Foothill Heights Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1515 North Fair Oaks Ave, Pasadena, California 91103
- CMS Provider Number
- 555894
- Inspections on file
- 53
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Foothill Heights Care Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, anxiety, unsteadiness of feet, and moderately impaired cognition was care planned as at risk for wandering/elopement, with interventions including door monitoring each shift. Despite this, staff interviews and records showed that the unsecured, non-alarmed front door—located on a busy street and expected to be continuously supervised and locked at night—was left unsupervised for a period, during which the resident left the building through that door. The resident, last seen in a wheelchair near the nurse’s station, was later confirmed to have exited via the front door and stated an intention to travel out of state, demonstrating a failure to implement required supervision and environmental safety measures to prevent elopement.
A resident with severe cognitive impairment and multiple wounds did not have wound care treatments accurately documented on the TAR for two dates, despite physician orders for daily dressing changes. The treatment nurse stated the care was provided but not recorded, which resulted in incomplete medical records and potential miscommunication among staff.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
A resident with a history of fluctuating mental status and cognitive intactness made allegations of sexual abuse upon readmission. The family reported these allegations to the DON, but the DON and Administrator did not acknowledge or report them to required authorities, contrary to facility policy.
A resident with multiple medical conditions and moderate cognitive impairment was left waiting for assistance for about an hour due to a non-functional call light system. The call light failed to produce an audible or visual signal, and staff confirmed its malfunction. Facility policy requires call lights to be operational at all times, but this was not ensured, resulting in delayed care.
Surveyors observed that opened containers of dressing and syrup, as well as multiple bags of frozen vegetables, were not labeled with the required use by date or food name. The Dietary Supervisor confirmed that this was not in accordance with facility policy, and acknowledged that the lack of labeling could lead to expired or incorrect food being served.
Staff did not consistently use full PPE, including N95 respirators, gowns, gloves, and eye protection, when entering rooms of residents on COVID-19 precautions, and soiled items were left on the floor instead of being properly contained, in violation of facility policy and CDC guidance.
A resident with moderate cognitive impairment had personal snacks removed from her bedside table and her boots washed by a CNA without her permission, despite her explicit refusal. The resident became upset after discovering her belongings were taken without consent. Staff interviews and facility policy confirmed that permission should have been obtained before removing or handling the resident's property.
A resident with severe joint mobility loss and at risk for contractures did not consistently receive or have documented restorative nursing care, including passive range of motion exercises and application of bilateral knee splints, as ordered. Staff interviews and record reviews confirmed lapses in both the provision and documentation of these interventions during multiple days, contrary to the resident's care plan and facility policy.
A resident with a g-tube, severe cognitive impairment, and a history of dysphagia and pneumonia did not receive appropriate care when an LVN failed to verify tube placement before administering a water flush and medications, contrary to physician orders and facility policy. The LVN only checked tube placement after the flush, and interviews confirmed that proper protocol was not followed.
A resident with respiratory disorders and on continuous oxygen therapy did not have a No Smoking/Oxygen in Use sign posted outside their room, as required by facility policy. Staff and the DON confirmed the omission, and the policy review indicated that such signage is necessary for safe oxygen administration.
A resident with severe cognitive impairment and incontinence was incorrectly documented as always voiding appropriately in their bowel and bladder assessment, despite other records indicating incontinence. This documentation error was confirmed by the DSD and DON, who acknowledged the assessment did not accurately reflect the resident's condition.
A resident with severe cognitive and physical impairments, including Alzheimer's disease and dependence on staff for daily activities, was found to have their call light out of reach despite care plan and facility policy requirements. The resident was unaware of the call light's location, and staff confirmed it was not accessible, resulting in the resident being unable to request assistance when needed.
Thirteen resident rooms were found to be below the required minimum square footage per resident, with both two-bed and four-bed rooms not meeting regulatory standards. Staff, including a CNA and an LVN, reported having enough space to provide care, and residents did not express concerns about room size. The facility submitted a waiver request, and the Department indicated it would recommend approval.
A facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The resident, with diagnoses including diabetes mellitus type 1 and schizoaffective disorder, made the allegation on March 5, 2025. Interviews with staff revealed a lack of adherence to the facility's policy on abuse reporting, as the Administrator did not initiate an investigation or report the allegation promptly. The facility's policies required immediate reporting of abuse allegations, but these were not followed, resulting in a deficiency.
The facility did not post accurate and complete DHPPD information as required. On a specific day, the DHPPD form was missing, and forms from previous days were incomplete, showing only projected hours. The DSD and APPD acknowledged their roles in this oversight, with the APPD citing illness as a reason for not completing the forms. The facility's policy requires posting within two hours of each shift, which was not followed.
A resident with impaired cognitive skills and mobility issues was found without a call light within reach, posing a risk for delayed assistance with ADLs. Staff confirmed the call light was misplaced behind curtains, contrary to facility policy requiring it to be easily accessible.
A resident with dementia and a history of falls fell while attempting to transfer to bed without assistance, despite requiring partial to moderate assistance for such activities. The CNA present did not assist, and the care plan lacked specific interventions for bed transfers. The facility's policies on fall risk assessment and intervention were not adequately followed, contributing to the incident.
A resident was not readmitted to the facility after hospitalization despite available beds, violating their right to return. The facility required the resident to be on hospice care for readmission, citing frequent hospitalizations and isolation needs. This decision contradicted the facility's policy allowing residents to return if a bed is available.
A facility failed to report an alleged abuse incident involving a resident with legal blindness, anxiety disorder, and type 2 diabetes mellitus within the required two-hour timeframe. The resident reported that a Social Services staff member made hurtful and insulting statements, which was recognized as emotional abuse by the Director of Staff Development (DSD). However, the DSD did not report it to the Administrator due to being busy, and the Administrator later decided not to report it to the California Department of Public Health, considering it a grievance instead.
A facility failed to suspend a Social Services staff member after an alleged abuse incident involving a resident with legal blindness, anxiety disorder, and type 2 diabetes. The resident reported that the staff member made hurtful statements, but the administrator did not suspend the staff member or submit a required investigation report to CDPH, violating the facility's policy.
The facility failed to submit MDS Discharge Tracking Forms to CMS within the required 31-day period for two residents, leading to potential inaccuracies in quality indicators. The MDS Consultant confirmed the oversight, and a review of the facility's manual and job description highlighted the importance of timely submission.
The facility failed to discard ground beef from the refrigerator after it was past the use-by date, as per the facility's policy. The Cook and Dietary Supervisor confirmed that the expired meat could cause foodborne illness, and the facility's policy requires supervisors to ensure food items are not expired.
The facility failed to ensure informed consent for Binding Arbitration Agreements for three residents. One resident signed without understanding the agreement, another had conflicting signatures indicating both agreement and refusal, and a third had a signature discrepancy and fluctuating decision-making capacity.
The facility staff failed to sanitize a blood pressure cuff between uses for two residents, leading to a potential risk of bacterial transmission. An LVN admitted to not disinfecting the cuff, and the Infection Preventionist confirmed the importance of this practice. The facility's policy requires reusable items to be cleaned and disinfected between residents.
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, violating their right to be fully informed about their treatment. One resident was prescribed Seroquel without consent, and another was administered quetiapine and lorazepam without consent, contrary to the facility's policy.
The facility failed to ensure that call lights were within sight and reach for four residents, all of whom had impaired cognitive skills and were dependent on others for ADLs. Observations revealed that the call lights were clipped to the sides of pillows and had cords that were too short, preventing residents from calling for assistance.
The facility failed to ensure that the responsible party for a resident with dementia, who lacked the capacity to understand medical conditions, received information regarding the resident's right to formulate an advance directive. The resident signed the Advance Directives Acknowledgement Form despite being severely cognitively impaired, and there was no documentation that the advance directive was discussed with the responsible party as required by the facility's policy.
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, admitted with anxiety disorder, schizophrenia, and malnutrition, was dependent on staff for ADL care and receiving nutrition through a G-tube. Both an LVN and an MDS Consultant confirmed the absence of the required care plan.
The facility failed to position a nephrostomy bag below kidney level for a resident with acute kidney failure and an infection related to the nephrostomy catheter. Observations and interviews confirmed that the bags were placed at the same level as the kidneys, contrary to facility policy, risking urine backflow and potential infection.
The facility failed to act on a pharmacist's recommendation for an A1C blood test for a resident with type 2 diabetes and psychosis. Despite the recommendation, no A1C test was performed from January to May, potentially compromising the resident's health. The facility's policy requires acting on and documenting pharmacist recommendations, which was not done in this case.
A facility failed to ensure the safe keep of medications when an LVN left medications unattended on a medication cart in an open hallway while taking a resident's blood pressure. The DON confirmed that medications should not be left unattended as it poses a risk of other residents or visitors taking them, potentially causing harm.
The facility failed to document a resident's influenza and pneumococcal vaccine administration in the Immunization Record and did not monitor the resident for side effects post-vaccination as required by the facility's P&P. The resident, admitted with colon cancer and intact cognitive skills, reported soreness after the influenza shot, but no documentation or monitoring was found in the clinical record.
A resident with a history of falls and cognitive impairments fell from a wheelchair and sustained a head injury. The nurse left a message and sent a text to the physician but did not receive a response and did not make further attempts to contact the physician or send the resident to the hospital. The facility's policy for unwitnessed falls with head injuries was not followed, resulting in a delay in appropriate care.
The facility failed to develop and implement a care plan for a resident with a history of falls and severely impaired cognitive skills, who was at high risk of falling. Despite staff awareness of the resident's behavior of getting up unassisted from a wheelchair, no formal care plan was documented, contrary to the facility's policy.
The facility failed to ensure that 13 out of 21 rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. Despite this, residents were able to ambulate freely and nursing staff had enough space to provide care. The Administrator acknowledged the deficiency and mentioned that a room waiver had been prepared and would be submitted.
The facility failed to maintain an effective training program for its staff, as in-service sign-in sheets lacked critical information such as dates, training length, topics, and summaries. This compromised the facility's ability to ensure staff received necessary training, potentially impacting resident safety and quality of care.
Failure to Supervise Exit Door Resulting in Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent elopement for a resident with known wandering and elopement risk. The resident was admitted with diagnoses including unsteadiness of feet, schizoaffective disorder, and an anxiety disorder, and was assessed on the MDS as having moderately impaired cognitive skills for daily decision-making. The resident’s care plan, initiated on 1/2/2026, identified risk for wandering/elopement based on prior attempts to leave the facility unattended and impaired safety awareness, including an incident on 1/2/2026 when the resident drifted away from a smoking group and was redirected back. The care plan interventions included door monitoring every shift and maintaining a safe, hazard-free environment. An Elopement Risk Evaluation dated 1/2/2026 documented a total score of 9 and noted that the resident had verbally expressed a desire to go home, packed belongings, or stayed near exit doors, and the summary of review stated the resident was at risk for elopement/wandering. On 3/14/2026, the resident was last observed at approximately 8:40 PM sitting in a wheelchair near the nurse’s station while a CNA supervised the front door. At approximately 9:00 PM, the charge nurse went to the resident’s room to administer scheduled nighttime medications and found the resident was not present. Immediate attempts were made to locate the resident within the unit and surrounding areas, but the resident was not found. Staff noted a bus in front of the facility and searched for it as part of the elopement search, but the resident was still not located. The Elopement Incident form indicated that the elopement occurred via the front door, and later documentation showed the resident stated she left through the front door and reported she was going to Oregon. Interviews with staff revealed that the front door did not have an alarm and was supposed to be supervised by staff and locked at night for safety reasons. CNAs and the LVN reported that staff routinely supervised the front door to prevent residents from leaving, and one CNA stated she supervised the front door from 8:00 PM to 8:30 PM on the night of the incident and did not see the resident near the front door or nurse’s station during that time. The LVN reported that when she returned to the nurse’s station after not finding the resident in the room, the resident’s wheelchair was present but the resident was not, and the front door was not supervised by the CNA who had previously been assigned there. The Social Services Director and DON both stated that the front door was to be supervised and monitored by staff to ensure residents’ safety and that it should not be left unattended, with the DON noting that the front door opens directly to a busy street and that the resident would not have been able to leave if the door had been supervised at the time of the incident. Facility policies on wandering/elopements and safety and supervision of residents stated that the facility would identify residents at risk, make the environment as free from accident hazards as possible, and ensure that supervision and interventions to reduce accident risks were implemented. Resident 1 was returned to the facility on 3/15/2026 at 1:15 PM.
Failure to Accurately Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain accurate documentation of wound care treatments for one of two sampled residents, as required by facility policy and professional standards. Specifically, the Treatment Administration Record (TAR) for a resident with severe cognitive impairment and multiple wounds did not reflect wound care treatments on two separate dates, despite physician orders for daily dressing changes to the left great toe and left fifth metatarsal. The treatments included cleansing with normal saline, application of Betadine, Medi Honey, collagen alginate, abdominal pad, and gauze bandage roll. During interviews, the treatment nurse acknowledged providing the wound care but admitted to forgetting to document the treatments in the TAR. The facility's policy required that all services provided to residents be documented in the medical record with objective, complete, and accurate information, including the date, time, and signature of the individual providing care. Both the DON and Administrator confirmed that wound care treatments should be accurately documented to confirm care was provided as ordered. The lack of documentation resulted in an inaccurate representation of the care provided to the resident and had the potential to cause miscommunication among staff.
Incomplete and Non-Measurable Care Plan Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident to the California Department of Public Health, the Ombudsman, and local law enforcement as required by its own policy and procedure. The resident, who had a history of fluctuating mental status and was cognitively intact at the time of assessment, made allegations of sexual abuse upon readmission to the facility. The resident's family member reported these allegations to the Director of Nursing (DON) and requested to be kept informed of any further abuse allegations. Despite this, the DON stated there were no known allegations of sexual abuse or inappropriate behavior by the resident, attributing any such reports to fabrication. The Administrator also indicated that the resident's abuse allegations were part of their past history. A review of the facility's policy confirmed that all abuse allegations must be reported to the appropriate authorities immediately or within 24 hours, depending on the severity, but this protocol was not followed in this case.
Non-Functional Call Light System Results in Delayed Resident Assistance
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional. The resident, who had diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and schizophrenia, was moderately cognitively impaired and required supervision or assistance with toileting hygiene. During an observation and interview, the resident reported waiting for help for about an hour, stating that the call light was not working. The resident was observed pressing the call light with no audible or visual response, and the call light was noted to have come out of the wall. Further interviews with the Director of Nursing and the Maintenance Supervisor confirmed the importance of a functioning call light system for resident care and safety. Review of facility policy indicated that call lights should be plugged in and functioning at all times. The failure to ensure a working call light system in the resident's room led to a delay in response to the resident's request for assistance.
Failure to Properly Label and Date Food Items in Kitchen and Freezer
Penalty
Summary
The facility failed to ensure that food items were stored in safe and sanitary conditions according to its own policies and procedures. During an observation of the kitchen with the Dietary Supervisor, it was found that an opened container of Creamy Italian Dressing and an opened container of Pancake & Waffle Syrup were labeled only with the delivery or received date, not the required use by date. Additionally, sixteen bags of frozen green vegetables stored in the freezer were not labeled with the name of the food item or the use by date, making it difficult to distinguish between similar items such as green beans and asparagus. The Dietary Supervisor confirmed during interviews that the facility's policy requires all food items in the kitchen, refrigerator, and freezer to be labeled and dated with the use by date to prevent serving expired food and to ensure correct menu items are used. The supervisor acknowledged that the lack of labeling could result in staff using the wrong ingredients and that the facility's policy was not followed in these instances. A review of the facility's policy confirmed the requirement for proper labeling and dating of all stored foods.
Failure to Follow Infection Control Protocols and Proper PPE Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control measures for five of nine sampled residents, as required by facility policy and CDC guidance. Specifically, staff did not consistently don full personal protective equipment (PPE), including N95 respirators, gowns, gloves, and face shields or goggles, before entering rooms of residents who were either COVID-19 positive or under transmission-based precautions due to exposure. Observations revealed that a certified nursing assistant entered the rooms of multiple residents wearing only an N95 mask, without a gown, gloves, or eye protection. Additionally, a housekeeping staff member was observed inside a COVID-19 isolation room wearing only a gown, gloves, and a surgical mask, without the required N95 mask or eye protection. These actions were in direct contradiction to both facility policy and CDC recommendations, which require full PPE for staff entering rooms of residents with suspected or confirmed COVID-19 infection. The residents involved had varying degrees of cognitive and physical impairment, with some being dependent on staff for most activities of daily living. Physician orders and care plans for these residents specifically indicated the need for transmission-based precautions due to either confirmed COVID-19 infection or exposure. Facility signage outside the affected rooms clearly indicated the need for contact and droplet precautions, including the use of gowns, gloves, and appropriate respiratory and eye protection. Despite these clear directives, staff interviews confirmed that the required PPE was not always used when entering these rooms. In a separate incident, a certified nursing assistant left a soiled diaper and dirty clothes on the floor in a resident's room, rather than immediately placing them in appropriate bags and hampers as required by facility policy. Staff interviews confirmed that soiled items should not be left on the floor due to the risk of contamination and cross-transmission. Facility policy mandates that all soiled laundry and personal items be handled as potentially contaminated and placed in designated containers at the point of use. The failure to follow these procedures was acknowledged by both the staff involved and the facility's infection preventionist.
Failure to Respect Resident's Rights and Dignity During Personal Property Handling
Penalty
Summary
Certified Nursing Assistant 4 (CNA 4) failed to provide dignity and respect to a resident by removing personal food items and washing the resident's boots without obtaining permission. The resident, who had moderately impaired cognitive skills for daily decision making but was independent in most activities, reported that she had won several individually packed Moon Pies during facility activities and stored them in her bedside table. CNA 4 cleaned the resident's closet and bedside table, taking the Moon Pies without informing or seeking consent from the resident. The resident expressed that this action was an invasion of her privacy and requested that her belongings be left alone. Additionally, CNA 4 took the resident's boots to be washed despite the resident's explicit refusal. The CNA stated that she noticed the boots were wet and smelled bad, and after the resident declined to have them washed, she reported the odor to the Charge Nurse, who instructed her to take the boots to laundry. The CNA did not inform the resident before removing the boots, which caused the resident distress when she discovered her boots were missing. The boots were returned two days later. Interviews with other staff, including LVNs and the Activities Director, confirmed that the resident was upset by these actions and that staff should have obtained permission before removing personal belongings or food items. Facility policy also required staff to explain procedures, answer questions, and obtain permission before implementing any care or removing resident property. The failure to follow these procedures resulted in a lack of respect for the resident's rights and dignity.
Failure to Provide and Document Restorative Nursing Care for Resident with Limited ROM
Penalty
Summary
The facility failed to provide and document restorative nursing care for a resident with limited range of motion (ROM) and mobility, as ordered by the physician and outlined in the resident's care plan. The resident, who had diagnoses including secondary parkinsonism, type 2 diabetes mellitus, and muscle wasting, was assessed as having severe joint mobility loss in both hips and knees, and was at risk for contracture development. Orders and care plans specified that the resident should receive passive range of motion (PROM) exercises to both upper and lower extremities and have bilateral knee splints applied for four hours, five times a week, or as tolerated. Observations on multiple dates revealed that the resident was not wearing the prescribed knee splints, and staff interviews confirmed that the splints were not consistently applied as ordered. One RNA admitted to forgetting to apply the splints on a specific day, and another stated that the splints were not reapplied after a shower due to a lunch break. Additionally, staff interviews indicated that documentation of the application of splints and provision of PROM exercises was not performed daily as required, but only once a week in progress notes. A review of the resident's documentation for the relevant period showed no evidence that the restorative nursing interventions were provided from 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025. The Director of Nursing confirmed the lack of documentation and stated that if it was not documented, it was not done. The facility's policy required restorative nursing care to be provided as needed to promote optimal safety and independence, but this was not followed for the resident during the specified periods.
Failure to Verify G-Tube Placement Prior to Water Flush and Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow physician orders and facility policy regarding the care of a resident with a gastrostomy tube (g-tube). The resident, who had diagnoses of dysphagia and pneumonia and was assessed as severely cognitively impaired and fully dependent for activities of daily living, had orders requiring that g-tube placement be checked prior to administering formula, medications, or water flushes. The care plan and facility policy also specified that tube placement and gastric residuals should be checked before any administration through the tube. During a medication pass, the LVN was observed pausing the resident's feeding and administering a 50 ml water flush through the g-tube without first verifying tube placement as required. Only after the flush was given did the LVN attempt to check tube placement by pushing air through the tube and listening for a sound in the abdomen. The LVN acknowledged not checking placement prior to the flush and was under the impression that either checking for residual or listening for a sound after air injection was sufficient. Interviews with the Director of Nursing (DON) and review of facility policies confirmed that tube placement should be verified before any flush or medication administration, and that checking residuals is also necessary to assess feeding tolerance. The facility's written procedures emphasized the importance of these steps to ensure safe administration and prevent complications. The failure to follow these protocols constituted a deficiency in providing appropriate care for a resident with a feeding tube.
Failure to Post Oxygen in Use Sign for Resident on Continuous Oxygen Therapy
Penalty
Summary
The facility failed to post a No Smoking/Oxygen in Use sign outside the entrance door of a resident's room who was receiving continuous oxygen therapy, as required by the facility's policy and procedure. The resident had a history of respiratory disorders, dyspnea, and atelectasis, and was admitted with orders for continuous oxygen at 2-3 liters per minute via nasal cannula or face mask. Observations confirmed that the resident was on oxygen therapy, but there was no sign posted outside the room to indicate oxygen use. Interviews with the treatment nurse and the Director of Nursing confirmed that the facility's policy was not followed, and both acknowledged the importance of posting the sign to inform staff and visitors of the oxygen in use. The facility's policy, reviewed during the investigation, specifically required the placement of a No Smoking/Oxygen in Use sign on the outside of the room entrance door and in a designated place over the resident's bed. The absence of the required signage was directly observed and confirmed by staff.
Inaccurate Bowel and Bladder Assessment Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of a bowel and bladder assessment for one resident, as required by its own policy. The resident in question had a history of metabolic encephalopathy and Alzheimer's Disease, was severely cognitively impaired, bed bound, and dependent on staff for all activities of daily living. Multiple records, including the Minimum Data Set (MDS) and Admission/Re-admission Data Tool, consistently indicated that the resident was always incontinent of both bowel and bladder. However, the Bowel and Bladder Assessment for this resident incorrectly documented that the resident always voided appropriately without incontinence. This discrepancy was identified during interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), both of whom confirmed the assessment was inaccurate and did not reflect the resident's actual condition. The facility's policy required documentation to be objective, complete, and accurate, but this was not followed in the resident's assessment.
Call Light Not Within Reach for Cognitively and Physically Impaired Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including rhabdomyolysis, lack of coordination, and Alzheimer's disease, was assessed as severely impaired in cognitive skills and dependent on staff for most activities of daily living. The resident's care plans specifically required that the call light be kept within reach and that staff respond promptly to requests for assistance. However, during observations, the call light was found hanging against the wall to the left side of the resident's bed and out of the resident's reach. The resident was unaware of the location of the call light, and this was confirmed by a Certified Nursing Assistant who acknowledged that the call light was not accessible to the resident. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed the importance of having the call light within reach to ensure residents can request help when needed. Review of the facility's policy also indicated that the call light should be within easy reach of residents who are in bed or confined to a chair. The failure to follow these care plan interventions and facility policy resulted in the resident being unable to access the call light to request assistance.
Resident Rooms Below Minimum Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 13 out of 21 resident rooms met the required minimum square footage of 80 square feet per resident in multiple occupancy rooms. Observations confirmed that rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 did not meet this requirement, with two-bed rooms ranging from 137.61 to 142.50 square feet (below the 160 square feet minimum for two residents) and four-bed rooms ranging from 283.40 to 294.70 square feet (below the 320 square feet minimum for four residents). Despite these measurements, staff and residents reported that there was sufficient space for mobility, care provision, and necessary furnishings and equipment. A review of the facility's room waiver request indicated that the facility believed the current room sizes were adequate for resident needs and did not adversely affect health and safety. Interviews with nursing staff, including a CNA and an LVN, confirmed that they had enough space to provide safe and proper care in the affected rooms. Residents interviewed from these rooms did not express concerns about room size. The Department indicated it would recommend the room waiver for the identified rooms as requested by the facility.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required two-hour timeframe to the State Survey Agency, ombudsman, and local law enforcement. The incident involved a resident who had been admitted with diagnoses including diabetes mellitus type 1, schizoaffective disorder, and anxiety disorders. The resident had modified independence in cognitive skills for daily decision-making and required supervision or assistance with various activities of daily living. The allegation of sexual abuse was made by the resident on March 5, 2025, but the facility did not report it promptly as required by their policy. Interviews with facility staff, including a Licensed Vocational Nurse, the Director of Nursing, the Administrator, and the Director of Staff Development, revealed a lack of adherence to the facility's policy on abuse reporting. The LVN acknowledged the responsibility to report any abuse incidents or allegations to the Administrator and other authorities. The Administrator admitted to not initiating an investigation or reporting the allegation to the State Survey Agency when the facility became aware of it. The Director of Staff Development confirmed that staff are mandated reporters and emphasized the need to report any abuse incidents or allegations within two hours. The facility's policies and procedures on abuse investigation and reporting were reviewed and indicated that all alleged violations involving abuse should be reported immediately, but not later than two hours if the alleged violation involves abuse. The policies specified that reports should be made to the State licensing/certification agency, the local/state ombudsman, the resident's representative, Adult Protective Services, and law enforcement officials. Despite these clear guidelines, the facility did not comply with the reporting requirements, leading to a deficiency in handling the abuse allegation.
Failure to Post Accurate DHPPD Information
Penalty
Summary
The facility failed to post accurate and complete Census and Direct Care Service Hours Per Patient Day (DHPPD) information in a prominent location accessible to residents and visitors, as required by their policy. On 9/16/2024, it was observed that the DHPPD form was not posted at the facility entrance, and the Director of Staff Development (DSD) admitted to not updating or posting the form for that day. Additionally, the DHPPD forms for the dates 9/8/2024 to 9/12/2024 were incomplete, only showing projected hours without the actual direct service hours. The DSD and the Accounts Payable and Payroll Director (APPD) both acknowledged their roles in this oversight, with the APPD citing illness as a reason for not completing the forms. The facility's policy requires that the DHPPD form be posted within two hours of the beginning of each shift, detailing the number of licensed and unlicensed nursing staff directly responsible for resident care. However, the DSD was preoccupied with other duties, and the APPD, who was working remotely due to illness, did not complete the actual DHPPD forms. The DSD stated that if the APPD is unavailable, she should cover the responsibility, but this was not done. The facility's policy also mandates that previous shift forms be maintained with the current shift form for a total of 24 hours in a single location, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach of a resident, identified as Resident 2, which could lead to delayed provision of services and assistance with activities of daily living (ADLs). Resident 2, who was initially admitted with diagnoses including difficulty in walking, lack of coordination, malnutrition, and dementia, was observed without a call light within reach. The resident expressed unawareness of the call light's location, indicating it had been taken away, which posed a risk in case of a fall or need for assistance. During observations and interviews, it was confirmed by multiple staff members, including a Certified Nurse Assistant (CNA1), Licensed Vocational Nurse (LVN1), Registered Nurse (RN), Director of Nursing (DON), and Director of Staff Development (DSD), that the call light was not within reach and was found behind privacy curtains. This was against the facility's policy, which mandates that call lights be within easy reach to ensure timely responses to residents' needs. The staff acknowledged the importance of having the call light accessible to prevent accidents and ensure resident safety.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a fall for one of the residents, who was identified as being at risk for falls due to several factors including dementia, a history of falling, and impaired cognitive skills. The resident required partial to moderate assistance for activities of daily living, including transfers. On the day of the incident, the resident attempted to transfer to bed without assistance, despite a Certified Nurse Assistant (CNA) being present in the room. The CNA did not assist the resident, resulting in the resident falling and sustaining a laceration on her left eyebrow. The resident's care plan included several interventions to mitigate fall risks, such as attaching a call light within reach and placing the resident close to the nursing station for observation. However, the care plan did not specify the need for assistance during bed transfers, which was a critical oversight given the resident's condition and history. The facility's policies required regular assessments for fall risks and appropriate interventions, but these were not adequately implemented in this case. Interviews with facility staff, including the MDS Consultant and the Director of Nursing, revealed that the resident's need for assistance during transfers was known, yet not acted upon. The post-fall evaluation incorrectly assessed the resident as low risk for falls, missing key indicators such as the resident's history of falls. This misassessment contributed to the lack of necessary precautions and supervision, ultimately leading to the resident's fall.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, violating the resident's right to return to the facility. The resident, who had been living at the facility since January 2022, was hospitalized and had a bed-hold order for seven days. Despite the availability of beds, the facility did not allow the resident to return, citing the need for hospice care as a condition for readmission. This decision was made despite the facility's policy allowing residents to return after hospitalization if a bed is available. The resident had multiple medical conditions, including type 2 diabetes, hemiplegia, acute kidney failure, acute respiratory failure, and ALS. The resident was moderately impaired cognitively and required assistance with daily activities. The facility initially agreed to readmit the resident and provided a bed assignment, but later rescinded the offer, stating that the resident needed to be on hospice care due to frequent hospitalizations and the need for isolation upon return. Interviews with facility staff revealed inconsistencies in the facility's bed availability and admission policies. The Business Office Manager stated that empty rooms could be assigned to any resident regardless of gender, while the Administrator and Director of Nursing cited full occupancy and the need for isolation as reasons for not readmitting the resident. The facility's policy indicated that residents could return to their previous room or the first available semi-private room, but this was not adhered to in the resident's case.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged violation of abuse within the required two-hour timeframe and did not notify the California Department of Public Health (CDPH) as per their policy and procedure. The incident involved a resident who reported that a Social Services staff member screamed, yelled, and made hurtful and insulting statements. The resident, who has legal blindness, anxiety disorder, and type 2 diabetes mellitus, reported the incident to the Director of Staff Development (DSD) shortly after it occurred. Despite recognizing the incident as emotional abuse, the DSD did not report it to the Administrator, who is the facility's abuse coordinator, due to being busy with work. The facility's policy mandates immediate reporting of such incidents to the Administrator and other relevant authorities. The Administrator, upon being informed, decided not to report the incident to CDPH, considering it a grievance rather than abuse. The Social Services staff member involved stated that during a conversation with the resident, she suggested that if the facility was not meeting his needs, they could find another place for him, which the resident perceived as a threat. The facility's policy, revised in 2017, clearly outlines the requirement to report all alleged violations involving abuse, neglect, exploitation, or mistreatment immediately, but not later than two hours if the alleged violation involves abuse. This failure to adhere to the policy resulted in the incident not being reported to all necessary entities as required.
Failure to Suspend Staff and Report Alleged Abuse
Penalty
Summary
The facility failed to prevent further allegations of abuse against a Social Services (SS) staff member by not suspending the staff member after an initial alleged violation and not submitting a required 5-day follow-up investigation report to the California Department of Public Health (CDPH). This deficiency was identified during a review of a resident's admission record and interviews with the resident and facility administrator. The resident, who was admitted with diagnoses including legal blindness, anxiety disorder, and type 2 diabetes mellitus, reported that the SS staff member screamed, yelled, and made hurtful statements to him. Despite being informed of the allegation, the facility administrator chose not to suspend the SS staff member and did not submit the investigation report to CDPH as required by the facility's policy. The facility's policy, titled 'Abuse Investigating and Reporting,' revised in July 2017, mandates the immediate suspension of any employee accused of resident abuse pending the outcome of an investigation. It also requires the administrator or designee to provide a written report of the investigation findings to the appropriate agencies, including CDPH, within five working days of the incident. The facility's failure to adhere to these procedures resulted in a lack of evidence that the alleged abuse was thoroughly investigated and posed a potential risk of failing to protect the resident from further abuse.
Failure to Submit Discharge Tracking Forms Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) Discharge Tracking Forms (DTFs) to the Centers for Medicare and Medicaid Services (CMS) within the required 31-day period for two residents. Resident 17, who had multiple diagnoses including type 2 diabetes mellitus, dementia, and hyperlipidemia, was discharged from the facility on December 29, 2023, but the DTF was not submitted. Similarly, Resident 37, who had diagnoses including Huntington's disease, dementia, and acute respiratory failure, was discharged to a General Acute Care Hospital on January 20, 2024, but the DTF was also not submitted. The MDS Consultant confirmed these oversights during an interview on May 4, 2024, stating that the DTFs should have been submitted within 14 days of discharge but were not. A review of the facility's manual and job description for the MDS Coordinator indicated that the Discharge Tracking Forms are essential for tracking resident movements and should be submitted no later than 31 days after discharge. The manual specifies that these forms are crucial for providing accurate data to CMS, which uses this information to monitor the quality of care and resident outcomes. The failure to submit these forms as required could lead to inaccuracies in the facility's quality indicators and care area concerns for review.
Failure to Discard Expired Ground Beef
Penalty
Summary
The facility failed to remove and discard ground beef from the refrigerator after it was past the use-by date according to the facility's policy and procedure titled, Refrigerators and Freezers. During an observation, interview, and record review, a package of unfrozen ground beef was found in the refrigerator with a label indicating it was for dinner on a specific date. The Meat Thawing Schedule indicated that the ground beef should have been used by a certain date, but it was not discarded even though it was past the three-day limit for thawed meat. The Cook acknowledged that the ground beef was expired and should have been discarded to prevent potential foodborne illnesses among residents. In an interview with the Dietary Supervisor, it was confirmed that kitchen staff are responsible for placing frozen meat in the refrigerator to thaw and that thawed ground meats are only good for one or two days. The Dietary Supervisor stated that all thawing meats needed to have a use-by date and that any meat not used by this date should be thrown away to prevent foodborne illness. The facility's policy and procedure indicated that supervisors are responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past their perish dates.
Failure to Ensure Informed Consent for Binding Arbitration Agreements
Penalty
Summary
The facility failed to comply with requirements for Binding Arbitration Agreements for three residents. Resident 12 signed an Arbitration Agreement without understanding its meaning, as it was late at night and no one explained it to her. This agreement was signed on the same day she was admitted to the facility, and her cognitive skills were unimpaired according to her Minimum Data Set (MDS). However, she was not informed about the implications of the agreement before signing it. Resident 19's Arbitration Agreement was signed in two conflicting locations, indicating both agreement and refusal to enter into a Binding Arbitration Agreement. This resident was severely impaired in cognitive skills and dependent on staff for all care, as indicated by the MDS. The conflicting signatures on the agreement suggest a lack of clarity and proper explanation during the signing process. Resident 200's Arbitration Agreement was also signed in two conflicting locations, and the signature on the document did not match the resident's other signatures on file. This resident had fluctuating capacity to understand and make decisions, as noted in their History and Physical (H&P) records. The discrepancy in signatures and the resident's statement that they would never agree to such an agreement indicate that the facility failed to ensure the resident's informed consent.
Failure to Sanitize Blood Pressure Cuff Between Uses
Penalty
Summary
The facility staff failed to maintain proper infection control measures by not sanitizing a blood pressure cuff between uses for two residents. During a medication administration observation, a Licensed Vocational Nurse (LVN) used the same blood pressure cuff on two different residents without disinfecting it in between. This action was observed during the care of Resident 34, who had diagnoses including hypertensive heart disease with heart failure and respiratory failure, and Resident 12, who had an immune mechanism disorder and was recovering from surgery for neoplasm removal. The LVN admitted to not sanitizing the blood pressure cuff and acknowledged the importance of doing so to prevent bacterial transmission. The Infection Preventionist (IP) confirmed that staff should sanitize medical devices like blood pressure cuffs between residents' use to prevent the spread of bacteria. The facility's policy, revised in October 2018, also indicated that reusable items should be cleaned and disinfected or sterilized between residents. The failure to follow this policy was identified as a deficiency with the potential to spread communicable diseases among residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, violating their right to be fully informed about their treatment. Resident 44, who was admitted with dementia and psychosis, was prescribed Seroquel without obtaining informed consent from the responsible party. The Infection Preventionist confirmed that there was no informed consent in the medical record, acknowledging that it is required for psychotropic medications due to their impact on the mind, emotions, and behavior. Similarly, Resident 101, diagnosed with anxiety disorder and schizophrenia, was administered quetiapine and lorazepam without informed consent. The resident's medical records and interviews with staff revealed that informed consent was not obtained prior to administering these medications. The facility's policy mandates that informed consent must be obtained from the resident or responsible party before initiating or increasing psychotropic drugs, but this procedure was not followed in these cases.
Call Lights Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call lights were within sight and reach for four residents while they were in bed. Resident 16, who was readmitted with dementia and Parkinsonism, was observed with the call light clipped to the right side of his pillow, out of his sight and reach. Resident 16's cognitive skills were severely impaired, and he was dependent on others for activities of daily living (ADL). This observation was made during a review of Resident 16's Admission Record and Minimum Data Set (MDS), and during an observation in his room on 5/3/2024 at 6:45 PM. Resident 35, admitted with cerebral infarction and encephalopathy, was also found with a call light that was out of reach. During an observation and interview on 5/3/2024 at 6:16 PM, Resident 35 stated needing something but could not reach the call light clipped to the right side of his pillow. The Assistant Director of Staff Development (ADSD) confirmed that the call light cord was too short and stated she would inform maintenance staff to replace it. Resident 35's cognitive skills were severely impaired, and he was dependent on others for ADL but needed only partial/moderate assistance for eating. Resident 41, readmitted with encephalopathy, and Resident 100, admitted with a fracture of the fourth lumbar vertebra and dementia, were also observed with call lights that were out of reach. Resident 41's call light was clipped to the left side of his pillow and was too short to reach him. Resident 100's call light was similarly clipped to the left side of her pillow and was out of her sight and reach. Both residents had impaired cognitive skills and were dependent on others for various ADLs. These observations were made during concurrent observations and interviews on 5/3/2024. The facility's policy and procedure titled 'Answering the Call Light' indicated that the call light should be within easy reach of the resident when they are in bed or confined to a chair.
Failure to Inform Responsible Party About Advance Directives
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident with dementia, who lacked the capacity to understand medical conditions, received information regarding the resident's right to formulate an advance directive. The resident, identified as Resident 38, was admitted with a diagnosis of dementia and was found to be severely impaired in cognitive skills for daily decision-making. Despite this, the Advance Directives Acknowledgement Form (ADAF) was signed by Resident 38, rather than being discussed with the RP as required by the facility's policy and procedure (P&P) on advance directives. During a review of Resident 38's clinical records, it was noted that the ADAF was signed by the resident on 1/22/2024, while the History and Physical (H&P) dated 1/23/2024 indicated that the resident was not competent to understand their medical condition. Further review of the Minimum Data Set (MDS) dated 3/10/2024 confirmed the resident's severe cognitive impairment. An interview with the Social Services Designee (SSD) revealed that there was no documentation showing that the advance directive was discussed with the RP, as required by the facility's P&P. This oversight had the potential to violate the rights of both Resident 38 and their RP to formulate an advance directive.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 101 within 48 hours of admission, as required by their policy. Resident 101 was admitted with diagnoses including anxiety disorder, schizophrenia, and malnutrition. Despite being able to make decisions for activities of daily living (ADL), Resident 101 was observed to be on contact isolation precautions and dependent on staff for ADL care. Additionally, Resident 101 was receiving nutrition through a gastrostomy tube (G-tube). During a review of Resident 101's clinical record, it was confirmed that no baseline care plan had been initiated or completed within the required timeframe. Licensed Vocational Nurse 2 (LVN 2) confirmed that Resident 101 was dependent on staff for ADL care. Minimum Data Set (MDS) Consultant 2 also confirmed the absence of a baseline care plan during a concurrent record review and interview. The facility's policy and procedure, dated December 2016, mandates that a baseline care plan must be developed within 48 hours of a resident's admission to meet their immediate needs. The failure to develop this plan had the potential to result in Resident 101 not receiving adequate and appropriate care.
Improper Positioning of Nephrostomy Bag
Penalty
Summary
The facility failed to ensure proper positioning of a nephrostomy bag for Resident 26, who was readmitted with acute kidney failure and an infection related to the nephrostomy catheter. During an observation, it was noted that the nephrostomy bags were placed on the bed next to the resident at the same level as the kidneys, which is against the facility's policy. This improper positioning was confirmed by LVN 3, who acknowledged that the bags should be placed below kidney level to prevent urine backflow and potential infection. Further interviews revealed that the Director of Nursing (DON) also confirmed that the nephrostomy bags should be positioned below kidney level to ensure proper drainage and prevent infection. The facility's policy, revised in October 2010, clearly states that the drainage bag should be below the level of the kidneys. This deficiency in care had the potential to cause significant health issues for Resident 26, including infection and inflammation of the kidneys.
Failure to Act on Pharmacist's A1C Test Recommendation
Penalty
Summary
The facility failed to act upon the pharmacist's recommendations for an A1C blood test for a resident with type 2 diabetes and psychosis. The pharmacist had recommended monitoring the A1C levels on the next convenient laboratory day and then every 3 to 6 months, depending on the treatment goals. However, a review of the resident's laboratory results from January to May revealed that no A1C test was performed during this period. The Infection Preventionist confirmed that the facility did not follow the pharmacist's recommendation, which is crucial for ensuring the resident receives the correct dose of blood sugar control medications. The resident's Minimum Data Set indicated that the resident had clear speech, sometimes understood others, and sometimes made themselves understood. Despite these communication abilities, the facility did not act on the pharmacist's recommendation, potentially compromising the resident's health. The facility's policy and procedure require that recommendations from the consultant pharmacist be acted upon and documented, but this was not done in this case, leading to a deficiency in care for the resident with diabetes.
Unattended Medications in Hallway
Penalty
Summary
The facility failed to ensure the safe keep of medications when a Licensed Vocational Nurse (LVN) left medications unattended during a medication administration observation for a resident. The incident occurred when the LVN took out six medications for the resident and placed them in medication cups on top of a medication cart. The LVN then left the medication cart unattended in the hallway, which was an open area with residents and visitors passing by, while the LVN went into the resident's room to take their blood pressure. The medication cart was out of the LVN's sight during this time. During interviews, the LVN acknowledged that the medications should not have been left unattended and that anyone passing by could have taken the medications, potentially causing harm. The Director of Nursing (DON) confirmed that licensed staff should not leave medications unattended in open areas, as it poses a risk of other residents or visitors taking the medications, which could lead to adverse reactions and harm to their health. A review of the facility's policy on the storage of medications indicated that drugs and biologicals should be stored in locked compartments under proper conditions.
Failure to Document and Monitor Vaccinations
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) for Influenza and Pneumococcal Vaccination for one of five sampled residents by not ensuring that the resident's vaccine administration was recorded in the Immunization Record and that the resident was monitored for side effects after receiving the vaccines. Specifically, Resident 12's influenza and pneumococcal vaccine administration were not documented in the Immunization Record, and there was no evidence that Resident 12 was monitored for side effects every shift for 72 hours post-vaccination as required by the facility's P&P. Resident 12, who was admitted with a diagnosis of colon cancer and had intact cognitive skills, reported receiving an influenza shot and experiencing soreness in the shoulder. However, the Infection Prevention Nurse (IPN) and Registered Nurse 1 (RN 1) confirmed that there was no documentation of the vaccine administration or monitoring for side effects in the resident's clinical record. The facility's P&P for Influenza and Pneumococcal Vaccination required documentation of vaccine administration and monitoring of the resident's response, which was not followed in this case.
Failure to Notify Physician and Provide Immediate Care After Resident Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident after a fall. Resident 22, who had a history of falling and was readmitted with diagnoses including head injuries and end-stage renal disease, fell from a wheelchair and sustained a laceration to the right eyebrow. The Licensed Vocational Nurse (LVN 3) left a message and sent a text to the resident's primary physician but did not receive a response. Despite the resident's condition, the nurse did not make further attempts to contact the physician or send the resident to the hospital for evaluation, as per the facility's policy for unwitnessed falls with head injuries. The Director of Nursing (DON) confirmed that the nurse should have called 911 and sent the resident for evaluation when the physician did not respond. The Dialysis Nurse (DN) observed discoloration and a laceration on the resident's forehead and eyes the following day, and the resident was sent to the hospital after the Physician Assistant at the dialysis center was informed. Interviews with other staff members indicated that the standard procedure for unwitnessed falls with head injuries was not followed, as multiple attempts to contact the physician should have been made, and the resident should have been sent to the hospital immediately. The facility's policy on assessing falls and their causes indicated that immediate medical treatment should be obtained for significant injuries or condition changes. The failure to follow this policy resulted in a delay in appropriate care for Resident 22, who was a known fall risk and had cognitive impairments. The Medical Director stated that the standard practice for unwitnessed falls with head injuries was to send the resident to the hospital for imaging and evaluation, which was not done in this case.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to develop and implement a care plan to address a resident's behavior of getting up out of the wheelchair unassisted. This deficiency was identified for one of 14 sampled residents (Resident 22). Resident 22 was readmitted to the facility with diagnoses including head injuries, end-stage renal disease, and dependence on renal dialysis. The resident had a history of falling and was assessed to have severely impaired cognitive skills, requiring varying levels of assistance for daily activities. Despite being identified as a high fall risk, no care plan was in place to address the resident's behavior of attempting to get up from the wheelchair unassisted. Interviews with the Director of Nursing and a Certified Nurse Assistant revealed that staff were aware of Resident 22's fall risk and behavior of trying to get up without assistance. The CNA mentioned placing the resident in visible areas to monitor him, but no formal care plan was documented. The Infection Preventionist Nurse confirmed that a care plan should have been developed to prevent falls. The facility's policy on comprehensive, person-centered care plans was not followed, leading to the potential risk of falls and injury for Resident 22.
Facility Failed to Meet Square Footage Requirements for Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 out of 21 rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. During an observation, it was noted that Rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 did not meet this minimum requirement. Despite this, residents were able to ambulate freely and maneuver in their wheelchairs, and nursing staff had enough space to provide care with dignity and privacy. The rooms had sufficient space for beds, side tables, dressers, and other medical equipment. During an interview, the Administrator acknowledged the deficiency and mentioned that a room waiver had been prepared and would be submitted for these rooms. The room waiver indicated that there was enough space for each resident's nursing and health needs and that the rooms were in accordance with the residents' needs without adversely affecting their health and safety. The waiver also showed that the rooms did not meet the minimum square footage requirements for 2-bed and 4-bed rooms. Residents interviewed did not express any concerns regarding the size of their rooms.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff members. During an interview with the Infection Preventionist (IP) and a review of the facility's training program and In-Service Sign in Sheets (ISS), it was found that the ISS sheets lacked critical information such as the date of in-services, the length of training, the topic, and a brief summary of the lecture. The IP confirmed that all in-service logs should include these details to ensure that staff received the necessary training. Without this information, the facility could not verify what training had been provided, on which day, and for how long. The facility's policy and procedure titled 'Staff Development Program,' revised in May 2019, indicated that all personnel must participate in initial orientation and regularly scheduled in-service training classes. The primary objective of the staff development program is to ensure that staff have the knowledge, skills, and critical thinking necessary to provide excellent resident care. However, the failure to maintain detailed records of the training sessions compromised the facility's ability to ensure that staff were appropriately trained, potentially impacting resident safety and quality of care.
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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