East Bay Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Castro Valley, California.
- Location
- 20259 Lake Chabot Road, Castro Valley, California 94546
- CMS Provider Number
- 055239
- Inspections on file
- 25
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at East Bay Post-acute during CMS and state inspections, most recent first.
Facility staff failed to ensure that entrance and exit doors were locked and supervised outside of visiting hours, with both the main entrance and rear exit doors found to have malfunctioning locks. The rear exit door was repeatedly propped open, and staff were observed leaving it unsupervised, allowing unrestricted access to resident areas. Interviews confirmed that staff were not consistently aware of the broken locks, and maintenance records did not reflect timely reporting or repair.
A facility failed to follow a physician's order for supervised feeding for a resident with dysphagia, who required one-on-one assistance due to a flaccid left upper arm from a stroke. The resident was observed eating alone, contrary to the care plan. Staff interviews confirmed the need for one-on-one feeding, indicating a lapse in care.
A resident with multiple health conditions developed a non-pressure ulcer that worsened due to inconsistent wound care. The facility's records showed missing documentation for several treatment dates, indicating that ordered care was not consistently provided. The resident's condition deteriorated, resulting in wound dehiscence and infection, and was eventually diagnosed with cellulitis and sent to the hospital.
A facility failed to maintain proper infection control during a wound dressing change for a resident. Treatment Nurse 2 and a CNA did not wear required disposable gowns, despite Enhanced Barrier Precautions being in place. Additionally, the nurse did not perform hand hygiene between glove changes, moving from a dirty to a clean procedure. The Infection Preventionist confirmed the necessity of these precautions to prevent infection.
The facility failed to properly store and dispose of garbage, with cracked and leaking bins, open lids, and waste spilling onto the ground. This unclean state was confirmed by both the housekeeping supervisor and the dietary services manager, highlighting a breach in the facility's waste disposal policy and FDA guidelines.
The facility failed to follow medication administration policies, provide adequate pharmacy services, and ensure controlled medications were fully accounted for. This led to a resident's hospitalization due to a medication error, delayed medication administration for another resident, and missing scheduled medications for a third resident. Additionally, there were significant documentation lapses for controlled medications, posing risks for misuse or diversion.
The facility failed to comply with Federal regulations by not employing a full-time dietitian or a qualified full-time dietetic services supervisor. The Dietary Supervisor was not yet certified, and the Registered Dietitian worked part-time, focusing mainly on clinical duties. This lack of qualified supervision led to multiple issues in food service operations, including staff competency, menu adherence, and food safety.
The facility failed to follow the planned menu and provide diet-specific items, resulting in the substitution of maple chicken with teriyaki chicken due to missing ingredients and the absence of diet salad dressing for residents on a Heart Healthy diet. The Dietary Supervisor did not order or purchase the necessary items, and the Registered Dietitian was unaware of the issue.
The facility failed to ensure food was palatable by not following standardized recipes, resulting in bland and over-seasoned meals. Multiple residents expressed dissatisfaction, and observations confirmed the issues with food preparation. The Dietary Supervisor admitted to not adding salt during preparation, and the Registered Dietitian was unaware of deviations from recipes.
The facility failed to ensure food safety and sanitation, including unmonitored personal refrigerators, serving unpasteurized undercooked eggs, unclean ice machines, improper cooldown monitoring of TCS food, unlabeled refrigerated food, uncovered frozen raw fish, poor hand hygiene, incorrect sanitizer temperature, and unclean kitchen areas.
The facility failed to provide a refrigerator to store perishable food brought in by family members and visitors for residents. Staff encouraged residents to eat the food immediately, and any uneaten food was discarded due to the lack of refrigeration. Additionally, there was no microwave available to heat resident food. The DSD confirmed that the facility's policy allowed for the storage of perishable food for up to 72 hours, but admitted that there was no refrigerator available for this purpose.
The facility failed to complete the Annual Minimum Data Sets (MDS) for four residents within the required 14-day timeframe from the Assessment Reference Date (ARD). This deficiency was confirmed through interviews and record reviews, revealing that the comprehensive MDS assessments were submitted late, potentially impacting the care and services provided to residents with conditions such as quadriplegia, Diabetes Mellitus, metabolic encephalopathy, and hemiplegia.
The facility failed to complete quarterly MDS assessments within the required timeframes for four residents, potentially impacting their care. The MDS assessments for residents with significant medical conditions were overdue by 32 to 46 days, as confirmed by the MDS Coordinator.
The facility failed to ensure that the Minimum Data Sets (MDS) for eight residents were completed and submitted to CMS within the required time frames. The Annual MDS for four residents and the Quarterly MDS for another four residents were significantly overdue, ranging from 32 to 46 days past the required submission dates. The affected residents had various medical conditions, and the delays potentially impacted the quality of care they received.
The facility failed to ensure its nursing staff was competent in disinfecting shared glucometers, with two nurses using ineffective alcohol prep pads instead of the recommended germicidal wipes. Additionally, the facility lacked evidence of training or competency for two registry nurses on glucometer disinfection, potentially leading to the transmission of bloodborne diseases among residents.
The facility failed to ensure proper medication storage and labeling, allowing a non-licensed staff member access to the medication room and finding multiple expired, unlabeled, and undated medications in the medication room and on medication carts. The DON and LVNs acknowledged these deficiencies, which were against the facility's policies.
The facility failed to ensure kitchen staff were competent in using the three-compartment sink for cleaning equipment and utensils. Cook 1 was unaware of the correct water temperature and duration for submerging items in the sanitizer. The Dietary Supervisor confirmed the correct procedures, which were not being followed, posing a risk of contamination and illness for 69 residents.
The facility failed to provide milk to 43 out of 69 residents as indicated on the lunch menu and did not offer a nutritionally equivalent substitute. Additionally, cheese tortellini served as an alternate to chicken did not provide the same protein content, leading to potential nutritional deficiencies.
The facility failed to implement proper infection control practices, including not disinfecting blood pressure cuffs and glucometers between uses and allowing a resident's foley catheter equipment to lie on the ground, increasing the risk of infections.
The facility failed to maintain essential kitchen equipment, with a double oven unit and a plate warmer being non-operational. The Dietary Supervisor was aware but did not document the issues, and the Maintenance Supervisor was unaware until the survey. The lack of proper communication and documentation led to prolonged equipment downtime.
A resident with multiple sclerosis and morbid obesity was made to wear a tight, uncomfortable gown due to the unavailability of her preferred larger-sized gown. The facility failed to adhere to its policy on dignity and respect for resident preferences.
The facility failed to provide adequate fingernail care to a resident, resulting in long and bothersome nails despite multiple records indicating nail care was provided. The resident's grooming preferences were not met, leading to discomfort and potential risk of self-injury.
A non-nursing staff member assisted a resident by helping her sit up in bed and serving her lunch tray, despite not being certified or licensed to perform such tasks. The resident had specific dietary needs and allergies, and the action was outside the staff member's scope of duties. The Administrator confirmed that the staff member should have handed the tray to a Certified Nursing Assistant instead.
A resident experienced significant weight loss over a period of time, and the facility failed to ensure a timely evaluation. The RD did not perform assessments or progress notes between the initial and re-admission assessments and did not ensure reweighs were done. The RD only performed one-month weight comparisons, missing the significant weight loss.
A resident diagnosed with Schizoaffective disorder and Depression was prescribed aripiprazole and sertraline without proper side effect and behavior monitoring. The facility's E-MAR did not document the required monitoring, and the care plan did not match the physician's order for side effects. This lack of documentation and discrepancy in the care plan were confirmed by facility staff.
The facility had a 7.41% medication error rate when two medication errors were observed. A resident did not receive carvedilol as ordered, and another resident received the wrong calcium product. The errors were acknowledged by the LVNs involved, who stated they would notify the doctor and clarify the orders.
The facility failed to document oxygen and nebulizer use for a resident with chronic respiratory failure and hypoxia. Despite the resident receiving these treatments, the active orders did not reflect them, leading to incomplete and inaccurate medical records and potential risks for the resident.
A resident with hemiplegia and other conditions was without a call device for three days, preventing them from getting staff assistance. The absence was confirmed by both an LVN and a housekeeper, who noted the device might have been unplugged during cleaning. The facility's policy requiring call lights to be within reach was not followed.
The facility failed to post nurse staffing information for four consecutive days and did not maintain the required 18-month records. The Staffing Coordinator was working from home and did not ensure the information was posted, and the facility lacked records from August 2023 to January 2024.
Failure to Secure Facility Entrances and Exits Due to Broken Locks and Lack of Supervision
Penalty
Summary
The facility failed to ensure that entrance and exit doors were properly secured and supervised, resulting in unlocked and unsupervised access points outside of designated visiting hours. Observations revealed that both the main entrance and rear exit doors had malfunctioning locks, with the rear exit door repeatedly found propped open by objects such as a wet floor sign and an orange traffic pylon. Staff were observed exiting and reentering the building without closing the rear exit door, and the main entrance door was found unlocked and accessible from the outside. During these times, surveyors were able to enter resident hallways and common areas without encountering staff or any security measures in place. Interviews with facility staff, including a registered nurse, licensed vocational nurse, maintenance director, and operations assistant, confirmed that the expectation was for all doors to be closed and locked from the outside outside of visiting hours. However, staff were not consistently aware of the broken locks, and maintenance records did not reflect timely reporting or repair of the issues. The maintenance director acknowledged being informed of the broken rear exit lock a week prior and had only recently placed an order for a replacement. The front entrance door was also found to have a misaligned locking mechanism, preventing it from being secured. Facility policy required doors to be locked from the outside after visiting hours, but this was not being followed due to the inoperable locks and lack of supervision.
Failure to Provide Supervised Feeding for Resident with Dysphagia
Penalty
Summary
The facility failed to adhere to a physician's order for supervised feeding for a resident with dysphagia, a condition characterized by difficulty swallowing. The resident, admitted in July 2023, required one-on-one feeding assistance with aspiration precautions due to a flaccid left upper arm resulting from a stroke. However, during an observation on September 6, 2024, the resident was seen eating breakfast alone without staff assistance, contrary to the care plan and physician's order. Interviews with the Dietary Manager, Registered Dietician, and Director of Nursing confirmed the resident's need for one-on-one feeding assistance, highlighting the facility's failure to provide the necessary care as prescribed.
Failure to Provide Consistent Wound Care Leads to Infection
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a non-pressure ulcer, leading to the worsening of the condition. The resident, who was admitted with multiple diagnoses including diabetes mellitus, morbid obesity, and heart disease, developed redness in the abdominal folds that progressed to open areas. Despite the initiation of treatment with Nystatin powder and other wound care measures, the Treatment Administration Record (TAR) showed multiple dates without documentation that the treatments were performed as ordered. The resident's condition deteriorated, resulting in wound dehiscence and infection. The facility's records indicated that the resident did not have any skin issues upon admission, but over time, the redness and skin tears worsened, leading to open areas in the abdominal folds. The resident was eventually referred to a wound doctor, but the lack of consistent treatment documentation suggests that the ordered care was not consistently provided. The resident was later diagnosed with cellulitis and was sent to the hospital, where further tests revealed bacterial infections. The facility's policy on wound care required documentation of the care provided, including the date, time, and name of the individual performing the care, which was not adhered to in this case. This lack of adherence to the facility's wound care policy contributed to the resident's avoidable wound complications.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Treatment Nurse 2 (TN 2) and Certified Nursing Assistant 1 (CNA 1) during a wound dressing change for Resident 2. Both TN 2 and CNA 1 did not wear disposable gowns, which were required as part of Enhanced Barrier Precautions (EBP) for high-contact activities such as wound care. This oversight occurred despite the presence of a posted sign outside Resident 2's room indicating the need for gowns and gloves during such procedures, and the availability of PPE supplies at the room entrance. Additionally, TN 2 failed to perform hand hygiene between glove changes during the wound dressing change, moving from a dirty procedure to a clean one without washing hands or using an alcohol-based hand rub. This lapse in protocol was acknowledged by TN 2, who admitted that hand hygiene should have been performed to prevent infection. The Infection Preventionist confirmed that EBP should be observed during care involving wounds and that staff are required to change gloves and perform hand hygiene between clean and dirty procedures.
Improper Garbage Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage of garbage and refuse, as observed during an inspection of the outside trash cans and dumpsters. Two of the four large green plastic bins designated for organic food waste were cracked and leaking dark brown liquid, with lids left open. Waste was piled over the tops of the bins, and food waste and trash were spilling onto the ground. The housekeeping supervisor confirmed the area was unclean and could result in infection due to insects, vermin, and pests. The dietary services manager also confirmed the unclean state of the outside trash area and noted that kitchen staff were responsible for maintaining cleanliness. The facility's policy on waste disposal, revised in January 2012, indicated that all infectious and regulated waste should be handled and disposed of in a safe and appropriate manner, with containers replaced routinely and not allowed to overfill. The United States Food and Drug Administration's 2022 Food Code requires that refuse be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The facility's failure to adhere to these guidelines resulted in the observed deficiencies.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to follow its medication administration policy, provide adequate pharmacy services, and ensure controlled medications were fully accounted for several residents. Licensed Vocational Nurse 8 (LVN 8) administered medications to two residents without verifying their identities and did not name the medications given. This resulted in Resident 400 receiving the wrong medications, leading to excessive sedation, respiratory failure, and hospitalization. Additionally, Resident 69 did not take her medications for one hour after LVN 3 left them on her overbed table without observing the administration. Resident 329 did not receive scheduled medication for 44 hours because the medications had not been delivered, potentially putting her at risk for high blood pressure complications. The facility also failed to document the administration of controlled medications properly. An as-needed controlled medication for Resident 42 was administered but not documented in the Electronic Medication Administration Record (E-MAR). Three controlled medications were administered but not documented in the Controlled Substance Accountability Sheet for Residents 20 and 70. Thirteen vials of lorazepam for Resident 30 were not counted during shift changes and were not removed from active stock for over a year. The Controlled Drugs-Count Record was incomplete for two medication carts, and controlled medication use audits for Residents 41, 57, and 330 did not reconcile, indicating discrepancies between the Count Sheet and the E-MAR. These failures resulted in significant adverse outcomes for the residents involved. Resident 400's hospitalization was due to an opioid overdose caused by the medication error. Resident 69's medications were delayed, and Resident 329's essential medication was not available for an extended period. The lack of proper documentation and accountability for controlled medications posed a risk for misuse or diversion, further compromising resident safety.
Non-Compliance with Food Service Management Standards
Penalty
Summary
The facility failed to comply with Federal regulations related to the oversight of food service operations by not employing a full-time dietitian or a qualified full-time dietetic services supervisor. According to the California Code, Health, and Safety Code - HSC S 1265.4, a health facility that employs a registered dietitian less than full-time must also employ a full-time dietetic services supervisor who meets specific educational and certification requirements. The Dietary Supervisor (DS) at the facility was not qualified for the position and was still working towards becoming a Certified Dietary Manager (CDM). The Registered Dietitian (RD) worked part-time at the facility, splitting her time between two facilities, and her primary responsibilities were clinical rather than kitchen-related. This lack of qualified supervision had the potential to result in unsafe food practices and foodborne illness for the 69 residents eating facility-prepared foods. During the Re-certification Survey, multiple issues were identified regarding Food and Nutrition staff competency, following the planned menu, providing palatable food, serving substitution food and drink of equal nutritive value, and ensuring food was stored, prepared, and served in a safe and sanitary manner. Interviews with the DS and RD revealed that the DS was not yet certified and the RD's time was primarily focused on clinical duties rather than overseeing kitchen operations. The Administrator confirmed that the DS did not have documentation of coursework toward CDM certification, further highlighting the facility's non-compliance with the required standards for food service management.
Failure to Follow Menu and Provide Diet-Specific Items
Penalty
Summary
The facility failed to ensure the menu was followed, resulting in the substitution of planned meals and the absence of diet-specific items. On 1/9/24, the lunch menu indicated maple chicken was to be served, but teriyaki chicken was prepared instead due to the unavailability of chicken thighs and maple syrup. The Dietary Supervisor (DS) confirmed that the substitution was made because the necessary ingredients were not ordered or purchased in time. The DS admitted that she could have purchased the needed items from a local grocery store but did not do so despite the Administrator being on-site and available to provide a credit card for the purchase. Additionally, the Registered Dietitian (RD) confirmed that the menu change was unnecessary if the ingredients had been available, indicating a lapse in proper menu planning and execution by the dietary staff. Furthermore, the facility failed to provide diet salad dressing for residents on a Heart Healthy diet as indicated on the lunch menu for 1/9/24. During the preparation of lunch trays, it was observed that all residents received the same Caesar dressing, regardless of their dietary restrictions. The Dietary Aide confirmed that diet dressing was not available, and the RD was unaware that residents were not receiving the appropriate diet dressing. The DS admitted to not ordering the diet dressings, further highlighting the failure to adhere to the planned menu and meet the nutritional needs of the residents.
Failure to Ensure Palatable and Properly Seasoned Food
Penalty
Summary
The facility failed to ensure food was palatable when recipes were not followed, resulting in bland and over-seasoned meals. During interviews, multiple residents expressed dissatisfaction with the food quality, describing it as bad or not good. Observations revealed that Cook 1 did not follow the standardized recipe for chicken teriyaki, instead using a ready-made teriyaki glaze. Additionally, the carrots and rice prepared were found to be bland, and the chicken teriyaki was very salty. The Dietary Supervisor (DS) admitted that salt was not added during food preparation, even if the recipe called for it, to cater to all residents, including those on no added salt diets. The Registered Dietitian (RD) confirmed that recipes should be followed and was unaware of the use of ready-made teriyaki sauce, which could alter the nutrient content of the meal. The facility's standardized recipes document indicated that only tested, standardized recipes should be used to prepare foods. Job descriptions for the cook, DS, and RD emphasized the importance of following recipes and preparing nutritionally adequate meals. Despite these guidelines, the facility's failure to adhere to standardized recipes and proper seasoning practices led to the preparation of unpalatable meals, placing 69 residents at risk for decreased nutrient intake and potential nutrition-related medical complications.
Facility Fails to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner. A resident's personal refrigerator was not monitored for temperature, food expiration dates, and cleanliness. The refrigerator contained various unlabeled and undated food items, including raw fish and cheese, and had significant residue buildup. The Director of Staff Development was unaware of who was responsible for monitoring and cleaning the refrigerator, and the administrator confirmed that all food in the refrigerator was discarded due to lack of labeling and dating. Unpasteurized, undercooked eggs were served to a resident upon request. The eggs were stored in a reach-in refrigerator and were confirmed to be unpasteurized by the cook and dietary supervisor. The registered dietitian stated that unpasteurized, undercooked eggs should not be served to residents as they are immunocompromised and could get very sick. The facility's policy indicated that only pasteurized eggs should be used for undercooked preparations. Two ice machines in the facility were found to be unclean, with pink, black, and brown residue on various surfaces. The maintenance staff confirmed that the ice machines had not been cleaned recently and were unaware of the cleaning schedule. Additionally, the facility failed to monitor the cooldown of prepared, leftover Time/Temperature Control for Safety (TCS) food, and refrigerated TCS food was not labeled with use-by or discard dates. Other issues included uncovered frozen raw fish, improper hand hygiene practices by kitchen staff, and surface sanitizer solution not being at the appropriate temperature for testing. The kitchen and food storage areas were also found to be unclean and in disrepair, with various equipment and surfaces having significant residue buildup and peeling paint.
Failure to Provide Refrigeration for Resident Food Brought by Family
Penalty
Summary
The facility failed to provide a refrigerator to store perishable food brought in by family members and visitors for residents. During an interview, an LVN stated that staff encouraged residents to eat the food immediately, and any uneaten food was discarded due to the lack of refrigeration. Additionally, there was no microwave available to heat resident food. The Director of Staff Development confirmed that the facility's policy allowed for the storage of perishable food for up to 72 hours, but admitted that there was no refrigerator available for this purpose. The policy also lacked guidance on time frames for use-by dates.
Failure to Complete Annual MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that the Annual Minimum Data Sets (MDS) for four residents were completed within the required time frames. Specifically, the MDS for Residents 31, 50, 47, and 53 were not completed within 14 days of the Assessment Reference Date (ARD). This deficiency was identified through interviews and record reviews, which revealed that the comprehensive MDS assessments for these residents were submitted late, potentially impacting the appropriateness of care and services provided based on their current health status. Resident 31 had a diagnosis of quadriplegia, Resident 50 had Diabetes Mellitus, Resident 47 had metabolic encephalopathy, and Resident 53 had hemiplegia and hemiparesis. During a concurrent interview and record review, the Minimum Data Set Coordinator (MDSC) confirmed that the MDS assessments for these residents should have been completed and submitted within the 14-day timeframe. The facility's Final Validation Report indicated that the care plans for these residents were completed late, exceeding the 14-day requirement. The MDS Manual from the Centers for Medicare and Medicaid Services (CMS) specifies that the MDS Completion Date for Annual Assessments should be no later than 14 days from the ARD, which the facility failed to adhere to in these cases.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure the quarterly Minimum Data Sets (MDS) were completed within the required timeframes for four residents. Resident 67, Resident 51, Resident 13, and Resident 30 had their quarterly MDS assessments delayed beyond the 14-day requirement from the Assessment Reference Date (ARD). Specifically, Resident 67's MDS was 34 days overdue, Resident 51's was 46 days overdue, Resident 13's was 32 days overdue, and Resident 30's was 40 days overdue. These delays were confirmed during an interview and record review with the MDS Coordinator, who acknowledged the overdue assessments and stated that they should have been completed and submitted in a timely manner to provide appropriate resident care. The residents involved had significant medical conditions, including diabetes mellitus, cerebral infarction, end-stage renal disease, and Alzheimer's disease. The failure to complete the MDS assessments on time had the potential to impact the care and services provided to these residents based on their current health status. The MDS Coordinator confirmed that the assessments were not completed within the required timeframes, which is essential for guiding resident care effectively.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Sets (MDS) for eight residents were completed and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required time frames. Specifically, the Annual MDS for four residents and the Quarterly MDS for another four residents were not completed and transmitted within 14 days of the Assessment Reference Date (ARD). This deficiency was identified through interviews and record reviews, which revealed that the MDS assessments for these residents were significantly overdue, ranging from 32 to 46 days past the required submission dates. The Minimum Data Set Coordinator (MDSC) confirmed the delays and acknowledged that the assessments should have been completed and submitted in a timely manner to ensure appropriate resident care. The residents affected by this deficiency had various medical conditions, including quadriplegia, diabetes mellitus, metabolic encephalopathy, hemiplegia, cerebral infarction, end-stage renal disease, and Alzheimer's disease. The delayed MDS assessments for these residents meant that their care plans were not updated in a timely manner, potentially impacting the quality of care they received. The facility's Final Validation Report further confirmed that the care plans and assessments for these residents were completed late, exceeding the 14-day requirement from the ARD. The MDS Manual from CMS specifies that both comprehensive and non-comprehensive assessments must be completed and transmitted within 14 days of the ARD to ensure effective resident care, a standard that the facility failed to meet in these cases.
Failure to Ensure Proper Disinfection of Shared Glucometers
Penalty
Summary
The facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers according to the manufacturer's instructions and accepted professional standards of practice. Two out of three nurses observed during medication administration did not use the appropriate disinfectant to clean and disinfect shared glucometers for two sampled residents. Instead of using the recommended Micro-kill Germicidal wipes, the nurses used alcohol prep pads, which are not effective against all bacteria or viruses. The nurses admitted they had not received proper orientation or training from the facility regarding the correct disinfecting wipes to use and were relying on their own experience. Additionally, the facility did not have evidence of training or competency related to blood glucometer cleaning and disinfection for two registry nurses. The Director of Nursing and the Director of Staff Development/Infection Preventionist acknowledged that the orientation provided to registry nurses did not include training on glucometer disinfection. The facility's checklist for registry orientation/training also did not include this training. The registry nurses' training records from the agency did not show documented training or competency on disinfecting glucometers or clinical training on infection control practices. The facility's policies and procedures, as well as the glucometer manufacturer's guidelines, were not followed. The facility's policy on cleaning and disinfection of resident-care items and equipment indicated that reusable items should be cleaned and decontaminated or sterilized between residents according to CDC recommendations and OSHA standards. However, the observed practices and lack of training documentation indicated non-compliance with these guidelines, potentially leading to the widespread transmission of bloodborne diseases among residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper medication storage and labeling, as observed in the medication room and on medication carts. A non-licensed staff member had access to the main medication room, which is against the facility's policy that only licensed nurses, pharmacy personnel, and those authorized to administer medications should have access. This was acknowledged by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) during the inspection. Multiple expired, unlabeled, and undated medications were found in the medication room and on medication carts. These included lorazepam, latanoprost eye drops, Victoza injectable pens, Trulicity injectable pens, lidocaine multi-dose vials, sterile water vials, Alphagan P eye drops, and Breo Ellipta inhalers. Some medications were also found to be stored improperly, such as ear drops stored with eye drops and a Covid-19 reagent stored with other medications. The DON and LVNs acknowledged these findings and confirmed that the medications were expired or improperly labeled. The facility's policies and procedures were reviewed and indicated that medications should be properly labeled with open dates and discarded within specified time frames to ensure medication purity and potency. The policies also stated that drug containers with missing, incomplete, or incorrect labels should be returned to the pharmacy for proper labeling. The facility failed to adhere to these policies, leading to the potential for medication errors and reduced potency of medications administered to residents.
Incompetence in Kitchen Staff Regarding Three-Compartment Sink Procedures
Penalty
Summary
The facility failed to ensure kitchen staff were competent regarding job duties, specifically in the use of the three-compartment sink for cleaning equipment and utensils. During an observation and interview, Cook 1 demonstrated the manual dishwashing process but was unaware of the correct water temperature for washing dishes and the appropriate duration for submerging items in the sanitizer. Cook 1 stated that the wash water should be warm but did not know the exact temperature, and she believed items should be submerged in the sanitizer for about three to four minutes. Further observation and interview with the Dietary Supervisor (DS) revealed that the correct temperature for wash water, rinse water, and sanitizer should be over 110 degrees Fahrenheit, and items should be submerged in the sanitizer for 30 seconds. A review of the facility's policy and procedure, as well as the manufacturer's instructions for the sanitizer, indicated that the wash water should be at least 171 degrees Fahrenheit for 30 seconds or follow the chemical sanitizing solution instructions, which required immersion for no less than one minute. This lack of knowledge and adherence to proper procedures had the potential to result in contamination of kitchen equipment and utensils, posing a risk of illness for the 69 residents receiving food from the kitchen.
Failure to Provide Nutritional Substitutes
Penalty
Summary
The facility failed to provide food and drink substitutes of similar nutritive value to residents, leading to potential nutritional deficiencies. Specifically, milk was indicated on the planned lunch menu but was not provided to 43 out of 69 residents who received food from the kitchen. The Dietary Supervisor stated that milk was only provided if indicated on the tray ticket, and the Registered Dietitian confirmed that milk was part of the approved menu and nutrient analysis. However, no consistent substitute for milk was provided to ensure residents received the necessary nutrients such as calories, protein, calcium, and vitamin D. The RD did not recommend supplements unless lab results showed deficiencies, and the tray tickets did not indicate milk for the majority of residents on diets that allowed milk, excluding those on renal diets or with lactose intolerance/allergies. Additionally, the facility did not provide an alternate of equal nutritional value for residents who did not like chicken during a lunch meal. The main entree was chicken, and cheese tortellini was served as an alternate. The RD approved the tortellini as an alternate but later acknowledged that it did not provide the same amount of protein as the chicken. The nutrition facts showed that the tortellini provided significantly less protein compared to the chicken, with 6 grams of protein per half-cup serving of tortellini versus 18.2 grams of protein for a two-ounce portion of chicken. This discrepancy in protein content meant that residents who chose the tortellini did not receive an equivalent nutritional substitute for the chicken entree.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices were implemented in several instances. Two out of three nurses did not disinfect the blood pressure cuff before and/or after use for two residents. One nurse acknowledged the oversight, while another stated she was not informed about the need to disinfect the cuff. The Director of Staff Development/Infection Preventionist confirmed that the blood pressure cuff should be disinfected between resident use, as per the facility's policy and procedure on cleaning and disinfection of resident-care items and equipment. Additionally, two out of three nurses were observed using alcohol prep pads instead of the appropriate disinfectant to clean shared glucometers for two residents. Both nurses admitted they were not oriented on the correct disinfectant to use, and one nurse mentioned that there were no germicidal wipes available in the medication cart. The Director of Nursing and the Infection Preventionist confirmed that alcohol prep pads were not acceptable for disinfecting shared glucometers, and the facility's policy required the use of disinfecting wipes based on the manufacturer's guidelines. Furthermore, a resident's foley catheter equipment was found lying on the ground, which could increase the risk of urinary tract infections. The resident's care plan indicated that the foley bag should have a privacy cover and the tubing should be kept off the ground. During an observation, a nurse corrected the placement of the foley bag and tubing but admitted not knowing how it ended up on the floor. The Infection Preventionist stated that staff were expected to check the proper placement of foley catheter equipment at least every shift and during incontinence care, as per the facility's policy on the care of catheters.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to ensure essential kitchen equipment was in operational working condition. The right-hand side of a double oven unit was not operational for about three months, and a plate warmer was broken for two days. Cook 1 reported the oven issue to the Dietary Supervisor (DS), who was aware of the problem but did not document it in the maintenance log. The Maintenance Supervisor (MS) was unaware of the broken equipment until the survey and confirmed the oven's pilot was not on. The Administrator (ADM) and Registered Dietician (RD) were also unaware of the ongoing issues with the kitchen equipment. The facility's policy and procedure documents indicated that maintenance issues should be documented and communicated to the Maintenance Director through work orders. However, the DS admitted to not following this procedure and did not provide documentation to show that the oven had been repaired. The lack of proper communication and documentation led to the prolonged non-operational status of essential kitchen equipment, impacting the facility's ability to prepare food efficiently.
Failure to Provide Appropriate Gown for Resident
Penalty
Summary
The facility failed to provide Resident 32 with an appropriate facility gown according to her size and preference. Resident 32, who has multiple sclerosis and morbid obesity, was observed wearing a green-colored facility gown that was tight on her upper arms and chest, making her feel restricted and uncomfortable. The resident expressed that it was important for her to choose her clothing, and she preferred the larger yellow-colored gowns, which had not been available for a week. Certified Nursing Assistants (CNAs) confirmed that the resident preferred the yellow gowns but had to wear the green gown due to the unavailability of the larger size. Housekeeping/Central Supply staff confirmed that the clean linen storages were replenished regularly, and the facility used outside laundry services for washing and providing clean linen supplies. However, the last order of yellow gowns was received on 12/19/23, and no replacements were ordered until 1/9/24. The facility's policy on dignity emphasized that residents should be cared for in a manner that promotes their well-being and respects their preferences, which was not adhered to in this case.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care to one of the sampled residents, Resident 13. Despite being admitted to the facility and requiring limited assistance with personal hygiene, Resident 13's fingernails were observed to be long and bothersome to him. The Minimum Data Set (MDS) assessment indicated that Resident 13 was able to understand others and make himself understood. During multiple observations and interviews, it was noted that Resident 13's fingernails remained long, even though records indicated that nail care was provided on several occasions. The Director of Staff Development (DSD) and the assigned Certified Nursing Assistant (CNA) both confirmed that nail care was supposed to include trimming and cleaning, but Resident 13's nails were still long and not trimmed to his preference. The facility's policy and procedure for fingernail care, dated February 2018, emphasized the importance of trimmed and smooth nails to prevent accidental scratching and injury. Additionally, the facility's policy on dignity, dated February 2021, stated that residents should be groomed as they wish to be groomed. Despite these policies, the facility did not meet the grooming preferences of Resident 13, as his nails were not trimmed to his satisfaction, leading to discomfort and potential risk of self-injury.
Non-Nursing Staff Provided Resident Care
Penalty
Summary
The facility failed to ensure care provided to a resident was in accordance with professional standards of practice when a non-nursing staff member provided resident care. Specifically, Maintenance Staff 1 (MS1) assisted Resident 27 by helping her sit up in bed and serving her lunch tray, despite not being a certified nursing assistant or licensed to perform such tasks. This action was observed on 1/9/24, when MS1 delivered a lunch tray to Resident 27, who was on a Consistent Carbohydrate, No Added Salt therapeutic diet and had allergies to gluten and iodine. The tray card indicated specific dietary needs and preferences, including small portions of starch foods and a dislike for wheat bread. In an interview, MS1 confirmed that he served food trays to residents as a way to get to know them, unaware that this was outside his scope of duties. The Administrator later stated that MS1 should not have entered the resident's room to pass the food tray directly to the resident and should have handed it to a Certified Nursing Assistant instead. According to the Board of Registered Nursing, unlicensed assistive personnel, such as MS1, are not permitted to perform nursing tasks or reassign tasks. Health and Safety Code Section 1338.5(a)(2)(A) also requires that any individual with direct resident care duties must be enrolled in a nurse aide training program and complete the training and competency testing within four months of employment.
Failure to Timely Evaluate Resident's Severe Weight Loss
Penalty
Summary
The facility failed to ensure a timely evaluation of a resident's severe weight loss. Resident 72, who was initially admitted on [DATE], experienced significant weight loss over a period of time. The resident's weight history showed a decrease from 207.8 pounds on 11/2/23 to 178.8 pounds on 12/27/23, which constitutes an 8.4% weight loss in 48 days. The Registered Dietitian (RD) did not perform any assessments or progress notes for Resident 72 between the initial assessment on 11/2/23 and a re-admission assessment on 12/26/23. The RD only reviewed residents' documented weights monthly and weekly if time permitted, and it was not until the resident was readmitted from the hospital on 12/26/23 that the RD noticed the weight loss. The RD suspected the initial weight of 207.8 pounds was inaccurate but did not have documentation to show a request for a reweigh was made, nor was a reweigh performed to verify the accuracy of the initial weight. The RD confirmed that Resident 72 had a significant weight loss of 8.5% when comparing the weight of 178.8 pounds on 12/27/23 to the weight of 195.3 pounds on 11/10/23. However, the RD did not catch this significant weight loss because she only performed one-month weight comparisons. The RD admitted that she did not ensure reweighs were done after requesting them and did not have documentation to support that a reweigh was requested. This failure to timely evaluate and address the resident's weight loss had the potential to result in further unintentional and undesirable weight loss for the resident.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident, who was diagnosed with Schizoaffective disorder and Depression, was prescribed aripiprazole and sertraline. However, there was no documentation of side effects and behavior monitoring for these medications. The Medical Record/Operations Manager acknowledged that the monitoring orders did not link with the Electronic Medication Administration Record (E-MAR), resulting in a lack of documentation. The Registered Nurse Supervisor confirmed that there was no evidence of staff monitoring for side effects and behaviors related to the use of these medications from August 2022 to January 2024. Additionally, the resident's care plan for antipsychotic medication did not match the side effect profile written on the physician's order. The care plan listed different side effects than those specified in the physician's order for aripiprazole. This discrepancy was confirmed by the Registered Nurse Supervisor. The facility's policy and procedure on psychotropic medication use emphasized the importance of adequate monitoring for efficacy and adverse consequences, which was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility had a 7.41% medication error rate when two medication errors out of 27 opportunities were observed during the medication pass for two of six sampled residents. Resident 28 did not receive carvedilol, a medication used to treat high blood pressure, as ordered. During a medication administration observation, the LVN preparing and administering medications to Resident 28 missed giving the carvedilol dose scheduled for 9:00 a.m. The LVN later found the missed dose in the medication cart drawer and acknowledged the error, stating she would notify the doctor about the missed dose. Resident 52 received the wrong calcium product during a medication administration observation. The LVN administered calcium 600 mg plus vitamin D 400 IU instead of the ordered calcium 600 mg plus vitamin D 800 IU. Upon checking the medication cart, the LVN found that the correct medication was not available and confirmed that the administered medication did not match the doctor's order. The LVN stated she would clarify the order with the doctor. The facility's policy and procedure for administering medications indicated that medications should be administered in accordance with prescriber orders, including any required time frame.
Failure to Document Oxygen and Nebulizer Use
Penalty
Summary
The facility failed to accurately document entries for one resident, resulting in incomplete and inaccurate medical records. Specifically, the current physician orders for a resident with chronic respiratory failure and hypoxia did not reflect the use of oxygen and a nebulizer, despite these treatments being observed in use. The resident's care plan indicated the need for oxygen and nebulizer treatments, but these were not included in the active orders, leading to a risk of the resident not receiving necessary care and treatments as needed. During an observation, the resident was noted receiving oxygen from a portable concentrator and had a nebulizer machine in the room. However, the resident's Order Summary Report did not include orders for these treatments. The Registered Nurse Supervisor confirmed the absence of these orders and acknowledged the risk of the resident not receiving appropriate oxygen treatment or experiencing medication errors. The facility's policies and procedures require physician orders for oxygen administration and nebulizer use, which were not followed in this case.
Failure to Provide Resident with Call Device
Penalty
Summary
The facility failed to ensure that Resident 34 had access to a call device, which resulted in the resident being unable to get staff assistance when needed. Resident 34, who was admitted in February 2019 with diagnoses including hemiplegia, hemiparesis, arthritis, and muscle wasting, reported not having a call light for three days. During an observation and interview, it was confirmed that there was no call device in Resident 34's room. The Licensed Vocational Nurse (LVN) and Housekeeper (HSKG) both confirmed the absence of the call device, with the HSKG noting that the cable might have been accidentally unplugged during cleaning. The LVN acknowledged that an unplugged call device would not alert staff via the panel at the nursing station, potentially compromising patient care. Further interviews revealed that Resident 34 had been moved to another bed three days prior and did not receive a call device afterward. The facility's policy and procedure on call lights, dated January 2024, indicated that staff should ensure call lights are within reach of residents. However, this policy was not followed, leading to Resident 34's inability to call for assistance, especially at night or when needing help with dropped items. The failure to provide a working call device directly impacted Resident 34's ability to receive timely care and assistance.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted and readily available for four consecutive days from January 8, 2024, through January 11, 2024. This deficiency was identified through observation, interview, and record review. The Director of Staff Development/Infection Preventionist (DSD/IP) stated that the Staffing Coordinator (SC) was working from home and unable to post the daily nurse staffing information in the designated location within the facility. The Operations Manager (OM) confirmed that the nurse staffing information had not been posted daily since January 8, 2024, due to the SC's unavailability to work in person. Additionally, the facility was unable to maintain the required 18-month records of nurse staffing information, with records missing from August 2023 through January 2024. During a telephone interview, the SC confirmed her responsibility for staffing and posting daily nurse staffing information but admitted to failing to ask the OM to post the information in her absence. The Director of Nursing 2 (DON 2) acknowledged that the facility was required to keep a minimum of 18-month records of nurse staffing information available upon request. A review of the facility's document titled 'Posting Direct Care Daily Staffing Numbers' indicated that the facility was supposed to post nurse staffing data daily and maintain records for at least 18 months. However, this protocol was not followed, resulting in the deficiency.
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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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