Fulton Gardens Post Acute, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 537 E. Fulton Street, Stockton, California 95204
- CMS Provider Number
- 055833
- Inspections on file
- 32
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fulton Gardens Post Acute, Llc during CMS and state inspections, most recent first.
A resident's medications were left unattended at her bedside, and a diagnostic test to determine the cause of her illness was delayed. The resident, with type 2 diabetes and hypertension, was unable to take her medications due to coughing, and the LN left them assuming it was permissible. The facility's policy required timely administration and completion of diagnostic services, which was not adhered to, leading to potential risks.
The facility did not follow the planned menu and recipes during lunch preparation, affecting 94 residents. The DSS substituted ingredients without RD approval, using insufficient cucumbers and unapproved items for the Asian Cucumber Salad. The Asian [NAME] Rice was served without necessary ingredients, and the Asian Smooth Sauce was not prepared, impacting residents needing specific food consistencies.
The facility failed to provide meals according to the dietary needs of 94 residents during a lunch meal. Residents on various diets, including regular, chopped, pureed, large portion, CCHO, and fortified diets, received incorrect portion sizes or missing items. These deficiencies were observed during a lunch tray line and confirmed through staff interviews and document reviews.
The facility failed to maintain proper food safety and sanitation standards, with issues including unclean kitchen equipment, improper food storage, and inadequate temperature monitoring. Spoiled produce and food stored beyond use-by dates were found, and a visibly ill employee prepared food without proper hand hygiene. Unwashed mushrooms were also served, increasing the risk of foodborne illness for residents.
The facility failed to implement proper infection control measures, including the use of PPE and EBP signage, for residents with indwelling devices. A nurse did not wear a gown while providing G-tube care, and another stored an open sterile dressing improperly. Additionally, a resident's room lacked EBP signage and PPE supplies, and a nurse did not wear a gown when accessing a PICC line, all of which increased the risk of infection.
The facility failed to follow its Antibiotic Stewardship Program, resulting in deficiencies in monitoring and optimizing antibiotic use. A resident was prescribed antibiotics without following the McGeer Criteria, as no laboratory specimen was sent for testing. The facility's documentation was incomplete, lacking details on the duration of antibiotic therapy and outcomes. The Pharmacist Consultant highlighted the risk of antibiotic resistance due to the lack of diagnostic tests, which could lead to incorrect medication prescriptions.
A resident's right to dignity was violated when two CNAs spoke a foreign language over her while providing care, making her feel uncomfortable. The facility's policy required staff to speak English to ensure residents' emotional comfort, which was not adhered to in this instance.
Two residents permitted to self-administer medications had their medications stored unsafely, with expired and unsecured medications accessible at the bedside and in a tote bag. The facility failed to follow its policy requiring medications to be stored in a locked container, increasing the risk of overdose and reduced efficacy. The residents' cognitive impairments and the presence of other residents with wandering behavior further heightened the risk.
A facility failed to implement an individualized care plan for a resident with dementia and schizophrenia by not incorporating PASRR Level II recommendations. The PASRR Level II screening was completed but not uploaded to the resident's EMR, and the recommendations were not included in the care plan, posing a risk of not receiving necessary specialized services.
A resident with a history of stroke and aphasia did not receive consistent Assisted Active ROM (AAROM) services as required by their care plan. The resident's right hand was contracted, and documentation of AAROM was often marked as 'Not Applicable' or missing. Staff interviews confirmed the inconsistency in performing and documenting AAROM, and the Therapy Director noted the need for a splint. The facility's leadership acknowledged the failure to adhere to policies, which could have affected the resident's hand function and quality of life.
Three shaving razors were left unattended on the counter in a shared bathroom used by four residents, posing a risk of injury and infection. A nurse confirmed the hazard, and interviews with the Director of Staff Development and the DON highlighted the violation of facility policy, which requires the containment of hazards to protect residents.
The facility failed to ensure safe pharmaceutical services by not replacing an opened emergency kit and inaccurately documenting narcotic medication use for a resident with intervertebral disc degeneration. The emergency kit was not replaced in a timely manner, and the required confirmation fax was not found. Additionally, the Medication Administration Record did not reflect the narcotic dosages signed out for the resident, indicating a failure to follow facility policy.
A resident was prescribed Ciprofloxacin for a UTI without meeting the McGeer Criteria for continued use, as no urine specimen was collected. The facility's policies on infection prevention and antibiotic stewardship were not followed, leading to unnecessary antibiotic use. The absence of urinalysis results and physician progress notes further highlighted the deficiency.
The facility failed to secure liquid controlled substances in a locked refrigerator, as required by policy, increasing the risk of unauthorized access. A nurse found the refrigerator unlocked and secured it immediately. The DON confirmed the policy breach, which mandates controlled medications be stored securely with limited access.
The facility failed to maintain closed garbage bins, as observed during an inspection with the Dietary Service Supervisor (DSS). The bins were found open, contrary to the facility's policy on sanitary garbage disposal, which aims to prevent pest infestations. The DSS confirmed that the dumpsters should be kept closed to avoid attracting pests.
A resident's medical records were mistakenly placed in another resident's EHR, breaching confidentiality. The Director of Medical Records and the Administrator confirmed the error, acknowledging it as a HIPAA issue. Despite using a software program to manage records, the facility failed to follow its Privacy and Confidentiality Policy, leading to potential exposure of private information.
A facility failed to coordinate care with a hospice agency for a resident receiving end-of-life care. After an incident involving the resident, the IDT recommended a medication review by hospice, but the facility did not follow up, leaving the review undocumented in the resident's record. The hospice agency confirmed the review was done and faxed to the facility, but it was not received due to staff oversight during shift changes. The DON admitted the facility's service agreement and policy for hospice services were not followed.
A resident experienced a delay in receiving physician-ordered Tramadol for pain management due to pharmacy prescription requirements, despite its availability in the E-kit. The resident endured moderate pain levels, and Tylenol was provided as an inadequate substitute.
Two residents did not receive scheduled showers, with one going a week and the other six days without one. Despite needing assistance, the facility failed to provide showers as per policy, leading to family members intervening. Staff confirmed the oversight and lack of documentation for missed showers.
Medication Mismanagement and Delayed Diagnostic Testing
Penalty
Summary
The facility failed to maintain professional standards of quality care for a resident when prescribed medications were left unattended at her bedside, and a diagnostic test ordered to determine the cause of her illness was not completed in a timely manner. The resident, who was admitted with diagnoses including type 2 diabetes mellitus and hypertension, was observed with her medications left in a plastic cup on her tray table. The resident stated she could not take her morning medications due to excessive coughing. The Licensed Nurse (LN) left the medications with the resident, assuming it was permissible since the resident was alert, despite the absence of an order allowing the resident to self-administer these medications. The Minimum Data Set Coordinator confirmed that the resident's assessment only permitted self-administration of Bengay, not other medications. The Director of Staff Development highlighted the risks associated with leaving medications unattended, such as potential access by other residents and the risk of choking. The LN acknowledged that the medications should not have been left at the bedside and should have been administered within the prescribed time frame. The facility's policy on administering medications emphasized the need for safe and timely administration per physician orders and compliance with state and federal guidelines. Additionally, there was a delay in completing a diagnostic chest X-ray ordered to rule out pneumonia. The order was placed on January 17, but the X-ray was not performed until January 19, with the report dated January 20. The delay was attributed to the X-ray provider's limited operating hours and a lack of follow-up by the facility staff. The facility's policy on laboratory services required timely completion of diagnostic services and prompt reporting of abnormal results to ensure quick action. The Licensed Vocational Nurse's job description also emphasized the responsibility to manage care plans and report any undelivered care to the Director of Nursing.
Failure to Follow Menu and Recipes During Meal Preparation
Penalty
Summary
The facility failed to adhere to the planned menu and recipes during lunch meal preparation, affecting 94 residents. The Dietary Service Supervisor (DSS) substituted ingredients without approval from the Registered Dietician (RD), which included using only eight cucumbers instead of the required three gallons for the Asian Cucumber Salad. The DSS also added unapproved ingredients like three-bean salad and Italian dressing, deviating from the standard recipe that required rice vinegar, honey, sesame oil, red crushed pepper, and salt. The RD confirmed that these substitutions were not approved and could lead to poor intake and weight loss among residents. Additionally, the facility did not follow the recipe for Asian [NAME] Rice, as it was served without the necessary ingredients such as low sodium chicken stock, soy sauce, sesame oil, and sliced green onions. Furthermore, the Asian Smooth Sauce, which was required for residents needing soft, bite-sized, minced, moist, and ground consistency, was not prepared. This oversight meant that no alternative was provided for these residents, potentially impacting their dining experience and nutritional intake.
Failure to Meet Dietary Needs During Meal Service
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the dietary needs of 94 residents during a lunch meal. Residents on regular portion diets received less than the required amount of food, as the kitchen staff used a #10 scoop instead of the #8 scoop specified in the facility's serving directions. Additionally, residents with orders for chopped, easy to chew, soft bite-sized, and minced and moist textured diets did not receive the correct portion sizes of Beef and Broccoli. Residents on pureed diets received incorrect portions of Asian Beef and Broccoli and did not receive Potstickers as required. Furthermore, three residents on large portion diets did not receive the correct amount of Asian Beef and Broccoli and Asian Rice. Residents on Consistent Carbohydrate Diets (CCHO) received incorrect portion sizes of Asian Rice, and 14 residents requiring fortified diets did not receive the additional items needed to increase their caloric intake. These deficiencies were observed during a lunch tray line observation and confirmed through interviews with dietary staff and a review of facility documents, indicating a failure to follow the established dietary guidelines and serving sizes.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by multiple observations of unsanitary conditions and improper handling of food. The stove and oven were found to have significant grease and food particle buildup, and the cleaning schedule was not adhered to due to staffing issues. Over-ripe and spoiled produce was found in the walk-in refrigerator, and food items were stored beyond their use-by dates or not kept at the required temperatures. Additionally, food labeled to be kept frozen was improperly stored in the refrigerator. The walk-in refrigerator and freezer were not maintaining the correct temperatures, posing a risk of food spoilage. The external and internal thermometers showed temperatures outside the safe range, and the facility's maintenance team had to adjust the equipment settings. Unit refrigerators and freezers at various nurse stations were also found to be unclean, with missing temperature logs and improperly labeled resident food. These conditions were confirmed by the Dietary Service Supervisor and other staff members, who acknowledged the risks of foodborne illness to residents. A visibly ill employee was observed preparing food without following proper hand hygiene protocols, such as washing hands after coughing. This employee was allowed to work despite showing symptoms of illness, and there was no clear policy for excluding sick staff from food preparation duties. Additionally, unwashed mushrooms with visible dirt were prepared and served, contrary to the facility's policy and FDA guidelines. These deficiencies in food safety practices placed residents at risk for foodborne illnesses.
Infection Control Deficiencies in PPE Usage and EBP Implementation
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control measures for several residents, leading to potential health risks. In one instance, a Licensed Nurse (LN) did not wear the required personal protective equipment (PPE) while providing gastrostomy tube care to a resident on Enhanced Barrier Precautions (EBP). Despite the presence of a sign indicating EBP isolation, the nurse only wore gloves and failed to don a gown, which is necessary to prevent cross-contamination and the spread of multi-drug resistant organisms. Another deficiency was observed when a sterile wound dressing was improperly stored in an open state within a treatment cart. A nurse admitted to opening the dressing package in preparation for a procedure that was postponed, and acknowledged that the dressing should have been discarded to prevent infection risks. The facility's policy mandates the disposal of unused opened dressings to avoid cross-contamination, which was not followed in this case. Additionally, a resident's room lacked the necessary EBP signage and PPE supplies outside the door, despite the resident having a permacath that required such precautions. Staff members, including a Certified Nurse Assistant (CNA), were unaware of the EBP requirements and did not use PPE when assisting the resident, increasing the risk of infection. Furthermore, another LN failed to wear a gown while accessing a PICC line for a resident, contrary to the EBP guidelines, which require gown and glove use during high-contact care activities involving indwelling devices.
Failure to Adhere to Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) and national standards, resulting in deficiencies in monitoring and optimizing antibiotic use. Specifically, the facility did not follow the McGeer Criteria for prescribing antibiotics to Resident 31, as no laboratory specimen was sent out for testing despite the criteria indicating that two infection criteria were met. Additionally, the facility did not consistently document the duration of antibiotic therapy or monitor the outcomes of antibiotic use, which are essential components of the ASP. During the review of the facility's ASP spreadsheet, it was found that the documentation was incomplete and inconsistent. The spreadsheet did not include the duration of antibiotic therapy, the date of diagnostic tests ordered, or the outcomes of antibiotic use. The Infection Preventionist (IP) confirmed that the spreadsheet used to include this information but no longer did. Furthermore, the IP acknowledged that outcome monitoring was not being conducted, and the McGeer Criteria marked as met for Resident 31 was done in error. The Pharmacist Consultant emphasized the importance of conducting diagnostic tests when prescribing antibiotics to prevent antibiotic resistance. The facility's failure to order culture and sensitivity tests when prescribing antibiotics could lead to prescribing incorrect medications, contributing to the development of Multiple Drug Resistant Organisms (MDRO). The facility's policy on the Antibiotic Stewardship Program, which aims to limit antibiotic resistance and improve treatment efficacy, was not being followed, as evidenced by the lack of infection surveillance data analysis and outcome measurement.
Violation of Resident's Right to Dignity Due to Language Barrier
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when two CNAs spoke a foreign language over the resident while providing care. During an observation, the CNAs were seen on opposite sides of the resident's bed, engaging in a conversation in a foreign language that was audible from outside the room. The conversation was personal and unrelated to the resident's care, which was confirmed by the CNAs during a joint interview. The resident expressed discomfort and dissatisfaction with the situation, stating that the CNAs should not have spoken in a foreign language over her. Interviews with the Director of Staff Development and the Director of Nursing revealed that the facility's policy required staff to speak English to avoid making residents feel emotionally uncomfortable. The facility's policy on dignity and respect emphasized the importance of treating residents with kindness, respect, and dignity at all times. The incident was identified as a violation of the resident's right to dignity, as it made the resident feel excluded and uncomfortable during care.
Failure to Secure Medications for Self-Administering Residents
Penalty
Summary
The facility failed to ensure that two residents, who were permitted to self-administer medications, had their medications stored safely. For Resident 16, a variety of both prescribed and over-the-counter medications were found unlocked and accessible at the bedside, some of which were expired. Despite having a physician's order to self-administer only Vitamin D3 and Centrum Silver, Resident 16 had numerous other medications, including Tylenol, Aspirin, and Metformin, which were not secured. The facility did not have a system to track the self-administration of these medications, and the medications were not stored in a locked container as required by the facility's policy. Resident 16's roommates were noted to have cognitive impairments, increasing the risk of accidental ingestion of the unsecured medications. The facility's Licensed Nurse confirmed that the medications should have been locked and acknowledged the risk of overdose and reduced efficacy due to expired medications. The facility's policies on medication storage and self-administration were not followed, as evidenced by the presence of expired medications and the lack of secure storage. Similarly, Resident 60 was found carrying medications in a tote bag on her walker, which was accessible to other residents. Although Resident 60 had a locked box for medications in her room, the medications were not stored securely when outside the room. The facility's Regional Nurse Consultant and Assistant Director of Nursing confirmed that the facility's policy was not followed, as medications should have been stored in a locked container to prevent access by other residents.
Failure to Implement PASRR Recommendations in Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan intervention for a resident who had recommendations from a PASRR Level II screening. This screening is designed to identify additional resources needed for residents with mental illness, intellectual, or developmental disabilities. The resident, who was admitted in 2023, had diagnoses including dementia and schizophrenia. Although the PASRR Level I screening results were present in the resident's electronic medical record (EMR), the PASRR Level II report was not attached. The Minimum Data Set Coordinator confirmed that the PASRR Level II screening was completed but not uploaded to the EMR, and the recommendations were not incorporated into the resident's care plan. The Director of Nursing acknowledged that the facility's policy was not followed, as the PASRR Level II recommendations should have been added to the resident's care plan. The facility's policy and procedure for developing comprehensive care plans emphasize the need to incorporate PASRR recommendations to address the resident's medical, physical, mental, and psychosocial needs. The failure to include these recommendations in the care plan posed a risk that the resident would not receive the necessary specialized services or rehabilitative services as identified by the PASRR Level II evaluation.
Failure to Provide Consistent ROM Services
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to Resident 12, who had a history of stroke and aphasia, resulting in limited mobility and a contracted right hand. The resident's care plan included Assisted Active ROM (AAROM) exercises for both upper and lower extremities during daily activities, but these were not consistently documented or performed. Observations and interviews revealed that the resident's right hand was contracted, and AAROM exercises were not regularly conducted or recorded, as evidenced by multiple instances where documentation was marked as 'Not Applicable' or missing. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), confirmed that AAROM exercises were not consistently performed or documented. The CNA admitted to not performing AAROM on a specific date, and the LN acknowledged the importance of these exercises in maintaining the resident's hand function. The lack of documentation for refusals of AAROM further indicated a failure to adhere to the facility's policy and procedures, which required reasons for not providing ROM services to be documented in the medical record. The Therapy Director assessed the resident and noted the stiffness in the resident's right thumb, suggesting the need for a splint, which had not been provided. The facility's Administrator and Director of Nursing reviewed the records and acknowledged the failure to ensure that AAROM was performed as required. This deficiency in care could have impacted the resident's ability to use his right hand effectively, potentially affecting his quality of life.
Unattended Razors Pose Risk in Shared Bathroom
Penalty
Summary
The facility failed to ensure the safety of residents by leaving three shaving razors unattended on the counter in a shared bathroom used by four residents. This oversight was observed during a survey on January 7, 2025, at 10:20 AM. The razors were accessible to residents, which posed a risk of injury and infection, particularly for those who might be confused or disoriented. Licensed Nurse 8 confirmed the presence of the razors and acknowledged the potential danger they posed to residents. Further interviews with the Director of Staff Development and the Director of Nursing reinforced the concern that leaving razors unattended in a shared bathroom was against facility policy and posed a risk of injury and infection. The facility's policy, dated March 2023, emphasized the importance of maintaining a resident environment free from accident hazards and ensuring adequate supervision. The policy specifically mentioned the need to contain hazards to protect residents from harm, highlighting the facility's failure to adhere to its own guidelines.
Deficiencies in Pharmaceutical Services and Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for its residents, as evidenced by two main deficiencies. Firstly, the emergency kit (E-kit) for oral medications was opened and resealed on January 2, 2025, but had not been replaced by January 7, 2025. During an observation and interview, a licensed nurse (LN) confirmed that medications were removed from the E-kit, and the required confirmation fax receipt from the pharmacy was not found. The Director of Nursing (DON) confirmed that the facility policy, which required the form to be faxed to the pharmacy within 24 hours and followed up to ensure receipt, was not followed. Secondly, the facility failed to accurately document the use of narcotic medication for a resident. The Controlled Drug Record (CDR) indicated that Hydrocodone-Acetaminophen was signed out for the resident on two occasions, but the Medication Administration Record (MAR) did not reflect these dosages. The DON acknowledged this discrepancy and confirmed that the facility policy was not followed, which required accurate documentation of medication administration. The resident involved had a medical history of intervertebral disc degeneration, which can cause significant pain. The failure to document narcotic medication use accurately could lead to unsafe medication practices and potential drug diversion. The facility's policies and procedures for administering medications and handling controlled substances were not adhered to, as confirmed by the DON.
Failure to Adhere to Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically antibiotics, as part of their drug regimen. Resident 31 was prescribed Ciprofloxacin for a urinary tract infection (UTI) without meeting the established McGeer Criteria for continued use of the antibiotic. The Infection Preventionist (IP) confirmed that the resident was started on the antibiotic based on an SBAR assessment tool, but a urine specimen was not collected to confirm the infection, which was a requirement for meeting the McGeer Criteria. The review of Resident 31's records revealed that there were no urinalysis results for December, and no physician progress notes addressed the assessment of a new infection or the review of antibiotic effectiveness. The Director of Medical Records confirmed the absence of urinalysis results, and the Pharmacist Consultant emphasized the importance of diagnostic tests to prevent antibiotic resistance. The facility's policy required a review of antibiotics 48 hours after initiation, but this was not documented in the resident's records. The facility's Infection Prevention and Control Program policy, as well as the Antibiotic Stewardship Interventions policy, were not adhered to in this case. The policies required maintaining records of infections and corrective actions, as well as performing a review of antibiotics to ensure appropriate use. The failure to collect a urine specimen and review the antibiotic regimen led to the unnecessary continuation of antibiotic therapy for Resident 31, which could contribute to the development of multi-drug resistant organisms.
Failure to Secure Controlled Medications in Locked Storage
Penalty
Summary
The facility failed to ensure the safe storage of medications, specifically liquid controlled substances, for a census of 104 residents. During an observation and interview, it was found that the refrigerator in the Medication Storage Room, which contained liquid narcotic medications and an emergency kit, was unlocked. A Licensed Nurse acknowledged that the refrigerator should have been locked and immediately secured it. The risk identified was that unauthorized individuals could access the medications if the refrigerator remained unlocked. Further interviews and record reviews with the Director of Nursing confirmed that the facility's policy was not followed. The facility's policy and procedure documents indicated that controlled medications should be stored separately and securely, with access limited to authorized personnel. The policy also specified that controlled medications requiring refrigeration must be stored within a locked, permanently affixed box inside the refrigerator. The failure to adhere to these policies increased the risk of drug diversion.
Failure to Maintain Closed Garbage Bins
Penalty
Summary
The facility failed to maintain a closed garbage (dumpster) bin, which had the potential to lead to insect and rodent infestation. During an observation and interview with the Dietary Service Supervisor (DSS), it was noted that the lids of the garbage bins were not in place, and the dumpsters were open. The DSS acknowledged that the garbage dumpsters should be kept closed to avoid pests. A review of the facility's policy titled 'Adequate Sewage Disposal and Plumbing,' dated 2019, indicated that improperly disposed of garbage is a source of unsanitary practices and unpleasant odors, and it can harbor vermin, flies, rodents, and cockroaches. The policy outlined practices to prevent this, including providing garbage containers in adequate supply to hold all garbage between collections and ensuring lids are tight-fitting and secure.
Confidentiality Breach in Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical records, specifically for one resident whose records were mistakenly placed in another resident's electronic health record (EHR). This error was identified during an interview and record review with the Director of Medical Records (DMR), who confirmed that the Preadmission Screening and Resident Review (PASSR) forms for the affected resident were found in another resident's EHR. The DMR acknowledged that this was a Health Insurance Portability and Accountability Act (HIPAA) issue and noted that this type of error had been an ongoing problem, which she had been addressing as they were discovered. The Administrator (ADM) also confirmed the error, acknowledging that the facility had been using a specific software program to scan medical records into the EHR for a year, but despite this, records were still being uploaded incorrectly. The ADM confirmed that the affected resident's records were removed from the incorrect chart and uploaded to the correct one. The facility's Privacy and Confidentiality Policy, which aligns with HIPAA standards, was not followed in this instance, leading to the potential exposure of private and confidential information to unauthorized individuals.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the hospice agency for a resident receiving end-of-life care. The resident, who was admitted with diagnoses including palliative care and Alzheimer's disease, was involved in an incident where they scratched another resident. Following this, the interdisciplinary team (IDT) recommended a medication review by the hospice agency on a specific date. However, the facility did not follow up on the outcome of this review, resulting in the medication review not being available in the resident's clinical record. During interviews and record reviews, it was confirmed that the hospice agency had conducted the medication review and faxed the report to the facility. However, the facility staff, particularly during shift changes, did not receive the faxed report. The Director of Nursing (DON) acknowledged that the facility's service agreement with the hospice agency and the facility's policy and procedure for hospice services, which required documentation of communication between the facility and hospice provider, were not followed. This oversight had the potential to impact the quality of care provided to the terminally ill resident.
Delayed Administration of Pain Medication
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice and the comprehensive care plan for a resident when a physician-ordered pain medication, Tramadol, did not arrive from the pharmacy until three days after the resident's admission. Despite the availability of Tramadol in the E-kit, the medication was not administered, leaving the resident at risk for increased, uncontrolled pain. The resident's medication administration record indicated a start date for Tramadol on the day of admission, with instructions to monitor and document pain levels. However, the resident experienced moderate pain levels of 5 on a 0-10 scale on the days following admission. The nursing staff attempted to address the issue by contacting the pharmacy and the physician, but the Tramadol prescription was delayed due to the need for a triplicate prescription. The resident was instead given Tylenol, which was deemed inadequate for the reported pain level. Interviews with nursing staff revealed that the resident repeatedly requested Tramadol, and there was an acknowledgment that uncontrolled pain could lead to other health concerns. The Tramadol prescription was eventually signed by the facility physician, and the medication was delivered to the facility, but not until after the resident had endured days of moderate pain.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary services for two residents, resulting in missed showers over a period of several days. Resident 1, admitted with generalized weakness and difficulty walking, did not receive a shower for a week, from June 19 to June 26, 2024. Despite needing partial to moderate assistance with bathing, Resident 1 reported that showers were sometimes only offered once a week, and bed baths were given without the option of a shower. The resident expressed a preference for showers and had never refused one. Family Member 1 had to intervene multiple times to ensure Resident 1 was scheduled for showers. Resident 2, admitted for generalized weakness and rehabilitation, also experienced missed showers, going six days without one. CNA 1 confirmed that showers were supposed to be given twice a week but acknowledged that new admissions might not be scheduled correctly, leading to missed showers. Resident 2's family member had to provide a shower after complaints to the staff went unaddressed. Both the Licensed Nurse and the Director of Staff Development confirmed the missed showers and acknowledged the lack of documentation for refusals or reasons for the missed showers. The facility's policy on dignity and respect, which emphasizes grooming according to residents' preferences, was not adhered to in these cases.
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Surveyors found multiple food safety deficiencies, including a cook preparing food without a beard restraint and a dietary aide with hair exposed outside a hairnet, contrary to facility policy requiring full hair coverage. The kitchen stove and oven had thick accumulations of grease, dark deposits, and sticky dust and oil residue on interior and exterior surfaces, indicating inadequate cleaning and sanitization. An opened bag of brown sugar was also found unsealed, unlabeled, and undated, despite facility policy requiring all food items to be labeled with the product name and use-by or discard date.
Surveyors found that the facility did not obtain or properly document informed consent for psychotropic medications for multiple residents. Several residents with depression, anxiety, bipolar disorder, and schizophrenia were receiving drugs such as sertraline, lorazepam, divalproex, trazodone, risperidone, escitalopram, lithium, chlorpromazine, haloperidol (including long-acting injectable), and Zyprexa without evidence that informed consent was obtained before initiation or dose changes. In some cases, consent forms were completed only after psychotropic medications had already been ordered and administered, and in others, no consent documentation existed at all, despite facility policies requiring informed consent prior to starting or increasing psychotropic therapy.
Surveyors identified a medication error rate of 17.14% during observed med passes, with multiple instances of nurses not following prescriber orders. One resident received only half the ordered dose of divalproex and in capsule form instead of the prescribed delayed-release tablet, while another was given gabapentin in capsule form instead of the ordered tablet. A G-tube resident was given ferrous sulfate instead of ordered iron glycinate, did not receive ordered docusate, and had eight medications administered via G-tube without required water flushes between each medication. Another resident did not receive a scheduled dose of quetiapine during the afternoon med pass. The report notes these failures resulted in medications not being administered according to physician orders and created potential for reduced therapeutic effect and G-tube blockage.
A resident with a history of cerebral infarction, schizophrenia, and depression was observed seated in a wheelchair during a lunch meal while a CNA stood over her and fed her with a spoon, contrary to facility policy requiring staff to sit at the resident’s eye level. The CNA later acknowledged she was expected to obtain a chair and sit beside the resident for comfort, and the DSD confirmed that staff are required to position themselves at eye level and not stand over residents when providing feeding assistance, as outlined in the facility’s dignity and meal-assistance policies.
A resident with schizophrenia had a PRN order for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for aggression renewed for an additional 14 days without a physician evaluation, contrary to facility policy and federal requirements. The DON confirmed there was no evaluation by the attending physician or prescriber before renewing the PRN antipsychotic order, despite the policy stating that PRN antipsychotic medications cannot be renewed without such an evaluation and documented appropriateness. Surveyors determined this resulted in an unnecessary psychotropic medication order.
Surveyors found that MDS assessments for two residents receiving antipsychotic medications contained incorrect dates for when prescribers had documented gradual dose reduction (GDR) as contraindicated. During interviews and record reviews, the MDSC confirmed that the GDR dates entered in Section N of the MDS did not match the dates in the residents’ plan of care notes, and acknowledged the need for correction. The MDSC and DON both stated that the MDS must accurately reflect the resident’s status to ensure services are based on current information, consistent with the facility’s policy that comprehensive MDS assessments are used to develop and revise person-centered care plans.
The facility failed to develop and implement an individualized care plan after a resident with gait and mobility abnormalities experienced an unwitnessed fall while getting out of bed. The resident reported the fall, and nursing staff, including an LVN, an RN, and the MDS coordinator, confirmed the incident and acknowledged that no short-term fall-related care plan or interventions were documented. This was inconsistent with facility policies requiring comprehensive person-centered care plans and fall risk management interventions based on assessment findings.
A resident had an order for PRN tramadol 50 mg for severe pain, and the controlled substance record showed that tablets were removed from stock on two occasions, but the MAR did not show that tramadol was administered on those dates. During interviews, an LVN acknowledged missing MAR documentation, and other nursing staff, the DSD, and the DON all stated that controlled substances were supposed to be documented on both the CSR and MAR and that the records should match. The facility’s medication administration policy required documentation immediately after administration, which was not followed in this case, resulting in inaccurate accountability of a controlled medication.
Surveyors found that a used urinal containing bloody urine was left on a resident's bedside table on multiple occasions, positioned next to a water pitcher and an empty food tray, with bloody urine visible on the outside and the lid open. A CNA confirmed the urinal should not have been stored there. The facility's infection control policy, as acknowledged by the IP, was not followed in this situation, resulting in a failure to maintain a safe and sanitary environment under the IPCP requirements.
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Unsanitary Food Handling, Equipment, and Storage Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in food safety practices related to employee hygiene and equipment cleanliness in the facility’s kitchen. During an observation, one cook was preparing food without a beard restraint, and a dietary aide had bangs exposed outside of a hairnet while working. In an interview, the Assistant Dietary Services Supervisor (ADSS) stated that kitchen staff were required by facility policy to have their hair completely covered and to wear hair nets and beard restraints properly. Review of the facility’s policy titled “Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices” confirmed that hair nets or caps and beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Additional observations showed that the stovetop and oven were not maintained in a sanitary condition. The stove was covered with a thick, crusty layer of brown and black grease. The oven’s interior and exterior surfaces, including the door and handle, were coated with thick, heavy buildup of old grease and dark deposits, and the bottom of the oven had a layer of sticky dust and oil residue. The ADSS verified these conditions and acknowledged that the stove and oven required cleaning. Surveyors also found an opened, unsealed bag of brown sugar that was unlabeled and undated. The ADSS confirmed it should have been labeled and dated, and review of the facility’s “Food Storage (Dry, Refrigerated, and Frozen)” policy indicated that all food items must be labeled with the name of the food and the date by which it should be sold, consumed, or discarded.
Plan Of Correction
F812 A. How corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/13/2026, Cook #1 immediately donned a beard restraint and ensured it was properly secured. The Dietary Aide immediately adjusted the hairnet to fully contain all hair, including bangs/fringe, prior to resuming food service duties. Both staff members were re-educated on facility grooming and infection control standards related to safe food handling. On 04/13/2026, the opened unsealed bag of brown sugar was immediately discarded. All dry storage items were reviewed for labeling, dating, sealing, and proper storage. Any items identified as unlabeled, undated, damaged, or improperly stored were immediately corrected or discarded. On 04/17/2026, the Administrator and the Registered Dietician conducted an immediate inspection of the kitchen and food service areas. No evidence of resident illness, food contamination, or foodborne outbreak related to the cited deficient practice was identified. On 04/17/2026 the Licensed Nurses conducted visual observation of all residents for any signs or symptoms of gastrointestinal distress, nausea, vomiting, diarrhea, fever, or other concerns. No adverse findings were noted. On 04/27/2026 the stove, oven interior, oven exterior surfaces, handles, and surrounding affected kitchen equipment were deep cleaned, degreased, sanitized, and returned to a clean operating condition. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 04/17/2026 the Registered Dietitian and assistant dietary supervisor completed a comprehensive audit of all kitchen staff for compliance with hair restraints, beard restraints, hand hygiene, and sanitary food handling practices. On 04/17/2026 all food storage items were reviewed to ensure procedures were properly labeled, dated, sealed, rotated, and stored in accordance with facility policy and safe food handling standards. On 04/28/2026 a full kitchen sanitation audit was completed to inspect all cooking equipment, ovens, stovetops, food contact surfaces, dry storage, refrigerators, freezers, shelving, and small wares for cleanliness and sanitation. No other deficient findings identified during the audits. C. What measures will be put into place or what systemic changes the facility will make to ensure the deficient practice does not recur: On 04/16/2026 the Administrator conducted an in-service education to dietary staff and cooks regarding: Proper use of hairnets, beard restraints, and personal hygiene during food preparation. Routine cleaning and sanitizing requirements for all kitchen equipment and food contact surfaces. Dry goods storage requirements, including sealing, labeling, dating, and stock rotation. Responsibility to immediately report sanitation concerns to the Dietary Manager and Administrator. On 04/17/2026 the facility developed and implemented a Dietary Sanitation / Food Safety Daily Audit Log (Food Procurement, Storage, Preparation & Service – Sanitary Compliance). This tool is utilized daily by the Dietary Supervisor or designee to conduct routine audits and ensure ongoing compliance with food safety and sanitation standards. D. How the facility will monitor its corrective actions to ensure the deficient practice is being corrected and will not recur: Beginning 04/20/2026 the assistant Dietary Services Manager will conduct an audit weekly x 4 weeks, Monthly x 3 months or until substantial compliance is achieved using the Kitchen Sanitation & Food Safety Audit Tool to ensure compliance. Any findings will be addressed promptly. Audit results will be presented by the Administrator to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary Date of completion: 05/08/2026
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
Surveyors identified a deficiency related to residents’ rights to be informed and to make treatment decisions when the facility failed to obtain and/or document informed consent for psychotropic medications for five sampled residents. The facility’s own policies required informed consent prior to initiation or dose increase of psychotropic drugs, with documentation of the discussion, understanding, and consent or refusal in the medical record. During interviews, the DON acknowledged that informed consent was supposed to be obtained before starting psychotropic medications or increasing doses, but records did not show that this occurred as required. For one resident with depression, anxiety, bipolar disorder, and multiple psychotropic prescriptions (sertraline, lorazepam, divalproex, and trazodone), review of psychotropic informed consent forms dated over several months showed no evidence of consent for the ordered doses of these medications, and the DON confirmed there were no additional consents. Another resident with schizophrenia had an order for risperidone, but the only documented psychotherapeutic drug informed consent was dated after the initial medication order, indicating consent was obtained after treatment had already begun. A third resident with depression and schizophrenia was receiving escitalopram, lithium carbonate, chlorpromazine, and haloperidol, including an additional lithium order, and the DON stated there was no documented informed consent for any of these psychotropic medications. For a fourth resident with an order for long-acting injectable haloperidol decanoate, the DON reported that the facility did not have documented informed consent for this psychotropic medication. For a fifth resident with schizophrenia, the physician ordered intramuscular Zyprexa 10 mg every eight hours as needed, and subsequent physician orders confirmed this regimen; however, the psychotherapeutic drug informed consent form was dated after the initial orders, again showing that consent was obtained only after the medication had been ordered. These findings collectively demonstrated that the facility did not ensure informed consent was obtained and documented in advance of initiating or changing psychotropic medication regimens, as required by regulation and facility policy.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F552-Right to be informed/Make Treatment Decisions. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #36-Informed consents for all the psychoactive medications were updated. For dates, please refer to the attachment of informed consents. On 4/3/26 Resident #53-Informed Consent for Risperdal was reviewed by [R] DNP. It did reflect the correct information with the exception of the date. On 4/13/26 Resident #41-Informed consents for all of the psychoactive medications were obtained and updated by [R] DNP. On 4/14/26 Resident #21-Informed consent for Haldol was obtained and updated by [R] DNP. On 3/28/26 Resident #1- Informed consent for Zyprexa was reviewed and adjusted for the increase in dosage by [R] DNP. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected. Based on the QAPI that the facility had developed in early March of 2026, all the residents who are on Psychoactive meds have been audited for current informed consents and all will be completed by May 9th, 2026. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed staff have been in-serviced on 4/1/26 - 5/1/26 by Director of Nursing regarding the process of completing Informed Consents for residents with Psychoactive meds. On 4/20/2026 The DON/Designee will review any new order for Psychoactive medication on a daily basis to ensure that : Documenting the informed consents are obtained verified to protect resident rights, promote safety, and facilitate appropriate use of the medications. Document the discussion, resident/representative understanding, and consent/refusal in the medical record. Initiation or dose increase; prescriber obtains the consent before administration. In addition, Medical records designee/MRD shall review/audit for compliance on monthly basis. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The Findings from the Medical records audit will be given to DON and presented to the monthly QAA committee for review and to ensure sustained compliance monthly for 3 months, then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
High Medication Error Rate and Failure to Follow Physician Orders During Med Pass
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5%, with surveyors calculating a 17.14% error rate based on six errors out of 35 observed opportunities during medication administration for four residents. For one resident, an LVN administered only 250 mg of divalproex in capsule form instead of the ordered 500 mg of divalproex delayed-release tablets prescribed twice daily for bipolar disorder. The LVN later confirmed that the resident was supposed to receive 500 mg of the delayed-release tablet formulation. Another resident with an order for gabapentin 100 mg tablets twice daily for nerve pain was given a 100 mg gabapentin capsule instead of the ordered tablet. The LVN acknowledged administering the capsule and confirmed that the order specified a tablet dosage form. A different resident with a G-tube had an order for iron glycinate oral liquid, 7.5 ml via G-tube once daily as a supplement, but was instead given ferrous sulfate liquid. The LVN confirmed that iron glycinate was ordered and that ferrous sulfate was administered in its place, meaning the ordered iron glycinate was not given. For the same G-tube resident, the LVN prepared three liquid medications (ferrous sulfate, valproic acid, and levetiracetam) but did not prepare or administer the ordered docusate liquid 10 ml via G-tube twice daily for constipation during the observed pass, and confirmed that the docusate was not given. During the G-tube medication administration, the LVN flushed the tube with 30 ml of water before starting and 30 ml after all medications were given but did not flush the tube between each of the eight medications, contrary to facility policy requiring water flushes between medications. In a separate observation, another resident with an order for quetiapine 200 mg by mouth twice daily at 8:00 AM and 4:00 PM did not receive the scheduled 4:00 PM dose during the observed medication pass; the LVN confirmed that quetiapine was not administered even though it was due at that time. The report states these failures resulted in medications not being given according to physician orders and had the potential for residents not to receive the full therapeutic effect of medications and for blockages to develop in the G-tube resident’s feeding tube.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F759- Free of Medication Errors Rts 5 percent or more. How Corrective action will be accomplished for those residents found to have been affected by this practice. Resident #28-Order for Divalproex was Reviewed. On 4/14/26 Residents received 250 mg instead of 500mg. MD was notified and informed the same day. No new orders and to continue with same dosage. No adverse reaction was noted from this. Resident #7- On 4/14/26 the order for Gabapentin tablet was changed to capsule as per MD order. There was no adverse reaction noted from resident receiving the capsule format vs. the tablet format. Resident #6- On 4/14/26 Resident's MD was notified about the incorrect type of Iron supplement order. The order was clarified to Ferrous Sulfate Oral Solution 220mg/5ml give 7.5 ml via G-tube QD instead of Glycinate. In addition, the MD was notified about resident not receiving Docusate. No new orders were given. Resident did not show any adverse reaction from missing this medication. LVN #5 - On 4/15/26 LVN 5 was in-serviced by DON regarding all prescribed medication will be administered correctly and in accordance with the prescribers order. Also to ensure that the correct formulation of medication, such as capsule vs. Tablet, will be administered correctly as prescribed by the MD. In addition, she was educated on proper way of administering medication via GT and the importance of flushing with 15 ml of water in between administration of each medication. Resident #40- On 4/14/26 the MD was notified about resident not receiving Seroquel at 4pm on 4/14/26. No new orders were given. Resident did not show any adverse effects from not receiving this dose. LVN#3- was in-serviced by DON on 4/15/26 regarding not omitting any scheduled medications that have been ordered. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have potential to be affected by this practice. The residents' medication administration records were reviewed by DON, and no other residents were affected by this practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: Licensed were in-serviced by DON on 4/15/2-26 – 5/1/26 regarding medication administration of all medications orally and via GT based on facility pharmacy Policy and Procedures. DON/Designee will conduct a GT medication administration pass/check off weekly for the first month on random shifts. Then the Pharmacy consultant will come monthly for 6 months to audit GT medication administration. All the new orders shall be reviewed daily by clinical IDT members for correct dose, root, and diagnosis. The MRD shall audit for medication administration completion on daily bases to assure that compliance is achieved. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall review the weekly audits/ monthly audits and present any issues to monthly QAA meeting for further interventions to assure compliance every 3 months Completion Date :5/8/2026
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during mealtime when a CNA provided feeding assistance while standing over the resident. The resident, who had been admitted with diagnoses including cerebral infarction, schizophrenia, and depression, was seated in a wheelchair in her room during a lunch meal. At that time, the CNA remained standing and continued to feed the resident with a spoon from a standing position rather than positioning herself at the resident’s eye level. During an interview, the CNA acknowledged that she was expected to obtain a chair and sit beside the resident while assisting with meals and stated that sitting at eye level was important for resident comfort. The Director of Staff Development confirmed that staff were expected to position themselves at the resident’s eye level when providing feeding assistance and stated that the CNA should have obtained a chair and sat beside the resident to avoid the resident feeling intimidated. Review of the facility’s “Quality of Life-Dignity” policy indicated residents are to be treated with dignity and respect at all times, and the “Assistance with Meals” policy specified that staff should not stand over residents while assisting them with meals.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F550-Resident Rights. How Corrective action will be accomplished for those residents found to have been affected: C.NA #1- was in-serviced 1:1 by the DON and DSD on 04/13/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. Resident #47 – on 04/14/2026 resident was being assessed by the licensed nurse with regards to his rights as a resident that should be treated with respect and dignity when being fed. Resident has no concerns. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential of being affected by this deficient practice. The consequent meal observations revealed that no other residents were being affected by the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The Nursing staff were in-serviced by the DON and DSD on 04/13/2026-05/01/2026 regarding Resident's Rights to treat them with respect and dignity when feeding residents by sitting down and providing the assistance at eye level. Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem. On 04/14/2026 the DSD and/or designee will conduct daily rounds to ensure continued compliance with the proper practice and report any deficient practice to DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall review compliance with the DSD rounds and report any deficient practiced to the monthly QAA committee to assure further and continued compliance monthly x 3 months then every 6 months and then annually until compliance is met and sustained. Completion Date :5/8/2026
Renewal of PRN Antipsychotic Without Required Physician Evaluation
Penalty
Summary
Surveyors identified a deficiency related to the use of psychotropic medications when a resident with a diagnosis of schizophrenia received a renewed PRN antipsychotic order without a required physician evaluation. The resident was initially admitted in January and had an admission record dated in April reflecting a diagnosis of schizophrenia. A physician’s order dated in March showed that the resident had renewed PRN orders for Zyprexa (olanzapine) 10 mg IM every 8 hours as needed for schizophrenia manifested by verbal or physical aggression, for 14 days. However, there was no documentation that the attending physician or prescribing practitioner evaluated the resident prior to renewing this PRN antipsychotic order. During an interview, the DON confirmed that there was no physician evaluation for the renewed PRN Zyprexa order and acknowledged that the physician was supposed to evaluate the resident before ordering the PRN antipsychotic. The facility’s own “Psychotropic Medication Use” policy stated that PRN orders for psychotropic medications are limited to 14 days and that PRN antipsychotic orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The prescribing information for Zyprexa injection listed somnolence as an adverse reaction, and the surveyors concluded that the resident received an unnecessary psychotropic medication order because it was renewed without the required evaluation.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F 605- Rights to be Free from Chemical Restraints How Corrective action will be accomplished for those residents found to have been affected: Resident #1- was evaluated by the prescribing MD and the Order for Zyprexa was renewed on 04/16/26 for 14 days until 04/30/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 04/15/2026, a review of all the residents on PRN psychoactive medications was conducted by DON. No other residents were found to be affected by this deficient practice. All the residents with Psychoactive medications had duration of therapy and were currently evaluated by the provider. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The licensed nurses were in-serviced by DON on 4/15-5/1/26 regarding the need for having duration of therapy for all PRN psychoactive medication and the need for prescriber's evaluation at the time of renewal. All new orders for PRN psychoactive medications shall be reviewed during daily clinical meeting by IDT to assure compliance with this practice. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DT/DON shall report any non-compliance regarding this issue to monthly QAA committee to assure further continue compliance monthly for 3 months then every 6 months, then annually until compliance is met and sustained. Completion Date :5/8/2026
Inaccurate MDS Documentation of Antipsychotic GDR Contraindications
Penalty
Summary
Surveyors identified a deficiency related to the accuracy of Minimum Data Set (MDS) assessments for two residents receiving antipsychotic medications. For one resident, review of the MDS Section N – Medications, dated 2/25/26, showed the resident was receiving an antipsychotic and that a gradual dose reduction (GDR) was documented as contraindicated. However, the clinical record indicated the prescriber had documented GDR as contraindicated on 8/14/23, and the MDS Coordinator (MDSC) acknowledged during concurrent interview and record review that the GDR date entered on the MDS was incorrect and needed to be corrected. The facility’s policy titled “Comprehensive Assessments” stated that comprehensive MDS assessments are conducted to assist in developing person-centered care plans and are used to develop, review, and revise the resident’s comprehensive care plan. For a second resident, the MDS Section N – Medications, dated 3/2/26, also indicated the resident was receiving an antipsychotic and that GDR was documented as contraindicated. The resident’s “Plan of Care Note,” dated 2/13/26, showed the prescriber had documented GDR as contraindicated on 9/14/23, but the MDSC confirmed that the GDR date recorded on the MDS was incorrect. In interviews, the MDSC stated that the MDS is a comprehensive assessment of the resident at a specific point in time and that accuracy is important to reflect correct information and to know whether services are being provided, further stating that incorrect MDS information could lead to needed services not being provided. The DON stated that the MDS was expected to be accurate and that an inaccurate MDS was not current for the resident’s care.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F641-ACCURACY OF ASSESSMENTS How Corrective action will be accomplished for those residents found to have been affected: Resident #21- This resident GDR was considered on 2/13/26 by provider and stated that it was counter indicated. The MDS dated 2/25/26 was modified to reflect the consideration for GDR. Resident # 53-The MDS assessment of 3/2/26 was modified by the MDS coordinator to reflect the last GDR consideration by the MD was on 2/13/26. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents who are receiving psychoactive medications have potential to be affected by this deficient practice. The DON and MDS coordinator reviewed all the residents with psychoactive medications who have had any GDRs attempted or have been evaluated for GDRs and reviewed the MDS assessment to accurately reflect these GDRs. There were no other residents identified with having the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The MDS coordinator was in-serviced by DON on 04/17/2026 regarding reflecting the correct GDR status for all the residents reviewed each month. In addition, the list of all the residents reviewed for GDRs is to be made available to MDS coordinator by DON so that the correct GDR date can be reflected on MDS. The MDS coordinator to check for accuracy and to ensure that the MDS assessments for the residents who are due each month and to report any issues to the DON. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report issues concerning accuracy of MDS assessments in Section N to monthly QAA committee for further review and intervention to ensure continued compliance monthly x 3 months then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Develop Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan following an actual fall experienced by Resident 32. The resident was admitted with a diagnosis of abnormalities of gait and mobility and reported losing balance and falling while getting out of bed on 4/13/2026. Review of the resident’s Admission Record and Care Plan Report showed there was no care plan problem or interventions related to this fall incident. During interviews, the resident confirmed the fall, and nursing staff, including an LVN and an RN, acknowledged that the resident had an unwitnessed fall on 4/13/2026 and that no care plan had been developed in response. Further review with the MDS Coordinator confirmed that no care plan was created for Resident 32 after the fall, despite the expectation that a short-term care plan should have been documented and initiated by the RN. The facility’s policies on comprehensive person-centered care plans and on managing falls and fall risk state that care plans must be developed and implemented for each resident, with interventions derived from comprehensive assessments and evaluations of fall risks and causes. These policies require staff to identify and document interventions related to specific risks to prevent falls and minimize complications, which was not done for Resident 32 after the documented fall event.
Plan Of Correction
Plan of Correction – F656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 4/15/26 The facility immediately corrected the deficient practice for Resident #32. Upon identification of the missing care plan following the unwitnessed fall on 4/13/2026, the Registered Nurse initiated a post-fall assessment A person-centered fall care plan, including individualized fall risk interventions, measurable goals, and monitoring parameters, was initiated and implemented in the resident's medical record. Interventions included safety precautions, fall prevention strategies, staff monitoring, and resident-specific measures based on the identified cause and circumstances of the fall. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/15/26 , the Director of Nursing and MDS Coordinator, conducted a facility-wide audit of residents who experienced falls within the past 60 days to ensure that individualized short-term and/or comprehensive care plans were initiated, updated, and implemented timely following each fall incident. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not occur: On 4/15/26 - 5/1/26 , the Director of Nursing conducted an in-service education for licensed nurses, MDS staff, and interdisciplinary team members regarding the facility policy titled "Care Plans, Comprehensive Person-Centered" and "Falls and Fall Risk, Managing." Education included requirements for timely initiation and revision of care plans following falls, development of individualized interventions, documentation standards, implementation of interventions, and interdisciplinary communication. On 5/7/2026 The facility implemented a standardized "Post-Fall Care Plan Review Process" requiring licensed nurses to notify the MDS Coordinator/designee immediately following any actual fall event to ensure timely initiation or revision of the resident's care plan.Fall events are reviewed during daily clinical stand-up meetings to ensure care plan follow-through. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur: The DON or designee will conduct audits of residents with falls to verify that individualized short-term and/or comprehensive care plans were initiated or revised timely and that interventions were implemented as ordered. Audits will be conducted weekly for four (4) weeks, then monthly for three (3) months or until substantial compliance is achieved. Any identified concerns will be addressed immediately through corrective action, re-education, and follow-up monitoring to ensure ongoing compliance.Audit results will be presented by the DON to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for three (3) months. The QAPI Committee will review trends, ensure sustained compliance, and implement additional interventions as necessary.Completion date: 5/8/26
Failure to Reconcile Controlled Substance Records With MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate accountability and documentation of controlled substances for a resident receiving tramadol for severe pain. The resident had a physician’s order dated 3/19/26 for tramadol 50 mg, one tablet by mouth every six hours as needed for severe pain. Review of the Controlled Substance Record (CSR) for this resident, dated 3/20/26, showed that nursing staff removed one tablet of tramadol on 3/24/26 at 7:48 AM and another tablet on 3/27/26 at 8:05 AM. However, the Medication Administration Record (MAR) for March 2026 did not show that tramadol was administered on those dates. During a concurrent interview and record review, an LVN acknowledged that the MAR was missing documentation and that it appeared the tramadol was not given on those dates, and stated that medication administration needed to be documented on the MAR. Additional staff interviews confirmed that facility expectations and procedures were not followed. Another LVN stated that nurses were supposed to verify controlled substance counts at each shift change to identify discrepancies and were required to document controlled substance administration in both the CSR and the MAR, and that these records should match. The Director of Staff Development stated that nurses were expected to sign out controlled medications on the CSR and document administration on the MAR, and that narcotic accountability procedures were intended to identify discrepancies. The DON similarly stated that the nurse was supposed to document the removed tramadol on the CSR and the administration on the MAR. The facility’s policy titled “Documentation of Medication Administration,” dated April 2007, indicated that administration of medication must be documented immediately after it is given, which was not reflected in the records for this resident’s tramadol doses.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations, Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F755-Pharmacy services/Procedures/Pharmacist/Records How Corrective action will be accomplished for those residents found to have been affected: Resident #41-The Controlled Substance Record (CSR) for this resident was reviewed by DON on 04/14/2026. The count of Tramadol on the CSR matched the pill count in the med cart. Residents continue to use Tramadol for pain. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents in the facility have the potential to be affected by this deficient practice. The DON/Designee reviewed all the Narcotic sheets/CSRs against the medication administration record for month of April 2026. There were no other residents found to be affected with the same deficient practice. C-What measures will be put in place or what systemic changes will you make to ensure the deficient practice does not recur: The licensed staff was in-serviced by DON on 04/15/2026- 05/01/2026 regarding documentation of medication administration that administration of medication must be documented after (never before) it is given. That is required for all PRN medications including Narcotics. The DON conducted a 1:1 in-service to LVN3 on 04/16/2026 regarding facility's policy on documentation of medication administration that administration of medication must be documented after (never before) it is given. The MRD shall conduct a weekly audit of Narcotic sheets in comparison to the documentation on the MARs to ensure compliance. The DON/Designee shall review these audits and intervene to ensure compliance. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur. The DON shall report the results of medical records audit to monthly QAA committee for review and to assure continued compliance monthly x 3 months then q 6months and then annually to ensure compliance is met and sustained. Date of Completion: 05/08/2026
Improper Storage of Used Urinal with Bloody Urine at Bedside
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control when a used urinal containing bloody urine was repeatedly observed on a resident's bedside table. During a morning observation, the urinal with bloody urine was placed next to the resident's water pitcher, with visible bloody urine on the outside near the opening and the lid left open. Later the same day, the urinal with bloody urine was again observed on the same bedside table, this time next to both a water pitcher and an empty food tray, with bloody urine still visible on the outside near the opening and the lid still open. A CNA confirmed during interview that the urinal with urine was on the bedside table next to an empty food tray and acknowledged that it should not be stored there. The facility's undated infection control policy, reviewed with the Infection Preventionist, stated that the infection control policies and practices are intended to maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Infection Preventionist stated that this policy was not followed when the urinal with bloody urine was found on the resident's bedside table.
Plan Of Correction
This Plan of Correction (POC) serves as our Credible Allegation of Compliance. Preparation and/or execution for this Plan of Correction does not constitute conclusions set forth in the Statement of Deficiencies. The facility will be in substantial compliance on or before 5/9/2026. The Plan of Correction is submitted as part of Federal Regulations. Title 42, Section 489.13, State Operations Manual, Section 2612 and California Health and Safety Code, Section 1280 and the facility does not waive its right to contest or pursue an appeal of the deficiency as allowed by the Federal and State Law. F880-Infection Prevention and Control How Corrective action will be accomplished for those residents found to have been affected: Resident #32 prefers to keep his urinal on his bedside table and has occasional blood in the urine due to his diagnosis of Malignant Neoplasm of bladder. This issue has been addressed with the resident, and he continues to refuse to allow staff to remove his urinal or place it in a different location. On 05/04/2026 the IDT conducted an IDT meeting with the resident to make him aware of the risk involved with infection control. Resident did not want to change his preference. How The facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All the residents have the potential to be affected by this deficient practice. On 05/04/2026 the IDT members reviewed other residents for similar issues, and no other residents were identified with the same deficient practice. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur: The nursing staff have been in-serviced by DSD/DON regarding attempting/offering to remove the urinals from the bedside tables on 04/15/2026-05/01/2026. The charge nurses and/or IP nurse shall conduct daily rounds to assure compliance and report any findings to DON for further follow up. How the facility plans to monitor its performance to make sure the solutions are sustained and to ensure deficiency practice will not recur: The DON shall report any findings from the IP rounds to monthly QAA committee for further review to ensure continued compliance monthly x 3 months and then every 6 months and annually until compliance is met and sustained. Completion Date: 05/08/2026
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
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