Diablo Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, California.
- Location
- 3806 Clayton Road, Concord, California 94521
- CMS Provider Number
- 055150
- Inspections on file
- 23
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Diablo Valley Post Acute during CMS and state inspections, most recent first.
Two cognitively intact residents reported being sexually abused by a CNA during personal care. One resident, admitted with a leg fracture and muscle weakness, stated that during an evening brief change the CNA repeatedly wiped her perineal area, went deeper between her labia, and rubbed her clitoris with his finger despite her telling him to stop; she later told multiple staff that the CNA had penetrated her vagina during the diaper change. Another resident with hemiplegia and hemiparesis reported that during a scheduled shower the same CNA rubbed her breast while removing her sweater, attempted to wash her breasts again in the shower, inserted his finger into her anus while cleaning her buttocks, and later squeezed her nipples while drying her; she reported feeling nervous and later disclosed the incident to staff and the Ombudsman. These events occurred despite a written abuse-prevention policy stating residents’ right to be free from sexual abuse by staff.
Two cognitively intact residents alleged sexual abuse by the same CNA during incontinence care and a shower. One resident reported that the CNA repeatedly wiped and penetrated her vaginal area despite only urinary incontinence and told multiple licensed nurses she had been inappropriately touched and did not want him to care for her again. Supervisory staff treated the concern as a care complaint, and staffing records show the CNA continued to work regular shifts with resident contact. During this period, another resident with hemiplegia reported that the same CNA rubbed her breasts, inserted a finger into her anus while washing her buttocks in the shower, and later squeezed her nipples while drying her. The facility’s own abuse policy required immediate reporting, protection of residents, and removal of accused staff from resident contact pending investigation, but the CNA was not removed after the first allegation.
A resident with severe cognitive impairment was not protected from physical abuse by another cognitively impaired resident with documented physical behavioral symptoms toward others. Staff, including an LVN, the DON, and the administrator/abuse coordinator, described the aggressor as easily agitated, frequently upset by disturbances, and known to require redirection and separation from others. Despite this history, an altercation occurred in which the aggressive resident was observed by a CNA swinging a coffee cup toward the other resident’s head, causing a bump with discoloration on the forehead and a cut on the upper lip, contrary to the facility’s abuse-prevention policy.
A resident with a history of cardiac issues experienced prolonged chest and abdominal pain without timely assessment, monitoring, or administration of physician-ordered nitroglycerin by an unlicensed nurse using another individual's RN license. Despite clear orders and symptoms consistent with a heart attack, appropriate interventions and emergency services were delayed, and the resident was only transferred to the hospital after several hours, where they later expired.
The facility failed to maintain complete and accurate records for controlled medications, with multiple instances where CDRs did not match MARs, and required documentation such as shipping manifests and destruction logs were missing or incomplete. An unlicensed staff member, using another individual's RN license, was found to have administered and documented narcotics, leading to further discrepancies. Staff interviews confirmed that these failures resulted in unaccounted doses and incomplete reconciliation of controlled substances.
A resident with a history of osteomyelitis accidentally ingested Dakin's solution, a wound cleansing agent, after a nurse mistakenly provided it as water during medication administration. The error occurred when one nurse prepared the medication and another administered it, contrary to facility policy requiring safe and direct administration by the preparer.
A registered nurse did not use required PPE while providing high-contact care to a resident with a pressure ulcer in a room designated for Enhanced Barrier Precautions (EBP). The nurse performed tasks such as checking vital signs and changing a Lidocaine patch without donning gloves or a gown, despite facility policy requiring EBP to prevent the spread of multi-drug resistant organisms.
The facility did not resubmit required PASRR Level I screenings for two residents with mental health diagnoses, resulting in missing or incomplete evaluations. One resident with bipolar disorder and depression did not have a new Level I screening completed after 30 days as required, while another resident with schizophrenia did not receive a follow-up Level I or Level II evaluation after initial screening and case closure. Staff interviews revealed unclear assignment of responsibility and lack of timely action on PASRR requirements.
A nurse administered several scheduled medications to a resident with multiple chronic conditions but failed to document the administration on the eMAR at the time the medications were given, instead entering the information nearly three hours later. Staff interviews confirmed that facility policy requires immediate documentation after medication administration.
A resident with dementia and mood disorders received an incorrect dosage of Seroquel due to a transcription error, where a physician's order for 50 mg was entered and administered as 25 mg. The error persisted over multiple days and was only discovered after review by nursing leadership. Staff interviews confirmed the mistake and acknowledged expectations for accurate order entry and medication administration.
Two residents with cognitive impairments and complex medical histories were found with cups of pills left at their bedsides, despite facility policy requiring secure medication storage and no orders for self-administration. An LPN documented the medications as administered but left them at the bedside at the residents' requests, and facility leadership confirmed this practice was not permitted.
Surveyors found that the facility's medication error rate was 17.86%, significantly above the acceptable threshold. Two residents were affected: one received the wrong form of aspirin, and another did not receive four prescribed medications during a medication pass. Staff interviews confirmed that required verification steps were not consistently followed, despite facility policy and leadership expectations for thorough medication administration checks.
A resident with a history of fractures and chronic pain received PRN opioid pain medication, but staff failed to consistently document its administration on the MAR, resulting in a discrepancy between the narcotic record and the MAR. Nursing staff and leadership confirmed that this lack of documentation led to an inaccurate medical record regarding the resident's pain management.
A resident's personal belongings were improperly stored on the floor, violating infection control protocols. A housekeeper failed to perform hand hygiene after removing soiled gloves, and a CNA improperly handled soiled linens by wearing gloves in the hallway and not using a hamper, contrary to facility policy.
A facility failed to report an alleged abuse incident involving a resident with cognitive and mental health conditions within the required timeframe. The incident, where an LVN allegedly slapped the resident, was reported to the ADON, DON, and Administrator. However, the report to the state agency was incomplete, lacking necessary details, and the Administrator could not provide proof of reporting to law enforcement, violating the facility's policy on immediate reporting.
A resident's responsible party experienced a delay in accessing medical records, which were needed for treatment at another facility. The request was made to the Medical Records Director, who required a signed DPOA before releasing the records. Despite receiving the DPOA, the records were not sent until several days later due to a busy schedule, and not all requested records were provided.
Failure to Protect Cognitively Intact Residents From Sexual Abuse by CNA During Personal Care
Penalty
Summary
The facility failed to protect cognitively intact residents from sexual abuse during the provision of personal care by a CNA. Resident 1, admitted with a left lower leg fracture and generalized muscle weakness and with a BIMS score of 15, reported that during an evening diaper change her brief was only wet with urine. She stated that CNA 1 stood on the left side of her bed and used wet wipes to clean her vaginal area multiple times. When she flinched, CNA 1 asked if it hurt, then wiped again, going deeper between her labia and rubbing his finger within her clitoris. Resident 1 reported that she told CNA 1 to stop and that it was not okay, declined her usual barrier cream because she wanted the care to be finished, and later documented the incident in four pages of personal notes she kept at her bedside. Later that evening, Resident 1 told CNA 2 that she was uncomfortable with CNA 1 and did not want him to change her again. CNA 2 confirmed that he worked that afternoon, that Resident 1 appeared uncomfortable when discussing the diaper change, and that she stated she did not want CNA 1 to return to provide care. Resident 1 also spoke with RN 1 during medication administration and stated she did not like CNA 1 and did not want him to change her diaper again. On the following night shift, LVN 1 encountered Resident 1 during medication pass and observed that she was emotional. Resident 1 told LVN 1 that she had reported sexual abuse to two staff members and felt that nothing had happened. She clearly described that her diaper had only urine and that during the diaper change CNA 1 repeatedly wiped her and at one point touched and wiggled his finger in her vagina. RN 2 later interviewed Resident 1 and reported that she appeared distressed and tense and recounted that CNA 1 wiped her vaginal area excessively and penetrated her with his finger. Resident 2, admitted with hemiplegia and hemiparesis following intracranial bleeding and with a BIMS score of 14, reported a separate incident of sexual abuse by CNA 1 during a scheduled shower. Resident 2 stated that CNA 1 took her from the patio to her room to prepare for the shower and, when removing her sweater, rubbed her breast. She reported that she swiped his hand away and told him to stop. While seated on a shower chair in shower room A, Resident 2 stated that CNA 1 again attempted to wipe her breast area with a washcloth, prompting her to request the washcloth so she could clean her own breasts. Because she could not reach her buttocks, she allowed CNA 1 to clean that area; she demonstrated that while he was behind her cleaning her buttocks, he inserted his finger into her anus. She stated she was shocked and told him she was done and to take her back to her room. Resident 2 further reported that once back in her room, CNA 1 used a towel to dry her breast area and squeezed her nipples, and she felt nervous during and after the event. She stated she reported the incident to RNA 1 the next day. RNA 1 confirmed working that day, noted that Resident 2 appeared emotional and about to cry while recounting the shower experience from the previous afternoon, and verified from the staffing schedule that CNA 1 had assisted Resident 2 with her shower. Progress notes documented that Resident 2 informed staff that a male CNA who assisted with her shower had touched her inappropriately and that she was alert and oriented. An Ombudsman representative later interviewed Resident 2 privately and observed that Resident 2 became distraught and cried when recounting the events. The facility’s abuse, neglect, and exploitation prevention policy stated that residents have the right to be free from sexual abuse and that the program is intended to protect residents from abuse by anyone, including facility staff, underscoring that the described conduct by CNA 1 constituted a failure to protect residents from sexual abuse.
Failure to Remove Alleged Perpetrator After Sexual Abuse Allegation Resulting in Second Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify and protect cognitively intact residents from alleged sexual abuse by a CNA, and to remove the alleged perpetrator from resident care after the first allegation. One resident, admitted with a left lower leg fracture and generalized muscle weakness and assessed with a BIMS score of 15 (cognitively intact), reported that during an evening incontinence care episode, a male CNA repeatedly wiped her vaginal area despite the brief being only wet with urine. She stated that the CNA wiped deeper between her labia and rubbed his finger within her clitoris, and that she told him to stop and that it was not okay. She usually required barrier cream but specifically declined it from this CNA and wanted the care to end. Later that evening, she told a familiar CNA that she had been inappropriately touched and asked who she could report it to; that CNA said he would inform the nurse. She then told an RN that she had been inappropriately touched by the CNA and that she never wanted him to change her again, but the RN did not ask further questions, focusing instead on ensuring the next shift knew she did not want that CNA assigned. The following early morning, the same resident, described as emotional, reported the incident again to an LVN, clearly stating that the brief contained only urine and that the CNA had repeatedly wiped her and wiggled his finger in her vagina. The LVN reported this to the nurse supervisor (an RN), who then visited the resident later that morning and heard a consistent account that the CNA had excessively wiped her vaginal area and penetrated her with his finger. The RN reported this to supervisory staff, including the Director of Staff Development and indicated that the Administrator would be notified. However, the Assistant DON later characterized the resident’s complaint as a “customer care complaint” and focused on the resident’s request not to have the CNA assigned to her, after confirming with the RN that the resident had reported rough incontinence care and requested not to be cared for by that CNA. Despite the resident’s clear allegations of sexual abuse and multiple reports to different licensed nurses, the CNA remained on the staffing schedule and continued to work resident care shifts. Staffing records show that the CNA worked the 2:45 p.m. to 11:15 p.m. shift on the date of the first alleged incident and then worked both the 6:30 a.m. to 3:00 p.m. and 2:45 p.m. to 11:15 p.m. shifts the following day, indicating he was not removed from resident contact after the initial allegation. During this time, a second cognitively intact resident, admitted with hemiplegia and hemiparesis following a non‑traumatic intracerebral bleed and with a BIMS score of 14, reported that the same CNA sexually abused her during a scheduled shower. She stated that when the CNA removed her sweater, he rubbed her breast, and she pushed his hand away and told him to stop. In the shower, she reported that he again attempted to wash her breast area with a washcloth, prompting her to request the washcloth so she could clean that area herself. She could not reach her buttocks, so the CNA washed that area from behind while she sat on a shower chair; she demonstrated that he inserted his finger into her anus. She further reported that after the shower, when drying her chest, he squeezed her nipples, leaving her feeling nervous during and after the event. She reported this to another staff member the next day. The facility’s abuse policy required immediate reporting to the administrator, protection of residents, and placing any employee accused of abuse on leave with no resident contact until the investigation was complete, but the CNA was not removed from duty after the first allegation, which allowed him to continue providing care and led to a second resident’s report of sexual abuse.
Failure to Protect a Cognitively Impaired Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in injury. Resident 1, who had a severely impaired cognition with a BIMS score of 3 out of 15 on the 11/14/25 MDS, was involved in a resident-to-resident altercation with Resident 2. Resident 2 had moderately impaired cognition with a BIMS score of 8 out of 15 on the 8/19/25 MDS, and the MDS Section E documented physical behavioral symptoms directed toward others occurring one to three days out of seven, including behaviors such as hitting, kicking, pushing, scratching, grabbing, or sexually abusing others. Staff interviews indicated that Resident 2 was easily agitated, sometimes irritated by other residents, and often required separation from others. The DON stated Resident 2 had good and bad days due to dementia, could be easily upset by various disturbances, and had prior behavior problems related to a need for medication adjustment. On 8/12/2025 at 10:15 a.m., an incident summary documented a resident-to-resident altercation between Resident 1 and Resident 2. A CNA observed Resident 2 swinging a coffee cup toward Resident 1's head, which resulted in Resident 1 sustaining a blue-purple bump with discoloration on the right frontal area of the head and a cut on the upper lip. Prior to this, on 1/28/26 at 11:24 a.m., Resident 1 had been observed sitting in a wheelchair outside the room with no discoloration or wounds noted on the face, indicating the injuries were associated with the altercation. The Administrator, who also served as the abuse coordinator, stated that Resident 2 was typically upset or agitated about anything and required communication or talking down to diffuse behavior, and that specific CNAs and Social Services staff were very familiar with Resident 2’s behavior and need for redirection. Despite the facility’s written Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021, which required protection of residents from abuse by anyone including other residents, Resident 1 was not protected from physical abuse by Resident 2.
Failure to Provide Timely Assessment and Intervention for Chest Pain by Unlicensed Nurse
Penalty
Summary
The facility failed to provide timely and appropriate nursing assessment, monitoring, and interventions for a resident who experienced ongoing chest and abdominal pain for approximately nine hours. The resident, who had a history of hypertension, gastric outlet obstruction, stroke, recent ventral hernia repair, and a recent non-ST elevated myocardial infarction (NSTEMI), was under the care of a staff member who was unlicensed and using another individual's RN license. Despite physician orders for nitroglycerin to be administered for chest pain and instructions to call 911 if pain persisted, the medication was not given, and emergency services were not initiated in a timely manner. Record reviews revealed that the unlicensed nurse did not document comprehensive pain assessments or nursing interventions beyond the administration of PRN pain medications, and there was no evidence that nitroglycerin was administered at any point during the resident's episode of chest pain. The resident's pain was not relieved by pain medication, and symptoms included increased respiration, moaning, groaning, facial grimacing, and physical signs of distress. Documentation also showed discrepancies in the administration and issuance of controlled substances, and there was no record of timely physician notification or appropriate escalation of care. Interviews with facility staff, including the DON, ADON, and nurse supervisor, confirmed a lack of awareness regarding the unlicensed status of the nurse and failures in following physician orders and facility policies for pain assessment, medication administration, and response to significant changes in condition. The resident was eventually transferred to the hospital, where nitroglycerin was administered by EMS, but the resident expired shortly after arrival due to an acute ST elevation myocardial infarction and cardiac arrest.
Deficient Controlled Substance Documentation and Unlicensed Medication Administration
Penalty
Summary
The facility failed to ensure that pharmaceutical services, specifically the management of controlled medications, were complete and accurate for multiple residents. Discrepancies were found between Controlled Drug Records (CDR) and Medication Administration Records (MAR) for several residents, including instances where medication removals did not correspond to documented administrations. In some cases, documentation was missing or illegible, and shipping manifests, CDRs, and destruction logs were incomplete or could not be located. These documentation failures were observed for at least six residents, with specific examples showing that doses of controlled substances were unaccounted for or not properly reconciled. One significant event involved an unlicensed individual who was employed as nursing staff and used another person's RN license to administer medications. This individual had a revoked LVN license due to prior drug diversion and was found to have signed out controlled substances under another nurse's initials. The facility's records showed that this unlicensed staff member was responsible for discrepancies in the administration and documentation of narcotics, including the removal of medication after a resident had already been transferred to the hospital. The facility's own policies required that only authorized, licensed personnel handle and document controlled substances, and that all removals and administrations be accurately recorded. Further review of the facility's medication management system revealed that for several residents, the required documentation for controlled substances was missing or incomplete. For example, one resident's shipping manifest indicated receipt of a controlled medication, but the corresponding CDR could not be found, and the MAR showed only a few doses administered with the remainder unaccounted for. In other cases, the CDR documented medication removals that did not match any MAR entries, and destruction or return records were not available. These failures were confirmed through interviews with facility staff, who acknowledged the discrepancies and the inability to account for all controlled substances as required by facility policy.
Improper Medication Administration Leads to Accidental Ingestion of Dakin's Solution
Penalty
Summary
A deficiency occurred when a licensed nurse prepared medication for a resident and handed it to another licensed nurse for administration, resulting in a breakdown of safe medication administration practices. Specifically, a resident with multiple diagnoses, including osteomyelitis, was admitted to the facility and required pain management with Morphine Sulfate ER. On the day of the incident, a nurse brought a cup containing a clear liquid, which was on top of the treatment cart, to the resident along with pain medication. The resident ingested the liquid and immediately reported that it tasted like bleach. Further review revealed that the clear liquid was Dakin's solution, a diluted bleach solution intended for wound cleansing, not for oral consumption. The progress notes indicated that the solution had been poured for wound treatment, but due to miscommunication and improper handoff, another nurse mistakenly gave it to the resident as water. The facility's policy required that medications be administered safely and by the individual who prepared them, with proper documentation, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow Enhanced Barrier Precautions (EBP) during the care of a resident who was admitted with diagnoses including a pressure ulcer, chronic diastolic heart failure, atrial fibrillation, and hypertension. The resident's room was clearly marked as requiring EBP due to the presence of a pressure ulcer, which necessitates targeted use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Despite this, the RN entered the resident's room multiple times to perform direct care activities, including checking blood pressure and pulse, administering medications, and removing and applying a Lidocaine patch, all without donning the required PPE. The RN acknowledged during an interview that the room was designated for EBP because of the resident's pressure ulcer but admitted to not using PPE while performing these care tasks. Facility policy specifies that EBP is intended to prevent the spread of multi-drug resistant organisms (MDROs) during high-contact activities involving resident care, equipment, or skin. The failure to consistently implement EBP as outlined in facility policy was directly observed and confirmed through staff interview and record review.
Failure to Resubmit PASRR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit required Preadmission Screening and Resident Review (PASRR) Level I evaluations for two residents with mental health diagnoses. For one resident with a history of bipolar disorder and major depressive disorder, the initial PASRR Level I screening was negative and the resident was admitted as an Exempted Hospital Discharge. However, the facility did not resubmit a new Level I screening on the 31st day as required, and there was no current Level I screening in the resident's record. Interviews with staff revealed that no individual had been assigned responsibility for ensuring the timely resubmission of the PASRR, and the process was not clearly defined among staff members. For another resident with a diagnosis of schizophrenia, the initial PASRR Level I screening was positive for suspected mental illness, and a Level II evaluation was required. The state agency closed the case after determining that the resident was isolated for health or safety reasons, instructing the facility to submit a new Level I screening to reopen the case. The facility did not submit the required new Level I screening, and as a result, the Level II evaluation was never completed. Staff interviews confirmed that the process for submitting PASRR evaluations was unclear, and the individual previously responsible for submissions was no longer employed at the facility. Throughout the investigation, staff including the Admissions Assistant, MDS Coordinator, DON, and Administrator acknowledged the lack of clear assignment of responsibility and failure to act promptly on PASRR-related correspondence. The facility's policy required maintenance of PASRR documentation and timely action on positive screenings, but these procedures were not followed for the two residents reviewed.
Failure to Timely Document Medication Administration on eMAR
Penalty
Summary
The facility failed to ensure that staff documented medication administration on the electronic Medication Administration Record (eMAR) in a timely manner for one resident. According to facility policy, the individual administering medication must initial the resident's MAR immediately after giving each medication and before administering the next. During an observed medication pass, a nurse administered several scheduled medications to a resident but did not document the administration on the eMAR at the time the medications were given. The nurse later confirmed in an interview that she had not documented the administration because she was in a hurry to move to the next resident. Audit reports showed that the documentation was entered nearly three hours after the medications were actually administered. The resident involved had a history of essential primary hypertension, type 2 diabetes mellitus, bilateral primary osteoarthritis of the knee, and adult failure to thrive, and was assessed as having moderate cognitive impairment. The resident's care plan included interventions for medication administration and monitoring for side effects. Multiple staff interviews, including with the ADON, DON, and Administrator, confirmed that the expectation was for medication administration to be documented immediately after giving the medication, and that delayed documentation was not consistent with good practice or facility policy.
Failure to Accurately Transcribe and Administer Medication Orders
Penalty
Summary
The facility failed to ensure that medication orders were accurately transcribed and administered as prescribed for one resident. A physician's order directed that the resident receive Seroquel 50 mg, one tablet twice daily and two tablets at bedtime. However, the order was incorrectly transcribed as Seroquel 25 mg, with instructions to give one tablet twice daily and two tablets at bedtime. This error was reflected in both the Order Summary Report and the Medication Administration Record (MAR), and the resident received the incorrect dosage over a period of time. The error was not identified until it was brought to the attention of the Assistant Director of Nursing (ADON), who acknowledged the mistake and indicated that more frequent audits or reviews might be necessary to prevent such errors. The resident involved had a history of dementia, major depressive disorder, and unspecified mood affective disorder, with moderate cognitive impairment as indicated by a BIMS score of 10. The care plan specifically noted the use of antipsychotic medication and the need to administer medications as ordered. Interviews with facility staff, including the LVN who entered the order and the DON, confirmed that the order was not transcribed correctly and that staff are expected to enter medication orders accurately. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance.
Medications Improperly Left at Bedside for Two Residents
Penalty
Summary
The facility failed to ensure that medications were properly stored and not left at the bedside for two residents, resulting in an accident hazard. Facility policy required that medications be administered safely and only allowed self-administration if the interdisciplinary team and physician determined it was appropriate, with medications stored securely. However, for both residents involved, there were no physician orders or care plan interventions permitting self-administration or bedside storage of medications. One resident, with a history of hypertension, COPD, cerebral aneurysm, and anemia, was observed on multiple occasions with a cup containing multiple pills at their bedside. The resident stated that staff gave them the pills but they were waiting to take them. The resident's care plan did not include self-administration, and the medication administration record showed that a nurse documented the medications as administered. The nurse later confirmed leaving the medications at the bedside at the resident's request, despite the resident not being assessed for self-administration. A second resident, with diagnoses including diabetes, chronic kidney disease, and cognitive decline, was also observed with a cup of pills at their bedside while they were in bed with their eyes closed. This resident's care plan and physician orders did not permit self-administration or bedside storage of medications. The nurse documented the medications as administered, but the medications were left at the bedside. Facility leadership confirmed that medications should not be left at the bedside and that the nurse was responsible for ensuring medications were taken as ordered.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 17.86%. During medication administration observations, five errors were identified out of 28 opportunities, affecting two residents. Facility policy required medications to be administered safely, timely, and as prescribed, with staff expected to verify the right resident, medication, dose, route, time, and method through multiple checks before administration. For one resident with a history of essential hypertension and intact cognition, the nurse administered enteric coated aspirin instead of the prescribed chewable aspirin for DVT prophylaxis. The nurse acknowledged the need to ensure the correct medication and perform multiple checks, as outlined in facility policy. Interviews with nursing leadership confirmed expectations for thorough verification and adherence to the six rights of medication administration, including comparing medication labels with the eMAR and ensuring residents receive the correct medications as ordered. Another resident, with a history of hypertension, asthma, and moderate cognitive impairment, did not receive four prescribed medications during the observed medication pass. The nurse omitted famotidine, fluticasone, lactobacillus, and loratadine, all of which were active orders. Nursing leadership reiterated the importance of line-by-line checks against the MAR and counting medications to ensure accuracy. The administrator stated an expectation for a 0% medication error rate and emphasized the need for nurses to be thorough in medication administration.
Failure to Accurately Document Pain Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records regarding the administration of pain medication for one resident with a history of a left lower leg fracture, bilateral primary osteoarthritis of the knees, and polyneuropathy. The resident, who was cognitively intact, had an active order for Percocet 10-325 mg to be given every four hours as needed for moderate to severe pain. Documentation review revealed a significant discrepancy: while the Medication Administration Record (MAR) showed that the medication was administered 37 times over a two-week period, the narcotic record indicated that 73 pills were signed out during the same timeframe. Interviews with nursing staff confirmed that medications were sometimes signed out on the narcotic record but not consistently documented on the MAR. Nurses acknowledged the importance of accurate documentation on both records, as the MAR is used by physicians to monitor medication administration and make necessary adjustments. Facility leadership, including the ADON and DON, also emphasized the need for proper documentation to ensure an accurate record of what medications residents receive. The failure to consistently document administration of pain medication on the MAR resulted in an inaccurate medical record for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to implement their infection prevention and control program in several instances. Personal belongings of a resident were found improperly stored on the floor, which was against the facility's infection control protocols. The resident, who had a history of urinary tract infection, irritable bowel syndrome, and type 2 diabetes mellitus with diabetic polyneuropathy, expressed dissatisfaction with her belongings being on the floor. The Licensed Vocational Nurse and Director of Nursing acknowledged that belongings should not be stored on the floor for infection control reasons, and the Infection Preventionist confirmed that staff were trained to store items in closets. Additionally, a housekeeper did not perform hand hygiene after removing soiled gloves, and there were no hand sanitizers available near the soiled utility room. The housekeeper, who only spoke Spanish, was not able to communicate effectively in English. Furthermore, a Certified Nursing Assistant improperly handled soiled linens by wearing gloves in the hallway and not using a hamper to transport the linens, contrary to the facility's policy. The Assistant Director of Nursing confirmed that staff were required to use hampers and not wear gloves in the hallway.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe to the State Survey Agency and Adult Protective Services for a resident. The resident, who was admitted to the facility in 2024, had diagnoses including Cognitive Communication Deficit, Intermittent Explosive Disorder, and Senile Degeneration of Brain. An alleged incident occurred where a Licensed Vocational Nurse was reported to have slapped the resident on the face during care. The Assistant Director of Nursing received the report of the alleged abuse on the morning of November 19, 2024, and subsequently informed the Director of Nursing and the Administrator. The facility's Report of Suspected Dependent Adult-Elder Abuse was faxed to the California Department of Public Health on the same day, but the report was incomplete, lacking details such as the contact name, telephone number, and the time the incident was reported to law enforcement and the local ombudsman. The facility's policy requires that all reports of abuse be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. However, the Administrator could not provide proof of the fax to law enforcement or a case number, indicating a failure to adhere to the policy and ensure timely reporting of the incident.
Delayed Access to Medical Records for Resident's Responsible Party
Penalty
Summary
The facility's nursing staff failed to provide a resident's responsible party with access to medical records within 24 hours of a written request, resulting in delayed treatment at another facility. The resident, admitted in 2024, had a responsible party designated for emergency contact and financial decisions. On May 30, 2024, the responsible party requested the release of medical records via telephone to the facility's Medical Records Director (MRD). The MRD required a signed Durable Power of Attorney (DPOA) before releasing the records. The responsible party sent the DPOA via email on July 11, 2024, but the MRD delayed sending the requested documents until July 19, 2024, citing a busy schedule with numerous Additional Documentation Requests from Medicare. The facility's normal process is to release records two days after receiving a signed release form, but this timeline was not adhered to, and not all requested records were provided.
Latest citations in California
Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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