Eastern Plumas Hospital- Portola Campus Dp/snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Portola, California.
- Location
- 500 First Street, Portola, California 96122
- CMS Provider Number
- 555433
- Inspections on file
- 25
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Eastern Plumas Hospital- Portola Campus Dp/snf during CMS and state inspections, most recent first.
A resident with multiple health conditions and an amputation was injured when a CNA transferred her without the required slide board and second staff member, contrary to her care plan and posted instructions, resulting in a fractured ankle. Additionally, two shower rooms were found with unlocked cabinets containing new razors and an overfilled sharps container with used razors accessible to residents, posing further safety risks. Staff confirmed these practices did not meet safety standards.
Surveyors observed that three shower rooms were inadequately maintained, with chipping paint, rust, unclean areas around tubs and toilets, and improper storage of cleaning equipment and used razors. Staff, including a CNA, a licensed nurse, the ADON, and the DON, confirmed that the rooms were not clean or maintained to acceptable standards, in violation of facility policy requiring cleaning and disinfection between uses.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that could restrain their ability to function, resulting in a deficiency related to medication management.
Surveyors found that the ice machine and the cupboard it sat upon were not maintained in a sanitary condition, with significant mineral buildup, debris, and unclean surfaces observed. Maintenance staff and the Director of Plant Management confirmed the presence of buildup and debris, indicating a failure to follow the facility's cleaning policy for kitchen equipment.
Staff did not adhere to infection control protocols during medication administration and feeding. A nurse used a writing pen to open a medication bottle, and another brought a medication box into a resident's room, placing it on a surface without a barrier. Additionally, a CNA assisted two residents with eating and touched various potentially contaminated surfaces without performing hand hygiene between tasks. These actions were confirmed by staff and leadership as breaches of infection control policy.
Nurses and nurse aides lacked the appropriate competencies to care for every resident in a way that maximizes each resident's well-being, resulting in care that did not support residents' highest level of physical, mental, and psychosocial well-being.
Staff did not follow a physician-ordered fortified diet for a resident, as the intended fortification (an extra pat of margarine) was not incorporated into the meal and was not offered to the resident by CNAs, who were unaware of its purpose. The DON confirmed staff were not trained on this requirement, and the RD expected fortification to be part of the recipe, not served separately.
A resident with severe cognitive impairment and high fall risk was left unsupervised after being observed in an unsafe position. Staff failed to assist the resident to safety, did not perform a post-fall assessment, and delayed notifying the physician after the resident was found on the floor in pain. The resident sustained a fractured hip, required hospitalization and surgery, and experienced significant pain and decline.
A resident with severe cognitive impairment and multiple health conditions experienced a fall and reported pain in her left arm and hip. Staff did not promptly assess her condition, failed to notify the physician in a timely manner, and administered acetaminophen ordered only for mild pain despite the resident experiencing moderate to severe pain. The resident remained in pain for several hours, did not eat, and was later found to have a fractured hip. Facility policies for post-fall assessment and pain management were not followed.
A resident with multiple comorbidities experienced a fall resulting in significant pain, but staff failed to promptly notify the physician and responsible party as required by facility policy. The LPN delayed notification for several hours, and documentation of required notifications was incomplete. The resident was later found to have a left hip fracture, and the delay led to unnecessary pain and suffering.
A resident in an LTC facility, admitted with age-related debility and other conditions, experienced a disrespectful interaction with the DON, who responded to a light-hearted comment by saying, 'I could let you sit in a wet diaper.' This was perceived as disrespectful, especially given the resident's history of conflicts with the DON. The facility's policy emphasizes treating residents with dignity, and the incident was corroborated by the ADON and a community advocate.
A resident with Alzheimer's and dementia developed a pressure ulcer on her left heel due to the facility's failure to provide timely and appropriate care. Despite identifying the ulcer, there was a 47-day delay in notifying the physician and obtaining a wound care order. Inadequate documentation and communication, along with the absence of a formal wound care policy, contributed to the deficiency.
The facility failed to ensure accurate MDS assessments for two residents, leading to potential care gaps. One resident, with Alzheimer's and dementia, was inaccurately marked as not at risk for pressure ulcers, missing a prevention care plan. Another resident, with quadriplegia and existing pressure ulcers, was not documented correctly in the MDS, despite ongoing treatment. These inaccuracies could lead to uninformed staff and inadequate care interventions.
Two residents with Alzheimer's and dementia were not provided adequate oral hygiene care, resulting in visible hygiene issues such as food residue and buildup on their teeth and tongues. Despite requiring maximal assistance, one resident missed oral care for 22 shifts, while the other had no intervention plan for care refusal. Staff interviews revealed systemic neglect, particularly during night shifts, and missing records confirmed the lack of consistent care.
The facility's nursing staff failed to maintain the Antibiotic Stewardship Program, resulting in missing and incomplete documentation for several residents. This included essential information such as dates, medical record numbers, and antibiotic details, hindering the facility's ability to monitor and minimize antimicrobial resistance. The Infection Preventionist and DON confirmed the deficiencies, which compromised the facility's infection control efforts.
The facility failed to maintain the Ice/Water Dispensing machine and the dishwashing machine's drain, leading to potential health risks. The Ice/Water machine had a buildup of black residue on the nozzle, and the dishwashing machine's drain overflowed due to a clog. The issues were not reported or addressed in a timely manner, impacting resident health.
A resident's jewelry was taken by a housekeeper who wore and pawned it, causing distress to the resident. The resident, with decreased mental functioning, had placed the jewelry in a cup before an X-ray procedure. The facility staff, including the ADON and DON, investigated after the resident's daughter reported the missing items. A Restorative Nurses Aid discovered photos online of the housekeeper wearing the jewelry, leading to the housekeeper's admission and the eventual return of the items.
The facility did not maintain handrails in the corridors for 10.5 months due to a renovation project. During a survey, it was noted that sections of the corridors lacked handrails. The Director of Plant Operations confirmed the removal of handrails for renovations and was unaware of the regulatory requirement for their presence.
Failure to Prevent Accidents and Secure Hazards
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents. One resident with significant medical conditions, including heart disease, lymphoma, a history of falls, osteoporosis, and an above-the-knee amputation, was transferred from her bed to a wheelchair by a CNA without the use of the required slide board and without a second staff member assisting. The resident's care plan, posted instructions, and therapy documentation all specified that a slide board and two-person assist were necessary for safe transfers. Despite this, the CNA attempted a stand-and-pivot transfer, which the resident could not safely perform due to her single leg and pain, resulting in a fall and a fractured ankle that required emergency room treatment. Additionally, the facility did not ensure the safety of shower rooms, as two out of three rooms were observed to have unlocked and open cabinets containing new disposable razors and an overfilled sharps container with used razors protruding from the opening. These items were easily accessible to residents, creating a risk of injury. Multiple staff, including a licensed nurse, the assistant director of nursing, and the director of nursing, confirmed that razors and sharps should not be left accessible in this manner. The facility's own policies and standard procedures, as well as external guidelines referenced by staff, required the use of proper equipment and secure storage of hazardous items to ensure resident safety. The observed failures directly resulted in a resident injury and created the potential for further harm to other residents.
Failure to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in three of three resident shower rooms, as evidenced by multiple observations of inadequate maintenance and cleanliness. Surveyors found paint chipping from walls and ceilings, missing paint and rust on door jambs, and rust on bolts, screws, and nuts securing tubs and toilets to the floor. In one shower room, a dry, flaky substance, possibly shampoo, was found spilled and dried on the bottom shelf of an open cupboard, with clean towels stacked on top. The foot of the bathtub and the area around the toilet were also unclean. Used razors were observed protruding from an almost full sharps container, and used hard bristle brushes intended for floor cleaning were left hanging on shower safety handrails in multiple rooms. Staff interviews confirmed the observations, with a CNA stating that the hard bristle brush should not be left on the handrails where residents could come into contact with it, and that the rooms were not maintained to acceptable standards. Both a licensed nurse and the assistant director of nursing acknowledged that the shower rooms were not adequately maintained or clean. The director of nursing also confirmed these findings upon review of the rooms and photographic evidence. The facility's own policy required cleaning and disinfecting of shared equipment and areas between each use, which was not adhered to in these instances.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements.
Unsanitary Ice Machine and Surrounding Area
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions for kitchen equipment, specifically the ice machine. The ice machine was found to have a significant amount of mineral buildup on the tray and inside the ice spout, as well as debris in the internal cabinet area. Additionally, the cupboard supporting the ice machine was unclean, with visible buildup, water, splash marks, and debris. These findings were confirmed during multiple observations and interviews with maintenance staff and the Director of Plant Management, who acknowledged the presence of buildup and debris and agreed that the machine and surrounding area appeared unclean. A review of the facility's policy on cleaning and sanitizing ice machines indicated that all ice machines should be properly maintained and cleaned, including the tray and spout, and that exterior scaling should be removed as needed. Despite this policy, the observed conditions did not meet these standards, as the ice machine and its surrounding area were not clean to sight or touch. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Failure to Follow Infection Control Standards During Medication Administration and Resident Feeding
Penalty
Summary
Staff failed to follow infection control standards during medication administration and resident feeding, as observed and confirmed through interviews and record reviews. In one instance, a nurse was unable to remove a safety seal from a new liquid medication and used a writing pen to puncture and scrape the inside edge of the bottle opening. The nurse later acknowledged that this was inappropriate and could cause an infection control issue. The facility's policy on standard precautions requires measures to reduce the risk of infection transmission, but this was not followed in this case. In another event, a nurse brought a medication in its manufacturer’s box into a resident’s room and placed it directly on the bedside table without a barrier. After administering the medication, the nurse returned the medication to the box and placed it back in the medication cart with other boxed medications. The nurse confirmed that the medication box is porous and cannot be thoroughly cleaned, identifying this as an infection control issue. Facility leadership, including the Assistant Director of Nursing and Director of Nursing, confirmed that these actions were not in line with infection control expectations. Additionally, a certified nursing assistant was observed assisting two residents with eating in the dining room and touching potentially contaminated surfaces such as wheelchair handles, chairs, other residents’ trays, and countertops without performing hand hygiene between these actions. The assistant admitted to not considering the need for hand sanitizing after touching these surfaces. Facility policy requires hand hygiene after touching patient surroundings and before feeding, but this was not adhered to during the observed meal service.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in residents not receiving care in a manner that supports their highest level of physical, mental, and psychosocial well-being.
Failure to Follow Physician-Ordered Fortified Diet for Resident
Penalty
Summary
Staff failed to follow a physician-ordered therapeutic fortified diet for one of six sampled residents on such diets. Specifically, the dietary manager was observed plating food for a resident requiring a fortified diet but did not add any fortification to the main entrée, instead placing an extra pat of margarine on the tray. The margarine, intended as the fortification, was not incorporated into the food but left on the tray alongside the napkin. When the tray was presented to the resident, the certified nursing assistant did not offer the margarine and was unaware it was part of the fortified diet order. Another CNA also did not know that the butter pat was intended as fortification, stating that residents could eat whatever they wanted. The Director of Nursing confirmed that nursing staff were not aware of the role of the butter pat in the therapeutic diet and had not received training to ensure its use for residents requiring fortified diets. The registered dietitian stated that her expectation was for additional calories to be incorporated into the recipes, not simply presented as margarine pats on the tray. Facility policy required that individuals needing supplemental nutrition be served a suitable high calorie/high protein diet, with nursing staff supervising delivery and consumption of supplements and recording this in the medical record. These steps were not followed for the resident in question.
Failure to Prevent and Respond to Resident Fall Results in Serious Injury
Penalty
Summary
A resident with a history of dementia, Parkinsonism, osteoporosis, traumatic brain injury, and severe cognitive impairment was identified as high risk for falls, with documented balance problems and poor safety awareness. Despite these risks, the resident was left unsupervised after being observed by a CNA leaning over and reaching for the floor while seated. The CNA did not assist the resident to a safe position or ensure her safety before leaving, and subsequently, the resident was found on the floor by a housekeeper, with no staff present in the hallway or at the nurse's station. After the fall, staff failed to perform a post-fall assessment or take vital signs, and the resident's care plan did not include specific interventions for unwitnessed falls. The nurse and CNA lifted the resident from the floor without assessing for injury, despite the resident expressing pain and being unable to bear weight. The nurse did not notify the physician or the resident's responsible party at the time of the incident and delayed communication until the end of the shift. The Director of Nursing later acknowledged that the facility's post-fall policy was not followed and that the incident should have been treated as a fall, regardless of the care plan's note about the resident sitting on the floor. As a result of the fall, the resident sustained a displaced left hip fracture, requiring hospital admission and surgery. Following the injury, the resident experienced significant pain, a decline in physical, social, and mental well-being, and became completely dependent on staff for assistance. The failure to provide adequate supervision, timely assessment, and appropriate post-fall interventions directly contributed to the severity of the resident's injury and subsequent decline.
Failure to Provide Timely Assessment and Appropriate Pain Management After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment and multiple comorbidities, including dementia, parkinsonism, osteoporosis, and a history of traumatic brain injury, experienced a fall in the facility. Staff failed to promptly assess the resident for a change in condition after the fall, despite the resident expressing pain in her left arm and hip. Instead of conducting an immediate assessment as required by facility policy, staff lifted the resident from the floor and placed her in a chair while she complained of pain. No vital signs or neurological assessments were performed at the time, and the physician was not notified immediately of the incident or the resident's complaints of pain. Following the fall, the resident continued to express moderate to severe pain, was unable to bear weight, and refused food. Staff administered acetaminophen, which was only ordered for mild pain, despite the resident reporting moderate pain levels. The medication was ineffective, and the resident's pain persisted for several hours. Documentation shows that the resident did not eat lunch or dinner due to her pain, and her pain was not adequately reassessed or managed according to the facility's pain management policy. The physician was not notified of the resident's ongoing pain and change in condition until several hours after the incident, and only after the pain had escalated to severe levels. Interviews with staff and witnesses confirmed that the resident was in visible distress, repeatedly vocalized her pain, and was unable to participate in normal activities. The lack of timely assessment, inadequate pain management, and delayed physician notification resulted in the resident experiencing prolonged pain and discomfort. The facility's own policies regarding post-fall assessment, pain management, and change in condition notification were not followed, directly contributing to the deficiency identified in the report.
Failure to Promptly Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to promptly identify and notify the physician and responsible party of a change in condition for a resident who experienced a fall resulting in new onset pain. According to the facility's policy, any accident involving a resident that results in injury requiring provider intervention, or a significant change in the resident's physical, mental, or psychosocial status, requires immediate assessment and notification of the primary provider, resident representative, and the resident. In this case, the resident, who had a history of dementia, parkinsonism, hearing loss, osteoporosis, and traumatic brain injury, fell from her chair and landed on her left side. Staff observed the resident in pain, crying, and expressing discomfort during and after being assisted back into her chair and later transferred to bed. Despite clear signs of pain and distress, the licensed nurse on duty did not notify the primary physician or the resident's responsible party at the time of the incident. Instead, the nurse waited until the end of her shift to send an email to the medical director, resulting in an eight-hour delay before the physician was made aware of the situation. The physician reported that the initial notification lacked critical details, such as the time of the incident and a proper assessment, and was not informed that the resident had fallen or was experiencing pain with movement. The responsible party was also not notified until later in the evening, just before the resident was sent to the emergency department. Documentation review revealed that required notifications to the physician and family were not completed or documented as done on the facility's alert charting forms. The director of nursing confirmed that there was no documentation of timely notification to the primary physician or responsible party following the change in the resident's condition. The delay in notification and treatment resulted in the resident experiencing unnecessary pain and suffering, and subsequent evaluation in the emergency department revealed an acute displaced subcapital left femoral neck fracture.
Resident's Right to Dignity Compromised by Disrespectful Staff Interaction
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination when a staff member, specifically the Director of Nursing (DON A), spoke to a resident in a manner perceived as disrespectful. The incident involved Resident 1, who was admitted to the facility with conditions such as age-related debility, arthritis, and heart disease, and required substantial assistance for daily activities. During an interaction on or around February 27, 2025, Resident 1, who is cognitively intact, made a light-hearted comment to DON A and LVN B, referring to them as 'Wonder Woman and Hercules.' In response, DON A remarked, 'I could let you sit in a wet diaper,' which Resident 1 interpreted as disrespectful, especially given their history of conflicts. The facility's policy on elder abuse reporting emphasizes treating residents with dignity and respect, explicitly defining verbal abuse as a form of abuse. Interviews with the Assistant Director of Nursing (ADON B) and a volunteer community advocate (ADV C) corroborated the resident's account of the incident. ADON B acknowledged that such a statement would be disrespectful and contrary to the facility's policy, while ADV C confirmed the ongoing tension between Resident 1 and DON A, noting that Resident 1 is a reliable source of information. The incident highlights a failure to maintain a respectful and home-like environment for the resident, as required by the facility's policies.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate care for a pressure ulcer that developed on a resident's left heel. The resident, who was admitted with Alzheimer's disease and dementia, was initially assessed as not having any pressure ulcers. However, a pressure ulcer was later identified by a licensed nurse, who noted a black, dry blister on the resident's heel. Despite this observation, there was a significant delay in notifying the physician and obtaining a wound care order, which occurred 47 days after the initial identification of the ulcer. The facility's documentation and communication practices were inadequate, contributing to the deficiency. The Director of Nursing and other staff members confirmed that there was no consistent documentation of the wound's condition, such as its stage, size, or any discharge. The facility lacked a specific policy for skin assessment, wound care, or pressure ulcer management, and staff relied on online resources instead of formal training. Additionally, the resident's care plan included interventions like floating the heels and using booties, but there was no evidence that these measures were consistently implemented. The facility's failure to accurately assess the resident's risk for pressure ulcers and to document and communicate the wound's condition led to a lack of timely intervention. The resident's medical records showed discrepancies, such as being marked as not at risk for pressure ulcers despite a Braden Scale score indicating otherwise. The lack of a coordinated approach to wound care and the absence of a wound care nurse or formal training further exacerbated the situation, resulting in the development and progression of the pressure ulcer.
Inaccurate MDS Assessments for Skin Conditions
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the skin status of two residents, leading to potential gaps in care. Resident 1 was admitted with a history of Alzheimer's disease and dementia and was assessed with a Braden Scale score indicating a risk for pressure ulcers. However, the MDS completed by a retired RN inaccurately marked Resident 1 as not at risk for pressure ulcers, resulting in the absence of a pressure ulcer prevention care plan. Resident 3, diagnosed with quadriplegia and existing pressure ulcers on the buttocks, was also inaccurately assessed in the MDS. The MDS, completed by the same retired RN, failed to document the presence of pressure ulcers, despite the resident being under treatment for these conditions since a previous diagnosis. This discrepancy was confirmed during a review with the Director of Nursing (DON). These inaccuracies in the MDS assessments for both residents could lead to staff being uninformed about the residents' true health status, potentially affecting the care interventions required. The facility's policy and the CMS guidelines emphasize the importance of accurate MDS assessments to ensure appropriate care planning, which was not adhered to in these cases.
Failure to Provide Adequate Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary oral hygiene care for two residents, leading to visible hygiene issues. Resident 1, who has severe cognitive impairment due to Alzheimer's disease and dementia, was observed with food from the previous day stuck between her teeth and on her tongue, along with a yellowish buildup on her tongue. Her family member reported never witnessing staff provide personal hygiene care during visits. Resident 1's medical records indicated she required maximal assistance for oral hygiene, yet there were 22 shifts where she did not receive oral care. Resident 2, also diagnosed with Alzheimer's disease and dementia, was observed with a thick yellowish substance on her tongue and blue cake residue around her mouth from the previous night. Despite having a care plan that aimed to keep her clean and well-groomed, there was no intervention plan for when she refused oral care. During an interview, Resident 2 expressed difficulty accessing water and locating the call light, indicating a lack of assistance in meeting her basic needs. Interviews with staff revealed systemic issues in providing oral care, with CNAs acknowledging that oral hygiene was often neglected, especially during night shifts. The Director of Nursing confirmed the absence of an ADL policy and acknowledged missing records for oral care. The facility's job postings outlined expectations for CNAs to provide oral hygiene, yet these duties were not consistently fulfilled, as evidenced by the observations and staff admissions.
Incomplete Antibiotic Stewardship Program Documentation
Penalty
Summary
The facility's nursing staff failed to update and maintain the Antibiotic Stewardship Program (ASP), which is crucial for identifying, tracking, and monitoring infections and antibiotic use among residents. This deficiency was identified through interviews and record reviews, revealing that the ASP log was missing or incomplete for several residents. Specifically, the log lacked essential information such as dates, medical record numbers, dose and duration of antibiotics, start and stop dates, clinical indications, and diagnosis. The absence of this information hindered the facility's ability to analyze, monitor, and minimize the emergence and spread of antimicrobial resistance. The review of medical records for multiple residents indicated that urinalysis tests were ordered, and culture and sensitivity results showed positive findings for various bacteria, including Escherichia coli and Staphylococcus aureus. However, the ASP log failed to document critical details such as the date of culture and the date and initials of nurses who faxed information to the pharmacy. This lack of documentation was confirmed by the Infection Preventionist and the Director of Nursing, who acknowledged that the ASP log was incomplete and needed to be updated to ensure the safe and appropriate use of antimicrobial agents. The facility's policies and procedures outlined the responsibilities of the Infection Preventionist and the Antimicrobial Stewardship Committee in monitoring and managing infections and antibiotic use. Despite these guidelines, the facility did not adhere to its own policies, resulting in missing and incomplete data in the ASP log. This failure compromised the facility's ability to effectively track antibiotic use and resistance trends, potentially leading to inappropriate antibiotic use and increased risk of antimicrobial resistance among residents.
Failure to Maintain Equipment Leads to Health Risks
Penalty
Summary
The facility failed to maintain the Ice/Water Dispensing machine according to the manufacturer's recommendations, resulting in a buildup of moist, black residue on the water supply nozzle. This issue was identified during an observation in the resident's kitchenette, where a white paper towel was used to wipe the nozzle, revealing the residue. The Biomed staff confirmed that the nozzle should have been clean and acknowledged that the machine was last cleaned by an outside contractor on 2/1/24, as per the manufacturer's guidelines. However, the service manual indicated that more frequent maintenance might be necessary. The Activities Director confirmed that residents obtained drinking water from this machine. Additionally, the facility did not maintain a functioning drain for the dishwashing machine, leading to water spilling onto the floor. During an observation in the kitchen, the Dietary Aide demonstrated that the dishwasher's drain required a stop-and-go method to prevent overflow. The Dietary Manager confirmed the ongoing issue with the drain and admitted to not reporting the problem to the Maintenance Director, who later identified a clogged drain as the cause of the overflow. The Maintenance Director noted that a similar issue had been repaired approximately six months prior, but was not informed of the current problem.
Housekeeper Takes and Pawns Resident's Jewelry
Penalty
Summary
The facility failed to protect a resident from abuse when a housekeeper took the resident's jewelry, wore it, and then pawned it. The resident, who was admitted with diagnoses including heart failure and a history of falling, required assistance for daily needs and was alert but had decreased mental functioning, scoring 8 out of 15 on the BIMS Test. The incident occurred when the resident placed her two gold necklaces in a Dixie cup before going for an X-ray procedure, and they were missing upon her return. The resident's daughter reported the missing necklaces, prompting a search by the facility staff. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were involved in the investigation, which revealed that a Restorative Nurses Aid (RNA) found photos on Facebook of the housekeeper wearing necklaces identical to those of the resident. The housekeeper admitted to taking and pawning the necklaces, which were eventually returned to the resident. The incident caused anxiety and stress for the resident, who had sentimental attachment to the jewelry, particularly a necklace given by her late husband.
Failure to Maintain Corridor Handrails During Renovation
Penalty
Summary
The facility failed to maintain handrails in the corridors for a period of 10.5 months, from June 6, 2023, until April 25, 2024. During an onsite visit from April 24 to April 26, 2024, the surveyor observed that sections of the corridors lacked handrails affixed to the walls. In an interview on April 25, 2024, the Director of Plant Operations confirmed that all handrails were removed on June 6, 2023, due to a major renovation project on the corridor walls. He also stated that the facility had been replacing the old handrails with new ones over the past two weeks, but the project was not yet completed. Furthermore, he admitted to being unaware of the regulatory requirement for corridor handrails to be in place.
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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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