Devonshire Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 1350 East Devonshire Avenue, Hemet, California 92544
- CMS Provider Number
- 056095
- Inspections on file
- 50
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Devonshire Care Center during CMS and state inspections, most recent first.
A resident with oropharyngeal dysphagia and Alzheimer’s disease, who had orders for a regular diet with mildly thick (IDDSI Level 2) liquids and care plans addressing altered texture and consistency, was observed receiving water that had been inadequately thickened by nursing staff. The thickener had settled at the bottom of the glass, leaving the liquid on top thinner than ordered, and when the resident drank it, the resident began coughing and choking and required repositioning and nursing assistance. In interviews, the DON explained that liquids require several minutes to reach the proper consistency, and an LN admitted not allowing enough time for the water to thicken, contrary to the facility’s guidelines for serving thickened liquids.
Two residents were found occupying a room with a damaged ceiling above one bed, showing a warped protrusion, peeling paint, and a crack exposing the board underneath. Additionally, a television cable outlet near the beds was missing a plate cover, leaving the cable wire exposed. The Maintenance Director confirmed the ceiling damage was likely from a past water leak and acknowledged both issues should have been addressed.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for supporting residents' physical, mental, and psychosocial health.
A resident did not receive a physician-ordered IV antibiotic for 35 days following a surgical procedure due to the facility's failure to identify and address the missed order through its QAPI program. The issue was not discussed in QAPI meetings, and the Administrator was unaware of the problem until a complaint investigation, resulting in Immediate Jeopardy and substandard quality of care.
The facility did not have a program in place to monitor antibiotic use, resulting in a lack of systematic tracking or evaluation of antibiotic prescribing and administration for residents.
The facility did not ensure adequate CNA staffing coverage during lunch breaks, resulting in periods where large areas of the facility were left without CNA presence. Multiple CNAs took extended or simultaneous breaks, leaving only a few staff to care for a high census of residents, which did not meet the facility's own standards for safe and responsive care.
Two nursing staff members were observed using personal cell phones in patient care areas, in violation of facility policy. One LVN was seen with a cell phone and earbud at a nurse's station, and a CNA was observed texting at another nurse's station. Both staff acknowledged that cell phone use was not permitted while working on the floor, and the Director of Staff Development confirmed the policy restricting such use to breaks or off-duty times.
A resident with COPD, heart disease, and recent hernia surgery did not receive required weekly CBC labs or follow-up appointments with a surgeon, cardiologist, and pulmonologist as ordered in hospital discharge instructions. Facility staff interviews and record review confirmed that these orders were missed during admission and not entered into the system, resulting in a delay in care.
A resident with end stage renal disease and diabetes, who was cognitively intact, reported that a CNA repeatedly placed her cell phone in his pocket without permission. The allegation was communicated to staff by the resident's family, but the required report to CDPH was not made within the facility's two-hour policy timeframe, as confirmed by staff interviews and record review.
The facility did not ensure accurate documentation and regular review of Advance Directives and POLST forms for multiple residents, with missing physician signatures, incomplete forms, and lack of evidence that residents or their representatives were offered information about advance directives or that these were reviewed as required by policy.
Multiple residents reported that meals were unpalatable, unattractive, and often served at improper temperatures, with some not receiving preferred diets or supplements. Delays in meal service, lack of communication about menu changes, and inconsistent snack availability were observed. Dietary staff confirmed that resident preferences were not consistently entered or followed, leading to dissatisfaction and unmet nutritional needs.
Surveyors found that an open box of breakfast patties was left exposed to air in the walk-in freezer, and black wet debris was present where the metal walls met the flooring on all sides of the walk-in refrigerator. The Dietary Manager confirmed these conditions could lead to cross-contamination, and both issues were not in compliance with facility policies requiring proper food storage and kitchen sanitation.
Staff did not follow infection prevention protocols when a CNA placed an ice scoop on a transport cart instead of in its designated container, a resident's IV site was left unlabeled without a date or nurse's initials, and an LVN failed to disinfect a blood pressure machine between uses and did not use PPE correctly during medication administration to a resident on enhanced barrier precautions.
Several residents did not have comprehensive or updated care plans for discharge, indwelling catheter use, or changes in condition such as UTIs. Despite ongoing discharge planning, physician orders, and new diagnoses, the interdisciplinary team did not consistently initiate or revise care plans as required, as confirmed by staff interviews and record reviews.
Several residents who were dependent on staff for ADLs, including toileting and hygiene, were left soiled and unchanged for extended periods. Residents and their roommates reported that call lights were not answered and requests for assistance were ignored, resulting in residents remaining in urine and feces. Staff interviews confirmed that residents were not cleaned in a timely manner, and facility policies requiring prompt response and maintenance of dignity were not followed.
Multiple residents with significant medical needs reported that call lights were not answered promptly and that they were left soiled for extended periods due to insufficient CNA staffing. Staff and management confirmed that required direct care service hours were not met on several days, and CNAs were assigned more residents than facility guidelines allowed, resulting in delays in assistance with activities of daily living (ADLs) and negatively affecting resident care.
A resident with significant ADL assistance needs and cognitive intactness was found with their call light placed out of reach, tucked in a bedside drawer. The resident reported previous concerns about not being able to access the call light when needed. Staff interviews confirmed the expectation that call lights should always be within reach, in accordance with facility policy and CNA job descriptions.
A resident with dementia and depression lost her lower dentures, which were not promptly reported or investigated according to facility policy. The DON was unaware of the loss for several days, and staff did not immediately search for or attempt to replace the dentures, resulting in resident distress.
A resident with congestive heart failure, chronic kidney disease, and an automatic cardiac defibrillator was incorrectly coded as receiving dialysis on an MDS assessment, despite only being on hospice care. The MDS Nurse and DON confirmed the resident was never on dialysis and that the assessment should have reflected hospice status, in accordance with facility policy.
A resident with diabetes and chronic kidney disease experienced symptoms of a UTI and underwent urinalysis and urine culture, which confirmed infection. Despite these results, there was no documented physician notification, no antibiotic order, and no care plan initiated. Staff interviews confirmed the resident was not informed of the results or treated, and the DON acknowledged that required protocols for change in condition and physician notification were not followed.
A resident with a history of major depressive disorder and diabetes cellulitis was admitted with broken eyeglasses and waited months for optometry services despite a physician's order and repeated requests. The facility failed to arrange for the resident to be seen by the optometrist during scheduled visits, and staff interviews confirmed that the need for ancillary care was communicated but not acted upon in a timely manner.
Two residents with indwelling urinary catheters experienced excessive sediment buildup and missed or delayed urology follow-up appointments. Staff failed to assess, document, and report changes in catheter condition to the physician, despite care plan requirements and repeated observations of catheter complications. Facility policy for daily catheter care and timely follow-up was not followed.
A resident with limited jaw movement was kept on a pureed diet despite a speech therapy evaluation and physician order for a regular texture, thin liquid consistency diet. The resident consumed only a quarter of meals and expressed dissatisfaction until the diet was corrected, indicating the facility did not promptly update the dietary plan as required.
A direct care staff member did not have documentation of an annual performance evaluation as required by facility policy. The Director of Staff Development confirmed the absence of this documentation during a review of the staff member's personnel file.
Surveyors found expired Biopatch IV dressings and an outdated bottle of Fluocinonide 0.05% topical solution with a damaged label stored in medication and treatment carts. Both a nurse and the DON confirmed these items should have been discarded according to facility policy, but were instead readily available for use.
Loose, unsecured wires were found hanging in a resident's room, despite facility policies and staff training requiring such hazards to be reported and addressed. The resident, who used mobility aids and required assistance with care, expressed concern about the exposed wires, and the Maintenance Director confirmed the wires should not have been left open or unreported.
A resident with end stage renal disease missed multiple scheduled hemodialysis treatments because transportation to the dialysis center was not arranged or verified by staff, despite physician orders and facility policy requiring such arrangements. Documentation and staff interviews confirmed that the lack of follow-up led to the missed treatments.
The facility failed to monitor three residents after falls, as per policy. A resident with Parkinson's and subdural hemorrhage fell and complained of neck pain but was not immediately sent to the ER. Another resident with encephalopathy and cerebral infarct had two falls without documented monitoring. A third resident with dementia had two falls, with inconsistent neuro checks. The administrator confirmed the need for monitoring per policy.
The facility failed to manage pain for two residents according to physician's orders. One resident, with encephalopathy and cerebral infarct, did not receive acetaminophen after a fall despite showing pain. Another resident, with congestive heart failure, received tramadol for severe pain without proper orders for such pain levels. The facility's pain management policy was not followed.
A resident with severe cognitive impairment and multiple health issues was found with unexplained discolorations on their body. Despite facility policy requiring immediate reporting of such injuries to CDPH, the incident was not reported. The DON and Administrator later acknowledged the oversight, recognizing the need for compliance with reporting regulations.
A facility failed to develop care plans for five residents with rashes, despite their identification through body checks. The residents had various medical conditions and cognitive impairments, requiring different levels of assistance with ADLs. Interviews with staff highlighted the importance of immediate care plan creation following changes in residents' conditions, as per facility policy. However, the absence of care plans for the rashes indicated non-compliance with these guidelines.
A resident's cash amounting to $1,176 went missing after admission to the facility, with discrepancies in documentation and handling by staff. The facility's policy on preventing misappropriation of resident property was not followed, leading to the unaccounted funds. Staff interviews revealed inconsistencies, with a CNA claiming to have given the money to an LVN, who denied receiving it.
During a COVID-19 outbreak, the facility failed to implement proper infection control practices. The DON wore an improperly fit-tested N95 mask, and 46 out of 70 direct care staff were not fit-tested. Additionally, rooms with COVID-19 positive residents were not properly isolated, and the outbreak was not reported to the CDPH as required.
A facility failed to report an allegation of physical abuse involving a resident to the CDPH, Ombudsman, and law enforcement within the required timeframe. The resident, who was cognitively intact, reported an incident of hair-pulling, but the facility did not document monitoring or investigation. The DON was aware of the allegation but did not report it, citing unsubstantiated claims and changing details.
A resident reported an abuse incident involving hair pulling, but the facility failed to conduct a thorough investigation. Despite the resident's cognitive intactness, the DON concluded the allegation was unsubstantiated without further inquiry, contrary to the facility's policy. This oversight potentially exposed the resident to further harm.
The facility failed to document treatment orders for two residents, potentially worsening their skin conditions. One resident with an ileostomy did not have documented care for 15 days, while another with severe cognitive impairment and MASD lacked documentation on four days. Staffing issues and workload were cited as reasons for the oversight, contrary to the facility's policy requiring timely documentation.
The facility failed to document physician-ordered treatments for pressure injuries for two residents. One resident, cognitively intact, did not receive documented care for a sacrococcyx ulcer for 14 days, while another with severe cognitive impairment had inconsistent treatment documentation for multiple pressure injuries. The absence of documentation was due to treatment nurses being out sick and heavy caseloads, contrary to the facility's policy requiring timely documentation.
The facility failed to arrange necessary medical consults for four residents as per physician orders, potentially delaying their care. A resident with lymphedema and anxiety disorder did not receive a follow-up with an orthopedic surgeon, while another with hemiplegia and diabetes had no follow-up for a clogged G-tube removal. A resident with multiple sclerosis required a cardiology consult due to falls, and another with hypertension needed a urology consult for urinary issues, but neither was arranged. Staff interviews revealed communication lapses, and the Administrator acknowledged the oversight.
A resident was admitted to the facility without a timely obtained list of home medications, resulting in the resident not receiving routine medications. Despite attempts to contact the resident's PCP, the facility staff failed to follow up adequately, leading to a potential adverse effect on the resident's health.
A visitor and a staff member failed to wear PPE before entering rooms with contact isolation precautions, leading to a breach in infection control. The visitor was not informed by staff about the need for PPE, and the Social Service Director entered a room without PPE despite knowing the requirements. The Infection Preventionist noted the risk of infection spread due to this oversight. The residents involved required isolation for rashes and a Methicillin-resistant Staphylococcus aureus infection.
A resident with multiple medical conditions, including diabetes and hemiplegia, did not receive necessary fingernail care, resulting in long, discolored nails with debris. The facility's policy required daily cleaning and trimming, but staff interviews revealed confusion over responsibility for nail care, leading to the deficiency.
A resident with a history of hemiplegia and other conditions developed untreated skin irritation on the neck due to the facility's failure to provide necessary services. Staff, including an LVN, CNAs, and a TN, were unaware of the issue, despite care plans requiring regular skin assessments. The facility's policies on skin integrity and ADLs were not followed, leading to this deficiency.
The facility failed to ensure timely responses to call lights, as observed with a resident who waited 15 minutes for assistance. Interviews with CNAs confirmed that the expected response time should be between three to ten minutes, and 15 minutes was deemed too long.
The facility failed to ensure appropriate care for pressure injuries for two residents. One resident did not receive weekly wound assessments, and another did not receive an air mattress as ordered. These failures led to potential worsening of their conditions.
The facility failed to ensure that a resident had floor mats on both sides of the bed, increasing the risk of injury if the resident fell out of bed on the right side. Despite the resident's history of falls and a care plan that included fall mats, only one mat was observed during an unannounced visit. Interviews with CNAs confirmed that floor mats should be on each side of the bed.
The facility failed to ensure that two residents did not share a bathroom with residents of the opposite sex, leading to complaints and an incident where one resident was walked in on by another of the opposite sex. Facility directors were unaware of the issue despite the policy against such sharing.
The facility failed to complete Level II mental health evaluations for two residents with positive Level I screenings. Despite having diagnoses that required further evaluation, the staff did not follow up with the state as required, resulting in incomplete assessments.
A resident did not receive their prescribed vitamin A capsule due to unavailability during medication administration. The facility's DON and Executive Director acknowledged issues with timely receipt of medications since changing pharmacies, despite the facility's policy requiring timely medication availability.
A facility failed to ensure proper infection control practices during incontinence care for a resident with urinary incontinence. A CNA did not change gloves or sanitize hands between dirty and clean tasks, which was confirmed by the CNA and acknowledged by the Infection Preventionist, DON, and Executive Director. The facility lacked a specific policy on glove changing, although it was implied in the standards of practice.
Improper Preparation of Thickened Liquids for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to provide food and drink in a form designed to meet an individual resident’s needs, specifically for a resident with oropharyngeal dysphagia and Alzheimer’s disease. The resident’s MDS documented coughing and choking during meals and when swallowing medications, pain when swallowing, and the need for a mechanically altered diet with changes in texture of food and liquids. The physician’s orders, effective October through December, specified a regular diet with regular texture, mildly thick consistency liquids, and fortified food, and the resident had active care plans for dysphagia and nutritional risk that included providing the diet as ordered and 1:1 assistance when needed. During an observation at lunchtime, the resident was seen receiving a meal tray and drinking water that had been thickened. A nurse brought another glass of water with thickener added, but the thickener had visibly settled at the bottom of the glass, leaving the water on top thinner than ordered. When the resident drank the liquid, he began coughing and choking and required assistance to be positioned upright at a 90-degree angle and leaned forward, and the nurse was called. In interviews, the DON stated that nursing staff are permitted to add thickener but that the process requires a few minutes for the liquid to reach the proper consistency, and the LN acknowledged adding thickener to the resident’s water without allowing sufficient time for it to thicken properly. This was inconsistent with the facility’s Diet and Nutritional Care Manual guidelines for serving thickened liquids and the ordered mildly thick (IDDSI Level 2) consistency.
Damaged Ceiling and Exposed Cable Outlet in Resident Room
Penalty
Summary
During an unannounced visit, surveyors observed that a resident room had significant environmental deficiencies. The ceiling above one bed in the room displayed an irregular, circular, warped protrusion with peeling paint and a central crack that exposed the underlying board. Additionally, a television cable outlet located between two closets near the foot of the beds was missing a plate cover, leaving the cable wire exposed and the inner wall visible through the opening. Both beds in the room were occupied by residents at the time of the observation. Interviews with facility staff revealed that the Maintenance Director identified the ceiling damage as likely resulting from a previous water leak, possibly due to heavy rains earlier in the year, and acknowledged that it should have been repaired. The Maintenance Director also confirmed that the cable outlet should have had a cover. The Administrator stated that maintenance staff are expected to conduct monthly rounds in every room and that department heads and all staff are responsible for reporting environmental issues. A review of the facility's maintenance policy indicated that the Maintenance Department is responsible for keeping the building in good repair and free from hazards at all times.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of physical, mental, and psychosocial well-being for residents, as required by regulatory standards.
Failure to Address Missed IV Antibiotic Order Through QAPI
Penalty
Summary
The facility failed to have a written Quality Assurance Performance Improvement (QAPI) plan in place to address the issue of not carrying out a physician's order for IV antibiotics for a resident following a surgical procedure. Despite identifying that the resident did not receive the IV antibiotic ordered by the orthopedic surgeon, the facility did not initiate a QAPI process to investigate or address the missed administration. The missed IV antibiotic order was not discussed in the QAPI meeting held after the issue was identified, and the Administrator was unaware of the problem until it was brought up during a complaint investigation. Facility records showed that QAPI meetings were held regularly and attended by key staff, but the specific issue of the missed IV antibiotic was not included in the agenda or addressed by the committee. The facility's policy indicated that the QAPI committee is responsible for overseeing and implementing the program, with the Administrator ultimately responsible for interpreting findings to the governing body. However, the lack of action and communication resulted in the resident not receiving the prescribed IV antibiotic for 35 days, leading to the identification of Immediate Jeopardy and substandard quality of care.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program indicates that antibiotic prescribing and administration were not being systematically monitored or assessed by the facility staff.
Failure to Maintain Adequate CNA Coverage During Lunch Breaks
Penalty
Summary
The facility failed to provide sufficient nursing staff coverage to meet residents' needs and ensure their safety when multiple Certified Nursing Assistants (CNAs) took extended lunch breaks without adequate coverage. On several occasions, including April 15, 16, and 27, 2025, documentation and timecard reviews showed that groups of CNAs clocked out for lunch simultaneously, leaving entire hallways or large portions of the facility without CNA coverage for periods ranging from 16 to 30 minutes. During these times, the remaining staff were insufficient to safely care for the number of residents present, with as few as two CNAs and one Restorative Nursing Assistant left to care for up to 96 residents. Interviews with the Director of Staff Development (DSD) confirmed that the facility's practice was to stagger CNA lunch breaks to maintain coverage, but this was not consistently followed. The DSD acknowledged that the number of staff left on the floor during these periods was not adequate to ensure resident safety or meet their needs. Payroll and schedule reviews corroborated that CNAs took extended or simultaneous breaks, and in at least one instance, a CNA attempted to adjust their timecard after taking a longer break. The facility's job description for CNAs emphasized the importance of providing care in a manner conducive to safety and comfort, which was not maintained during these uncovered periods.
Staff Use of Personal Cell Phones in Patient Care Areas
Penalty
Summary
Two nursing staff members were observed using their personal cell phones in patient care areas, contrary to facility policy. One LVN was seen at a nurse's station looking at her cell phone with an earbud in her ear, and admitted she should not have been using her phone or earbud while on duty. Another CNA was observed texting on her cell phone at a different nurse's station and acknowledged that cell phone use was not permitted while working on the floor, stating that staff were supposed to use their phones only in the break room. The Director of Staff Development confirmed that personal cell phone use is discouraged on the floor to prevent staff distraction and ensure attention to residents, and that use is only allowed before or after shifts or during breaks. The facility's employee handbook also restricts the use of personal electronic devices in work areas, especially those with cameras or recording capabilities. These observations and staff admissions demonstrate a failure to adhere to professional standards of quality regarding the use of personal electronic devices in resident care areas.
Failure to Schedule Follow-Up Appointments and Labs per Hospital Discharge Orders
Penalty
Summary
The facility failed to ensure that follow-up appointments and laboratory work were completed according to the discharge instructions from the acute hospital for one resident. Upon admission, the resident had a history of chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and had recently undergone surgical repair of an inguinal hernia. The hospital discharge summary specified the need for weekly CBC (complete blood count) tests and follow-up appointments with a surgeon, cardiologist, and pulmonologist. However, a review of the resident's medical record revealed that only one CBC was completed, and there was no documentation of any follow-up appointments being scheduled or conducted with the required specialists. Interviews with facility staff, including the Social Services Director, Licensed Vocational Nurse, RN supervisor, and MDS nurse, confirmed that the process for reviewing and implementing hospital discharge orders was not followed. The Social Services Director stated that nursing staff were responsible for scheduling appointments and notifying social services for transportation, but there was no record of such actions for this resident. The RN supervisor and MDS nurse both acknowledged that the necessary orders for ongoing labs and specialist appointments were missed during the admission process and were not entered into the system. The facility's policy required support in scheduling specialty healthcare appointments and arranging transportation, with documentation in the electronic medical record. Despite this policy, there was no evidence that the required follow-up care was arranged for the resident, resulting in a delay in care and treatment. The deficiency was identified during an unannounced complaint investigation, and the lack of follow-up had the potential to affect the resident's overall health condition.
Failure to Timely Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to notify the California Department of Health (CDPH) within the required two-hour timeframe after an allegation of abuse was reported against a Certified Nursing Assistant (CNA) by a resident. The incident involved a resident with end stage renal disease and diabetes mellitus, who was cognitively intact as indicated by a BIMS score of 15. The resident reported that a male CNA repeatedly placed her cell phone in his pocket without permission, and she informed her family about the incident during their visit. The family then reported the allegation to facility staff. Despite the facility's policy requiring immediate or within two-hour reporting of abuse allegations to CDPH, the report was not made in a timely manner. Interviews with facility staff, including the Social Service Director (SSD) and the Administrator, confirmed that the Registered Nurse Supervisor (RNS) did not report the abuse allegation to CDPH immediately or within the required timeframe after being informed. Review of the resident's records and care conference notes further indicated delays in communication and documentation of the incident.
Failure to Accurately Document and Review Advance Directives and POLST Forms
Penalty
Summary
The facility failed to ensure accurate and complete documentation of residents' wishes regarding their care, specifically related to Advance Directives (AD) and Physician Orders for Life-Sustaining Treatment (POLST) forms, for 12 out of 18 residents reviewed. In several cases, POLST forms were either missing required physician signatures, lacked physician information or license numbers, or were signed by a physician different from the one listed on the form. For example, one resident's POLST was not signed by the physician since January, and another's form was missing both the physician's information and signature. These omissions were confirmed through record reviews and interviews with the Social Services Director (SSD) and Director of Nursing (DON), who acknowledged that the forms should have been properly completed and signed according to facility policy. Additionally, the facility did not consistently document periodic reviews of POLST forms as required by policy. For multiple residents, there was no evidence that the POLST had been reviewed quarterly or annually, either during interdisciplinary team (IDT) meetings or care conferences. The SSD and DON both stated that POLST forms are supposed to be reviewed every three months and at annual assessments, but admitted that this documentation was lacking for several residents. Facility policy requires that the IDT review advance directives with residents during quarterly care planning sessions and document any changes, but this was not done in these cases. Furthermore, there was no documented evidence that residents or their representatives were offered information about formulating an Advance Directive upon admission, nor that ongoing reviews of advance directives were conducted as required. This was the case for all 12 residents identified in the report, regardless of their cognitive status. The facility's own policies and job descriptions require that residents be provided with written information about their rights to accept or refuse treatment and to formulate an advance directive, and that these discussions and any changes be documented in the care plan and medical record. However, interviews with facility staff confirmed that this documentation was not present.
Failure to Provide Palatable, Preferred, and Timely Meals and Snacks
Penalty
Summary
The facility failed to provide food and drink that met residents' preferences for temperature, flavor, consistency, and appearance. Multiple residents reported that meals were unpalatable, unattractive, and often served at inappropriate temperatures. Specific complaints included food being tasteless, poor in appearance, and either too hot or too cold. One resident, who was on a pureed diet despite being able to swallow without difficulty, repeatedly requested a regular diet and expressed dissatisfaction with the pureed food. Another resident reported not receiving preferred flavors of nutritional supplements, while others noted missing or insufficient meal components, such as eggs at breakfast, and a lack of meat options. Residents also indicated they were not informed of menu changes and were unaware of available alternatives. Observations during meal service revealed significant delays, with lunch arriving nearly an hour late, and residents expressing dissatisfaction with both the taste and presentation of the food. Some residents resorted to using their own food or having family bring meals from outside due to dissatisfaction with facility offerings. Additionally, there were issues with the availability and distribution of snacks. One resident reported being denied a snack at night because the facility had run out, and others noted that snacks were not consistently available or distributed, especially if not specifically labeled for individual residents. Interviews with dietary staff and review of facility records confirmed that resident food preferences were not consistently entered or followed in the dietary system, particularly after a recent menu and program change. The dietary manager acknowledged missing or incomplete entries of resident preferences. The facility's policy required identification and accommodation of individual food preferences, timely provision of alternatives, and consistent snack availability, but these standards were not met, as evidenced by resident complaints and staff interviews.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to follow safe and sanitary food preparation and storage practices in the kitchen. Specifically, an open box of breakfast patties was found exposed to air in the walk-in freezer, which the Dietary Manager acknowledged could result in cross-contamination and food deterioration. Facility policy requires all foods to be stored wrapped or in covered containers to prevent cross-contamination, but this was not followed in this instance. Additionally, black wet debris was found where the metal walls met the flooring on all four sides of the walk-in refrigerator. The Dietary Manager confirmed the presence of this debris and stated it should not be present, as it poses a risk for cross-contamination with food stored in the refrigerator. Facility policy mandates that the kitchen, including floors and walls, be maintained in a clean and sanitary manner, and that staff are knowledgeable in proper cleaning and sanitizing procedures to prevent cross-contamination.
Infection Control Lapses in Equipment Handling and IV Site Labeling
Penalty
Summary
Staff failed to adhere to infection prevention and control practices in several observed instances. One certified nursing assistant was seen placing a metal ice scoop on top of a transport cart instead of returning it to the designated ice bag cover while refilling residents' water pitchers. Both the CNA and the DON acknowledged that this action was not in line with facility policy, as the cart surface could be contaminated and potentially transfer germs or bacteria to the scoop. A resident with a peripheral intravenous (IV) saline lock was observed without a date or licensed nurse's initials on the IV site. The DON and Director of Staff Development confirmed that facility policy requires IV sites to be labeled with the date and initials of the nurse who inserted it, to ensure timely changes and reduce the risk of infection. The resident's medical record indicated recent IV hydration, and the lack of labeling was not consistent with the facility's procedures for infection control. During medication administration, an LVN was observed not disinfecting a blood pressure machine between resident uses and not following proper infection control practices when administering medications to a resident on enhanced barrier precautions. The LVN handled used medical equipment and medication cups without appropriate PPE and failed to disinfect the plastic tray after use. The DON confirmed that these actions did not meet the facility's infection control standards, which require disinfection of equipment between uses, proper use of PPE, and adherence to hand hygiene protocols.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive and updated care plans were developed and maintained for several residents, as required. Specifically, no discharge care plans were developed or updated for four residents, despite ongoing discharge planning activities and changes in their discharge status. For example, one resident with dementia and fluctuating decision-making capacity had a care plan that was not updated to reflect changes in discharge arrangements, even after multiple placement attempts and behavioral concerns. Another resident, admitted with congestive heart failure and respiratory failure, had no documented discharge care plan despite being informed of a short-term stay and receiving resources for post-discharge needs. Additional residents, including one with osteomyelitis and another with encephalopathy and kidney failure, also lacked documented discharge care plans, even as discharge planning and placement activities were underway. Interviews with staff confirmed that care plans should have been initiated and updated as discharge processes progressed, but this was not done. The facility also failed to develop a care plan for the use of an indwelling catheter for a resident with multiple urinary diagnoses, including benign prostatic hyperplasia and urinary retention. Despite physician orders for daily catheter care and specific instructions for catheter management, there was no care plan addressing the resident's catheter use. Observations confirmed the presence of cloudy urine with sediment, and both nursing staff and the DON acknowledged the absence of a care plan for this intervention. Additionally, the facility did not develop a care plan to address a change in condition for a resident who developed a urinary tract infection (UTI). The resident reported symptoms, and diagnostic testing confirmed a UTI caused by E. coli, but there was no documented care plan to address this new condition. The DON confirmed that a care plan should have been developed in response to the change in condition. Facility policies and job descriptions reviewed indicated that care plans should be developed and updated by the interdisciplinary team to reflect residents' needs and changes in condition, but this was not consistently done.
Failure to Provide Timely Incontinence Care and Assistance with ADLs
Penalty
Summary
Multiple residents who were dependent on staff for activities of daily living (ADLs), including toileting and hygiene, were left soiled, wet, and unchanged for extended periods. For example, one resident, who was cognitively intact and required substantial to maximal assistance for personal care, reported being left in urine and feces for 35-40 minutes after a CNA failed to respond to her request for help. This was corroborated by the resident's roommate and another CNA, who confirmed the resident and her linens were soiled and that the resident felt uncared for. Another resident stated that her call light was not answered in a timely manner and that she was not changed from morning until mid-afternoon, resulting in her bed being wet from incontinence. This resident, also cognitively intact and dependent for ADLs, expressed feeling terrible and dehumanized by the experience. A third resident reported being left wet and soiled in urine for an entire day shift, and recalled a previous incident of being left in stool. This resident also indicated that call lights were not answered and that staff and administration did not follow up after being informed of the issue. A registered nurse confirmed seeing soiled sheets and stated that CNAs are expected to check and clean residents before shift changes. A fourth resident, who was nonverbal and dependent for ADLs, was reported via an anonymous complaint to have not received care for an entire day, as witnessed by his roommate. Staff interviews revealed that all staff are responsible for answering call lights and that residents should not wait more than ten minutes to be changed. Facility policies reviewed emphasized the importance of timely response to call lights, maintaining resident dignity, and providing care that promotes well-being and self-worth. Despite these policies, the documented events show that residents were left soiled and unattended, with their needs for hygiene and dignity unmet.
Failure to Provide Sufficient Nursing Staff and Timely ADL Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple resident interviews, staff interviews, and record reviews. Several residents reported that their call lights were not answered in a timely manner, and that they were left soiled in urine and stool for extended periods. One resident stated that call lights were not answered 30% of the time, and that there was no coverage when CNAs went to lunch. Another resident reported being left wet and soiled for an entire day shift, and that staff did not respond to complaints. Additional residents described being left in urine and stool multiple times, particularly on weekends, and feeling that administration did not care. Residents involved had significant medical conditions, including morbid obesity, acute respiratory failure, heart failure, diabetes, amputations, and mobility limitations, and were dependent on staff for activities of daily living (ADLs) such as toileting, bathing, and dressing. Record reviews confirmed that the facility did not meet the required minimum Actual Total Direct Care Service Hours (DCSH) of 3.5 and CNA DCSH of 2.4 hours for multiple days in March. On several dates, the number of residents assigned to each CNA exceeded the facility's own guidelines, with some CNAs responsible for up to 16 residents per shift. Staff interviews corroborated these findings, with CNAs reporting high resident assignments, feeling rushed, and being short-staffed on both weekdays and weekends. The Director of Staff Development (DSD) and Director of Nursing (DON) acknowledged that staffing levels and direct care hours were not met, and that this affected the quality of resident care. Facility policies and job descriptions reviewed indicated that staff were expected to respond to call lights promptly and ensure that residents' needs were met in accordance with their care plans. However, the documented staffing shortages, high resident-to-CNA ratios, and failure to meet direct care hour requirements resulted in residents not receiving timely assistance with ADLs, leading to frustration, anger, and negative impacts on their quality of care.
Call Light Not Accessible to Resident
Penalty
Summary
A deficiency was identified when a resident's call light was found tucked away in a bedside drawer, out of the resident's reach, during an observation. The resident, who was alert, oriented, and able to make his needs known, had a history of cerebral infarction, seizures, and ulcerative colitis, and required substantial to maximal assistance with activities of daily living. The resident expressed concern about not being able to reach the call light when needed, confirming that this had occurred previously. Interviews with facility staff, including a CNA and the Director of Nursing, confirmed that the call light was not accessible to the resident and acknowledged that it should always be within reach. The facility's job description for CNAs and its policy on answering call lights both require that the call light be kept within easy reach of residents to ensure timely response to their needs. The failure to ensure the call light was accessible represented a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Protect Resident's Dentures from Loss
Penalty
Summary
The facility failed to exercise reasonable care to protect a resident's personal property, resulting in the loss of the resident's lower dentures. The resident, who had dementia and depression and was assessed as having moderately impaired cognition, reported the dentures missing to a nurse the morning after they were lost. Despite this, the Director of Nursing (DON) was not made aware of the missing dentures until several days later, and there was no immediate search or notification to administration as required by facility policy. The resident expressed distress over the loss, and staff were unable to locate the dentures after the incident. Record review showed that the resident required assistance with denture hygiene and was encouraged to wear dentures. Facility policies required prompt investigation and reporting of lost property, as well as timely referral for dental services if dentures were lost. However, these procedures were not followed, as the loss was not promptly reported to the DON, and there was no documentation of immediate efforts to replace the dentures or ensure the resident's oral health needs were met following the loss.
Inaccurate MDS Coding for Hospice Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with a history of congestive heart failure, chronic kidney disease stage 3, and an automatic cardiac defibrillator. The resident was admitted without hospice or dialysis services, later placed on hospice, and never received dialysis. However, a review of the MDS Section O dated January 22, 2025, incorrectly indicated the resident was on dialysis, despite documentation and staff interviews confirming the resident was only on hospice care at that time. The MDS Nurse acknowledged the error, stating the resident was never on dialysis and that the assessment should have reflected hospice care. The Director of Nursing also confirmed that the MDS should have been coded to match the resident's actual status. Facility policy requires that MDS assessments accurately reflect information in progress notes, care plans, and resident observations, which was not followed in this instance.
Failure to Notify Physician of UTI Lab Results and Initiate Treatment
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely physician notification of a resident's urine culture and sensitivity results, resulting in a lack of prompt treatment for a urinary tract infection (UTI). The resident, who had a history of diabetes and stage 3b chronic kidney disease, reported burning during urination, prompting a physician order for urinalysis with culture and sensitivity. The urinalysis, collected the following day, showed signs of infection, and the subsequent urine culture confirmed the presence of Escherichia coli sensitive to several antibiotics. Despite these findings, there was no documented evidence that the physician was notified of the results, no antibiotic was prescribed, and no care plan was initiated for the UTI. Interviews with the resident and staff confirmed that the resident was not informed of the results and had not received any antibiotics. Nursing staff stated that although attempts were made to notify the physician, there was no documentation of these communications, and no orders were obtained. The Director of Nursing acknowledged that the expected protocol—notification of the physician, obtaining orders, and care planning—was not followed, and the facility's policy required immediate notification of significant changes in a resident's condition, which did not occur in this case.
Failure to Coordinate Timely Optometry Services for Resident with Broken Glasses
Penalty
Summary
The facility failed to coordinate optometry services for a resident who requested them, resulting in the resident wearing eyeglasses with a missing right lens for an extended period. The resident, who was cognitively intact and had diagnoses including major depressive disorder and diabetes cellulitis, was readmitted to the facility with broken glasses. Documentation showed that the broken glasses were noted upon readmission, and a physician's order for an ophthalmology consult and treatment was present. Despite this, the resident reported waiting months to see the optometrist, and the facility did not arrange for the resident to be seen during the optometrist's scheduled visit. Interviews with facility staff revealed that the resident had communicated the need for optometry services to a CNA, and the Social Services Director confirmed the optometrist's regular schedule but acknowledged the resident was not seen. The Director of Nursing stated that an authorization for ancillary care should have been requested sooner after the broken glasses were identified. The facility's policy required social services to coordinate referrals for medical services based on physician orders and to document these referrals, but this process was not followed in this case.
Failure to Assess and Address Catheter Complications and Missed Urology Follow-Ups
Penalty
Summary
Two residents with indwelling urinary catheters experienced deficiencies in care related to the identification, assessment, and management of catheter complications. For one resident with a suprapubic catheter, excessive sediment was observed in the tubing, and the resident reported pain. Despite repeated reports from CNAs about the catheter's condition and the resident's discomfort, there was no documented assessment, care plan, or follow-up by licensed nursing staff. The resident also missed a scheduled urology follow-up appointment, and there was no documentation of weekly catheter care or physician notification regarding the catheter's condition. Another resident with an indwelling Foley catheter was observed to have increasing amounts of white sediment in the catheter tubing over several days. The resident had a history of urinary retention and a recent surgical procedure, with a physician order for a urology follow-up within two weeks of admission. However, the follow-up appointment was not scheduled in a timely manner, and staff failed to report the changes in the catheter tubing to the physician as required by the care plan. Both the Infection Preventionist and the DON confirmed that staff should have recognized and reported the changes in the catheter tubing and that the follow-up appointment should have been arranged promptly. Facility policy required daily assessment and documentation of catheter care, including monitoring for unusual appearance, sediment, and signs of infection, as well as prompt reporting of changes to supervisors and physicians. In both cases, there was a lack of timely assessment, documentation, and physician notification regarding catheter complications, and scheduled urology follow-up appointments were missed or delayed.
Failure to Follow Physician Order for Diet Consistency
Penalty
Summary
A resident with a history of an open wound of the left cheek and temporomandibular area, resulting in limited jaw movement, was admitted to the facility and initially placed on a pureed texture diet. Despite a speech therapy evaluation recommending a regular texture (chopped meat) diet and a physician order specifying a regular, no added salt, regular texture, thin liquid consistency diet, the resident continued to receive a pureed diet. The resident reported consuming only 25% of meals and expressed dissatisfaction, stating he should be receiving a regular diet as per his previous habits at home. The deficiency was identified when it was observed that the facility failed to update the resident's diet in accordance with the physician's order and the speech therapy recommendation. The DON confirmed that the resident should have been on a regular textured, thin liquid consistency diet following the speech therapy evaluation. The facility's policy requires that individual dining and food preferences be identified and that meal plans be adjusted after consultation with the resident, but this was not followed, resulting in the resident not receiving the appropriate diet for a period of time.
Annual Performance Evaluation Not Completed for Direct Care Staff
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of eight direct care staff members reviewed. During an interview and review of the personnel file with the Director of Staff Development, it was confirmed that the staff member had been employed since January 3, 2012, but there was no documentation of an annual performance evaluation in the file. The facility's policy requires performance evaluations after the first 90 days of employment and annually thereafter, but this was not followed for the staff member in question.
Expired Medical Supplies and Medications Found in Medication Carts
Penalty
Summary
Surveyors observed that four Biopatch IV dressings, with two past their expiration date and two expiring soon, were found inside the Station 1 IV cart and readily available for use. During the inspection, a registered nurse confirmed that the expired IV dressings should not have been present in the cart. Additionally, a bottle of Fluocinonide 0.05% topical solution with a torn and faded label and an open date was found in the treatment cart. A licensed vocational nurse confirmed that this medication was expired and should not have been in the cart. The Director of Nursing also acknowledged that both the Biopatch dressings and the Fluocinonide solution should have already been discarded and not stored in the carts. Review of the facility's policy indicated that outdated, contaminated, or deteriorated medications and supplies are to be immediately removed from stock and disposed of according to procedures. The presence of expired medical supplies and medication in accessible storage areas constituted a failure to follow national standards and facility policy regarding the storage and labeling of drugs and biologicals.
Failure to Secure and Report Exposed Wiring in Resident Room
Penalty
Summary
Loose hanging wires were observed at the base of the back wall in a resident's room. The resident, who had a history of surgical amputation, muscle weakness, unsteadiness, and diabetes mellitus, required the use of a wheelchair and walker and needed partial to moderate assistance with personal care. The wires were identified as low voltage but were not properly secured, covered, or reported to maintenance. The Maintenance Director confirmed that the wires should not have been exposed and acknowledged the potential for fire, stating that no one had reported the issue through the facility's maintenance reporting system. The resident expressed concern about the open wires, specifically mentioning the risk of fire. Interviews with the DON and Maintenance Director revealed that staff were trained to report such hazards using the facility's maintenance application or by calling maintenance directly. Facility policy required hazardous areas and equipment to be identified and addressed to ensure resident safety, including securing or covering exposed wiring. Despite these protocols, the wires remained unsecured and unreported, creating a hazardous environment for the resident.
Failure to Arrange Transportation Resulting in Missed Dialysis Treatments
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease did not receive scheduled hemodialysis treatments due to the facility's failure to arrange necessary transportation. The resident was admitted with physician orders specifying dialysis days, times, and transportation requirements. Documentation showed that transportation was not finalized or authorized, resulting in missed dialysis appointments. Nurses' progress notes and interviews confirmed that the resident missed multiple treatments because transportation was not arranged, and the issue was not followed up by responsible staff. The case manager acknowledged responsibility for arranging and verifying transportation for dialysis residents and admitted to not following up, which led to the missed treatments. The director of nursing stated that facility policy required arranging transportation upon admission and communicating this to avoid missed treatments. The facility's policy on dialysis care also specified the need to arrange transportation as ordered by the attending physician, but this was not carried out, resulting in the resident missing several dialysis sessions.
Failure to Monitor Residents After Falls
Penalty
Summary
The facility failed to ensure appropriate monitoring for three residents, A, B, and C, following falls, as per the facility's policy and procedure. Resident A, diagnosed with Parkinson's disease, subdural hemorrhage, and aphasia, fell in the dining room and complained of neck pain. Despite being assessed by an RN and the administrator, who found no apparent injuries, Resident A was not immediately sent to the hospital. Neurological checks were initiated but were not completed as per the recommended schedule before Resident A was eventually sent to the ER. Resident B, with diagnoses including encephalopathy and cerebral infarct, experienced two falls. On January 14, Resident B was found on the floor without pain, and on February 8, fell forward from a wheelchair. Despite recommendations for monitoring every shift for 72 hours, there was no documented evidence of such monitoring after either fall. Resident C, diagnosed with encephalopathy and dementia, was found on the floor on February 3 and again on February 9. Although a stat X-ray was requested after the first fall, there was no monitoring documented. After the second fall, neuro checks were initiated but not consistently documented according to the facility's protocol. The administrator confirmed that the residents should have been monitored according to the facility's policy, which mandates neurological evaluations for falls with potential head injuries.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, Residents B and D, according to the physician's orders and their care plans. Resident B, who was admitted with encephalopathy and cerebral infarct, experienced a fall and exhibited signs of pain, such as groaning and guarding behavior. Despite having a physician's order for acetaminophen to be administered for mild to moderate pain, there was no documented evidence that the medication was given to Resident B following the fall and subsequent pain complaints. Resident D, admitted with congestive heart failure and an implanted cardiac defibrillator, reported pain associated with a wound on his backside. The physician's orders included acetaminophen for mild pain and tramadol for moderate pain, but there was no order for severe pain management. Resident D received tramadol for severe pain on two occasions, but there was no documentation of a call to the provider for further orders to address the severe pain level. The facility's policy on pain management emphasizes maintaining comfort and following physician's orders, which was not adhered to in these cases.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the California Department of Public Health (CDPH). The resident, who was admitted with multiple serious health conditions including chronic respiratory failure, cirrhosis of the liver, and chronic kidney failure, was found to have maroon and purple discolorations on both upper extremities, lower abdomen, and left lateral trunk on March 10, 2025. The discolorations were first noted by a Certified Nursing Assistant (CNA) during a shower and reported to the Treatment Nurse. Despite the facility's policy requiring immediate reporting of such injuries to state authorities, the Director of Nursing (DON) and the Administrator acknowledged that the incident was not reported as required. The resident's medical records indicated a severely impaired cognitive function, with a Brief Interview for Mental Status (BIMS) score of 03, and the resident was dependent on staff for most daily needs. The discolorations were documented in the resident's shower sheets and body check records, but the facility did not notify CDPH, as the DON initially believed the discolorations were not unexpected due to the resident's multi-system failure. However, upon review, both the DON and the Administrator recognized that the incident should have been reported as an injury of unknown origin, in accordance with the facility's policy and state regulations.
Failure to Develop Care Plans for Residents with Rashes
Penalty
Summary
The facility failed to develop and implement care plans to address rashes for five residents, which was identified during an unannounced visit. The residents affected had various medical conditions, including aftercare following surgery, cerebral infarction, spastic quadriplegic palsy, Alzheimer's, and complications of urinary catheter use. Despite the identification of rashes through body checks, no care plans were developed to address these skin conditions. Resident 2, who required maximum assistance with activities of daily living (ADLs) and had no cognitive impairment, was found to have a posterior trunk rash with scattered papules. Similarly, Resident 6, with severe cognitive impairment, had liver spots and a rash on the posterior trunk. Resident 7, with moderate cognitive impairment and dependent on ADLs, was noted to have decreased scattered papules responding to treatment, yet no care plan was in place. Resident 8, with severe cognitive impairment, had scattered papules on the anterior and posterior trunk, and Resident 10, with moderate cognitive impairment, had a general body rash with scattered papules. Interviews with the Treatment Nurse and the Director of Nursing revealed that care plans should be created immediately after any changes in a resident's condition are identified. The facility's policy emphasized the importance of individualized comprehensive care plans to meet residents' needs and prevent declines in their functional status. However, the lack of care plans for the identified rashes indicated a failure to adhere to these guidelines, potentially resulting in unmet needs and worsening of the residents' conditions.
Failure to Protect Resident's Money from Theft
Penalty
Summary
The facility failed to protect a resident's money from theft and loss, as evidenced by the missing cash of $1,176 that was not accounted for after the resident's admission. The resident, who had no cognitive impairment, was admitted with a documented amount of cash on an Inventory Sheet, but subsequent documentation failed to account for the money. Interviews with staff revealed inconsistencies in the handling and documentation of the resident's cash, with CNA 3 claiming to have handed the money to an LVN, who denied receiving it. The facility's policy on preventing exploitation and misappropriation of resident property was not adhered to, as evidenced by the lack of proper documentation and safeguarding of the resident's money. The Director of Staff Development and the Administrator acknowledged the failure to review and validate the inventory sheet, which contributed to the misappropriation of the resident's funds. This deficiency highlights a lapse in the facility's procedures for protecting residents' belongings, as outlined in their policy.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement proper infection control practices during a COVID-19 outbreak, affecting both residents and staff. The Director of Nursing (DON) was observed wearing an N95 respirator mask that was not fit-tested, and the presence of a beard further compromised the mask's effectiveness. The Infection Preventionist (IP) confirmed that the DON was fit-tested for a different brand of N95 mask and should not have facial hair when wearing it. This oversight was against the facility's policy, which requires proper fit-testing and no facial hair to ensure a secure fit. Additionally, a significant number of direct care staff were not fit-tested for N95 respirator masks, as required by the facility's policy and CDC guidelines. Out of 70 current direct care staff, 46 had not undergone fit-testing. Interviews with staff members revealed that some had never been fit-tested since their hire, and the IP acknowledged the lapse in ensuring all staff were fit-tested upon hire and annually. This lack of fit-testing compromised the staff's ability to safely care for residents during the outbreak. The facility also failed to maintain proper isolation protocols for rooms under SPECIAL DROPLET CONTACT PRECAUTIONS. Eight rooms with COVID-19 positive residents had open doors, contrary to the facility's policy and CDC guidelines, which require doors to be closed to prevent the spread of infection. Furthermore, the facility did not report the COVID-19 outbreak to the California Department of Public Health (CDPH) as required, indicating a lack of awareness among the administration about reporting obligations during an outbreak.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of physical abuse involving Resident 1 to the California Department of Public Health (CDPH), the Ombudsman, and law enforcement within the required timeframe. The incident was initially reported to Adult Protective Services (APS) by an external party, indicating that Resident 1 was allegedly assaulted by another resident. However, the facility did not report this allegation as required by their policy, which mandates immediate reporting, or within two hours if the allegation involves abuse. The Director of Nursing (DON) acknowledged awareness of the allegation but did not report it, citing a lack of substantiation and changing details in the resident's account. Resident 1, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported waking up on December 19, 2024, with someone pulling her hair. Despite this, there was no documented evidence of monitoring or investigation by the Interdisciplinary Team (IDT) following the allegation. The facility's policy, revised in July 2017, clearly outlines the requirement for prompt reporting of abuse allegations to various authorities, which was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident who reported that someone pulled her hair. The incident was initially reported to the facility staff on December 20, 2024, but was not properly investigated. The Director of Nursing (DON) acknowledged awareness of the report but concluded the allegation was unsubstantiated without conducting further investigation, such as interviewing other residents and staff. The facility's policy requires all abuse allegations to be thoroughly investigated, which was not adhered to in this case. The resident involved had a history of traumatic subdural hemorrhage, multiple sclerosis, and cerebral palsy, and was cognitively intact with a BIMS score of 15. Despite the resident's capacity to understand and make decisions, there was no documented evidence of monitoring or a comprehensive investigation by the Interdisciplinary Team following the abuse allegation. The facility's failure to investigate the incident as per their policy potentially exposed the resident to further abuse and did not provide sufficient protection.
Failure to Document Treatment Orders for Residents
Penalty
Summary
The facility failed to adhere to physician's treatment orders for two residents, leading to potential worsening of their skin conditions. Resident 3, who was cognitively intact and had a gastrostomy and ileostomy, did not receive documented care for their ileostomy and skin redness for a total of 15 days in January 2025. The Treatment Administration Record (TAR) lacked signatures from licensed nurses on specific dates, indicating that the required care might not have been provided. Treatment Nurse 1 acknowledged the oversight, citing workload and staffing issues as contributing factors. Resident 4, who had severe cognitive impairment and moisture-associated skin damage (MASD), also did not have documented care for their skin condition on four specific days in January 2025. The Director of Nursing (DON) and Nurse Consultant confirmed that Licensed Vocational Nurse (LVN) 1 was responsible for treatments during a period when both treatment nurses were out sick. However, LVN 1 failed to document the care provided, as required by the facility's policy. The facility's policy on nursing documentation mandates timely and accurate recording of care provided to residents. The DON and Nurse Consultant emphasized the importance of documenting treatments immediately after they are administered. The lack of documentation for both residents suggests a failure to comply with this policy, potentially impacting the residents' health outcomes.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that physician's orders for the treatment of pressure injuries were conducted for two residents. Resident 3, who was cognitively intact, had a sacrococcyx pressure ulcer that was not treated according to the prescribed regimen for a total of 14 days in January 2025. The Treatment Administration Record (TAR) lacked signatures from licensed nurses on multiple dates, indicating that the treatment was not documented as completed. The absence of documentation was attributed to both treatment nurses being out sick and a heavy caseload that prevented the remaining nurse from completing the documentation. Resident 4, who had severe cognitive impairment, also did not receive consistent treatment for pressure injuries on the right and left lateral malleolus and the sacrococcyx. The TAR for January 2025 showed missing signatures on several dates, suggesting that the prescribed treatments were not documented as administered. The Director of Nursing (DON) and a Nurse Consultant confirmed that the licensed nurses were expected to document treatments immediately after completion, but this was not done. The facility's policy on nursing documentation requires timely entry of care provided, but this was not adhered to, leading to a lack of accountability and potential worsening of the residents' conditions. The facility had 13 residents with pressure injuries, highlighting the importance of consistent and documented care. The failure to document care as per the facility's policy and procedure was a significant deficiency identified during the survey.
Failure to Arrange Medical Consults for Residents
Penalty
Summary
The facility failed to arrange necessary medical consults for four residents as per physician orders, potentially delaying their care and treatment. Resident 3, who was admitted with conditions including lymphedema and anxiety disorder, had a physician order for a follow-up appointment with an orthopedic surgeon related to a prosthetic limb, which was not arranged. Similarly, Resident 4, admitted with conditions such as hemiplegia and diabetes, had a physician order for the removal of a clogged G-tube, which was not followed up after the initial insurance call. Resident 6, with diagnoses including traumatic subdural hemorrhage and multiple sclerosis, required a cardiology consult due to multiple falls, as per physician orders, but this was not arranged. Resident 7, who had conditions like embolism and hypertension, had a physician order for a urology consult due to pain on urination and blood in the urine, which was also not arranged. Interviews with facility staff revealed a lack of communication and follow-up on these consults, with the Social Service Assistant and nurses acknowledging the oversight. The facility's policy required social services to coordinate referrals based on physician orders, collaborating with nursing staff to arrange necessary services. However, the Administrator admitted there was no excuse for the failure to process these consults, emphasizing the importance of addressing residents' health concerns for their safety and rights. The deficiency was identified during an unannounced visit to investigate a quality-of-care issue.
Failure to Obtain Timely Medication List for Resident
Penalty
Summary
The facility failed to ensure that a list of home medications was obtained in a timely manner for a resident upon admission, which resulted in the resident not receiving routine medications. The resident, who was admitted with diagnoses including a sprain in the right knee, falls, difficulty walking, pain in the right knee, and muscle weakness, did not have a medical history or home medication list on file upon admission. Despite attempts by the nursing staff to contact the resident's primary care physician for a medication list, there was no response, and the necessary medications were not administered. Interviews with nursing staff revealed that there was a lack of follow-up with the primary care physician and that the facility's policy for medication reconciliation was not adhered to. The policy required gathering information needed to reconcile the medication list and ensuring that medications the resident had been taking continued to be administered without interruption. The failure to follow this procedure had the potential to adversely affect the resident's health.
Infection Control Breach Due to Lack of PPE Use
Penalty
Summary
The facility failed to ensure proper infection control practices when a visitor and a staff member did not wear personal protective equipment (PPE) before entering rooms marked with contact isolation precautions. During an unannounced visit, a visitor was observed sitting on a resident's bed without wearing any PPE, despite the room having signage indicating contact isolation. The visitor stated that facility staff did not inform him of the need to wear a gown before entering the room. Additionally, the Social Service Director was observed inside another resident's room without PPE, despite the room also having contact isolation signage. The Social Service Director acknowledged the requirement for staff to wear gowns and gloves and to wash hands before and after donning and doffing PPE. The Infection Preventionist nurse confirmed that the visitor should have been stopped at reception and educated on wearing PPE, as not doing so could lead to the spread of infection and cross-contamination. The facility's policy on transmission-based precautions requires staff and visitors to wear disposable gowns upon entering rooms with contact isolation precautions. The residents involved had specific medical conditions requiring contact isolation: one had rashes, and the other had a Methicillin-resistant Staphylococcus aureus infection. The facility's infection prevention and control program emphasizes educating staff and ensuring adherence to proper techniques and procedures to prevent the spread of communicable diseases.
Failure to Provide Necessary Fingernail Care
Penalty
Summary
The facility failed to provide necessary services to maintain appropriate hygiene for a resident who was unable to perform activities of daily living independently. Specifically, the resident did not receive proper fingernail care, as observed during a survey. The resident's fingernails were found to be discolored, with dark debris underneath, long, and untrimmed. The resident, who was unable to trim and clean his fingernails on his own, reported that the staff had not provided nail care. This lack of care was confirmed by the observations and interviews conducted with the resident and staff members. The resident had a medical history that included hemiplegia, diabetes mellitus type II, cerebral edema, aphasia, and vascular dementia, which required assistance with personal hygiene. The facility's policy indicated that nail care should include daily cleaning and regular trimming, except for diabetic residents or those with circulatory impairments, who should have their nail care performed by a podiatrist. However, the facility failed to ensure that the resident received the necessary nail care, as there was no documentation of fingernail care in the resident's body check assessment. Interviews with staff revealed a lack of clarity and responsibility regarding who should perform the nail care, leading to the deficiency.
Failure to Prevent Skin Breakdown in Resident
Penalty
Summary
The facility failed to provide necessary services to prevent skin breakdown for a resident who developed skin irritation on the neck. During an observation and interview, the resident was found to have a red area of skin irritation on the right side of the neck, which had not been treated. The resident confirmed that no treatment had been provided for the redness. Licensed Vocational Nurse (LVN) 1, Certified Nursing Assistant (CNA) 1, and the Treatment Nurse (TN) were unaware of the skin issue, despite the resident's care plan indicating a need for daily skin condition observation and weekly skin assessments by a licensed nurse. The resident's medical history included hemiplegia, diabetes mellitus type II, cerebral edema, aphasia, and vascular dementia, which increased the risk for skin breakdown. The facility's policy required skin inspections on admission and weekly, but the resident's records did not document the skin redness. Interviews with CNAs and a Registered Nurse (RN) revealed a lack of awareness and communication regarding the resident's skin condition, which was deemed unacceptable by RN 2. The facility's policies on skin integrity management and activities of daily living were not adhered to, contributing to the deficiency.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure call lights were answered in a timely manner for one of nine residents, specifically Resident 5, who waited 15 minutes for the call light to be answered. This was observed during an unannounced visit to investigate four complaints and one Facility Reported Incident (FRI). Resident 5 reported that staff were terrible about responding to the call light, often turning it off and leaving without returning. This was corroborated by an observation where Resident 5 activated his call light at 11:40 a.m., and it was not addressed until 11:55 a.m. Interviews with multiple Certified Nursing Assistants (CNAs) revealed that the expected response time for call lights should be between three to ten minutes, with all CNAs agreeing that 15 minutes was too long. Resident 5's medical record indicated he had been admitted with serious conditions including pneumonia, sepsis, dysphagia, and acute kidney failure, and had the capacity to make decisions. The facility's policy on answering call lights, revised in March 2021, was reviewed but not detailed in the report.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure appropriate care and treatment services for pressure injuries for two residents. For Resident 1, the facility did not conduct weekly assessments of the intergluteal cleft linear and right buttock linear excoriations after the initial identification of the wounds. This lack of follow-up assessment meant that the facility could not determine if the wounds were healing or worsening. The resident had multiple serious conditions, including acute and chronic respiratory failure, pneumonia, and pulmonary fibrosis, and was capable of making decisions. Despite the initial wound care provided, there was no documented evidence of follow-up assessments from January 20, 2024, to January 23, 2024, when the resident was transferred to the hospital. Interviews with treatment nurses confirmed that weekly assessments should have been conducted but were not completed in this case. For Resident 5, the facility failed to place an air mattress on the bed at admission as per the physician's order and the wound care specialist's recommendation. The resident, who had diagnoses including pneumonia, sepsis, arthritis, muscle weakness, and acute kidney failure, was observed lying on a standard mattress instead of an air mattress. The resident's records indicated a sacrococcyx suspected deep tissue injury, and the treatment plan included pressure reduction and offloading. However, the air mattress was not provided until March 7, 2024, leading to a delay in the implementation of care and treatment. Interviews with the treatment nurse and the Director of Nursing confirmed that the air mattress should have been provided at admission to prevent worsening of the pressure injury. The facility's policy on pressure ulcers and skin breakdown required full assessment and documentation of pressure sores, including the use of pressure reduction surfaces. The National Pressure Injury Advisory Panel guidelines also emphasized the importance of support surfaces in preventing and treating pressure injuries. Despite these guidelines, the facility did not adhere to the required protocols, resulting in deficiencies in the care provided to Residents 1 and 5.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that Resident 7 had floor mats on both sides of the bed, increasing the risk of injury if the resident fell out of bed on the right side. During an unannounced visit, it was observed that Resident 7's bed was in the lowest position with only one floor mat on the left side. Interviews with the resident and Certified Nursing Assistants (CNAs) confirmed that floor mats should be on each side of the bed. Resident 7 had a history of falls, as indicated in her care plan, which noted a fall on January 29, 2024, with no injuries sustained. The care plan included interventions such as a low bed and fall mats, but these were not fully implemented as required. Resident 7's medical records showed she was readmitted to the facility with multiple diagnoses, including acute respiratory failure, chronic obstructive pulmonary disease (COPD), and epilepsy. Despite being alert and oriented, the resident was at risk for falls, as documented in her care plan. The facility's policy on fall management, dated May 26, 2021, stated that patients at risk for falls should receive appropriate interventions to reduce risk and minimize injury. However, the facility did not adhere to this policy, as evidenced by the lack of floor mats on both sides of Resident 7's bed.
Failure to Ensure Bathroom Privacy for Residents
Penalty
Summary
The facility failed to ensure that two residents, one with acute respiratory failure and type 2 diabetes mellitus, and another with cellulitis and muscle weakness, did not share a bathroom with residents of the opposite sex. Resident #56, who was cognitively intact and independent with toileting hygiene, complained about having to share a bathroom with residents of the opposite sex. Resident #296, who was alert and oriented and required limited assistance with toileting, reported an incident where a resident of the opposite sex walked in on them while they were using the bathroom, leading them to start locking the bathroom door. Interviews with the Executive Director and the Social Service Director revealed that the facility's policy was to ensure that bathrooms were not shared by residents of the opposite sex. However, both directors were unaware that such sharing was occurring. The Executive Director reviewed the facility's current census and did not find any instances of opposite-sex bathroom sharing, while the Social Service Director stated that they were not aware of the issue until the day of the interview.
Failure to Complete Level II Mental Health Evaluations
Penalty
Summary
The facility failed to ensure a Level II mental health evaluation was completed for two residents who had positive Level I screenings. Resident #41 was admitted with diagnoses including alcohol abuse with alcohol-induced anxiety disorder and post-traumatic stress disorder. Despite a positive Level I screening indicating the need for a Level II mental health evaluation, there was no evidence in the medical record that this evaluation was completed. Interviews revealed that the Social Service Director (SSD) and the Director of Nursing (DON) did not follow up with the state after the initial submission, as required by facility policy. The Executive Director (ED) confirmed that it was the facility staff's responsibility to follow up with the state if no response was received within four days. Similarly, Resident #17 was admitted with a diagnosis of bipolar disorder and had a positive Level I screening, necessitating a Level II mental health evaluation. However, the medical record showed no evidence of this evaluation being completed. The SSD admitted that no follow-up was conducted with the state for the Level II evaluation. Both the DON and the ED stated that they expected staff to follow up with the state within the specified timeframe to ensure the evaluation was completed. The lack of follow-up resulted in the failure to complete the required Level II mental health evaluations for both residents.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure all medications were available for administration during medication rounds for one resident. Specifically, Resident #68, who was admitted with diagnoses including lymphedema and mild protein-calorie malnutrition, did not receive their prescribed vitamin A capsule as it was not available. The resident's cognitive status was intact, as indicated by a BIMS score of 15. The deficiency was observed during a medication administration round, where the LVN acknowledged the unavailability of the medication and confirmed it should have been available. The Director of Nursing and the Executive Director both stated that medications should be available for administration and acknowledged issues with timely receipt of medications since changing pharmacies. The facility's policy on Pharmacy Services Overview, revised in April 2019, mandates that residents have a sufficient supply of their prescribed medications and receive them in a timely manner. Despite this policy, the facility failed to provide the necessary vitamin A for Resident #68. Interviews with the LVN, DON, and Executive Director confirmed the medication was not available and highlighted ongoing issues with the new pharmacy service. The DON emphasized the importance of having medications available when needed, aligning with the facility's policy requirements.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection control practices during the provision of incontinence care for a resident with moderate cognitive impairment and urinary incontinence. During an observation, a CNA did not change gloves or sanitize hands after cleansing the resident's perineal area and before handling clean items, including a new incontinence brief and the resident's clothing. This action was confirmed by the CNA during an interview, acknowledging the failure to change gloves between dirty and clean tasks. Interviews with the Infection Preventionist, Director of Nursing, and Executive Director revealed that the facility staff were expected to change gloves and perform hand hygiene when transitioning from dirty to clean tasks. However, it was noted that the facility did not have a specific policy on glove changing, although it was implied in the standards of practice. The deficiency was identified through observation, interviews, and record review, highlighting a lapse in infection control practices during incontinence care for the resident.
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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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