Franciscan Post-acute Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Merced, California.
- Location
- 3169 M Street, Merced, California 95348
- CMS Provider Number
- 055979
- Inspections on file
- 31
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Franciscan Post-acute Care Center during CMS and state inspections, most recent first.
A resident with Type 2 DM and COPD was admitted with orders for Glipizide and continuous oxygen therapy, but the care plan lacked individualized interventions for blood glucose and oxygen monitoring. Nursing staff did not document blood glucose checks or monitor oxygen saturation as ordered, even as the resident refused meals and showed signs of respiratory distress. This resulted in the resident developing severe hypoglycemia and hypoxemia, leading to altered mental status and emergency hospitalization. Staff interviews confirmed the care plan was incomplete and not followed.
A resident was served sliced tomatoes with lunch despite a documented dislike for tomatoes on their meal tray ticket. Staff interviews and record reviews confirmed that dietary and nursing staff failed to properly check the meal tray contents against the resident's preferences, resulting in the resident receiving and leaving untouched a food item they had previously reported disliking.
The facility did not refer two residents with newly diagnosed serious mental illnesses for a required Level II PASARR evaluation, as mandated by policy. Despite staff awareness that a new PASARR should be completed when a resident receives a new mental illness diagnosis, there was no evidence in the records that this process was followed for either resident.
A resident in a LTC facility, known to be a smoker and on continuous oxygen, suffered second-degree burns after smoking unnoticed in their room. Despite staff awareness of the resident's smoking habits and possession of cigarettes and lighters, effective measures were not implemented to prevent the fire hazard. The incident resulted in the resident being hospitalized in a burn unit.
A facility failed to accurately reflect a resident's smoking status and oxygen use in the MDS assessment. The resident, who was cognitively intact, was known to smoke and bring cigarettes from hemodialysis, despite the facility's smoke-free policy. The MDS Coordinator admitted to coding tobacco use as 'no' for all residents, and the resident's continuous oxygen therapy was not marked in the MDS. This inaccuracy could lead to unmet care needs, particularly concerning smoking and oxygen safety.
A resident known to be a smoker suffered second-degree burns after attempting to smoke while on continuous oxygen in a smoke-free LTC facility. Despite staff awareness of the resident's smoking habits and previous attempts to bring cigarettes and lighters into the facility, effective care plan interventions were not implemented. The care plans in place were not individualized or specific to the resident's needs, leading to the incident and subsequent hospitalization.
A facility failed to prevent abuse between residents, leading to two altercations involving three residents. Despite known histories of conflict and severe cognitive impairments, staff did not adequately separate or supervise the residents, resulting in one resident being scratched and another being bitten. The facility's abuse prevention policy was not effectively implemented, contributing to these incidents.
A resident who had knee surgery did not receive the ordered physical therapy (PT) services for four days due to the absence of the Physical Therapy Assistant (PTA) and lack of backup coverage. The resident was supposed to receive PT and occupational therapy (OT) five days a week to aid in recovery and improve mobility, but missed crucial sessions, risking further decline in physical well-being.
A resident with a history of falls and cognitive impairment was not monitored hourly as required by the facility's 4 P's Rounding Tool policy. Despite being placed on the program after a fall that resulted in a fractured arm, staff failed to perform and document the necessary checks, leading to multiple missing entries in the resident's logs. This oversight was acknowledged by both an LVN and the DON, highlighting a deficiency in the facility's care provision.
Three residents were improperly restrained using wedge pillows placed under their mattresses, restricting their movement and preventing them from getting out of bed. These actions were taken without physician orders or care plan interventions, violating the residents' rights to be free from physical restraints. Staff acknowledged the use of wedge pillows as a fall prevention measure, but the facility's policy prohibits such use without proper authorization.
A resident with hemiplegia and diabetes was injured during transport to a medical appointment due to inadequate supervision. The resident's left foot slipped off the wheelchair and dragged on the pavement, causing abrasions to four toes. The resident was transported without shoes, wearing only socks, and experienced pain requiring daily dressing changes and pain management. Facility staff expected residents to wear shoes and have leg rests during transport, but these measures were not followed.
A resident with dementia and muscle weakness was left unsupervised while drinking hot tea, resulting in second-degree burns. Despite the care plan indicating the need for staff assistance, the resident was not supervised, leading to the accident. The facility's policy on accident prevention was not followed, contributing to the incident.
Failure to Develop and Implement Individualized Care Plan for Resident with Diabetes and COPD
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan for a resident with multiple diagnoses, including Type 2 Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD). Upon admission, the resident was prescribed Glipizide for diabetes management, but the care plan did not include individualized interventions such as regular blood glucose monitoring or instructions to withhold Glipizide during periods of poor oral intake. Nursing staff did not document blood glucose checks from admission through discharge, despite the resident refusing several meals while continuing to receive Glipizide. This omission led to the resident experiencing severe hypoglycemia, as evidenced by a blood glucose level of 53 mg/dl, altered mental status, and subsequent emergency hospitalization. Additionally, the resident had a physician's order for continuous oxygen therapy and monitoring of oxygen saturation every eight hours or as needed for symptoms of dyspnea or cyanosis. The care plan included interventions to monitor for signs and symptoms of respiratory distress and to check oxygen saturation, but these interventions were not followed. There was no documentation of oxygen saturation checks for extended periods, and the resident's oxygen level was not monitored according to the physician's order or care plan. This failure resulted in the resident being found with an oxygen saturation of 86%, altered mental status, and requiring emergency transport to a higher level of care. Interviews with nursing staff and the Director of Nursing confirmed that the care plans were incomplete and not individualized to the resident's needs. Staff acknowledged that the lack of specific interventions and failure to follow physician orders contributed to the resident's significant change in condition, including hypoglycemia and hypoxemia, which necessitated hospitalization. Facility policy and professional references reviewed during the survey emphasized the requirement for person-centered, comprehensive care plans with measurable objectives and individualized interventions, which were not met in this case.
Resident Served Food Contrary to Documented Preferences
Penalty
Summary
A deficiency occurred when a resident was served sliced tomatoes with lunch, despite a documented dislike for tomatoes on the resident's meal tray ticket. The resident confirmed during an interview that they had previously informed staff of their dislike for tomatoes, yet continued to receive them. Observation showed the tomatoes were left untouched, and the meal tray ticket clearly listed tomatoes as a dislike. Both the Certified Nursing Assistant and Dietary staff acknowledged that the meal tray contents were not properly checked against the resident's documented preferences prior to serving the meal. Further review with the Dietary Manager confirmed that the expectation was for dietary staff to compare meal tray contents with the tray ticket, which was not done in this instance. The facility's policies require that resident preferences be honored and that ongoing communication and coordination occur to meet residents' dietary needs. The failure to follow these procedures resulted in the resident receiving food that did not accommodate their stated preferences.
Failure to Refer Residents for PASARR After New Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses to the appropriate state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR), as required by facility policy. Specifically, two residents were identified who received new diagnoses of serious mental illnesses—one with major depressive disorder, anxiety disorder, and bipolar disorder, and another with schizoaffective disorder. Despite these new diagnoses, there was no evidence in the medical records that the facility initiated or completed a new PASARR evaluation for either resident. Interviews with facility staff, including the Quality of Life Director, Director of Nursing, and Administrator, confirmed that the expectation was for a new PASARR to be completed when a resident received a new mental illness diagnosis. However, this process was not followed for the two residents in question, as documented in their records and confirmed by staff interviews. The deficiency was identified through record review and staff interviews, which revealed a lack of compliance with both facility policy and regulatory requirements regarding PASARR referrals for residents with new serious mental illness diagnoses.
Failure to Prevent Smoking-Related Fire Hazard
Penalty
Summary
The facility failed to address the risk of fire while smoking for a resident who was known to be a smoker and required continuous oxygen. Despite being aware of the resident's smoking habits and history of bringing cigarettes and lighters into the facility, staff did not implement effective measures to ensure the resident's safety from fire hazards. This oversight led to an incident where the resident smoked unnoticed while wearing oxygen, resulting in a fire that caused second-degree burns to the resident's face and right forearm. The resident, who was cognitively intact, had a history of smoking at the facility and during hemodialysis sessions. Staff were aware of the resident's non-compliance with the facility's smoke-free policy and had previously found cigarettes and lighters in the resident's possession. Despite this knowledge, the facility's interventions, such as locking up cigarettes and lighters, were not consistently effective, and the resident continued to access smoking materials. On the night of the incident, the resident attempted to smoke in their room while on oxygen, leading to a fire that required emergency intervention and hospitalization in a burn unit. The facility's policies and procedures for maintaining a smoke-free environment and ensuring safety with oxygen therapy were not adequately enforced, contributing to the preventable accident and injury to the resident.
Inaccurate MDS Assessment for Resident's Smoking and Oxygen Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the health and functional status of a resident, specifically regarding smoking status and oxygen use. The resident, who was cognitively intact, had a history of smoking and was known to bring cigarettes and lighters back from hemodialysis sessions, despite the facility being smoke-free. The MDS Coordinator admitted to automatically coding tobacco use as 'no' for all residents because the facility was smoke-free, even though the resident was known to smoke while at dialysis. The resident was on continuous oxygen therapy since admission, but the MDS assessment did not reflect this, as the section for oxygen therapy was not marked. The Director of Nursing acknowledged that the MDS did not indicate the resident's tobacco use and that oxygen use was not checked, despite the resident being admitted with oxygen. This inaccuracy in the MDS assessment could lead to unmet care needs for the resident, particularly concerning smoking and oxygen safety. The facility's policy and procedure for resident assessment emphasized the importance of conducting comprehensive and accurate assessments to support the resident's care needs. However, the MDS assessments were not accurately completed, as evidenced by the failure to document the resident's smoking status and oxygen use. This discrepancy was further highlighted by the facility's practice of coding all residents as non-smokers due to the smoke-free policy, despite evidence to the contrary.
Failure to Implement Effective Smoking Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to prevent accidents for a resident who was known to be a smoker. Despite the staff's awareness of the resident's smoking status and his attempts to bring cigarettes and lighters into the facility, effective care plan interventions were not established. The resident, who was cognitively intact, had a history of smoking at dialysis and had been caught smoking at the facility, which was smoke-free. The care plans in place did not accurately address the resident's behaviors or provide effective interventions to prevent smoking-related injuries. On a specific date, a Certified Nursing Assistant (CNA) heard a loud noise from the resident's room and discovered that the oxygen tubing and nasal cannula were on fire. The resident had attempted to smoke a cigarette while on continuous oxygen, resulting in second-degree burns to his face. The facility's staff, including the Administrator, Licensed Vocational Nurse (LVN), and Director of Nursing (DON), acknowledged that the care plans were not individualized or specific to the resident's needs and behaviors. The interventions listed, such as using a cigarette holder and smoking apron, were inappropriate given the facility's smoke-free policy. The facility's policy and procedure on comprehensive care plans emphasized the need for person-centered plans that address medical, nursing, physical, mental, and psychosocial needs. However, the care plans for the resident did not meet these requirements, as they failed to address the resident's non-compliance with smoking rules and did not include effective strategies to prevent him from smoking onsite. The lack of appropriate interventions and documentation contributed to the incident, resulting in the resident's injury and hospitalization.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two incidents involving three residents. In the first incident, two residents with a known history of verbal altercations were not adequately separated after an altercation. Despite staff intervention, one resident was able to sit next to the other and scratch her face while the CNA's back was turned. Both residents had severe cognitive impairments, and the staff was aware of their history of conflicts, yet failed to provide adequate supervision to prevent further altercations. In the second incident, the same resident involved in the first altercation was not adequately supervised after the initial incident, leading to another altercation with a different resident. The resident, who had a history of causing verbal altercations, bit another resident on the shoulder in the dining room. Despite being placed on 15-minute checks after the first incident, the resident was unsupervised in the dining room, allowing the second altercation to occur. The facility's policy on abuse prevention was not followed, as staff failed to separate residents immediately after altercations and did not provide adequate supervision to prevent further incidents. The Director of Nursing and other staff members acknowledged the need for supervision and separation of residents involved in altercations, yet these measures were not effectively implemented, resulting in harm to the residents involved.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitative services as required by the comprehensive plan of care for a resident who had undergone knee surgery. The resident was ordered by a physician to receive physical therapy (PT) and occupational therapy (OT) five days a week to aid in recovery and improve mobility, weight bearing, and transferring abilities. However, the resident did not receive PT from October 19 to October 25 due to the absence of the Physical Therapy Assistant (PTA) who was out sick, and there was no backup coverage available to continue the resident's rehabilitation during this period. Interviews with the Physical Therapy Assistant, Administrator, Director of Nursing, and Regional Director of Rehabilitation confirmed that the resident missed four days of PT during the specified week, which was crucial for the resident's recovery from surgery and to prevent further decline in physical well-being. The resident's medical history included aftercare following joint replacement surgery, muscle weakness, and difficulty in walking, emphasizing the importance of consistent rehabilitative services. The facility's policy required that each resident receive specialized rehabilitative services as determined by their comprehensive plan of care, but this was not adhered to in this case.
Failure to Adhere to Hourly Monitoring Protocol
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident when staff did not perform hourly monitoring in accordance with the facility's policy and procedure titled, 'Rounding Using the 4 P's Rounding Tool.' The resident, who had a history of falling, difficulty in walking, dementia, and muscle weakness, was admitted with a diagnosis of Type 2 diabetes mellitus with hyperglycemia. The resident's cognitive status was moderately impaired, as indicated by a Brief Interview of Mental Status assessment score of 09 out of 15. Following an unwitnessed fall that resulted in a fractured left humerus, the resident was placed on the 4 P's program as an intervention to prevent further falls. Despite the implementation of the 4 P's program, which required hourly rounds to check on the resident's pain, positioning, personal needs, and personal items, the facility staff failed to adhere to this schedule. The logs for the resident showed multiple missing entries on various dates, indicating that the hourly rounds were not consistently performed. The Licensed Vocational Nurse and the Director of Nursing both acknowledged that the care plan interventions and the 4 P's program were not followed, which was intended to prevent falls. This lack of adherence to the established care plan and monitoring protocol constituted a deficiency in the facility's provision of care.
Improper Use of Wedge Pillows as Restraints
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by the use of wedge pillows placed under the mattresses of three residents. These wedge pillows were positioned in such a way that they restricted the residents' freedom of movement and prevented them from getting out of bed. This action was taken without proper physician orders or care plan interventions, violating the residents' rights to be free from physical restraints. Resident 2 was observed with a wedge pillow under the mattress, causing the mattress to tilt and restrict movement. The resident had a history of falling and was diagnosed with atherosclerotic heart disease, atrial fibrillation, dementia, and unsteadiness on feet. Similarly, Resident 3, diagnosed with epilepsy, contracture, difficulty in walking, and dementia, was found with a wedge pillow under the mattress, restricting his ability to get out of bed. Resident 4, with Parkinson's Disease, abnormalities of gait and mobility, dementia, and difficulty in walking, was also observed with wedge pillows under the mattress, preventing her from moving freely. Interviews with staff, including a CNA, LVN, and the Director of Nursing, revealed that the wedge pillows were used as a fall prevention measure, but they acknowledged that the pillows could be considered restraints if residents were unable to move freely. The facility's policy on physical restraints prohibits the use of such devices for convenience or to inhibit a resident's freedom of movement. The lack of physician orders and care plan interventions for the use of wedge pillows further highlighted the deficiency in ensuring residents' rights to be free from physical restraints.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to ensure that a resident was free from injury during transportation to a medical appointment. The resident, who had hemiplegia and diabetes, was transported without shoes, wearing only socks, and his left footrest was initially missing. During the transport, the resident's left foot slipped off the wheelchair and dragged on the pavement, resulting in abrasions to four toes on his left foot. This incident occurred because the transport driver did not notice the resident's foot slipping off the wheelchair. Upon returning to the facility, the resident's sock was found to be worn and bloody, and he had skin injuries on his toes. The resident experienced pain and required daily dressing changes by the nursing staff. The resident's cognitive status was intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status. The resident expressed discomfort and pain, which was managed with pain relievers, including acetaminophen and later Norco, a stronger narcotic-based medication. Interviews with facility staff, including the Director of Occupational Therapy and the Director of Nursing, revealed that it was expected for residents to wear shoes and have leg rests when leaving the facility. The staff also expected transportation personnel to be attentive to residents' needs and ensure their safety during transport. However, these expectations were not met, leading to the resident's injury.
Resident Burned Due to Lack of Supervision with Hot Beverage
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident diagnosed with dementia, poor safety awareness, and muscle weakness. The resident, who was totally dependent on staff for eating and drinking, was left unsupervised while drinking hot tea, resulting in the resident spilling the tea and suffering second-degree burns on her chest. This incident occurred despite the resident's comprehensive care plan indicating the need for staff assistance with eating and drinking. The resident's medical history included cerebral infarction, hemiplegia, and contracture of the left hand, which impaired her ability to safely feed herself. The Minimum Data Set assessment indicated severe cognitive impairment, and the resident required one-person physical assistance for eating. The facility's Hot Beverage Safety Evaluation suggested that the resident might require setup assistance but did not explicitly state the need for supervision, which was questioned by the staff given the resident's medical conditions. Interviews with facility staff, including Licensed Vocational Nurses and the Director of Nursing, confirmed that the resident was not safe to handle hot beverages without assistance. The facility's policy on quality of care emphasized the need for individualized, resident-centered interventions to prevent avoidable accidents, which were not followed in this case. The Director of Nursing acknowledged that the resident's care plan was not adhered to, which may have prevented the accident.
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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