Flower Villa, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 1480 S. La Cienega Bl, Los Angeles, California 90035
- CMS Provider Number
- 056438
- Inspections on file
- 20
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Flower Villa, Inc during CMS and state inspections, most recent first.
The facility failed to provide required infection preventionist (IPN) coverage to oversee its infection prevention and control program. Review of schedules and timecards showed the IPN only worked a few 8‑hour shifts per month, despite leadership acknowledging a 40‑hour‑per‑week IPN coverage requirement. Staff interviews indicated the IPN was present only once or twice a week for a few hours and did not provide consistent infection prevention in‑services or training, even though the IPN was responsible for setting isolation protocols and infection control guidelines. The facility’s own policies and Facility Assessment identified infection prevention and control, including dedicated infection control staff and systems for preventing, identifying, reporting, investigating, and controlling infections, as necessary for the resident population.
A resident with multiple chronic conditions experienced severe weakness, inability to eat, and inability to speak. Staff did not immediately assess or notify the physician of these significant changes, initially attributing symptoms to the need for rest. Only after further decline and abnormal vital signs did staff contact the physician, who ordered emergency transfer to a hospital. This delay was inconsistent with facility policy and resulted in the resident's further decline.
The facility did not ensure an RN was onsite for at least 8 consecutive hours daily, as required, on multiple occasions. Staffing records and interviews with the DSD and DON confirmed the lack of RN coverage, impacting the oversight of nursing services for 31 residents.
The facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare-covered skilled nursing services for three residents. Instead, the NOMNC was issued only one day prior to the last covered day, despite residents having varying medical conditions and cognitive statuses. This was confirmed by record review and staff interview, and was not in accordance with facility policy or federal requirements.
Surveyors found that drawers in three resident rooms did not close properly and had chipped paint, as confirmed by the Maintenance Director and DON. This failure to maintain resident room furniture in good condition did not meet facility policies for providing a safe, clean, and homelike environment.
The facility did not post actual nursing hours worked by licensed and unlicensed staff for three consecutive days, displaying only projected hours and omitting required calculations for unlicensed staff. Staff interviews revealed confusion about posting requirements, and review of facility policy confirmed that daily posting of actual hours and NHPPD values was not being followed.
Surveyors identified failures in food safety and kitchen sanitation, including unclean storage areas, grease accumulation on kitchen equipment, and multiple open food containers in the refrigerator lacking required use-by dates. Staff confirmed the labeling oversight, and the DON reported that hand sanitizer had been removed from the kitchen.
The facility did not ensure that medical records and transfer documentation were accurate and complete for several residents. One resident's POLST and Advance Directive forms contained errors, including incorrect relationship information and missing signatures. For three other residents, Notice of Proposed Transfer/Discharge forms were not signed by the residents or their representatives, and there was no documentation that the Ombudsman was notified of their transfers. These deficiencies resulted in incomplete and inaccurate records.
The facility did not submit complete and accurate PBJ staffing data to CMS for three required quarters, resulting in reported gaps in RN and LVN coverage on multiple days. The DSD confirmed that the data submitted by the corporate office was inaccurate, despite facility policies requiring accurate reporting. This deficiency had the potential to impact all residents by risking delays in necessary care and services.
A Hoyer Lift was found without documentation of annual manufacturer inspection, showing rust and chipped paint. The Maintenance Director stated that the lift had not been professionally inspected as required, and that he performed repairs without manufacturer certification, contrary to facility policy.
A resident with multiple psychiatric diagnoses and prescribed Ativan for anxiety did not have a care plan developed to address the use of this psychotropic medication. Despite receiving numerous doses and being cognitively intact, the facility failed to document a care plan to guide staff in managing the resident's anxiety or monitoring medication effects, as confirmed by staff interviews and record review.
A resident with COPD did not receive required pre- and post-nebulizer lung sound assessments as ordered by the physician and outlined in facility policy. Nursing staff administered and completed nebulizer treatments without consistently auscultating lung sounds before and after therapy, and staff interviews revealed a lack of awareness of this requirement.
A resident's ipratropium-albuterol inhalation solution was found in the medication cart with an opened foil pouch and undated unit-dose vials, despite manufacturer guidelines requiring use within one week of opening. The LVN and DON confirmed that the medication should have been labeled with the date it was first opened, but this was not done.
A medication error rate above 5% was identified when an LVN crushed and combined three oral medications—ProAmatine, Risperdal, and Vitamin D3—before administering them to a resident with severe cognitive impairment and multiple diagnoses. This practice was not in accordance with facility policy, as confirmed by the DON, and resulted in three errors out of 28 medication opportunities.
A nurse crushed and administered three medications together for a resident with severe cognitive impairment and multiple medical conditions, contrary to facility policy and accepted standards. The DON confirmed that these medications should not have been crushed and given together.
A resident with multiple chronic conditions and moderate cognitive impairment was not provided a routine dental visit as ordered, despite the facility's policy and the availability of dental services for other residents. This was confirmed through record review and staff interview.
Eighteen resident rooms did not meet the required minimum of 80 square feet per resident, with room sizes ranging from 67 to 76.38 square feet per bed. Despite this, observations indicated that residents and staff had enough space to move and provide care, and all necessary furnishings and equipment were present.
A resident at high risk of fractures was improperly repositioned by a single CNA, contrary to the care plan requiring two to three-person assistance. The resident's refusal of care was not documented or reported, leading to a humerus fracture. The facility also failed to document a change of condition, delaying appropriate care.
Insufficient Infection Preventionist Coverage for Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to employ and schedule a qualified Infection Preventionist Nurse (IPN) at least part time, as required by state expectations and as outlined in the facility’s own Facility Assessment Tool and infection prevention and control policy. Review of the LVN schedules and IPN timecards for November and December 2025 and January 2026 showed the IPN was only scheduled and actually worked a limited number of days and hours each month, far below the 40 hours per week of IPN coverage that the DON and administrator stated were required. In November 2025, the IPN worked three 8‑hour days; in December 2025, three 8‑hour days; and in January 2026 through 1/27/2026, two 8‑hour days. The facility’s policy stated that the designated infection preventionist is responsible for oversight of the infection prevention and control program, including consultation on infectious diseases, room placement, isolation precautions, exposures, surveillance, and epidemiological investigations. Staff interviews confirmed that the IPN was not present on a full‑time basis and did not provide consistent infection prevention in‑services and trainings. A CNA reported that the IPN did not have a full‑time schedule and did not consistently conduct infection prevention education. The MDS coordinator stated that resident isolation protocols and guidelines were set by the IPN and that the IPN came to the facility only once or twice a week for a few hours. The DON and administrator both acknowledged awareness of the 40‑hour IPN coverage requirement but stated that, because the building was smaller, the IPN only came a few times a week. In a telephone interview, the IPN stated she considered herself full time, working two to three 8‑hour shifts per week, and was aware that skilled nursing facilities are required to have 40 hours of IPN coverage. The Facility Assessment Tool identified infection prevention and control as a needed type of care for the resident population and specified that infection control and prevention staff were required, as well as systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and contracted providers.
Failure to Promptly Notify Physician of Resident Change in Condition
Penalty
Summary
Facility staff failed to immediately assess and notify the physician when a resident experienced a significant change in condition, including severe weakness, inability to eat, and inability to speak during a morning shift. The resident, who had a history of type 2 diabetes, hypertensive heart disease, anxiety disorder, schizophrenia, COPD, and hypertension, was noted to have intact cognitive skills prior to the incident and was partially dependent on staff for mobility and transfers. On the morning in question, the resident was found unresponsive to verbal communication and refused breakfast, with initial vital signs showing a heart rate of 59 and oxygen saturation of 94%. Despite these changes, the initial response by one of the LVNs was to allow the resident to rest, believing more sleep was needed, and did not immediately recognize the situation as a change of condition. It was only after further decline, including a heart rate dropping to 40 and oxygen saturation to 89% on nasal cannula, that the charge nurse was notified and the physician was contacted. The physician then ordered the resident to be transferred to an acute care hospital via 911 for further evaluation and treatment. Interviews with staff and review of facility policies confirmed that the delay in assessment and notification was contrary to facility procedures, which require prompt physician notification for significant changes in a resident's condition. The Director of Nursing acknowledged that such delays pose a resident safety risk. The deficiency was identified based on the failure to promptly assess and notify the physician, resulting in further decline of the resident and the need for emergency transfer.
Plan Of Correction
F0580 Notify of Changes (Injury / Decline / Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15) On 12/11/25, resident 3 was transferred to the General Acute Care Hospital (GACH) via 911. On 12/21/25, resident 3 was readmitted to the facility and is currently safe and comfortable. To identify other residents with the potential to be affected, the DON reviewed any changes of condition for the last 30 days and no other residents were found to be affected by this deficient practice. On 12/29/25, the DON in-serviced licensed nurses regarding the facility's policy and procedure titled "Change in a Resident's Condition or Status," with emphasis on the nurse supervisor/charge nurse notifying the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical, emotional, or mental condition. On 12/29/25, the DON also in-serviced licensed nurses regarding the facility's policy and procedure titled "Vital Signs," with emphasis on vital signs being indicators of health status. Licensed nurses are responsible for knowing the usual range of a resident's vital signs, analyzing and interpreting routine vital signs, and notifying the physician of abnormal findings. To ensure that the systems in place are sustained and maintained, the DON or designee will conduct a random audit of five residents weekly for twelve (12) consecutive weeks. These residents will be reviewed to ensure that if there was any change of condition that has been identified, they were properly evaluated and communicated to the appropriate people. The DON will report any negative findings to the Quarterly Quality Assurance and Assessment (QA&A) Committee for review and recommendations for the next 3 months. Corrective Action Completion Date: 12/31/2025
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was onsite for at least 8 consecutive hours a day, seven days a week, as required. Review of the CMS Payroll Based Journal (PBJ) staffing data and the facility's own nursing staffing records revealed that there was no RN coverage on multiple specific days within the reviewed period. This was confirmed through interviews with both the Director of Staff and Development (DSD) and the Director of Nursing (DON), who acknowledged the absence of RN coverage on the identified dates. The facility's policy and procedures state that adequate staffing, including licensed RNs, must be maintained to meet the care and service needs of residents. Despite this policy, the lack of RN coverage was documented and verified, affecting the facility's ability to manage and oversee nursing services for 31 residents. The deficiency was identified through observation, interview, and record review, and was cross-referenced to F851.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the last covered day of skilled nursing services for three residents. For each resident, the NOMNC was issued and signed only one day before the end of Medicare-covered services, rather than the required two days. This was confirmed through review of admission records, NOMNC forms, and the SNF Beneficiary Protection Notification Review Forms for all three residents. Resident 7, who had diagnoses including COPD, diabetes mellitus, and schizophrenia, was cognitively intact and required supervision for daily activities. The NOMNC for this resident indicated services would end on a specific date, but the notice was provided only one day prior. Similarly, Resident 11, with bipolar disorder and major depressive disorder and also cognitively intact, received the NOMNC one day before the end of covered services. Resident 18, who had gout, chronic kidney disease, and muscle wasting, and was moderately cognitively impaired, also received the NOMNC only one day before coverage ended. During an interview and record review, the Social Services Director confirmed that the facility notified all three residents only one day prior to the end of their covered services, acknowledging that the required notification period is at least two days. Facility policy and the State Operations Manual both require that the NOMNC be provided at least two days before the end of Medicare coverage, which was not followed in these cases.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
Surveyors observed that three of seven residents' rooms (Rooms 1, 16, and 20) were not maintained in a safe, clean, and comfortable condition. Specifically, the drawers in these rooms, where residents stored their clothes and belongings, did not close completely and had chipped paint. These issues were identified during a concurrent interview and observation with the Maintenance Director, who confirmed that the drawer sliders needed replacement to restore proper function for resident use. Further interviews with the Director of Nursing confirmed that equipment not in proper condition should be replaced as needed. A review of the facility's policies indicated that the facility is required to provide a safe, clean, and homelike environment and to maintain all equipment and infrastructure regularly. The failure to address the malfunctioning and damaged drawers in residents' rooms was inconsistent with these policies and procedures.
Failure to Post Actual Nursing Hours Per Patient Day
Penalty
Summary
The facility failed to ensure that the actual nursing hours worked by both licensed and unlicensed nursing staff directly responsible for resident care were posted for three consecutive sampled days. Observations on each of these days revealed that only projected nursing hours were displayed on the Direct Care Services Hours Per Patient Day (DHPPD) postings, with no actual hours or calculations for unlicensed nursing staff included. Additionally, there was no DHPPD posting for the previous day on each observed date. Interviews with facility staff, including the Director of Staff and Development, Minimum Data Set Coordinator, and Director of Nursing, confirmed a lack of clarity and understanding regarding the requirements for posting actual nursing hours and including unlicensed staff in the calculations. Review of facility policies indicated that daily posting of actual nursing hours, patient census, and NHPPD values is required, but these procedures were not being followed as observed and confirmed by staff statements.
Deficient Food Safety, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food safety and kitchen sanitation practices. Dirt and debris were found under dry storage racks in the corners of the dry food storage room, and grease drips were noted on the sides of the range oven. During a review of open food containers in the kitchen refrigerator, several items including tuna salad, salsa, shredded cheese, mayonnaise, and soy milk were found without required use-by dates. Kitchen staff confirmed that labeling had been overlooked. The Director of Nursing stated that hand sanitizer had been removed from the kitchen, but it was only used when staff left the kitchen. Facility policies reviewed indicated requirements for cleanliness in food service areas and proper labeling of food items, which were not followed.
Incomplete and Inaccurate Medical Records and Transfer Documentation
Penalty
Summary
The facility failed to ensure that medical records for four of five reviewed residents were accurate and complete. For one resident with severe cognitive impairment and multiple diagnoses, the POLST form was incorrectly filled out, listing the brother in the relationship field instead of 'self,' and the Advance Directive form was missing the physician's signature date and had the surrogate decision maker's name entered in error instead of the resident's. The Director of Nursing confirmed these errors during record review and interview. Additionally, three other residents' Notice of Proposed Transfer/Discharge forms were not signed by the residents or their representatives. These residents had varying levels of cognitive function and assistance needs, with some being independent and others requiring substantial or total assistance with activities of daily living. The forms indicated that these residents were transferred to a general acute care hospital, but there was no documentation that the Ombudsman had been notified of the transfers, as verified by the Medical Records Director. Facility policy requires all documentation to be accurate, complete, and reliable. However, the observed deficiencies included incomplete and inaccurate completion of critical forms related to end-of-life care and resident transfers, as well as missing required notifications. These failures resulted in inaccurate and incomplete forms in the medical records, with the potential to affect the delivery of care.
Failure to Submit Accurate PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to ensure the complete and accurate submission of Payroll Based Journal (PBJ) staffing data to CMS for three out of four required quarters in 2024. Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) and CMS PBJ Staffing Data Report revealed missing Registered Nurse (RN) and Licensed Vocational Nurse (LVN) coverage on multiple dates across the 1st, 2nd, and 4th fiscal quarters. Specifically, there were numerous days with no RN hours reported and several days with no 24-hour LVN coverage, as reflected in the PBJ data submitted to CMS. The Director of Staff and Development (DSD) confirmed that PBJ reporting was managed by the corporate office and acknowledged inaccuracies in the data submitted, despite stating that RN and LVN coverage was present on some of the dates in question. Facility policies required accurate and timely PBJ submissions, including all direct care staff and contract employees, in compliance with federal regulations. The CMS PBJ Policy Manual also mandates that staffing information be complete and accurate, with facilities responsible for verifying the accuracy of their submissions prior to the deadline. The failure to submit accurate staffing data had the potential to affect all 41 residents in the facility, as it could result in delays in care, treatment, and services necessary for their physical and emotional wellbeing.
Failure to Maintain and Inspect Hoyer Lift per Manufacturer Guidelines
Penalty
Summary
A Hoyer Lift in the facility was found to be lacking evidence of proper maintenance and inspection. During an observation and interview with the Maintenance Director, it was noted that the lift did not have stickers indicating the date of the last manufacturer's inspection. The lift also showed visible signs of wear, including rust and chipped paint. The Maintenance Director confirmed that the Hoyer Lift had not been inspected annually by the manufacturer, and that he personally replaced broken parts as needed without holding a manufacturer certification to service the equipment. A review of the facility's policies revealed that all Hoyer lifts are required to be regularly inspected, maintained, and repaired according to manufacturer guidelines, with annual inspections by a certified technician. The policies also require comprehensive safety checks, parts replacement, load capacity testing, and maintenance records. These procedures were not followed, as evidenced by the lack of inspection records and the Maintenance Director's statements.
Failure to Develop Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was prescribed Ativan, a psychotropic medication, for anxiety disorder. Despite the resident having active diagnoses of schizophrenia, major depressive disorder, anxiety disorder, and psychotic disorder, and being cognitively intact with the capacity to make decisions, there was no care plan initiated to address the use of Ativan or the resident's anxiety. The resident received multiple doses of Ativan over the course of two months, as documented in the Medication Administration Records, but the care plan documentation did not reflect this intervention. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the absence of a care plan for Ativan meant there was no documented approach to guide staff in managing the resident's anxiety or monitoring for potential side effects of the medication. The facility's policy required a person-centered comprehensive care plan to be developed by an interdisciplinary team within seven days of assessment and to be reviewed and revised as needed, but this process was not followed for the resident in question.
Failure to Perform Required Respiratory Assessments During Nebulizer Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care services for a resident diagnosed with COPD, TIA, and anemia by not following physician orders to auscultate lung sounds before and after nebulized medication administration. Specifically, staff did not listen to the resident's lung sounds prior to or following the administration of Ipratropium/Albuterol (Duoneb) via nebulizer, as required by the physician's order and the facility's own policy. Observations showed that one nurse administered the medication without auscultating lung sounds beforehand, and another nurse removed the nebulizer mask without performing the required post-treatment assessment. Interviews with staff revealed a lack of awareness regarding the physician's order to auscultate lung sounds pre- and post-treatment, despite this being a common practice to assess medication effectiveness. The resident confirmed that staff sometimes, but not always, listened to lung sounds before and after treatments, and on the day in question, the nurse only listened prior to administration. The facility's policy also required documentation of respiratory assessments before and after nebulizer therapy, which was not consistently followed.
Failure to Label Opened Inhalation Medication with Date
Penalty
Summary
A deficiency was identified when a resident's ipratropium-albuterol inhalation solution, used for the treatment of chronic obstructive pulmonary disease (COPD), was found in the medication cart with an opened foil pouch and visible unit-dose vials that were not labeled with the date of opening. The medication label specified that it expires seven days after opening, and manufacturer guidelines require that individual vials be used within one week of opening the foil pouch. During observation and interview, the LVN confirmed that the medication should have been labeled with the date it was first opened. The resident involved had a history of hypertensive heart disease, chronic kidney disease, and COPD, and was independent in activities of daily living with intact cognitive skills. The DON also confirmed that inhalation medication foil pouches should be dated upon opening, in accordance with manufacturer and pharmacy recommendations. Facility policy on nebulizer therapy requires proper administration by nursing staff, but did not specify labeling requirements. The failure to label the medication with the open date was directly observed and confirmed by staff.
Medication Error Rate Exceeds 5% Due to Improper Crushing and Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a medication error rate of 10.71%. This was identified during observation, interview, and record review, where three medication errors were observed out of 28 medication administration opportunities for one resident. The errors occurred when a Licensed Vocational Nurse (LVN) crushed and combined three medications—ProAmatine, Risperdal, and Vitamin D3—together before administering them to a resident, contrary to facility policy and standards of practice. The resident involved had multiple diagnoses, including dementia, vitamin D deficiency, paranoid schizophrenia, anxiety disorder, encephalopathy, and hypotension, and was assessed as having severe cognitive impairment and being dependent on staff for all activities of daily living. The facility's policy required that medications be crushed and administered in accordance with safety and accuracy standards, considering the resident's needs and medication schedule. The Director of Nursing confirmed that the medications should not have been crushed and administered together, indicating a failure to follow established procedures.
Crushing and Administering Multiple Medications Together
Penalty
Summary
A deficiency occurred when a nurse crushed and administered three medications—ProAmatine, Risperdal, and Vitamin D3—together for a resident with multiple diagnoses, including dementia, vitamin D deficiency, paranoid schizophrenia, anxiety disorder, encephalopathy, and hypotension. The resident was severely cognitively impaired and dependent on staff for all activities of daily living. The nurse removed the medications from their packaging, placed them together in a pouch, crushed them simultaneously, and mixed them with applesauce before administration. The facility's policy stated that medications may be combined and administered orally when appropriate, considering resident safety and standards of practice. However, during an interview, the DON confirmed that the medications should not have been crushed and administered together, and that the nurse should have known this. The incident was identified through observation, interview, and record review, and it was determined that the nurse's actions did not align with facility policy or accepted standards for medication administration.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide a routine dental visit for one resident who had an order for dental consult and treatment as indicated. The resident, admitted with multiple diagnoses including COPD, bipolar disorder, schizoaffective disorder, CVA, and paraplegia, had moderately impaired cognition and required varying levels of assistance with daily activities. Record review and interview with the Social Services Director confirmed that the resident had not been seen by a dentist since admission, despite the facility's policy to assist residents in obtaining routine and emergency dental care and the presence of a dentist in the facility for other residents.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that 18 out of 21 resident rooms met the required minimum area of 80 square feet per resident for multiple occupancy rooms, as specified by federal regulations. Documentation, including a room waiver request letter and a Client Accommodation Analysis, confirmed that these rooms provided less than the required square footage per resident, with measurements ranging from 67 to 76.38 square feet per bed. Observations conducted over several days showed that both residents and staff had sufficient space to move and provide care, and all necessary furniture and equipment were accommodated within the rooms. The facility's own policy also stipulated the same minimum square footage requirements, which were not met in these rooms.
Failure to Prevent Injury and Document Care Refusal
Penalty
Summary
The facility failed to ensure a safe environment for a resident at high risk of fractures, who required maximum assistance with repositioning and perineal care. On 6/10/2024, the resident, who had a care plan requiring two to three-person assistance, was improperly repositioned by a single CNA during perineal care. The CNA did not follow the facility's protocol for turning and repositioning, which led to the resident being turned to her left side for an extended period, despite her hemiplegia on that side. This improper handling resulted in the resident sustaining a humerus fracture. The resident's care plan also included interventions for her resistance to care, which were not followed. The resident expressed refusal to be changed, but the CNA proceeded without seeking additional assistance or reporting the refusal to a supervisor, as required by the facility's policy. The resident's refusal and the CNA's actions were not documented, and the incident was not reported to the charge nurse, which contributed to the oversight of the resident's condition. Furthermore, the facility failed to document a change of condition after the resident sustained the fracture. The Director of Nursing confirmed that no change of condition was completed, which was necessary for a comprehensive assessment of the resident's status. This lack of documentation and communication resulted in a delay in addressing the resident's injury, as evidenced by the resident's severe pain and subsequent transfer to a hospital for further evaluation and treatment.
Latest citations in California
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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