Fairmont Rehabilitation Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Lodi, California.
- Location
- 950 S. Fairmont Avenue, Lodi, California 95240
- CMS Provider Number
- 055242
- Inspections on file
- 25
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fairmont Rehabilitation Hospital during CMS and state inspections, most recent first.
The facility failed to submit a required 5‑day written investigation summary to the state after a resident‑to‑resident altercation in which one resident blocked a bathroom door, preventing another resident with dementia from exiting. The initial abuse report was completed and sent, and both residents’ care plans were updated to reflect risk for psychosocial and mood changes related to the incident. However, the SSD acknowledged not submitting the 5‑day investigation report, and the DON confirmed there was no documentation or confirmation of submission, despite facility policy requiring a written report of investigation findings to be provided to the appropriate agencies within five working days.
A resident with dementia and moderate cognitive impairment frequently used a shared bathroom for extended periods, limiting timely access for other residents and contributing to a prior resident-to-resident altercation over bathroom use. Several residents reported having to wait, hold urine, or seek staff help or alternate toileting locations due to the resident’s prolonged bathroom occupancy. Staff, including a CNA and an LN, acknowledged the resident’s forgetfulness, lack of call light use, removal of a personal alarm, and need for supervision, yet no individualized care plan was developed to address bathroom use behaviors or to prevent further conflict, despite facility policy requiring comprehensive, person-centered care plans.
A facility failed to implement a comprehensive water safety management program to minimize the risk of Legionella and other waterborne pathogens. After a resident tested positive for Legionella, it was found that the facility lacked a detailed risk assessment, a mapped water system, adequate monitoring protocols, and a contract with a certified water testing company. The existing policy was insufficient and did not meet CDC or public health standards, leaving gaps in prevention and response measures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents with physician-ordered small portion diets were served full meal portions instead of the prescribed reduced portions. Despite clear dietary orders and care plans, dietary staff did not follow portion control guidelines, and both residents received the same amount of food as others without such orders. Staff interviews indicated that the correct portion sizes were not called out or served, and the Food and Nutrition Services director confirmed the error.
The facility failed to label open food packages with use by dates and improperly stacked wet plate covers, risking food quality and safety for 56 residents. The Dietary Manager and Director of Nursing confirmed these practices could lead to bacterial growth and illness. Facility policies on dishwashing and food labeling were not followed.
The facility failed to ensure the safe use of facility-owned smartphones for communication with medical providers, compromising residents' Protected Health Information (PHI). Smartphones were used to send sensitive information, including residents' names and medical conditions, without secure messaging software, violating HIPAA regulations. The facility's policy required secure messaging, but this was not followed, leading to a significant breach of residents' privacy.
The facility failed to ensure safe medication storage practices, including undated and improperly stored medications on a medication cart, expired test tubes in a medication closet, and an opened, undated vial of Aplisol in a medication refrigerator. These deficiencies were acknowledged by the DON, who confirmed the potential for ineffective treatments due to these lapses.
A resident received a daily dose of Vitamin D3 at 50,000 units for two months due to a medication error. The pharmacy consultant did not identify the error during routine medication regimen reviews. The MD was unaware of the daily dosage, which could lead to adverse effects. The DON confirmed the error and expected the pharmacy to ensure medication safety.
A resident was found with three unlabeled medications at their bedside, including an inhaler and nasal sprays, without a doctor's order or facility awareness. The resident claimed these were prescribed by their allergy doctor, but the facility's policies require medications to be assessed and authorized for self-administration. The facility failed to ensure safe storage and use, leading to unauthorized medication use.
The facility failed to properly clean and sanitize a shared glucometer between uses for two residents, as observed during medication administration. An LPN used a Sani-Cloth-Bleach wipe for less than 10 seconds, not meeting the required 4-minute wet time. Interviews revealed that staff were educated on the correct procedure, which involves a two-step cleaning and disinfecting process using two wipes, as per the manufacturer's instructions. The observed practice did not align with these guidelines, posing a risk of infection spread.
The facility failed to ensure that prescription medication delivery manifests, including narcotic controlled medications, were consistently signed by licensed staff upon delivery. During an inspection, it was found that delivery sheets were not consistently signed, which may contribute to unsafe medication handling and risk of drug diversion. The Director of Nursing stated that staff signed a copy for the driver but not the facility copy, contrary to the facility's policies.
A facility failed to ensure the safe use of psychotropic medications for a resident due to an unsupported diagnosis of bipolar disorder and inadequate communication of mental health consults and medication adjustments. The resident's medical records did not reflect the bipolar disorder diagnosis used to justify aripiprazole administration, and the primary psychiatrist confirmed the absence of such a diagnosis. Additionally, the facility's process for handling mental health consults hindered the continuity of care, as critical information was not included in the resident's medical record.
The facility exceeded the acceptable medication error rate with two incidents involving medication administration errors. A nurse documented medications as given despite a resident's refusal, and another nurse administered insulin after a resident began eating, contrary to the prescribed timing. The facility's policies lacked guidance on medication refusal and nursing responsibilities.
A facility failed to ensure nursing staff followed infection prevention practices and Enhanced Barrier Precaution (EBP) guidelines during IV antibiotic administration to a resident. A nurse entered the resident's EBP-marked room without a gown and with her mask below her nose, accessing the mid-line without the required protective gown. Despite being aware of EBP requirements, the nurse admitted to forgetting to wear the gown, potentially exposing the resident to infection. Interviews confirmed staff were educated on EBP importance, and facility policy required gown and gloves during high-contact care activities.
Failure to Submit 5‑Day Investigation Summary for Resident‑to‑Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to submit a required 5‑day written investigation summary to the Department following a reportable resident‑to‑resident altercation. Resident 1, admitted with diagnoses including unspecified dementia, chronic kidney disease, and cognitive function and awareness symptoms, was involved in an incident on 11/8/25 at 6 AM in which a former roommate, Resident 5, blocked the bathroom door while Resident 1 was inside, preventing Resident 1 from exiting. Resident 5 had diagnoses including orthopedic aftercare, a displaced intertrochanteric fracture of the right femur, history of falling, gait and mobility abnormalities, type 2 DM, and depression. Care plans for both residents were initiated on 11/8/25, documenting each resident as being at risk for psychosocial and mood changes related to the bathroom‑locking incident. The Social Services Director completed and submitted the initial Report of Suspected Dependent Adult/Elder Abuse to the Department on 11/8/25 but did not submit the 5‑day investigation summary. In interview, the Social Services Director stated that he completed the 5‑day investigation for the resident‑to‑resident altercation but did not send the 5‑day investigation report to the Department. In a separate interview, the DON confirmed that the 5‑day investigation summary for the altercation involving these two residents was not submitted and that there was no documentation or confirmation of submission, despite her awareness that the summary was required within five working days. The facility’s undated Abuse Investigation and Reporting policy states that the Administrator or designee will provide a written report of investigation findings to the appropriate agencies within five working days of the incident, which was not followed in this case.
Failure to Care Plan for Resident’s Prolonged Bathroom Use and Resulting Conflicts
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized care plan to address one resident’s frequent and prolonged use of a shared bathroom, despite known cognitive impairment and a prior resident-to-resident altercation related to bathroom access. The resident was admitted with diagnoses including unspecified dementia, chronic kidney disease, and other cognitive symptoms, and a BIMS assessment later showed moderate cognitive impairment. A Report of Suspected Dependent Adult/Elder Abuse documented an incident in which the resident’s former roommate blocked the bathroom door while the resident was inside, preventing her from exiting. Staff interviews confirmed that this altercation was related to the resident’s bathroom use and that no care plan had been created to address the underlying issues or prevent recurrence. Multiple residents reported that the cognitively impaired resident used the shared bathroom very frequently and remained inside for extended periods, which delayed their own access and caused them to seek staff assistance or use alternative toileting locations. One resident stated she had to hold her urine and call a nurse to help the resident complete bathroom use so she could enter, while others described the situation as unfair and problematic. Staff, including a CNA and an LN, stated that the resident was forgetful, did not use the call light, removed her personal alarm, and required supervision to prevent prolonged bathroom use, yet there was no care plan addressing these behaviors or the prior altercation. The MDS coordinator and LN confirmed that the resident’s care plans did not include a problem, root cause, or individualized interventions related to bathroom use or resident-to-resident conflict, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timetables based on ongoing assessments.
Failure to Implement Comprehensive Water Safety Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella and other opportunistic waterborne pathogens. The deficiency was identified after a resident, who had been transferred to a local hospital, tested positive for Legionella pneumophila. Following this, the facility was instructed by the local Public Health Department (PHD) to test residents with respiratory symptoms and to conduct water testing for Legionella. Initial water testing was deemed inadequate by the PHD, as it was not performed by a certified company, and the facility did not have a contracted provider for certified water testing or maintenance at the time. The facility subsequently arranged for a certified company to collect water samples, but this was only after the PHD's intervention. Further review revealed that the facility's Water Safety Management Program policy and procedure (P&P) was insufficient and lacked critical components required by the CDC's Legionella Toolkit and public health guidance. The policy did not include a full facility-wide assessment of potential Legionella growth areas, a flow chart or diagram of the water system, or documentation of all water sources and their inlets and outlets. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that a comprehensive risk assessment had not been conducted, and the policy did not specify procedures for handling waterborne pathogen outbreaks or include a contract with a certified testing company. Observations and interviews with the Maintenance Director (MTD) further indicated that while some preventative measures, such as installing specialized filters, were being implemented, there was no established process for decontaminating the water system or a contracted provider for such services prior to the Legionella case. The local Public Health Officer confirmed that the facility's water management plan was essentially a copy of the CDC toolkit and lacked the required building-specific details, such as a mapped diagram of the water system and an actionable intervention plan. These deficiencies were present for a census of 54 residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Serve Prescribed Small Portion Diets to Two Residents
Penalty
Summary
The facility failed to ensure that dietary staff served the correct meal portions to two residents who were prescribed small portion diets. For both residents, medical records and care plans indicated the need for small portions as part of their dietary orders, with one resident on a no added salt diet and the other on a regular diet with small portions requested. During a lunch meal observation, both residents received meal trays with the same portion sizes as other residents who did not have small portion orders. The diet cards for both residents clearly indicated the need for small or half portions, but the food served did not reflect these instructions. Interviews with the residents confirmed that they consistently received full portions despite their dietary orders, and one resident expressed distress over not losing weight as a result. Staff interviews revealed that the process for calling out portion sizes during meal service was not followed correctly, leading to the error. The Food and Nutrition Services director acknowledged that the expectation was for correct portions to be served and confirmed that the observed trays did not meet the prescribed dietary requirements. Facility policy and job descriptions also required adherence to portion control guidelines, which was not followed in these instances.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to ensure safe food storage and production for 56 residents by not labeling open food packages with a use by date and improperly stacking wet plate covers. During an observation in the kitchen, it was noted that a bag of bran cereal, a five-gallon storage bin with rice, and a bag of biscuit mix were not labeled with a use by date. The Dietary Manager (DM) acknowledged that these items should have been labeled to prevent the use of potentially expired food, which could affect the quality and nutritional value of the food served to residents. Additionally, the facility did not adhere to proper dishwashing procedures, as observed when a Dietary Aid (DA) stacked wet plate covers after removing them from the dishwasher. Both the DA and the DM confirmed that dishes should be air-dried before being stacked to prevent bacterial growth. The Director of Nursing (DON) also stated that stacking wet dishes could lead to bacterial growth, posing a risk of illness to residents. The facility's policies on dishwashing and food labeling were not followed, contributing to these deficiencies.
Facility's Unsafe Use of Smartphones Compromises Resident Privacy
Penalty
Summary
The facility failed to ensure the safe use of facility-owned smartphones for communication with medical providers regarding residents' Protected Health Information (PHI). During an inspection, a smartphone was found unattended at a nurse station, containing numerous text messages and photos with sensitive resident information. The messages included residents' names, medical conditions, and photos of laboratory test results, which were communicated to medical providers without secure messaging software, violating HIPAA regulations. Licensed Nurse 7 confirmed that the smartphone was used to communicate with medical providers, and the Director of Nursing (DON) admitted that the facility did not have a special software for secure messaging. The facility's policy required the use of a secure messaging application for text-based communication involving PHI, but this was not adhered to. Instead, the facility used iMessage, which is not HIPAA compliant, to communicate sensitive information, further compromising residents' privacy. The facility's Administrator acknowledged that the smartphones were provided to assist with communication but was unsure if anyone monitored their use or the messages sent. The facility's policy on smartphone use was not followed, as evidenced by the storage of over 3,000 items, including pictures and documents with resident information, on the device. This lack of adherence to policy and secure communication practices led to a significant breach of residents' health information privacy and confidentiality.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage practices in several areas, including a medication cart, a medication closet, and a medication refrigerator. Specifically, Medication Cart 2 in Station 2 stored an undated inhalation medication called Ipratropium/Albuterol (DuoNeb), which was removed from its protective foil wrap and lacked proper labeling with the resident's name, date, and time of opening. Additionally, Medication Closet 1 in Station 1 contained expired test tubes, which were intended for blood collection and testing but were past their expiration date. The Director of Nurses (DON) acknowledged that these expired test tubes could lead to inaccurate test results if used. Furthermore, the medication refrigerator in Station 2 contained an opened and undated vial of Aplisol, a testing agent for Tuberculosis, which should have been discarded after 30 days of opening. The refrigerator also stored an expired container of Golytely liquid, which was never used by the resident it was intended for. The DON confirmed that the lack of proper dating and the presence of expired medications could result in ineffective treatments. The facility's policy on medication storage emphasizes the importance of proper labeling and the disposal of outdated drugs, which was not adhered to in these instances.
Significant Medication Error with Vitamin D3 Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when Vitamin D3 oral capsules were administered daily at a dosage of 50,000 units from late October to late December 2024. This error was identified during a review of the resident's physician order, which incorrectly indicated the daily administration of the high-dose Vitamin D3. The pharmacy consultant confirmed that medication regimen reviews were conducted during this period but did not catch the error. The consultant acknowledged that if the error had been identified in real-time, a recommendation would have been made to reduce the dosage and request laboratory tests for Vitamin D levels. The Medical Doctor (MD) responsible for the resident was unaware that the order was for daily administration and stated that such a dosage could lead to adverse effects like nausea, vomiting, and hypercalcemia. The Director of Nursing (DON) confirmed the daily administration of the high-dose Vitamin D3 and expressed an expectation for the pharmacy to ensure the efficacy and safety of medications. The facility's policy on medication regimen review was not effectively implemented, as the pharmacist failed to identify the clinically significant risk associated with the medication error.
Unauthorized Medication Use and Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage and use of medications for a resident, leading to unauthorized medication use without a doctor's order. During a medication administration observation, it was found that a resident had three unlabeled medications stored at their bedside, including an inhaler and two nasal sprays. The Licensed Nurse (LN) present was unaware of these medications and confirmed that there were no doctor's orders for them in the resident's Medication Administration Record (MAR). The resident stated that these medications were prescribed by their allergy doctor and had been used for years, but the facility was not informed of their use since the resident's admission. The Director of Nursing (DON) stated that residents could use their own medications with a doctor's order and an assessment of safe storage and the resident's mental status. The facility's policies indicated that any medications brought in by residents should be given to the charge nurse and that self-administered medications should be stored securely. However, the resident's medications were not assessed or authorized for self-administration, posing a potential safety risk. The facility's failure to adhere to its policies resulted in the unauthorized use and unsafe storage of medications.
Improper Cleaning of Shared Glucometer
Penalty
Summary
The facility failed to ensure the safe cleaning and sanitization of a shared glucometer between resident uses, as observed during medication administration for two residents. Licensed Nurse 2 (LN 2) was seen using the glucometer on Resident 39 and then on Resident 10 without following the proper cleaning protocol. The nurse used a Sani-Cloth-Bleach wipe for less than 10 seconds to clean the glucometer's outer surface, which did not meet the required 4-minute wet time specified by the manufacturer and facility policy. Interviews with LN 2 and the Infection Prevention nurse (IP) revealed that the nursing staff had been educated on the correct procedure for cleaning and disinfecting shared glucometers. The IP stated that the process involved a two-step cleaning and disinfecting procedure using two wipes, as per the manufacturer's instructions. However, LN 2 did not adhere to this protocol, potentially compromising infection control measures. The facility's policy and the manufacturer's instructions both emphasized the importance of using two wipes to clean and disinfect the glucometer, with a visible wet time of four minutes to ensure effective germ elimination. Despite this, the observed practice did not align with these guidelines, posing a risk of infection spread among residents. The Director of Nursing acknowledged the importance of following the correct cleaning procedures but did not provide further details on how the process should be implemented by the nursing staff.
Failure to Sign Medication Delivery Manifests
Penalty
Summary
The facility failed to ensure that prescription medication delivery manifests, including those for narcotic controlled medications, were consistently signed by licensed staff upon delivery from the provider pharmacy. During a medication area inspection, it was observed that the delivery sheets for prescription and narcotic medications at Station 1 were not consistently signed by nursing staff upon receipt. Licensed Nurse 6 acknowledged signing the paper from the delivery driver but was unsure why most sheets were unsigned. This inconsistency in signing the delivery manifests may contribute to unsafe medication handling and the risk of drug diversion. In an interview, the Director of Nursing stated that staff signed a copy of the delivery sheet for the driver and were not required to sign the facility copy. The facility's policy on controlled substances indicated that controlled substances should be reconciled upon receipt, and both the nurse receiving the medication and the delivery agent should sign the controlled substance record of receipt. Additionally, the policy on accepting delivery of medications required that a nurse sign the delivery ticket, indicating review and acceptance of the delivery. The failure to adhere to these policies resulted in a deficiency in the facility's pharmaceutical services.
Failure to Ensure Safe Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for a resident, identified as Resident 44, who was selected for unnecessary medication use. The resident's documented diagnosis of bipolar disorder, which was used to justify the administration of aripiprazole, was not reflected in the medical doctor's progress notes, history and physical, or previous hospitalization records. Additionally, the resident's mental health consult and medication adjustments were not communicated to the primary medical doctor, the Director of Nursing, licensed nursing staff, or the resident's representative. Resident 44 was admitted to the facility with multiple diagnoses, including Parkinson's disease, dementia, encephalopathy, psychosis, anxiety disorder, major depressive disorder, and bipolar disorder. However, the diagnosis of bipolar disorder was not supported by the medical records from the attending physician or previous hospital records. The resident's psychiatric visit progress report relied on facility records for the diagnosis, and the resident herself denied ever being diagnosed with bipolar disorder. Furthermore, the resident's primary psychiatrist confirmed that she had never been diagnosed with bipolar disorder. The facility's process for handling mental health consults and medication orders was flawed, as the social services director retained the psychiatric progress notes due to confidentiality concerns, preventing them from being included in the resident's medical record. This lack of access to critical information hindered the continuity of care and the ability of licensed nurses and attending physicians to make informed decisions about the resident's treatment. The failure to communicate and document the mental health consults and medication adjustments contributed to the unsafe use of psychotropic medications for Resident 44.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.67%, which is above the acceptable threshold of 5%. During a medication pass observation, a licensed nurse administered medications to a resident who refused three pills, including a laxative, Vitamin C, and a multivitamin. Despite the refusal, the nurse documented these medications as administered in the resident's electronic medical record without noting the refusal. The nurse admitted to documenting the administration before entering the resident's room and forgetting to update the record to reflect the refusal. In another instance, a licensed nurse failed to administer insulin to a resident according to the prescribed timing. The nurse measured the resident's blood sugar and administered insulin after the resident had already started eating lunch, contrary to the doctor's order to administer insulin 5-10 minutes before meals. The Director of Nursing acknowledged that the blood sugar measurement and insulin administration should have been coordinated with meal delivery to ensure accuracy and adherence to the doctor's orders. The facility's policies on medication administration and insulin administration did not adequately address medication refusal and the responsibilities of nursing staff.
Failure to Follow Enhanced Barrier Precautions During IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure that nursing staff adhered to infection prevention practices and the Enhanced Barrier Precaution (EBP) guidelines during the administration of intravenous (IV) antibiotics to Resident 47. During an observation, Licensed Nurse 5 (LN 5) was seen entering Resident 47's room, which was marked with an EBP sign, without wearing a gown and with her mask worn below her nose. LN 5 proceeded to administer the IV antibiotic by accessing the mid-line without the required protective gown, which could potentially expose the resident to infection. LN 5 acknowledged awareness of the EBP requirements but admitted to forgetting to wear the gown. Interviews with the Infection Prevention nurse and the Director of Nursing confirmed that staff were educated on the importance of following EBP guidelines to prevent the spread of infection. The facility's policy and the posted EBP sign in Resident 47's room required staff to wear a gown and gloves during high-contact care activities, such as accessing an IV line, to prevent the transfer of multi-drug resistant organisms. Despite this, LN 5 did not comply with these precautions, which are crucial for residents with indwelling medical devices like central venous catheters.
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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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