Eisenberg Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 18855 Victory Bl, Reseda, California 91335
- CMS Provider Number
- 055013
- Inspections on file
- 51
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Eisenberg Village during CMS and state inspections, most recent first.
A resident with dementia and Alzheimer's, whose primary language was Farsi, was not provided with a communication board, hindering communication with staff. The resident's care plan included the use of a communication board, but it was unavailable, and no staff spoke Farsi. The facility's policy required communication tools for non-English speakers, but this was not adhered to.
The facility failed to lock wheelchair brakes for two residents, both with severe cognitive impairments and high fall risk, as per their care plans. Observations revealed unlocked brakes, confirmed by staff, despite the facility's policy requiring locked brakes for seated residents. Interviews with the DSD and DON reiterated the importance of this safety measure.
A medication cart was found unlocked and unattended in the nurse's station, with residents and staff passing by. The MDSN and LVN 1 confirmed the cart belonged to an LVN on lunch, and both acknowledged it should be locked to prevent unauthorized access. The DON reiterated the importance of keeping medication carts locked when unattended, in line with the facility's policy.
Two residents were found to be on psychotropic medications without specific, measurable target behaviors as required by facility policy. One resident, non-verbal, was prescribed Zoloft for verbalization of sadness, while another was on Seroquel for sudden verbal agitation without clear indicators of psychosis. The facility failed to clarify these orders, leading to inaccurate monitoring and potential risks.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate due to the omission of Sinemet and Terazosin for a resident with multiple diagnoses. Miscommunication among nursing staff led to the incorrect holding of these medications, despite physician orders to administer them.
A resident with Parkinson's disease and BPH did not receive prescribed medications due to miscommunication among nursing staff. RN 1 and LVN 4 were instructed to hold medications contrary to physician's orders, leading to significant medication errors. The DON confirmed the medications were not administered as required.
The facility failed to label several food items with a use by date, including oatmeal, powdered sugar, quinoa, bulgur, cream of wheat, lemon curd, chicken, and ground beef, as observed with the Dietary Supervisor. Additionally, expired chlorine test strips were used to check the sanitizing solution, as noted with the Kitchen Supervisor. These practices could lead to foodborne illness and compromised dishware sanitation.
A facility failed to follow infection control guidelines in three instances: a nurse left a resident's room wearing an isolation gown, a housekeeper entered a room under droplet precautions without eye protection, and an LVN did not wash hands between administering eye drops to a resident. These actions were against the facility's policies, potentially increasing the risk of infection spread.
A resident with dementia and a suprapubic catheter repeatedly refused catheter care, but the facility failed to notify the physician as required. The resident's cognitive skills were severely impaired, and they were dependent on staff for personal care. Despite multiple refusals documented in the Treatment Administration Record, there was no record of physician notification, which is a deficiency in communication and care management.
The facility failed to develop care plans for a resident refusing to wear a mask while on contact/droplet precautions and another resident refusing care for a suprapubic catheter. The first resident, with severe cognitive impairment, was observed without a mask despite physician orders. The second resident, also with severe cognitive impairment, refused catheter care multiple times, and there was no documentation of physician notification or updated care plans. These deficiencies could delay necessary care and increase infection risk.
A facility failed to update a resident's care plan after the removal of an indwelling urinary catheter. The resident, with severe cognitive impairment and multiple diagnoses, had their catheter discontinued per a physician's order. Despite this, the care plan was not revised to reflect the change, as confirmed by staff interviews and record reviews.
A facility failed to provide a communication device in a language understood by a resident with severe cognitive impairment and multiple medical conditions. Despite the care plan's intervention to provide a communication board in Farsi, the resident did not have access to one, hindering effective communication and potentially leaving the resident's needs unmet.
A resident at risk for pressure ulcers was found to be lying on a low air loss mattress (LALM) that was not properly monitored for functionality. The resident, who was severely cognitively impaired and dependent on staff, had a care plan requiring the use of a LALM for skin management. However, staff failed to document the monitoring of the LALM, and the physician's order was not properly recorded, leading to a lack of follow-through. This oversight was confirmed by the DON, who acknowledged the absence of documentation and monitoring.
A facility failed to act on a Pharmacy Consultant's recommendation to clarify the behavior manifestation for Seroquel use in a resident with dementia and psychotic disorders. The resident's Seroquel order lacked a specific behavior to monitor, leading to inaccurate monitoring and potential exposure to side effects. Despite facility policies requiring clarification of inappropriate psychotropic medication orders, the facility did not follow up on the recommendation.
A facility failed to remove a discontinued medication, amlodipine, from a medication cart, risking accidental administration to a resident with hypertensive heart disease and cognitive impairment. The medication was supposed to be removed immediately upon discontinuation, as per facility policy, but was found during an inspection.
The facility failed to ensure hospice service provision for two residents, lacking documentation of hospice staff visits and not providing required hospice care training to staff, as confirmed by the DON and MRTM.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication board for a resident whose primary language was Farsi, which hindered effective communication between the resident and the staff. The resident, who was diagnosed with unspecified dementia and Alzheimer's disease, required assistance with daily activities and had a care plan that included the use of a communication board as an intervention for communication impairment. However, during an observation, it was found that the communication board was not available at the resident's bedside or at the nurses' station, and no staff members on duty spoke Farsi. The deficiency was further highlighted during interviews with the Certified Nursing Assistant (CNA) and the Social Services Designee (SSD), who confirmed the absence of a Farsi communication board and the lack of Farsi-speaking staff. The Director of Nursing (DON) acknowledged the importance of the communication board in overcoming language barriers and ensuring the resident's needs were understood. The facility's policy on interpreter services emphasized the need for communication tools for non-English speaking residents, but the lack of a communication board for the resident indicated a failure to adhere to this policy.
Failure to Lock Wheelchair Brakes for Resident Safety
Penalty
Summary
The facility failed to adhere to its policy on wheelchair use by not ensuring that the wheelchair brakes were locked while residents were seated, which was observed in two of the three sampled residents. Resident 2, who has a history of unspecified convulsion-seizures, dementia with psychotic disturbance, Parkinson's disease with dyskinesia, and muscle weakness, was found sitting in a wheelchair with the left brake unlocked. The resident's care plan indicated a high risk for falls and injury, yet during an observation, the MDS Nurse and a Certified Nursing Assistant confirmed the brake was not engaged, contrary to the facility's safety protocols. Similarly, Resident 3, diagnosed with unspecified dementia with agitation and Alzheimer's disease, was also observed sitting in a wheelchair with the left brake unlocked. The resident's care plan highlighted a risk for falls due to dementia, and during observations, both the MDS Nurse and a Certified Nursing Assistant noted the unlocked brake. Interviews with the Director of Staff Development and the Director of Nursing confirmed that both brakes should be locked when residents are seated in wheelchairs, although the DSD mentioned that one brake could be unlocked if staff were supervising. The facility's policy, however, mandates that brakes should be locked when residents remain in the same location.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that a medication cart was locked while it was left unattended, which was observed with one of the two sampled medication carts, referred to as Medication Cart A. On February 27, 2025, at 11:24 a.m., Medication Cart A was observed parked in the nurse's station, unlocked and unattended, with residents and other facility staff walking by. This observation was confirmed by the Minimum Data Set Nurse (MDSN) at 11:25 a.m., who acknowledged that the cart was indeed unlocked and unattended. Further confirmation came from Licensed Vocational Nurse 1 (LVN 1) at 11:30 a.m., who stated that the cart belonged to LVN 2, who was on lunch, and reiterated that the cart should always be locked to prevent unauthorized access. The Director of Nursing (DON) also confirmed during an interview that medication carts should be kept locked when unattended for safety reasons. A review of the facility's policy on the storage of medications, updated in January 2017, indicated that medications should be stored securely and only accessible to authorized personnel, with medication carts required to be locked or attended.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary use of psychotropic medications, as required by their policy and procedure. Resident 61 was prescribed Zoloft for depression, with the indication being verbalization of sadness. However, the resident was non-verbal and unable to express feelings, making the indication for Zoloft incorrect and unclear. The MDS Coordinator and LVN confirmed that the resident's inability to verbalize sadness meant there was no specific behavior to monitor, leading to inaccurate monitoring and an inability to measure the medication's effectiveness. Resident 64 was prescribed Seroquel for a psychotic disorder with delusions due to dementia, manifested by sudden verbal agitation. However, the MDS indicated that the resident did not exhibit potential indicators for psychosis such as hallucinations and delusions. The facility's Pharmacy Consultant recommended clarifying the target behavior, as sudden verbal agitation could occur for various reasons unrelated to psychosis. The Director of Nursing acknowledged that the facility failed to follow up on the recommendation to clarify the order, resulting in inaccurate monitoring and an inability to measure the medication's efficacy. The facility's policy on psychotropic medication assessment and monitoring requires that such drugs are used only when necessary and at the lowest effective dose. The policy also mandates that the IDT team assesses and monitors the appropriateness, effectiveness, and side effects of psychotropic medications. In both cases, the facility did not adhere to its policy, as the psychotropic medication orders lacked specific, measurable target behaviors, leading to potential risks for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate during a medication administration task. This was due to two medication errors out of 32 opportunities for a resident with multiple diagnoses, including diabetes mellitus, BPH, Parkinson's disease, dysphagia, and a G-Tube. The errors involved the omission of Sinemet and Terazosin, which were not administered as per the physician's orders. The deficiency was identified during a review of the resident's Medication Administration Record (MAR) and confirmed by the Director of Nursing (DON). The MAR indicated that Sinemet and Terazosin were not given on the specified date and time, despite the physician's orders to administer these medications. The DON confirmed that the medications were marked as 'Not Administered: On Hold' in the MAR, which was contrary to the physician's instructions. Interviews with nursing staff revealed a miscommunication regarding which medications were to be held or administered. RN 1 stated they were instructed by the night RN supervisor to hold all medications except for potassium chloride, blood sugar checks with insulin, and the ipratropium-albuterol breathing treatment. However, the physician, during a phone interview, clarified that medications for BPH and Parkinson's disease should have been given. This miscommunication led to the omission of necessary medications, contributing to the facility's failure to maintain an acceptable medication error rate.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically for a resident with Parkinson's disease and benign prostatic hyperplasia (BPH). The resident, who was severely impaired in cognition and dependent on staff for daily activities, did not receive prescribed medications including Sinemet, terazosin, and finasteride as ordered by the physician. These medications were crucial for managing the resident's Parkinson's disease and BPH. The deficiency occurred when Registered Nurse 1 (RN 1) and Licensed Vocational Nurse 4 (LVN 4) did not administer the medications as per the physician's orders. RN 1 and LVN 4 were instructed by the night RN supervisor to hold all medications except for potassium chloride, insulin, and ipratropium-albuterol treatment. This instruction was contrary to the physician's orders, which specified that medications for BPH and Parkinson's disease should be given. The failure to administer these medications was confirmed through interviews and record reviews. The Director of Nursing (DON) confirmed that the medications were not given as indicated by the medication administration record, which showed the medications as 'Not Administered: On Hold'. The facility's policy on medication administration required that medications be administered in a timely manner and in accordance with the physician's orders, which was not followed in this case.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling several food items with a use by date. During an observation and interview with the Dietary Supervisor, it was noted that containers of oatmeal, powdered sugar, quinoa, bulgur, cream of wheat, lemon curd, chicken, and ground beef were not labeled with a use by date. The Dietary Supervisor acknowledged that the absence of these labels could lead to residents consuming food past its use by date, potentially causing illness. Additionally, the facility did not ensure that the chlorine test strips used to check the sanitizing solution were not expired. During an observation with the Kitchen Supervisor, it was found that the test strips used to measure the concentration of the sanitizing solution in the dishwasher had expired. The Kitchen Supervisor confirmed that expired test strips could compromise the effectiveness of the sanitizing solution, which is essential for cleaning and sanitizing dishware. The facility's policies and procedures indicated that dietary items should be labeled and dated, and sanitizing solutions should maintain the manufacturer's recommended concentration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to observe infection control guidelines when a registered nurse (RN) was observed leaving a resident's room during a medication pass while still wearing an isolation gown. This occurred with a resident who was on enhanced barrier precautions (EBP) due to the presence of a G-Tube. The RN exited the room without removing the isolation gown, which then came into contact with the medication cart. This action was contrary to the facility's policy, which requires the removal of PPE before leaving a resident's room to prevent the spread of infection. In another instance, a housekeeper entered a resident's room, which was under contact and droplet precautions due to a respiratory syncytial virus (RSV) infection, without wearing the required eye protection. The room had clear signage indicating the need for a gown, mask, gloves, and eye protection. The housekeeper was observed cleaning the room without the necessary eye protective equipment, which was confirmed by the Infection Prevention Nurse. This was against the facility's policy for contact and droplet precautions, which mandates the use of eye protection to prevent the spread of infection. Additionally, a licensed vocational nurse (LVN) failed to follow the facility's policy for administering eye drops. The LVN did not wash hands between administering drops to each of a resident's eyes, which could lead to cross-contamination. The facility's policy requires handwashing before treating each eye to prevent infection. The LVN was unaware of this requirement, and the Infection Preventionist was also not aware of the need for hand hygiene between treatments of each eye.
Failure to Notify Physician of Resident's Refusal of Catheter Care
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal of suprapubic catheter care, which is a deficiency in communication and care management. The resident, who was admitted with diagnoses including unspecified dementia and retention of urine, had a suprapubic catheter in place. The resident's Minimum Data Set indicated severely impaired cognitive skills and a dependency on staff for various personal care tasks. Despite the resident's refusal of catheter care on multiple occasions, there was no documentation of physician notification, as required by the facility's policy. The Director of Nursing confirmed that the licensed staff were responsible for notifying the physician about the resident's refusal of care, but acknowledged the absence of such documentation. The facility's policy on indwelling catheter care mandates the development and re-evaluation of a care plan, including physician communication regarding changes in the resident's condition. The lack of notification placed the resident at increased risk for infection due to the absence of appropriate care.
Failure to Develop and Implement Care Plans for Resident Non-Compliance and Catheter Care
Penalty
Summary
The facility failed to develop a care plan for a resident who refused to wear a mask while on contact/droplet precautions due to exposure to Respiratory Sinus Virus (RSV). The resident, who had severely impaired cognition and required moderate assistance for most activities of daily living, was observed without a mask in a common area, despite physician orders for mask use. The Infection Preventionist and Director of Nursing confirmed that there was no care plan addressing the resident's non-compliance with mask-wearing, which could delay necessary care and services. Another deficiency involved the facility's failure to address a resident's refusal of care for a suprapubic indwelling catheter. The resident, who had severe cognitive impairment and was dependent on staff for personal care, refused treatment for the catheter's surrounding skin on multiple occasions. The Director of Nursing acknowledged that there was no documentation of notifying the resident's physician about the refusals, and the care plan did not reflect current interventions such as monitoring for hematuria and checking for signs of infection. The facility's policies required comprehensive care plans with measurable objectives and timetables to meet residents' needs, which were not followed in these cases. The lack of updated care plans and implementation of interventions could lead to inadequate care and increased risk of infection for the residents involved.
Failure to Revise Care Plan After Catheter Removal
Penalty
Summary
The facility failed to revise the care plan for a resident following the removal of an indwelling urinary catheter. The resident, who was originally admitted on January 25, 2024, and readmitted on October 12, 2024, had diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease. The Minimum Data Set (MDS) dated October 19, 2024, indicated that the resident had severely impaired cognition and required maximal assistance for various activities of daily living. A physician order dated November 3, 2024, instructed the discontinuation of the indwelling urinary catheter. Despite the removal of the catheter, the care plan, which was created on October 14, 2024, was not updated to reflect this change. During an observation on December 3, 2024, a Certified Nursing Assistant confirmed that the catheter had been discontinued. However, the care plan still addressed the risks associated with having an indwelling catheter. Both the Licensed Vocational Nurse and the Minimum Data Sheet Coordinator acknowledged that the care plan should have been revised to accurately reflect the resident's current condition. The Director of Nursing also confirmed that the care plan needed to be updated after the catheter was removed.
Failure to Provide Communication Device in Resident's Language
Penalty
Summary
The facility failed to provide a communication device in a language understood by a resident, identified as Resident 22, which led to a deficiency in communication care. Resident 22, who was admitted and readmitted to the facility with diagnoses including sepsis, metabolic encephalopathy, and chronic kidney disease, had a preferred language of Farsi. The Minimum Data Set (MDS) indicated that the resident had severely impaired cognition and required maximal assistance for daily activities. Despite these needs, the facility did not provide a communication board in Farsi, as observed during a surveyor's visit. During the survey, it was noted that the resident's care plan, which addressed the language barrier, included an intervention to provide a communication board. However, this intervention was not implemented, as confirmed by the Social Service Director and the Director of Nursing. The absence of a communication board meant that staff could not effectively communicate with the resident, potentially leaving the resident's needs unmet. The facility's policy on interpreter services, which required communication boards for residents unable to communicate, was not adhered to in this case.
Failure to Monitor Low Air Loss Mattress Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of a low air loss mattress (LALM) for a resident, which is crucial for preventing pressure ulcers. The resident, who was severely cognitively impaired and dependent on staff for daily activities, was at risk for developing pressure ulcers. The resident's care plan included the use of a LALM for skin management, but the staff did not monitor the functionality of the mattress as required. During an observation, it was noted that the LALM was powered on, but its display was not showing any information, indicating a potential malfunction. Licensed staff were required to monitor the LALM every shift and document this in the resident's Treatment Administration Record (TAR) or Medication Administration Record (MAR). However, there was no documentation of such monitoring for the resident, and the physician's order for the LALM was not properly recorded, leading to a lack of follow-through. The Director of Nursing confirmed that the staff did not notice the LALM was off and failed to document its monitoring, which could result in the development of pressure injuries.
Failure to Clarify Seroquel Use for Resident
Penalty
Summary
The facility failed to act upon a recommendation from the Pharmacy Consultant (PC) to clarify the behavior manifestation for the use of Seroquel for one of the residents, identified as Resident 64. The resident was admitted with diagnoses including major depressive disorder, dementia, and psychotic disorders. The Minimum Data Set (MDS) indicated that the resident's cognitive skills for daily decision-making were severely impaired, and the resident was taking antipsychotic and antidepressant medications. The physician's order for Seroquel was based on the resident's psychotic disorder with delusions due to dementia manifested by sudden verbal agitation. The Pharmacy Consultant's Monthly Regimen Review (MRR) noted that Resident 64 had been on Seroquel with a target behavior of sudden verbal agitation and recommended clarifying what the resident said and how this presented a danger to self and others. However, the facility did not follow up on this recommendation. During interviews, both LVN 5 and the Director of Nursing (DON) acknowledged that the Seroquel order did not specify the behavior to monitor, and sudden verbal agitation was not a clear indication for administering Seroquel. The lack of a clear indication and measurable target behavior led to inaccurate monitoring and potential exposure of the resident to side effects. The facility's Policies & Procedures (P&P) for psychotropic medication assessment and monitoring require that psychotropic drugs are used only when necessary and at the lowest effective dose. The P&P also state that the PC reviews the appropriateness of psychotropic medication orders and that any inappropriate orders should be clarified with the attending physician. Despite these guidelines, the facility failed to act on the PC's recommendation, resulting in a deficiency in the monitoring and administration of Seroquel for Resident 64.
Failure to Remove Discontinued Medication from Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to accepted professional principles, as evidenced by the presence of a discontinued medication in a medication cart. Specifically, a medication cart on the second floor contained a blister pack of amlodipine, a medication used to lower blood pressure, which had been discontinued for a resident. The medication was not removed from the cart after the discontinuation order was issued, which was confirmed during an observation and record review with a registered nurse. The resident involved had a history of hypertensive heart disease and was severely impaired in cognition, requiring assistance with daily activities. The physician's order for amlodipine was discontinued on a specific date, yet the medication remained in the cart, posing a risk of accidental administration. The Director of Nurses confirmed that the facility's policy required immediate removal of discontinued medications to prevent medication errors, which was not followed in this instance.
Deficiencies in Hospice Service Provision and Training
Penalty
Summary
The facility failed to ensure the provision of hospice services for two residents, leading to deficiencies in documentation and training. For Resident 1, the facility did not have documented evidence that hospice staff signed the Interdisciplinary Team Sign-in Sheet upon arrival, despite the resident being admitted to hospice care. This was confirmed during an interview and record review with the Director of Nursing (DON), who acknowledged the absence of the sign-in sheet in the resident's hospice binder. Similarly, for Resident 3, the facility did not have a hospice Interdisciplinary Team Sign-in Sheet in the resident's hospice binder, indicating a lack of documented evidence that hospice staff provided care from the date of hospice admission. The DON and the Medical Records Team Leader (MRTM) both confirmed the absence of the sign-in sheet and acknowledged that medical records should have conducted audits to ensure the presence and completion of these sheets. Additionally, the facility did not ensure that the hospice agency provided training programs in hospice care for facility staff, as required by the contractual agreement. Interviews with two Certified Nursing Assistants (CNAs) revealed that they had not received any training from the hospice agency. The DON confirmed that the hospice contract included a provision for training programs, but the facility had not been aware of or implemented this aspect of the agreement.
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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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