Downey Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Downey, California.
- Location
- 13007 S. Paramount Blvd., Downey, California 90242
- CMS Provider Number
- 055519
- Inspections on file
- 47
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Downey Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, ESRD, and dependence in ADLs did not receive care consistent with professional standards when an LVN administered Tylenol for reported pain but failed to document the dose, assessment, and reassessment in the MAR in a timely manner, contrary to facility medication administration policy. In addition, the same resident, who had a Foley catheter and a care plan addressing prior hematuria, was observed without a StatLock or other securement device, despite a care plan intervention to secure the catheter to promote urine flow and prevent kinking and accidental removal. Staff acknowledged that the care plan and standard of care were not followed, and the DON noted the resident’s risk for penile trauma due to prolonged Foley use and the need for a securement device.
A resident with a history of falls, cognitive impairment, and recent femur fracture was left unsupervised on the toilet by a CNA, despite requiring maximal assistance and supervision. The resident attempted to stand, fell, and sustained a head laceration requiring sutures. Staff interviews confirmed the resident should not have been left alone, and the care plan lacked specific instructions for supervision during toileting.
Nurses and nurse aides failed to demonstrate the competencies needed to care for residents in a manner that maximizes their well-being, resulting in a deficiency related to staff qualifications and resident care.
The facility failed to develop comprehensive care plans for four residents, leading to potential delays and negative impacts on their care. A resident did not receive a prescribed nutritional supplement due to staff unfamiliarity, while two residents with vision impairments had inappropriate or missing care plans. Another resident's medication refusal was not addressed with a care plan, risking delays in necessary treatment.
The facility failed to document a resident's medication refusal and educate them on the risks, while also not informing a physician of another resident's change in condition. One resident refused medications due to timing issues, and the staff did not document or educate as required. Another resident's brownish urine was noted post-dialysis, but the staff failed to notify the doctor, potentially delaying care.
A resident with cataracts was not referred to an ophthalmologist as recommended by an optometrist, due to the Social Services Director's failure to review consultation notes and follow up on the referral. This oversight delayed necessary treatment for the resident's eye condition.
A resident requiring dialysis did not receive appropriate post-dialysis care when the facility failed to remove the pressure dressing from the AV shunt site as ordered. The resident, with conditions including ESRD and diabetes, returned from dialysis with the dressing still intact, leading to potential complications. The oversight was acknowledged by the LVN and ADON, highlighting a failure to adhere to the facility's post-dialysis care policy.
A facility failed to accurately document the administration of lorazepam for a resident with multiple diagnoses, including seizure disorder and major depressive disorder. The MAR showed three doses administered, but a review revealed a missing nurse's signature and an incorrect tablet count. An LVN admitted to not signing the NCS immediately, which was confirmed as a medication error by the ADON. The facility's policy requires immediate documentation, which was not adhered to, resulting in the deficiency.
A resident with a history of stroke and gastrointestinal issues was nearly given a chewable aspirin tablet instead of the prescribed delayed-release form by an LVN, who did not have a physician's order for the change. The LVN was stopped by a surveyor, and the ADON confirmed the need for physician clarification before altering medication forms.
The facility failed to implement proper infection control practices for two residents. A resident's nebulizer mask was improperly stored on a nightstand without a protective bag, contrary to infection control policies. Another resident's dirty clothes and linen were left unattended on the bed, violating the facility's procedures for handling soiled items. Staff acknowledged these lapses, which posed potential infection risks.
A facility failed to conduct weekly skin IDT meetings for a resident who developed redness on the left hip and iliac crest. Despite the resident's dependency on staff and a history of pressure-induced damage, no meetings were held between January 2025 and February 2027, contrary to facility policy. The DON confirmed that meetings should have been conducted, especially after a change in the resident's skin condition was noted.
The facility failed to meet the required room size of 80 sq. ft. per resident in multiple-resident rooms, with four rooms measuring below the standard. Despite this, observations showed that residents had privacy, space for personal items, and maneuverability for wheelchairs. The administrator acknowledged the deficiency, and a room waiver was recommended by the California Department of Public Health.
A resident with dementia and other medical conditions sustained a fractured wrist of unknown origin, but the facility did not report the injury to CDPH within the required two-hour timeframe or submit the investigation results within five working days, as mandated by policy. The delay in reporting was confirmed through staff and family interviews and review of facility records.
A resident with dementia and psychotic disorder exhibited erratic behaviors, including thrashing arms and striking furniture, but did not have a care plan addressing these actions. Staff and family observed the resident guarding a painful wrist over several days, but a change of condition assessment and pain interventions were not provided, resulting in an undiagnosed wrist fracture and hospital transfer.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency. One resident's call light was clipped to a curtain, and they rely on it for assistance due to a history of falls and other conditions. Another resident also had their call light out of reach and often cannot find it, despite needing assistance due to difficulty walking. Both residents have the mental capacity to make medical decisions, and the facility's policy requires call lights to be accessible.
A resident's legal representative requested medical records, but the LTC facility failed to release them within the 24-hour timeframe as per policy. Despite multiple follow-ups, the records were delayed by about a month, violating the resident's rights. The facility's policy requires records to be accessible within 24 hours of a request.
A resident fell and sustained a femur fracture due to a CNA's failure to provide a two-person assist during a Hoyer Lift transfer. The CNA did not inspect the sling, which broke during the transfer. Facility staff did not follow procedures for checking and maintaining lift slings, contributing to the incident.
A resident experienced a fall due to a broken Hoyer lift sling, resulting in a right distal femur fracture. Despite severe pain and an X-ray confirming the fracture, the transfer to a general acute care hospital was delayed by 10 hours. The facility's Director of Nursing acknowledged the delay and the risk it posed for delayed care and treatment.
A facility failed to provide restorative nursing exercises as ordered for three residents, leading to a deficiency in care. Residents with conditions like hemiplegia and end-stage renal disease were not consistently receiving prescribed range of motion exercises. Documentation showed multiple days without exercises, marked as not applicable or resident refused. Interviews confirmed the lack of adherence to physician orders, with residents not receiving exercises as frequently as required.
Two residents with moisture-associated skin damage (MASD) did not have individualized care plans developed, despite receiving treatment. Interviews with staff revealed that care plans are essential for guiding treatment and preventing further skin breakdown, but the facility's policies were not followed, leading to potential negative impacts on care delivery.
The facility failed to obtain authorization from the responsible party of a resident with severe cognitive impairment before discharging the resident to another facility. The primary emergency contact was not notified, and the discharge was not properly documented, contrary to the facility's policy.
A resident with impaired cognitive skills and complete dependence on staff developed a Stage III pressure ulcer. Despite documented high risk and ongoing treatments, the facility failed to create a care plan for over a month, as confirmed by the Treatment Nurse and Director of Nursing.
Failure to Document Pain Medication Timely and to Secure Foley Catheter per Care Plan
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not ensuring timely documentation of pain assessment and medication administration, and by not following the resident’s catheter care plan. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent for ADLs, with diagnoses including metabolic encephalopathy, muscle weakness, and ESRD. On one observed date, an LVN stated she had administered Tylenol 325 mg for the resident’s 2/10 pain but did not document the administration, assessment, or reassessment in the MAR right away because she had to attend to another resident. The facility’s own Medication Administration policy required the person administering the medication to record the administration on the MAR after the medication pass and to review the MAR at the end of each pass to ensure doses were administered and documented. Another LVN acknowledged that late documentation of medication administration could result in another dose being given. The facility also failed to follow the resident’s care plan related to an episode of blood in the urine. During an observation, the resident was noted to have an indwelling Foley catheter without a StatLock or other securement device in place. Review of the resident’s care plan titled “Resident with an episode of blood in the urine” showed an intervention to secure the catheter to facilitate urine flow and prevent kinking and accidental removal. An LVN confirmed that the facility did not follow the resident’s care plan or the standard of care when the catheter was not secured. The DON stated that the resident was at risk for penile trauma due to long-term Foley catheter use and needed a StatLock to prevent trauma and skin irritation. The facility’s Indwelling Urinary Catheter policy indicated that residents with indwelling catheters receive catheter care daily and PRN, and that staff may secure the tubing with a securement device PRN to prevent migration, friction, or tension of the catheter.
Failure to Provide Adequate Supervision During Toileting for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident, assessed as high risk for falls due to a history of right femur fracture, Alzheimer's disease, osteoporosis, and severely impaired cognition, was left unsupervised on the toilet by a CNA. The resident required maximal assistance with toileting hygiene and was dependent on staff for toilet transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs, the CNA left the resident alone in the restroom to inform another resident she was assisting the high-risk resident, during which time the resident attempted to stand, fell, and sustained a forehead laceration requiring five sutures at a general acute care hospital. Interviews with facility staff, including the CNA, LVN, RN, Director of Rehabilitation, and Assistant Director of Nursing, confirmed that the resident should not have been left unattended due to cognitive deficits, poor understanding of safety measures, and toe-touch weight-bearing status following a recent femur fracture. Staff acknowledged that supervision should have been maintained, and the CNA admitted it was unsafe to leave the resident alone. The care plan for the resident lacked specific instructions regarding the type and level of assistance required during toileting, which staff indicated could lead to miscommunication and increased risk of avoidable mistakes. The facility's policy on fall management required individualized care plans and interventions for high fall risk residents, but the care plan in this case did not specify the necessary supervision or assistance. The lack of clear guidelines and staff adherence to supervision protocols directly contributed to the resident's fall and injury while using the toilet.
Nursing Staff Lacked Required Competencies
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 due to a lack of appropriate skills and knowledge among the nursing staff, which impacted the quality of care provided to residents. There were no specific details provided about individual residents, their medical histories, or their conditions at the time of the deficiency. The report focuses on the general failure of staff to meet competency requirements necessary for resident care.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential delays and negative impacts on their care. Resident 27, who had severe cognitive impairment and was entirely dependent on staff for activities of daily living, did not receive a magic cup, a nutritional supplement, with his lunch as ordered by his physician. This oversight was due to a lack of awareness among the staff, as the Certified Nursing Assistant (CNA) was unfamiliar with the magic cup, and the Dietary Supervisor confirmed that it was not included on the meal tray. Resident 71, who was legally blind due to diabetic retinopathy, had a care plan that included inappropriate activities such as playing cards, cooking, and gardening, which were not suitable for someone with vision impairment. The Assistant Director of Nursing (ADON) acknowledged that these interventions were not resident-centered and did not cater to the resident's needs, highlighting a failure to develop a care plan that was beneficial and safe for the resident. Resident 78, who had cataracts and required bifocal glasses, did not have a care plan addressing his vision impairment, which could affect his quality of life and the meeting of his needs. Similarly, Resident 62, who had end-stage renal disease and other conditions, refused several medications on multiple occasions, yet there was no care plan to address this refusal. The ADON confirmed that a care plan should have been developed to manage the medication refusal, as it is standard practice to ensure proper care and avoid delays in necessary treatment.
Failure to Document Medication Refusal and Report Change in Condition
Penalty
Summary
The facility failed to meet professional standards of care for two residents, Resident 62 and Resident 142, as identified in a survey. For Resident 62, the facility did not document the resident's refusal of medications in the Progress Notes, nor did they educate the resident on the risks and benefits of refusing medications. Resident 62, who had diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, refused medications such as auryxia, clopidogrel, atorvastatin, and Rena Vite on multiple occasions in March 2025. The resident expressed a preference to take medications with dinner and reported that the nursing staff did not offer the medications at the appropriate time or provide an explanation for the delay. Interviews with the Licensed Vocational Nurse and the Assistant Director of Nursing confirmed that the standard practice of documenting medication refusals and educating the resident was not followed. Additionally, the facility failed to inform Resident 142's doctor of a change in the resident's condition, specifically the presence of brownish urine, which was noted on the Nurse's Dialysis Communication form. Resident 142, who was dependent on renal dialysis and had diabetes mellitus, reported brown urine and pain during urination to the nursing staff. However, the licensed nurse did not review the dialysis communication form or notify the physician of this change, which could indicate a potential urinary tract infection. The Assistant Director of Nursing acknowledged that the licensed nurses should have reviewed the dialysis nurse's comments and informed the doctor of the change in condition. The facility's policies and procedures, as well as job descriptions, emphasize the importance of documenting medication refusals, educating residents on medication compliance, and reporting changes in residents' conditions to physicians. The failure to adhere to these standards resulted in deficiencies in the care provided to Residents 62 and 142, potentially delaying necessary medical care.
Failure to Refer Resident for Ophthalmology Consultation
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 78, was referred to an ophthalmologist as recommended by an optometrist. Resident 78, who was admitted with diagnoses including diabetes mellitus and a left below-the-knee amputation, was found to have cataracts in both eyes during an optometry consultation. The optometrist recommended bifocal glasses and an ophthalmology referral due to the cataracts. However, the Social Services Director (SSD) was not aware of the need for this referral and did not review the consultation notes, resulting in a failure to make the necessary appointment. Interviews with the SSD and the Assistant Director of Nursing (ADON) revealed that the optometry consultation notes were supposed to be followed up by the SSD, who should have informed the nursing staff to obtain an order for the referral. The ADON emphasized the importance of timely follow-up on referrals to prevent further vision impairment. The facility's job description for the social services manager indicated that the SSD was responsible for referring residents to appropriate services when needed. The lack of follow-up on the ophthalmology referral delayed necessary treatment for Resident 78's cataracts.
Failure to Provide Appropriate Post-Dialysis Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care for a resident, identified as Resident 62, who required dialysis treatment. The deficiency occurred when the facility did not remove the pressure dressing from Resident 62's arteriovenous (AV) shunt site as ordered by the physician. The physician's order specified that the pressure dressing should be removed two hours after dialysis on designated days. However, observations and interviews revealed that the dressing was not removed until the following day, which was contrary to the care plan and physician's orders. Resident 62, who had diagnoses including end-stage renal disease, peripheral vascular disease, and diabetes mellitus, returned from dialysis with the pressure dressing still intact. The resident reported itching at the AV shunt site and confirmed that the dressing had not been changed after returning from dialysis. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) acknowledged the oversight, noting that the failure to remove the dressing could lead to complications such as clotting of the shunt, fluid overload, and electrolyte imbalance. The facility's policy on post-dialysis care was not followed, resulting in this deficiency.
Failure to Document Lorazepam Administration
Penalty
Summary
The facility failed to accurately account for and document the administration of lorazepam, a controlled medication, for a resident. The resident, who was admitted with diagnoses including seizure disorder, autistic disorder, and major depressive disorder, had an active order for lorazepam to be administered as needed for crying without apparent reason. The Medication Administration Record (MAR) indicated that the resident received three doses of lorazepam over two days. However, a discrepancy was found during a review of the Narcotic Count Sheet (NCS) and the bubble pack, revealing one missing nurse's signature and an incorrect count of tablets. During an interview, a Licensed Vocational Nurse (LVN) admitted to forgetting to sign the NCS after administering the medication, acknowledging it as a medication error and dangerous practice. The Assistant Director of Nursing (ADON) confirmed that the nurse should sign the MAR and NCS immediately after administration to ensure the narcotic count is correct and to avoid medication errors. The facility's policy on controlled substances requires immediate documentation of administration details, which was not followed in this instance, leading to the deficiency.
Medication Error Due to Unauthorized Change in Aspirin Form
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) administered a chewable aspirin tablet without a physician's order. During a medication pass observation, the LVN was stopped by a surveyor from administering a crushed mixture of aspirin chewable tablet and applesauce to the resident. The resident's active aspirin order indicated the administration of an 81 mg delayed-release (DR) tablet once daily for stroke prevention, which should not be crushed. The LVN admitted to changing the medication form without physician approval, mistakenly believing the chewable and DR forms were the same. The resident involved had a history of cerebral infarction, gastritis with bleeding, and gastroesophageal reflux disease (GERD). The resident's care plan highlighted the risk of bleeding or bruising related to anticoagulant therapy, specifically aspirin. The Assistant Director of Nursing (ADON) confirmed that the nurse should have clarified the order with the physician before changing the medication form, as the DR tablet was likely prescribed to minimize gastrointestinal risks. The facility's policy required medications to be administered according to the physician's written orders.
Infection Control Deficiencies in Nebulizer and Linen Handling
Penalty
Summary
The facility failed to implement proper infection control practices for two residents, leading to potential risks of infection. For Resident 33, the deficiency involved the improper handling of a nebulizer mask. The mask, which was used to deliver medication for respiratory conditions, was repeatedly observed placed directly on the nightstand surface without being stored in a plastic bag as required by the facility's infection control policy. This oversight was noted during multiple observations and interviews, where both the resident and staff acknowledged the improper storage of the nebulizer mask. The resident expressed concerns about the risk of infection and feelings of neglect due to the nurse's actions. In the case of Resident 62, the deficiency involved the improper handling of dirty clothes and linen. Observations revealed that dirty clothes and linen were left unattended on the resident's bed for extended periods. Despite the resident's preference for staff to clean the bed in his presence, the staff failed to remove the soiled items in a timely manner. Interviews with the resident and staff confirmed that the dirty clothes and linen were not properly managed, which was against the facility's infection control policy. The staff acknowledged the importance of removing soiled items to prevent infection and maintain resident dignity. The facility's infection control policies were not adhered to in both cases, as evidenced by the improper storage of medical equipment and the mishandling of soiled linen. The Infection Preventionist Nurse and other staff members recognized the deficiencies and the potential for infection due to these lapses in protocol. The facility's policies clearly outlined the need for proper storage and handling of items to prevent infection, yet these guidelines were not followed, leading to the identified deficiencies.
Failure to Conduct Weekly Skin IDT Meetings
Penalty
Summary
The facility failed to conduct weekly skin interdisciplinary team (IDT) meetings for a resident who developed redness on the left hip and left anterior iliac crest. This deficiency occurred between January 9, 2025, and February 27, 2027, for one of the six sampled residents. The resident, who was entirely dependent on staff for activities of daily living, had a history of dysphagia, cerebral infarction, hemiplegia, and pressure-induced deep tissue damage. Despite the facility's policy requiring weekly skin reviews and IDT meetings after any change in skin condition, no such meetings were conducted during the specified period. The Director of Nursing (DON) acknowledged that the normal practice was to conduct weekly skin IDT meetings and additional meetings whenever there was a change in the resident's skin condition. The DON confirmed that an IDT meeting should have been conducted after the resident developed skin redness on February 10, 2025. The facility's policy and procedure documents, revised in December 2023, also indicated the necessity of these meetings to monitor pressure injuries and document the collaboration in the resident's clinical record. The absence of these meetings had the potential to result in worsening skin impairments for the resident.
Room Size Deficiency in Multiple-Resident Rooms
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in rooms with multiple residents. During a review of the facility's Client Accommodations Analysis form dated March 24, 2025, it was found that four rooms did not meet this requirement. The rooms measured 217, 232, 238, and 234 square feet, respectively, and each housed three residents. Despite the deficiency in room size, observations indicated that the rooms provided privacy with curtains and had enough space for bedside tables, dressers, and maneuverability for wheelchairs. Interviews and observations conducted on March 27, 2025, revealed that the residents in these rooms were comfortable and had sufficient space for personal property, nursing care, and treatments. The administrator confirmed the deficiency, acknowledging that the rooms did not meet the size requirement but emphasized that the residents had privacy, dignity, and safety. The California Department of Public Health recommended a room waiver, indicating an acknowledgment of the deficiency but no immediate corrective action was detailed in the report.
Failure to Timely Report Injury of Unknown Source and Investigation Results
Penalty
Summary
The facility failed to report an injury of unknown source within the required two-hour timeframe to the California Department of Public Health (CDPH) for a resident who sustained a fractured right wrist. The resident, who had diagnoses including dementia, cerebral infarction, and a psychotic disorder with delusions, was noted to have a swollen right wrist during a therapy session. The injury was later confirmed by x-ray to be an acute, mildly displaced fracture of the distal radial metaphysis and an acute fracture of the ulnar styloid. Despite these findings, there was no documented evidence that the injury was reported to CDPH as required. Additionally, the facility did not ensure that the results of its internal investigation into the injury were reported to CDPH within five working days of the incident. Interviews with staff and family revealed that the resident had been observed guarding his right wrist and complaining of pain prior to the x-ray, and that these concerns had been reported to nursing staff. The facility's investigation concluded that the injury occurred during an episode of erratic behavior, but the reporting to CDPH was delayed until after the surveyor's initial visit. The facility's own policies require immediate reporting of all alleged violations involving abuse, neglect, or injuries of unknown source, especially those resulting in serious bodily injury, and mandate that investigation results be submitted to the state agency within five working days. The failure to adhere to these policies and regulatory requirements resulted in delayed notification to CDPH and delayed investigation by the authorities.
Failure to Develop and Implement Care Plan for Behavioral and Medical Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident exhibiting erratic behaviors, including thrashing and swinging arms, and did not address the resident's behavioral risks in the care plan. Despite staff observations and reports of the resident's impulsive and potentially harmful actions, such as striking furniture, these behaviors were not formally documented or targeted in the resident's care plan. The Director of Nursing confirmed that no care plan was in place to address these specific behaviors, which could have contributed to improper care. Additionally, the facility did not follow its own policy and procedure regarding significant changes of condition. The resident was observed by staff and family members to be guarding his right wrist and complaining of pain over several days. Although these changes were reported to nursing staff, a formal change of condition assessment was not completed in a timely manner, and pain-relieving interventions were not provided. The registered nurse acknowledged that a change of condition assessment should have been performed and that care should have been provided, as the resident's pain could have worsened. The lack of a care plan for the resident's behavioral issues and the failure to implement the facility's significant change of condition policy resulted in the resident not receiving appropriate interventions. This ultimately led to the resident sustaining an acute, mildly displaced fracture of the distal radius and ulnar styloid, requiring transfer to a general acute care hospital for further evaluation and treatment.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for two residents, leading to a deficiency in accommodating their needs and preferences. During an observation and interview, it was found that Resident 3's call light was clipped to a curtain and not visible, which was confirmed by a CNA who stated that the call light should be within the resident's reach. Resident 3, who has a history of falls, diabetes, and hypertension, and requires supervision for activities of daily living, stated that they rely on the call light to request assistance from nurses. Similarly, Resident 4's call light was also found clipped to a curtain, out of reach. The resident, who has a history of falls and difficulty walking, expressed that they often cannot find the call light and instead go directly to the nurses for help. Both residents have the mental capacity to understand and make medical decisions, as indicated in their medical records. The facility's policy requires call lights to be within residents' reach, which was not adhered to in these cases.
Delayed Release of Medical Records Violates Resident Rights
Penalty
Summary
The facility failed to release medical records requested by a resident's legal representative within the 24-hour timeframe as stipulated in their policy and procedure on Residents Rights, Release of Information. The resident, who had been admitted and readmitted with diagnoses including dementia, cardiac pacemaker, and hypertension, had fluctuating capacity to understand and make medical decisions. Despite the resident's ability to make themselves understood and understand others, the facility did not provide the requested medical records in a timely manner, resulting in a violation of the resident's rights. The request for the resident's medical records was initially sent by a legal services office via fax and followed up multiple times via email. The Medical Records Director acknowledged the delay, stating that the request was sent to the facility's legal team, which approved the release, but the records were not sent to the legal services office until nine days later. The Director of Nursing emphasized the importance of timely release of medical records, acknowledging that it was unacceptable for the resident and their representative to wait for about a month for the records to be released. The facility's policy indicated that residents should have access to their records within 24 hours of a written or oral request, excluding weekends or holidays.
Failure to Ensure Safe Transfer Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent a fall for a resident by not ensuring that a Certified Nursing Assistant (CNA) provided a two-person physical assist when using a Hoyer Lift to transfer the resident from a wheelchair to the bed. This resulted in the resident falling and sustaining a right distal femur fracture, which required surgical intervention. The resident was admitted to a general acute care hospital for an open reduction internal fixation surgery. The incident occurred when the CNA attempted to transfer the resident alone, despite the resident's care plan indicating the need for a two-person assist. During the transfer, the Hoyer lift sling broke, causing the resident to fall. The CNA admitted to not checking the sling for damage prior to use and acknowledged that assistance should have been sought. The facility's Director of Nursing confirmed that the CNA should have asked for help and that CNAs were responsible for inspecting the lift sling before use. Interviews with staff revealed that the facility's procedures for checking and maintaining the Hoyer lift slings were not followed. The laundry aid and maintenance supervisor were responsible for inspecting and replacing damaged slings, but records showed no entries for sling checks during the days leading up to the incident. The facility's policy required a safe environment free of accident hazards, but the failure to inspect and maintain equipment contributed to the resident's fall and injury.
Delayed Transfer to Hospital After Resident's Fall
Penalty
Summary
The facility failed to transfer a resident immediately to a general acute care hospital (GACH) after the resident experienced an unavoidable fall that resulted in a right distal femur fracture. The incident occurred when a Certified Nursing Assistant (CNA) was transferring the resident from a wheelchair to a bed using a Hoyer lift, and the sling broke, causing the resident to fall. Despite the resident reporting severe pain and an X-ray confirming an acute comminuted supracondylar fracture, the transfer to the hospital was delayed by 10 hours. The resident, who had been admitted to the facility with diagnoses including diabetes, hypertension, and muscle weakness, was totally dependent on staff for transfers. After the fall, the resident reported a pain level of 10 out of 10, and the facility's Director of Nursing (DON) was notified. An X-ray was ordered, and the results, received at 11:00 p.m., confirmed the fracture. However, the resident was not transferred to the GACH until the following morning, resulting in a significant delay in receiving necessary medical evaluation and treatment. Interviews with the resident, the responsible party, and the DON revealed that the facility did not provide an explanation for the delay in transfer. The facility's policy and procedure for significant changes in condition and fall management were reviewed, indicating that immediate attention was warranted in such circumstances. The DON acknowledged that the facility should not have waited longer than one hour to transfer the resident, and the delay placed the resident at risk for delayed care and treatment.
Failure to Provide Prescribed Restorative Nursing Exercises
Penalty
Summary
The facility failed to provide restorative nursing exercises as per physician orders for three residents, leading to a deficiency in care. Resident 1, diagnosed with hemiplegia and hemiparesis, was ordered to receive passive range of motion (PROM) exercises five times a week. However, documentation showed that these exercises were not consistently provided, with several days marked as not applicable or resident refused. Similarly, Resident 2, with end-stage renal disease and diabetes, was ordered active assisted range of motion exercises, but records indicated multiple days without documentation of these exercises being performed. Resident 5, also diagnosed with hemiplegia and hemiparesis, was ordered PROM exercises five times a week. The documentation for Resident 5 showed numerous days without evidence of exercises being conducted, with some days marked as not applicable or resident refused. Interviews with the residents revealed that they were not receiving the prescribed exercises as frequently as ordered, with Resident 5 stating they only received exercises once or twice a week. During interviews, the RNA staff and the Director of Nursing acknowledged the lack of adherence to the physician's orders for restorative exercises. The RNA staff mentioned that residents often refused the exercises, but there was no indication that refusals were consistently reported to the charge nurse. The facility's policy on restorative care emphasized providing services according to individual needs and desires, but the documentation and interviews indicated a failure to meet these standards.
Failure to Develop Care Plans for Residents with MASD
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans with measurable objectives, timeframes, and interventions for two residents who had moisture-associated skin damage (MASD). This deficiency was identified during a review of the records and interviews with staff. Resident 1, who had peripheral vascular disease and was dependent on renal dialysis, did not have a care plan for MASD despite receiving treatment for it. Similarly, Resident 3, who had peripheral vascular disease and diabetes mellitus, also lacked a care plan for MASD, even though treatment was being administered. Interviews with the Treatment Nurse, Licensed Vocational Nurse, MDS Nurse, and Director of Nursing revealed that the facility's policy required all skin issues, including MASD, to be care planned. The staff emphasized the importance of care plans in providing guidance for treatment and prevention of further skin breakdown. However, the absence of care plans for these residents meant that staff might not have been fully informed about the residents' conditions and the necessary interventions. The facility's policies on change of condition reporting and comprehensive resident-centered care planning were not followed, as evidenced by the lack of updated care plans for the residents with MASD. This oversight had the potential to negatively affect the delivery of skin treatments and the prevention of further skin breakdown for the affected residents.
Failure to Obtain Authorization and Notify Responsible Party Before Resident Discharge
Penalty
Summary
The facility failed to ensure a written or verbal authorization was obtained from the responsible party of a resident prior to the resident's discharge to another facility. This resulted in the resident's primary responsible person not being aware of the discharge. The resident, who had severe cognitive impairment and was unable to make decisions, was admitted with diagnoses including dysphagia and cognitive communication deficit. The admission record indicated that the resident's family member 1 (FM1) was the first emergency contact person, and family member 2 (FM2) was the second emergency contact person. However, the facility did not document when FM2 requested the resident to be transferred out of the facility, nor did they notify FM1 of the discharge. Interviews with the Social Services Director (SSD), Licensed Vocational Nurse (LVN) 1, and the Director of Nursing (DON) revealed that the facility's protocol was to notify the first emergency contact person listed in the admission record if a resident was unable to make decisions. The DON emphasized that documentation of any communication with the family regarding discharge was necessary to protect the resident. A review of the facility's policy and procedure indicated that for resident-initiated transfers or discharges, the resident or their representative must provide verbal or written notice of intent to leave, and this must be documented in the medical record. The failure to follow these procedures led to the deficiency noted in the report.
Failure to Develop Timely Care Plan for Stage III Pressure Ulcer
Penalty
Summary
The facility failed to develop an individualized person-centered care plan addressing a Stage III pressure ulcer for a resident. The resident was admitted with moisture-associated skin damage, which progressed to a Stage II and then a Stage III pressure ulcer. Despite the resident's high risk for pressure ulcers and the presence of a Stage III ulcer documented in the Treatment Administration Record and Wound Doctor Notes, the care plan was not developed until over a month after the pressure ulcer was discovered. This delay in care planning was confirmed by both the Treatment Nurse and the Director of Nursing during interviews. The resident's Minimum Data Set indicated impaired cognitive skills and complete dependence on staff for all activities of daily living. The resident was receiving various interventions for pressure injury, including a pressure-reducing device, nutrition, hydration interventions, and topical treatments. However, the care plan for the Stage III pressure ulcer was only created after a significant delay, which the Director of Nursing acknowledged as a failure to provide timely and necessary care. The facility's policy required the development of a comprehensive care plan upon the discovery of such conditions, which was not adhered to in this case.
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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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