Elmwood Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Berkeley, California.
- Location
- 2829 Shattuck Avenue, Berkeley, California 94705
- CMS Provider Number
- 555819
- Inspections on file
- 27
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Elmwood Care Center during CMS and state inspections, most recent first.
A resident with schizophrenia, moderate cognitive impairment, and a high fall risk score used a wheelchair and required supervision for ambulation but was allowed to walk independently in a hallway. Despite multiple prior falls and an interdisciplinary recommendation to transfer the resident to a high‑risk unit with 15‑minute rounding, the resident was not moved because a previous fall had not caused injury. While returning from the patio after smoking, the resident sustained an unwitnessed fall in the hallway, was found on the floor near a wheelchair with right hip pain, and was later diagnosed by X‑ray with an acute comminuted intertrochanteric femur fracture requiring hospital surgery. The facility’s own fall prevention policy required adequate supervision and assistive devices to prevent accidents, and leadership acknowledged the fall could have been prevented with closer monitoring and constant supervision during ambulation.
The facility failed to maintain a functional, locking front entry door, resulting in the door being found ajar and unlocked, with no audible alarm and no staff present at reception when surveyors entered unnoticed. The Administrator and Maintenance Supervisor reported they were unaware the door did not lock, and observation confirmed the locking mechanism did not engage and no alarm sounded when the door was opened. A prior quote for commercial door repair existed, but the Maintenance Supervisor did not know if or when the repair project started or was completed, and the maintenance logbook contained no entry or follow-up request for the broken lock.
During a COVID-19 outbreak, the facility failed to ensure consistent staff masking and active visitor screening. A maintenance worker and a laundry aide were observed moving through the building without face masks, and the maintenance supervisor and infection preventionist confirmed gaps in documented COVID in-service training for laundry and housekeeping staff. At the same time, the entrance reception area was left unmanned, with visitors expected to self-sign in and self-screen despite posted signs and available N95 masks; a visitor was seen entering without masking or completing the log. The DON acknowledged that no staff were actively monitoring visitor screening, contrary to CDC and CDPH guidance for outbreak conditions.
The facility did not report suspected abuse within the required timeframe for two residents—one with a bruise of unknown origin and another who alleged verbal abuse by a CNA. Required notifications to the State Survey Agency and the LTCO were not made as per facility policy, and staff interviews confirmed the omissions.
A resident with cellulitis and an ileostomy reported verbal abuse by a CNA, but the facility did not complete or document a thorough investigation within the required timeframe. Leadership confirmed the absence of an investigation summary, and there was no record of findings or actions taken in response to the allegation.
During a COVID-19 outbreak, multiple rooms with COVID-19 positive residents were left with doors open, and two residents were observed outside their isolation rooms. A CNA assisted a COVID-19 positive resident without full PPE, and the trash receptacle for soiled PPE was not properly placed. These actions were not in accordance with the facility's infection control policy, which required isolation, proper PPE use, and closed doors.
The facility did not create or implement individualized care plans for several residents when the call light system was down, instead providing handheld bells without assessing each resident's ability to use them. Some residents had cognitive or physical impairments that made using the bells difficult or impossible, and staff confirmed that no person-centered planning was done to address these needs.
Nursing staff at the facility failed to follow proper infection control protocols, as observed with two residents. A nurse was seen with a trash bag of waste tied to a treatment cart, and blood pressure machines had trash bags with used gloves. A CNA mishandled dirty gloves, using them to open doors and assist a resident without proper disposal. The facility's policy requires used gloves to be discarded in designated receptacles.
The facility failed to maintain a clean and safe environment for food storage and preparation, with issues such as unclean floor drains, poor kitchen tile conditions, improper cooling and thawing of meats, and unclean food storage equipment. Additionally, expired tube feeding formulas were available for use for residents with serious medical conditions, posing a risk to their safety.
The facility failed to provide a designated location for safely storing perishable food brought in by family members or visitors. Observations showed inconsistent practices, with some food stored in a staff refrigerator lacking a thermometer and temperature log. The facility's policy did not specify safe storage durations, potentially leading to foodborne illness. The DON was unaware of proper storage times, and no specific storage area was designated for residents' personal perishable food.
The facility did not follow prescribed Renal and Renal CCHO diets for six residents, serving cappuccino chocolate mousse instead of the specified cookies. This error was observed during a tray line inspection, and interviews revealed a lack of communication and clarity among dietary staff regarding the correct dietary requirements.
The facility failed to provide the correct food texture for residents on a Mechanical Soft diet, serving dry roast beef and coleslaw without necessary moistening. This oversight, confirmed by the CDM and SLP, contradicted the facility's Diet Manual, which requires moistening of meats and coleslaw for residents with chewing or swallowing limitations.
The facility failed to fortify food according to physician orders for two residents, potentially decreasing their calorie intake. During trayline service, staff did not call out the fortified component, leading to the omission of margarine on sweet potato fries. The Certified Diet Manager confirmed the oversight, which contradicted the facility's Diet Manual guidelines for fortified diets.
The facility failed to maintain a functioning call light system for 13 residents, leading to potential delays in care. Residents with various medical conditions, including Parkinson's Disease and cognitive impairments, reported broken or ineffective call lights. Staff confirmed the ongoing issues, and maintenance efforts to repair the system were unsuccessful, impacting the quality of care.
A facility failed to provide a comfortable, temperature-controlled environment for a resident due to a non-functional window missing a crank handle. The resident, who could communicate needs despite moderately impaired mental status, reported feeling cold at night due to a draft. Maintenance staff was unaware of the issue and did not use a maintenance log to track repairs.
A facility failed to maintain a medication error rate below five percent, resulting in a 15.38% error rate. An LVN administered expired insulin to a diabetic resident, and another LVN gave medications to a resident with Cerebral Infarction outside the prescribed timeframe. These actions deviated from the facility's policies, which require adherence to expiration dates and scheduled times to ensure medication effectiveness.
A facility failed to follow infection control practices during blood sugar testing for two residents. An LVN did not clean the glucose monitor between tests, disposed of contaminated lancets in residents' trash cans, and neglected hand hygiene. These actions violated facility policies and risked cross-contamination and infection.
A facility was found to have 34 resident rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. Despite this, observations indicated sufficient space for care, no interference from equipment, and no resident complaints or safety concerns.
Failure to Adequately Supervise High‑Risk Resident Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident with a known high risk for falls. The resident was admitted in early April and had a Minimum Data Set dated in October showing a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment, and a diagnosis of schizophrenia. The MDS documented that the resident used a manual wheelchair, could wheel at least 50 feet, and could walk at least 50 feet with supervision or touching assistance, but was not assessed to walk 150 feet due to medical or safety concerns. A Fall Risk Assessment dated in October showed a fall score of 50 related to a history of falls, unsteady and weak gait, and wheelchair use, and the fall care plan identified the resident as at risk for falls. The care plan included an intervention dated in September to admit the resident to a high-risk unit, anticipate and meet needs, and follow the facility’s fall protocol. Staff interviews confirmed that the facility had a designated high fall risk unit where staff conducted 15‑minute rounds on high fall risk residents. However, the resident was not moved to this high‑risk unit after a fall on September 10, which had occurred due to loss of balance while ambulating, despite the interdisciplinary team’s recommendation to do so. The administrator later stated the facility decided not to move the resident because there were no injuries from that September fall. As a result, the resident remained outside the high‑risk unit at the time of the subsequent fall. On the night of the incident in November, the resident ambulated independently in the hallway while returning from the patio after smoking and experienced an unwitnessed fall. Nursing documentation and interviews indicated the resident was found sitting on the ground in the hallway near his room, next to his wheelchair, awake and alert, and complaining of right hip and leg pain. An RN assessed the resident, noted pain in the right hip and groin area, and obtained a STAT X‑ray, which showed an acute comminuted fracture of the right intertrochanteric femur. The resident was transferred to an acute care hospital and underwent right hip surgery. The acting DON later stated that the fall could have been prevented if staff had monitored the resident closely and provided constant supervision while he was walking alone, and the facility’s fall prevention policy required that all residents receive adequate supervision and assistive devices to prevent accidents.
Failure to Maintain Functional, Secure Front Entry Door Lock
Penalty
Summary
The facility failed to ensure the front entry door locked, compromising the resident's right to a safe, clean, comfortable, and homelike environment, including safe supports for daily living. During an observation, the survey team found the front door ajar and unlocked, and they were able to enter the building without staff awareness. There was no audible alarm to indicate that someone had entered, and the reception area was unattended. The report states this failure had the potential to result in a significant security and safety issue potentially endangering residents, staff, and visitors. In a subsequent phone interview, the Administrator and Maintenance Supervisor both stated they did not know the entry door did not lock. During a concurrent observation and interview, the Maintenance Supervisor demonstrated that when the front entry door was pushed closed from the outside, the locking mechanism did not activate, and confirmed there was no alarm to notify staff when the door was opened. The Maintenance Supervisor stated he did not know how long the door lock had been malfunctioning. He presented a quote dated several months earlier for commercial door repair but had no knowledge of the project start or completion date. Review of the maintenance logbook for the current year showed no entry or request for follow-up on the broken entry door lock, and the Maintenance Supervisor stated he did not have access to prior logbooks.
Failure to Enforce Staff Masking and Active Visitor Screening During COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its infection prevention and control program during a COVID-19 outbreak, specifically related to staff masking and visitor screening. On one observation date, a maintenance worker was seen walking through the facility without a face mask and acknowledged he was aware of the COVID outbreak and did not have a mask. Around the same time, a laundry aide was observed exiting a stairwell and walking to the time clock without a face mask or name badge; she stated she was not wearing a mask and had received the facility’s COVID education training. The maintenance supervisor stated staff should always wear a mask upon entry and exit during a COVID outbreak, but reported that the maintenance worker and laundry aide were not listed on the general in-service record, and he did not keep minutes of his staff meetings. The infection preventionist’s review of COVID isolation and PPE in-service training sheets showed that CDC and California Department of Public Health (CDPH) COVID-19 guidance had been reviewed with CNAs, RNs, and all departments, but the in-service report did not include names or signatures for laundry and housekeeping staff. The infection preventionist stated that staff not receiving in-service training and not wearing a face mask could cause transmission of the COVID outbreak to residents, staff, and visitors. A second deficiency was identified regarding visitor screening and source control during the same COVID outbreak. On two separate observations, the receptionist area at the entrance was unmanned, with boxes of N95 masks and signs instructing visitors to wear a mask due to the outbreak, but no staff were present to perform visitor screening or temperature monitoring. A visitor was observed entering the facility without putting on a mask or signing the visitor logbook, which contained symptom-related questions. The DON stated that the receptionist and several other staff were out due to COVID, that the receptionist area was unmanned, and that visitors were expected to self-sign in, with no one monitoring the self-sign-in process. Review of CDPH Healthcare-Associated Infections Program guidance for 2024–2025 indicated that during periods of increased community transmission of respiratory viruses and in the event of an outbreak, facilities should implement active screening of visitors for signs and symptoms of respiratory virus infections.
Failure to Timely Report Suspected Abuse and Notify Ombudsman
Penalty
Summary
The facility failed to report suspected allegations of abuse within the required 24-hour time frame for two residents. One resident, who had diagnoses including dementia, cognitive decline, and major depressive disorder, was observed with a bruise of unknown origin on her right upper arm. The bruise was first noted in the morning, but the investigation and required notifications to the State Survey Agency were not initiated until two days later. Additionally, the facility did not notify the Long-Term Care Ombudsman (LTCO) about this incident as required by policy. Another resident, admitted with cellulitis and an ileostomy, reported that a CNA was verbally inappropriate, making a statement that was considered verbally abusive. The facility did not provide evidence that this allegation was reported to the LTCO. Interviews with facility staff, including the Infection Preventionist and the Administrator, confirmed that notifications to the LTCO were not made for either incident. The facility's policy requires prompt reporting of all abuse allegations, including injuries of unknown source, to both the State Survey Agency and the LTCO, but this was not followed in these cases.
Failure to Complete Timely Abuse Investigation and Documentation
Penalty
Summary
The facility failed to conduct and complete a thorough investigation within five working days following an allegation of abuse involving a resident who was admitted with cellulitis of the abdominal wall and an ileostomy. The resident reported that a CNA was verbally inappropriate and rude, specifically stating, "You're here because God doesn't like you." Documentation review revealed that there was no investigation summary available for this allegation, and the Infection Preventionist, who also served as the DON designee, confirmed the absence of documentation regarding the findings or results of the investigation. Interviews with facility leadership, including the Administrator, confirmed that the required investigation summary was not completed as per facility policy, which mandates that all abuse allegations be thoroughly investigated and findings reported within five working days. The lack of documentation meant that it could not be determined what actions, if any, were taken during the investigation, nor whether protective interventions or corrective actions were implemented to address the allegation.
Failure to Maintain Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during a COVID-19 outbreak. Multiple resident rooms housing COVID-19 positive individuals were observed with doors left open, despite posted contact precaution signs indicating the need for closed doors. COVID-19 positive residents were seen outside of their isolation rooms, including one resident walking unassisted in the hallway and another seated in a wheelchair outside their room with their mask lowered below the nose and mouth. Staff interviews confirmed that these residents should have remained in their rooms under isolation, and that doors to COVID-19 rooms should have been kept closed to prevent the spread of infection. Additionally, a certified nurse assistant was observed inside an isolation room assisting a COVID-19 positive resident without wearing complete personal protective equipment (PPE). The trash receptacle for soiled PPE was not positioned near the exit door, requiring staff to cross the room to dispose of PPE, increasing the risk of contamination. After providing care, the CNA exited the isolation room without closing the door. The facility's own policy required exposed or symptomatic residents to remain in their rooms, staff to adhere to hand hygiene and PPE protocols, and isolation room doors to remain closed except when entering or exiting.
Failure to Develop and Implement Person-Centered Care Plans During Call Light System Outage
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for five residents when the call light system was not operational. Instead of a functioning call light system, residents were provided with handheld bells, but there was no individualized care planning to address each resident's ability to use these devices or their specific needs. The Director of Nursing confirmed that no such care plans were created for residents using handheld bells during the period when the call light system was inoperative. Observations and interviews revealed that residents had varying degrees of cognitive and physical abilities, which affected their capacity to use the handheld bells. For example, one resident with a history of falls and intact cognition refused to use the bell, preferring to call out for help. Another resident with moderate cognitive impairment and a recent fall reported delays in staff response when using the bell. Residents with significant cognitive or physical limitations, such as those with advanced dementia or who were rarely understood, often had the bell placed out of reach or were unable to use it effectively. Staff interviews corroborated that the call light system had been nonfunctional for an extended period, and that the use of handheld bells posed risks, especially for residents unable or unwilling to use them. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed for residents affected by the call light system failure.
Infection Control Breach Due to Improper Glove Disposal
Penalty
Summary
The facility's nursing staff failed to adhere to proper hand hygiene and infection control protocols, as observed during interactions with two residents. One resident was admitted with malignant neoplasm of the prostate and mild intermittent asthma, while the other had heart failure, bacteremia, sepsis, and COPD. During an observation, a Licensed Vocational Nurse was seen pushing a treatment cart with a trash bag filled with waste and used gloves tied to it, which is against infection control standards. Additionally, blood pressure machines in the hallway had trash bags tied to them, containing used gloves and dirty paper towels. A Certified Nurse Assistant was observed mishandling dirty gloves after cleaning a standing scale. Instead of disposing of the gloves, the CNA held them in her hand, used hand sanitizer, and then entered a resident's room, using the gloves to open a bathroom door and assist a resident. The CNA acknowledged the mistake during an interview, admitting that the gloves should have been discarded before entering the room. The facility's Infection Preventionist confirmed that tying trash bags to equipment used for resident care is not allowed, as it poses a risk of spreading infection. The facility's policy on glove use, revised in 2010, mandates that used gloves be discarded in designated waste receptacles inside the room.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to maintain a clean and safe environment for food storage and preparation, as evidenced by several observations and interviews. Floor drains in the kitchen were not properly maintained, with thick sludge build-up and standing water, which attracted small flies and emitted a bad odor. The kitchen tile floors were also in poor condition, with loose and broken tiles, missing grout, and pooling water, all of which could harbor bacteria. Additionally, the facility did not ensure proper cooling of Time/Temperature Control for Safety Food (TCS), as there was no documentation of cooldown temperatures for cooked meats, and meat was not thawed appropriately, leading to potential cross-contamination. The facility's food storage practices were also deficient. The inside of a food storage refrigerator was found to be unclean, with sticky residue on the wire shelving. An industrial can opener was not properly maintained, with dark matter and sticky residue on its surfaces, posing a risk of foodborne illness or metal contamination. Clean plates were handled with dirty oven mitts, and a food service equipment drawer contained food crumbs and sticky substances, increasing the risk of cross-contamination. Furthermore, the ceiling above a food preparation area was not clean, with visible gray, fuzzy matter on the tiles. The facility also failed to ensure the safety of tube feeding formulas, as expired formulas were stored and available for use for three residents with serious medical conditions, including Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Nontraumatic Intracerebral Hemorrhage. The Director of Nursing acknowledged the expired formulas and stated they would not be given to residents. The facility's policy required maintaining inventory controls and discarding expired formulas, which was not adhered to, potentially compromising resident safety.
Deficiency in Safe Storage of Perishable Food Brought by Family
Penalty
Summary
The facility failed to ensure that residents had a designated location to safely store perishable food brought in by family members or visitors. Observations and interviews revealed that perishable food items were sometimes stored in the staff refrigerator, which lacked an internal thermometer and a temperature log. Certified Nursing Assistants (CNAs) reported inconsistent practices regarding the storage and disposal of perishable food, with some food items being left at residents' bedsides for extended periods. The Director of Nursing (DON) was unaware of the proper duration for which perishable food could be stored without refrigeration, and there was no specific place designated for storing residents' personal perishable food. The facility's policy on food brought by family or visitors, last revised in 2014, required perishable foods to be stored in re-sealable containers with tightly fitting lids in the refrigerator, labeled with a use-by date. However, the policy did not specify the duration for which perishable food could be safely stored. According to the 2022 Federal Food Code, Time/Temperature Control for Safety (TCS) food must be maintained at specific temperatures to prevent foodborne illness. The lack of a clear policy and proper storage facilities had the potential to result in foodborne illness and did not create a homelike environment for the residents who consumed food brought in by family members.
Failure to Follow Prescribed Renal Diets
Penalty
Summary
The facility failed to adhere to the prescribed dietary requirements for six residents on Renal diets and Renal Consistent Carbohydrate (CCHO) diets. During a lunch service, these residents were served cappuccino chocolate mousse instead of the specified desserts for their diets, which were two small sugar cookies for Renal diets and two small diet sugar cookies for Renal CCHO diets. This discrepancy was observed during a tray line inspection, where it was noted that the dietary aide placed the incorrect dessert on the trays and did not replace them with the appropriate cookies. Interviews with the dietary staff revealed a lack of clarity and communication regarding the correct dietary requirements. The dietary aide confirmed the error but did not rectify it, and another staff member claimed no responsibility for the desserts. The Certified Dietary Manager (CDM) admitted to not consulting with the Registered Dietitian (RD) about the correct number and type of cookies for the Renal diets. The RD later confirmed that the menu should have been followed and expressed uncertainty about the availability of appropriate diet cookies in the kitchen.
Failure to Provide Appropriate Food Texture for Mechanical Soft Diets
Penalty
Summary
The facility failed to provide the appropriate food texture for residents prescribed a Mechanical Soft diet, which is designed for individuals with chewing or swallowing limitations. During an observation of the trayline food service, it was noted that residents were served dry, shredded roast beef on a bun without the necessary au jus, and dry coleslaw without dressing or moistener. The Certified Dietary Manager (CDM) confirmed that the mechanical beef was dry and should have been moistened with au jus, and the coleslaw should have been mixed with dressing as per the recipe. The Speech Language Pathologist (SLP) indicated that moist food is generally safer for residents on a Mechanical Soft diet. The facility's Diet Manual specifies that meats should be ground with meat juices, gravy, or sauce, and dry meat is not allowed. This deficiency had the potential to cause difficulty with eating, chewing, and/or swallowing, leading to an increased risk of choking for all 10 residents who received the prescribed Mechanical Soft diets.
Failure to Fortify Diets as Prescribed
Penalty
Summary
The facility failed to fortify resident food according to physician orders, which had the potential to result in decreased calorie intake for two residents out of seven who had physician-prescribed fortified diets. During an observation of the trayline food service, it was noted that the tray tickets included fortified diets for seven residents. However, the staff member responsible for calling out the diets did not mention the fortified component, leading to the omission of margarine on the sweet potato fries for the first food cart delivered, which included the trays for the two affected residents. The Certified Diet Manager confirmed that fortified diets were physician-prescribed, and the facility's Diet Manual outlined that the Fortified Diet is intended for residents who cannot consume adequate calories or protein to maintain their weight or nutritional status. The manual specifies that the goal is to increase calorie density by approximately 300-400 calories per day, with examples such as adding extra margarine or butter to food items. The failure to follow these orders was confirmed during an interview with the Certified Diet Manager.
Call Light System Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light system was functioning for 13 of 68 sampled residents, leading to potential delays in care and services. Residents reported that their call lights were either broken or ineffective, with some residents waiting extended periods for assistance. Observations confirmed that call lights were not working in several rooms, and staff interviews corroborated the ongoing issues with the call light system. Residents affected by the malfunctioning call lights had various medical conditions, including Parkinson's Disease, urinary tract infections, and cognitive impairments. Many of these residents required assistance with toileting and transfers, making the call light system crucial for their care. Despite being aware of the problem, the facility's attempts to fix the call lights were unsuccessful, leaving residents without a reliable means to request help. Staff interviews revealed that the call light issues had persisted for weeks, with some staff members noting that the problem existed since they began their employment. Maintenance staff confirmed the broken call lights and reported unsuccessful repair attempts to the Operations Manager. The facility's failure to address the call light deficiencies impacted the quality of care provided to residents, as they were unable to effectively communicate their needs to staff.
Failure to Maintain Temperature-Controlled Environment
Penalty
Summary
The facility failed to provide a comfortable, temperature-controlled environment for a resident due to a non-functional window. The window in the resident's room was missing a crank handle, preventing the resident from opening or closing it to control the room's temperature. This issue was observed during an interview with the resident, who reported feeling cold at night due to a draft from the open window. The resident, who had a moderately impaired mental status but could communicate needs, had reported the issue to staff the previous day. However, the maintenance staff was unaware of the broken crank and did not use a maintenance log to track or report broken items.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 15.38 percent due to four errors out of 26 opportunities. One significant error involved a Licensed Vocational Nurse (LVN) administering expired insulin to a resident with Type 2 Diabetes Mellitus and Diabetic Neuropathy. The insulin was expired for 13 days, which could potentially decrease its effectiveness. The facility's policy required documenting the open date on insulin vials and disposing of them according to the manufacturer's expiration guidelines, which was not followed in this instance. Another error involved a different LVN administering medications to a resident with Cerebral Infarction outside the prescribed timeframe. The medications, including Senna, Divalproex, and Levetiracetam, were given two to three hours past their scheduled times. The facility's policy allowed for a one-hour window before or after the scheduled time, which was not adhered to, potentially affecting the resident's medication schedule and effectiveness. Interviews with the LVNs and the Director of Nursing (DON) confirmed the deviations from the facility's medication administration policies. The DON emphasized the importance of adhering to scheduled times and expiration dates to ensure medication effectiveness. The facility's policies clearly outlined the procedures for safe medication administration, which were not followed, leading to the identified deficiencies.
Infection Control Lapses During Blood Sugar Testing
Penalty
Summary
The facility failed to adhere to proper infection control practices during fingerstick blood sugar tests for two residents. Licensed Vocational Nurse 3 (LVN 3) did not clean and sanitize the glucose monitor between tests for Residents 5 and 39. Additionally, LVN 3 disposed of the contaminated lancets in the residents' trash cans instead of the designated sharps container. Furthermore, LVN 3 did not perform hand hygiene between the tests for the two residents. These actions were observed during a specific incident and were confirmed through interviews and record reviews. Resident 5 was admitted to the facility in 2021 with multiple diagnoses, including unspecified sequelae of cerebrovascular disease. Resident 39 was admitted in 2024 with type 2 diabetes mellitus and diabetic neuropathy. The facility's policies require that reusable resident care equipment be decontaminated between uses, contaminated sharps be disposed of in designated containers, and appropriate hand hygiene be performed between resident interactions. The Director of Nursing confirmed that the failure to follow these policies placed residents at risk for injury, cross-contamination, and infection.
Deficiency in Resident Room Size
Penalty
Summary
The facility was found to have 34 resident rooms with multiple beds that did not meet the required minimum of 80 square feet per resident. The rooms in question included numbers 100, 102, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 116, 118, 200, 202, 204, 208, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 225. The square footage per resident in these rooms ranged from 71.18 to 79.06 square feet, which is below the regulatory requirement. This deficiency was identified through observations conducted between July 15 and July 18, 2024. Despite the deficiency in room size, observations during the same period indicated that there was sufficient space for the provision of care, and no heavy equipment was present in the rooms that could interfere with resident care. Each resident had adequate personal space and privacy, and there were no complaints from residents regarding insufficient space for their belongings. Additionally, there were no negative consequences or safety concerns reported as a result of the decreased space in these rooms.
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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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