a diagnosis of Alzheimer's Disease and dementia. Despite Resident 3 being cognitively intact and reporting these incidents to the Social Services Department, there was no documentation of these incidents in Resident 3's medical records. Staff interviews indicated that Resident 4 had a history of wandering into female residents' rooms and making sexual remarks, yet these allegations were not reported to the state agency. Additionally, staff witnessed Resident 4 being sexually inappropriate with Resident 5, who had severe cognitive impairment and multiple disabilities. The incident was reported to a supervisor, but there was no further action taken or report made to the state agency. The facility's policy required all allegations of abuse to be reported to the appropriate authorities, but this was not followed, leading to a failure in ensuring the safety of the residents.
Failure to Obtain Timely Dental Services for Residents
Penalty
Summary
The facility failed to obtain necessary dental services for two residents, leading to potential oral health issues. Resident 6, who was cognitively intact, was observed with multiple discolored and broken teeth, swollen gums, and reported severe pain. Despite expressing his need for dental services to social services, no action was taken to address his dental issues. The resident had been recommended for extractions in April 2024, but the necessary referrals and follow-ups were delayed, leaving him in pain without any pain management. Resident 7 also required dental care, specifically oral surgery on four teeth, as recommended in June 2024. However, the referral for this procedure was not sent until late August 2024, indicating a significant delay in addressing his dental needs. The Business Clerk, who began assisting with referrals in July, was unsure of the process prior to her involvement and acknowledged the delay in sending the referral. The Director of Nursing confirmed that referrals for medical clearance should be made promptly, ideally the same day or the next business day, to prevent complications such as infection, pain, and eating issues. The facility's policy on dental services emphasized the importance of providing necessary routine and emergency dental care, yet the delays in referrals and lack of follow-up demonstrated a failure to adhere to these guidelines.
Failure to Process Resident Complaints on Medication Administration
Penalty
Summary
The facility failed to process complaints from four cognitively intact residents regarding medication administration issues by registry nurses (RNNs) according to their policy and procedure. Resident 2 reported that medications were not passed on time during night shifts, while Resident 3 stated that not all medications were given, with the last incident occurring approximately a week prior. Resident 1 mentioned forgetfulness in medication administration by nurses but could not specify which medications or when the incidents occurred. Resident 4, who is familiar with the shape and color of her medications, reported that an RNN forgot to give her heart medication the previous week. The Facility Scheduler (FS) acknowledged receiving complaints about RNNs not administering medications and stated that she contacted the registry to prevent the return of certain RNNs. However, FS did not verify the competency of new RNNs for medication pass and was unsure of the identities of the RNNs involved or the residents affected. LVN 3 confirmed that Resident 3 had complained about missing medications and noticed a similar issue with Resident 4, where medications were signed off as given but were not administered. The Director of Staff Development (DSD) and the Director of Nursing (DON) both confirmed that RNN 1 was asked not to return due to medication errors, but they were unable to identify the affected residents or the specific medications involved. The facility's policy requires grievances to be logged and resolved within five business days, but this process was not followed, as evidenced by the lack of documentation and resolution of the residents' complaints.
Medication Administration Competency Failure
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) was competent in administering medications, which led to a medication error involving a resident. LVN 1 observed that a resident's tube feeding bag contained medication, which was not the correct procedure. The resident, who was cognitively intact, mentioned that nurses at night could be forgetful with medications. The Director of Nursing (DON) confirmed that medications should not be placed in a tube feeding bag and acknowledged this as a medication error. Further investigation revealed that LVN 2, a new nurse, had been administering medications without having completed the required competency evaluation by the pharmacy or being observed by other staff nurses. LVN 2 admitted to placing medications into the resident's tube feeding bag. The facility's policy requires all staff to demonstrate competency in their duties, but LVN 2 had not been properly evaluated, leading to this oversight.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident, leading to a potential risk of serious injury or harm. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, aphasia, muscle weakness, and a history of falls, was identified as high risk for falls. Despite this, the facility did not adhere to its own protocols for fall prevention. On a specific date, the resident experienced an unwitnessed fall in her room, resulting in a laceration and fracture of the right pinky finger, requiring hospital treatment. The facility's policy required staff to document interactions with the resident every two hours, anticipate her needs, and check alarms to prevent falls. However, the Director of Nursing confirmed that there was no documentation of these required interactions and checks in the resident's electronic medical record. This lack of documentation and adherence to the fall prevention protocol contributed to the resident's fall and subsequent injuries. The facility's policies on fall prevention and documentation were not followed, as evidenced by the absence of records indicating compliance with the required interventions.
Failure to Label Tube Feeding Bags
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Enteral Therapy/Tube Feeding' by not labeling tube feeding bags with dates and times for two residents. During an observation, it was noted that Resident 1 had two tube feeding bags hanging in their room that were not labeled with the required information. Resident 1 had a diagnosis related to gastrostomy and was receiving Jevity 1.5, a tube feeding formula. A Licensed Vocational Nurse confirmed that the bags were not labeled as per the facility's policy. Similarly, Resident 5, who also had a diagnosis related to gastrostomy and was on Jevity 1.5, was observed at the nurse's station with an unlabeled tube feeding bag. A Registered Nurse acknowledged that the bag was not labeled with the time, as required by the facility's policy. The facility's policy, dated June 5, 2014, clearly states that each bag should be labeled with the resident's name, date, room number, and the time the formula was started. This oversight had the potential to result in the residents consuming contaminated feeding formula from old tube feeding bags.
Failure to Maintain Safe Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature in a resident's room, which was observed to be 84.4 degrees Fahrenheit. This temperature exceeded the facility's policy range of 71 to 81 degrees Fahrenheit, as verified by the Facility Director during an observation and interview. The Administrator confirmed that room temperatures should be maintained within this specified range. The resident involved had multiple medical diagnoses, including epilepsy, aphasia, hemiplegia, encephalopathy, and dysphagia, and was unable to participate in cognitive assessments due to cognition issues. The facility's policy and procedure for resident environment, dated 5/6/11, emphasized the importance of maintaining ambient temperatures to minimize residents' susceptibility to health risks. However, the facility did not adhere to this policy, resulting in a potential risk for the resident's comfort and safety.
Failure to Report and Act on Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure on abuse prevention for a resident who was allegedly abused by a Certified Nursing Assistant (CNA). The incident involved a cognitively intact resident who reported an altercation with the CNA, during which the CNA allegedly punched him. The resident's family member was informed of the alleged abuse but did not report it to the facility staff, believing the resident might be fabricating the incident. The CNA, who was accused of the abuse, did not report the allegation to facility management and continued working his shift, contrary to the facility's policy that mandates immediate reporting of such incidents. The facility's policy requires that any suspected abuse be promptly reported to management and that the accused employee be placed on administrative leave during the investigation. However, the CNA was not removed from duty immediately after the allegation was made, which could have delayed the investigation and potentially allowed the abuse to continue. The facility's Director of Nursing and Administrator acknowledged the need for additional training for the CNA on the abuse reporting process. The facility's policy also mandates that all reports of abuse be thoroughly investigated, but the initial failure to report the incident promptly could have compromised this process.
Inadequate Assistance During Ambulation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate physical assistance and use of a transfer device during ambulation for a resident, resulting in a fall and injury. The Director of Rehabilitation (DOR) was assisting the resident while walking but did not provide hand support because she was holding a cellphone in her left hand and a wheelchair in her right hand. This lack of support led to the resident losing balance and falling, causing a right shoulder tendon tear and severe pain, necessitating a hospital visit. The resident had a history of difficulty walking, unsteadiness on feet, and muscle weakness, as indicated in her admission record. Her care plan identified her as high risk for falls, requiring one-person assistance with transfers. During the incident, the DOR did not apply a gait belt, which is a standard safety measure for residents with mobility issues. The resident expressed feeling dizzy and attempted to sit back in her wheelchair, which was not within reach, leading to her fall. Interviews and record reviews confirmed that the DOR did not follow the facility's policy and procedure for ambulation, which requires the use of a gait belt and correct guarding or spotting. The physical therapy progress report indicated that the resident required contact guard assistance, meaning a caregiver should have one hand on the resident for stability. The failure to adhere to these protocols directly contributed to the resident's fall and subsequent injuries.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by observations and interviews with two residents. Resident 1, who was cognitively intact, reported seeing a possible black widow spider on a patio chair and noticed other black spiders in the area. The patio area where Resident 1 sat had large, thick, irregularly shaped webs covering the bottom portions of tables and chairs, as well as planters. Similarly, Resident 2, also cognitively intact, reported seeing black widow spiders and cockroaches in the patio area daily, particularly under a gazebo structure used for smoking. The gazebo and surrounding areas were observed to have thick webs and webbed egg sacs. Interviews with maintenance staff revealed that the patio area was cleaned daily, which included emptying trash cans, disinfecting tables and chairs, pressure washing weekly, and knocking down cobwebs. However, the Facilities Maintenance Director acknowledged that the pest control services had changed in April 2024, and there was no tracking binder for the new company. The facility's policy on pest control, dated 2011, stated that the facility should maintain an effective pest control program to ensure the safety and well-being of residents, staff, and visitors. Despite these policies, the presence of spiders and webs indicated a failure to maintain a pest-free environment.
Resident Moved to Dining Room for Sleeping Due to COVID-19 Admission
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when the resident was moved to the dining room to sleep for one night. This incident occurred after a late admission tested positive for COVID-19, and the facility had no other rooms available. The Registered Nurse (RN) and the Director of Nursing (DON) confirmed that this was not the facility's normal process. The resident expressed feeling scared and rushed during the move, and the resident's representative stated that there was no consent given for the room change, describing the situation as humiliating for the resident. The resident's Nurses Note indicated that the family was informed about the need to move the resident to the dining room due to the roommate being on droplet isolation precautions. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate impairment. The facility's policy on Resident Rights emphasizes the right to a dignified existence and self-determination, which was not upheld in this situation. The Interdisciplinary Team (IDT) meeting note confirmed the temporary move due to unexpected circumstances.
Failure to Provide Timely Medical Attention for Resident Experiencing Seizures
Penalty
Summary
The facility failed to provide necessary care and services for a resident experiencing repeated seizures. The resident, who had a history of unspecified convulsions, muscle weakness, and chronic obstructive pulmonary disease, experienced multiple seizures that were not promptly identified or addressed by the registered nurse (RN). Despite the resident's seizures lasting between seven to ten minutes each and occurring back-to-back, the RN did not call the physician promptly, send the resident to a higher level of care, or ensure that qualified staff monitored the resident. Instead, the RN dismissed the seizures as pretended and was more concerned with drying her cell phone after spilling coffee on it. The resident's condition deteriorated significantly due to the lack of timely medical intervention. The resident required continuous oxygen and had difficulty swallowing after returning from the hospital. The resident's functional abilities also declined, necessitating increased assistance from staff for daily activities. The resident's seizures were severe enough to require hospitalization, where it was confirmed that the resident had recurrent breakthrough seizures and status epilepticus, a medical emergency. Interviews with various staff members, including licensed vocational nurses (LVNs) and certified nursing assistants (CNAs), revealed that the RN ignored multiple requests to send the resident to the hospital. The RN instructed CNA students, who were not adequately trained, to monitor the resident, further compromising the resident's safety. The facility's Director of Nursing (DON) confirmed that the RN's actions were inappropriate and did not align with the facility's policies and procedures for handling changes in a resident's condition.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat four residents with dignity and respect, as evidenced by multiple incidents involving a registered nurse (RN 1). Resident 2 reported that RN 1 dismissed his concerns about Resident 1's health, who was experiencing multiple uncontrolled seizures. RN 1 told Resident 2 to leave the room and did not check on Resident 1, who was later sent to the hospital. Resident 1 confirmed the account and expressed worry about his condition. Additionally, Resident 3 and Resident 7 described RN 1 as having a bad attitude and being intimidating, respectively. The facility's administrator acknowledged receiving complaints about RN 1 and stated that an investigation was ongoing. Further review of RN 1's employee file revealed a history of similar complaints and disciplinary actions. RN 1 had been written up for not responding promptly to a family's request during a change of condition, making discourteous remarks, and failing to stay on shift until properly relieved. The facility's social services director also documented numerous complaints from residents about RN 1's attitude. Despite these documented issues, no policy and procedure on dignity and respect were provided upon request.
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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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