Garden View Post Acute Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Baldwin Park, California.
- Location
- 14475 Garden View Lane, Baldwin Park, California 91706
- CMS Provider Number
- 055187
- Inspections on file
- 34
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Garden View Post Acute Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced a breach of privacy and dignity when staff failed to close privacy curtains during care. One resident was exposed during a bed bath, and another during a surgical site check. The facility's policy requires privacy measures to be in place during such procedures.
The facility failed to ensure that call lights were within reach and properly explained to residents, affecting four residents. A resident with severe cognitive impairment had their call light on the floor, while another could not reach theirs due to its placement on an oxygen concentrator. A third resident's call light was tangled on a bed rail, and a fourth resident was not instructed on its use, leaving them to shout for help. Staff interviews confirmed the need for call lights to be accessible and explained, as per facility policy.
The facility failed to provide necessary care for residents with indwelling catheters, leading to potential infection risks. A resident's Foley catheter was not secured and had white sediments, while another's suprapubic catheter was not properly maintained. Nephrostomy tubes for a third resident were positioned incorrectly, and a fourth resident's catheter showed signs of potential infection. Facility policies on catheter care were not followed.
The facility failed to follow its policy on bedrails and grab bars for two residents, leading to deficiencies. For one resident with impaired cognition, grab bars were installed without attempting alternatives or obtaining informed consent. Another resident with intact cognition had bedrails installed without consent or alternative attempts. The facility's policy required assessment and consent, which were not followed.
The facility failed to ensure staff wore required PPE while providing care to residents on Enhanced Barrier Precautions (EBP). A CNA provided care to a resident with a Foley catheter without a gown, an LVN entered a resident's room without PPE to check a G-tube, and another CNA entered a room to provide a bed bath without a gown. These actions were against the facility's infection control policies, risking the spread of infection.
A facility failed to provide a communication board for a non-English speaking resident, impacting their ability to communicate effectively with staff. The resident, who preferred speaking Spanish, had no communication board in their room, contrary to facility policy. This oversight had the potential to affect the resident's care and quality of life.
A resident with a history of falls and multiple medical conditions was at risk due to the facility's failure to maintain their bed in the lowest position, as required by their care plan. Observations confirmed the bed was not adjusted properly, despite the resident's medium fall risk and the facility's fall management policy.
A facility failed to label the nasal cannula (NC) tubing for a resident, which could lead to infection. The resident, with acute respiratory failure and dysphagia, was on continuous oxygen via NC. The NC was not dated or labeled, contrary to the facility's policy requiring weekly changes. The Infection Preventionist Nurse confirmed the labeling requirement to prevent bacterial accumulation.
A facility failed to act on a pharmacist's medication regimen review (MRR) recommendation for a resident prescribed PRN Ondansetron. The MRR suggested specifying the therapy length, but no action was taken until the medication was discontinued months later. Interviews revealed the facility did not notify the prescribing physician or update the order, missing the opportunity to prevent unnecessary medication use.
A facility failed to document a specific indication for the use of Mirtazapine for a resident with major depressive disorder, as required by its policy on psychotropic medications. The resident's physician order cited mood, sleep, and appetite stimulant as reasons for the medication, but these were not considered specific manifestations by the DON. This lack of documentation could lead to unnecessary psychotropic drug use.
A facility failed to keep an electric fan in a safe and sanitary condition for a resident with severe cognitive impairment and health issues like CHF and asthma. The fan was dusty and covered with lint, which was noted by a CNA as potentially harmful. The DON stated that housekeeping should ensure personal equipment is clean, as per the facility's housekeeping policy.
The facility failed to accurately post the actual number of nursing staff on duty, leading to discrepancies in staffing information available to residents and family members. The Director of Staff Development acknowledged the inaccuracies, which could mislead residents and family members about staffing levels.
A resident with multiple health conditions, including edentulous status, did not have a timely care plan developed for their dental needs. The facility failed to adhere to its policy requiring a baseline care plan within 48 hours of admission and a comprehensive care plan within seven days of MDS completion. This delay in care planning was acknowledged by staff and had the potential to impact the resident's health.
A resident with diabetes and dementia experienced a delay in podiatric care due to the facility's failure to arrange a timely consult with a podiatrist. Despite a care plan indicating the need for foot care, the consult was delayed by three months, leading to untreated foot issues. Staff interviews confirmed the oversight, acknowledging the risk of complications due to the resident's condition.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of two residents, resulting in a deficiency. Resident 138, who was admitted with diabetes mellitus and generalized muscle weakness, was found exposed from above the knee to the chest area while lying in bed. The privacy curtain was not closed, allowing the resident's body to be visible from the hallway. This occurred after a Certified Nursing Assistant (CNA) prepared the resident for a bed bath and forgot to close the privacy curtain, which is a necessary step to ensure the resident's privacy and dignity. Similarly, Resident 238, admitted with a fracture of the right femur, experienced a breach of privacy when a Minimum Data Set Nurse (MDSN) checked the resident's surgical site without closing the privacy curtain. This action exposed the resident's thigh, compromising their privacy. The Director of Nursing (DON) confirmed that the privacy curtain should have been closed to maintain the resident's dignity. The facility's policy and procedure on resident rights emphasize the importance of maintaining privacy during examinations and treatments by using closed doors or drawn curtains.
Failure to Ensure Call Light Accessibility and Understanding
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of four residents, specifically regarding the accessibility and understanding of the call light system. For Residents 13, 20, and 57, the call light was not within reach, which is crucial for residents to request assistance from the nursing staff. Resident 13, who had severe cognitive impairment and was at risk for falls, had their call light on the floor, making it inaccessible. Similarly, Resident 20, who was assessed as high risk for falls, could not reach their call light as it was hanging on an oxygen concentrator three feet away. Resident 57, with severely impaired cognition, had their call light tangled on the bed rail, rendering it unusable. Resident 39, who had moderately impaired cognition and was at high risk for falls, did not know how to use the call light, and its purpose was not explained to them. This lack of instruction left Resident 39 without a reliable means to communicate with staff, as they resorted to shouting for help. The facility's policy requires that the call light be within reach and that its use be explained to residents, but this was not adhered to in Resident 39's case. Interviews with staff, including the Director of Nursing and the Director of Staff and Development, confirmed that the call lights should be within reach and that residents should be instructed on their use. The facility's policy and procedure on call lights emphasize the importance of providing residents with a means of communication with the nursing staff, which was not consistently implemented, leading to the deficiencies observed.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to provide necessary care and services for residents with indwelling catheters, as observed in four residents. Resident 19's Foley catheter tubing was not secured and had visible white sediments, which were not monitored as required. The resident's care plan indicated the need for a catheter stabilizer and monitoring of urine characteristics every shift, but these interventions were not followed, placing the resident at risk for urinary tract infections. Resident 26 had a suprapubic catheter that was not secured, and the site dressing was wet and unclean. The care plan required securing the catheter to prevent kinking and accidental removal, and the dressing was to be changed daily. However, during observation, the catheter tubing was found under the resident's leg, and the dressing was not maintained as per the facility's policy, increasing the risk of infection and skin irritation. Resident 32's nephrostomy tubes were not covered with a privacy bag and were positioned higher than the bladder, contrary to the care plan's instructions to position the bags lower to prevent backflow and infection. Resident 78's Foley catheter tubing had white sediments, which were not reported to the medical doctor as required. The facility's policies on catheter care and management were not adhered to, leading to potential risks of infection for the residents involved.
Failure to Implement Bedrail and Grab Bar Policies
Penalty
Summary
The facility failed to adhere to its Policy and Procedure regarding the use of bedrails and grab bars for two residents, leading to deficiencies in care. For Resident 51, who was admitted with a displaced fracture and dislocation, the facility did not document any attempts to use appropriate alternatives before installing grab bars. The resident, who had moderately impaired cognition, was unaware of the reason for the grab bars, indicating a lack of informed consent and understanding of the risks and benefits associated with their use. Similarly, for Resident 33, who had diagnoses including hemiplegia and neuropathy, the facility installed bedrails without attempting alternative interventions or obtaining informed consent. The resident, who had intact cognition, was not informed about the bedrails and did not request them. The facility's Director of Nursing acknowledged that alternatives should have been attempted and consent obtained before installation. The facility's policy required an interdisciplinary team assessment and informed consent prior to the use of bedrails, which was not followed in these cases.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring that staff wore the required personal protective equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). In one instance, a Certified Nurse Assistant (CNA 2) provided care to a resident with an indwelling catheter without wearing a gown, only using gloves. This resident was on EBP due to the presence of a Foley catheter, which required the use of gown and gloves during high-contact care activities to prevent the spread of multidrug-resistant organisms (MDROs). Another incident involved a Licensed Vocational Nurse (LVN 4) who entered a resident's room without donning the required PPE before checking the resident's gastrostomy tube (G-tube) placement for medication administration. The resident was on EBP due to the presence of a G-tube, and the facility's policy required staff to wear gown and gloves during such care activities to prevent the transmission of infections. Additionally, a Certified Nurse Assistant (CNA 6) entered a resident's room to provide a bed bath without wearing a gown, despite signage indicating the need for PPE due to the resident being on EBP for an open wound. The facility's policy mandated the use of gown and gloves during high-contact care activities, such as bathing and providing hygiene, to protect both residents and staff from infection. These failures in adhering to the facility's infection control policies had the potential to result in the spread of infection and cross-contamination.
Failure to Provide Communication Board for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide an effective communication method for a non-English speaking resident, identified as Resident 138, which had the potential to impact the resident's ability to receive necessary care and services. Resident 138 was admitted with diagnoses including diabetes mellitus and generalized muscle weakness. The resident's Minimum Data Set (MDS) indicated that they had clear speech, intact cognition, and a preference for speaking Spanish. However, during an observation and interview, it was noted that Resident 138 was unable to communicate in English, and there was no communication board present in the resident's room to facilitate communication with non-Spanish speaking staff. The Minimum Data Set Coordinator (MDSC) and the Social Service Director (SSD) both acknowledged the absence of a communication board, which was against the facility's policy for non-English speaking residents. The facility's policy required that a communication board with universally known drawings be provided to residents who do not speak English to ensure effective communication and meet the resident's needs. The lack of a communication board in Resident 138's room was a failure to adhere to this policy, potentially affecting the resident's quality of life and care.
Failure to Maintain Bed in Lowest Position for Fall Risk Resident
Penalty
Summary
The facility failed to maintain an environment free of accident hazards for a resident, identified as Resident 40, by not ensuring that the resident's bed was in the lowest position. This oversight was observed during multiple visits to the resident's room, where the bed was found to be 25 to 26 inches from the top of the mattress to the floor, contrary to the care plan's directive for fall reduction measures. The resident, who has a history of falls and multiple medical conditions including Parkinson's disease and arthritis, was assessed as being at medium risk for falls. The resident's care plan, initiated on July 29, 2024, specifically indicated that the bed should be adjusted to the lowest position to mitigate fall risks. Despite this, observations on January 7 and January 8, 2025, confirmed that the bed was not in compliance with the care plan. Interviews with the resident and a Certified Nursing Assistant (CNA) further highlighted the resident's need for assistance with transfers and the importance of maintaining the bed in the lowest position to prevent falls. The facility's policy on fall management, revised in June 2020, mandates an environment as free of accident hazards as possible, which was not adhered to in this instance.
Failure to Label Nasal Cannula Tubing
Penalty
Summary
The facility failed to label the nasal cannula (NC) tubing for a resident, identified as Resident 64, which had the potential to result in infection. Resident 64 was admitted with acute respiratory failure and dysphagia and was dependent on others for certain activities. The resident's Minimum Data Set (MDS) indicated clear speech and the ability to understand and communicate. The Order Summary Report (OSR) for January 2025 showed an order for continuous oxygen via NC at 2 liters per minute every shift. During an observation, it was noted that the NC was not dated or labeled with the application date. The Infection Preventionist Nurse (IPN) confirmed that the NC should be labeled with the date of application and changed weekly to prevent bacterial accumulation. The facility's policy on Oxygen Therapy, dated January 2024, required oxygen tubing to be replaced every 7 days.
Failure to Act on Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to act upon the consultant pharmacist's medication regimen review (MRR) recommendation for a resident, identified as Resident 40. The MRR, conducted between August 1, 2024, and August 26, 2024, suggested specifying the length of therapy for the resident's PRN Ondansetron prescription, which is typically used for short-term nausea and vomiting. However, there was no documentation or change in the physician's order regarding this recommendation until the medication was discontinued on December 3, 2024. Interviews with the registered nurse and the Director of Nursing revealed that the facility did not notify the prescribing physician or update the order based on the pharmacist's recommendation, which was acknowledged as a missed action. Resident 40 was readmitted to the facility with diagnoses including depression disorder and hypertension. The resident's Minimum Data Set indicated they had clear speech, could understand others, and required assistance with personal hygiene and dressing. Despite the pharmacist's recommendation, the facility did not act within the stipulated time frame of seven days as per their policy and procedure, potentially exposing the resident to unnecessary medication and adverse health consequences. The Director of Nursing confirmed that the MRR should have been addressed promptly to prevent such risks.
Failure to Document Specific Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and document a specific indication for the use of Mirtazapine, an antidepressant, for Resident 20, as required by the facility's policy on psychotropic medications. Resident 20 was admitted with diagnoses including spondylolisthesis and major depressive disorder. The Minimum Data Set (MDS) indicated that Resident 20 had intact cognition for daily decision-making and required supervision during showers. The physician's order for Mirtazapine was related to major depressive disorder, manifested by mood, sleep, and appetite stimulant, but these were not considered specific manifestations or behaviors by the Director of Nurses (DON). During an interview and record review, the DON acknowledged that the medication needed to be administered with a specific diagnosis and symptoms, which were not adequately documented. The facility's policy stated that psychotropic medications should not be used for discipline or convenience and should only be administered to treat the resident's medical symptoms. The lack of specific documentation for the use of Mirtazapine had the potential to result in unnecessary psychotropic drug use, which could lead to significant adverse consequences for Resident 20.
Failure to Maintain Sanitary Conditions for Resident's Equipment
Penalty
Summary
The facility failed to maintain an electric fan in a safe, operating, and sanitary condition for a resident with severe cognitive impairment and multiple health conditions, including congestive heart failure and asthma. The fan, located at the resident's bedside, was observed to be dusty and covered with lint, which was acknowledged by a Certified Nurse Assistant as potentially harmful to the resident's health. This observation was made during a room inspection and interview with the CNA. The Director of Nursing confirmed that housekeeping staff are responsible for ensuring that residents' personal equipment is kept clean and in good working condition. The facility's policy and procedure for the housekeeping department, revised in 2007, mandates effective environmental sanitation to reduce exposure to contaminated air, dust, and equipment. The policy emphasizes frequent cleaning to remove microorganisms that could pose health hazards, with the housekeeping supervisor collaborating with the infection control team to maintain high cleanliness standards.
Inaccurate Posting of Nursing Staff Numbers
Penalty
Summary
The facility failed to accurately post the actual number of nursing staff who worked on specific dates, leading to discrepancies in the staffing information available to residents and family members. On January 1, 2025, during the night shift, five CNAs worked instead of the six that were posted. On January 2, 2025, during the morning shift, 16 CNAs worked instead of the 14 that were posted. On January 3, 2025, during the morning shift, 13 CNAs worked instead of the 14 that were posted. On January 5, 2025, during the night shift, seven CNAs worked instead of the six that were posted. The Director of Staff Development acknowledged that the staffing information was not accurate, which could mislead residents and family members about the actual staffing levels. The facility's policy and procedure required the posting of accurate staffing numbers for those directly responsible for resident care.
Failure to Develop Timely Dental Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's oral/dental status, which was necessary due to the resident's edentulous condition. The resident, who was admitted with diagnoses including a cerebral vascular accident, type 2 diabetes, and dementia, required assistance with eating and oral hygiene. Despite these needs, the facility did not create a care plan for the resident's dental condition until several months after admission, which was not in compliance with the facility's policy. Interviews with the Assistant Director of Nursing/MDS Nurse and a Registered Nurse revealed that the care plan for the resident's dental condition was not initiated until months after admission, and a dental consult was delayed. The facility's policy required a baseline care plan within 48 hours of admission and a comprehensive care plan within seven days of the MDS completion, which was not adhered to in this case. This oversight had the potential to impact the resident's health, as noted by the staff, who acknowledged the risk of weight loss due to the lack of a timely care plan.
Delay in Podiatric Care for Diabetic Resident
Penalty
Summary
The facility failed to ensure timely podiatric care for a resident, leading to a delay in necessary foot treatment. The resident, who was admitted with a history of a cerebral vascular accident, type 2 diabetes, and dementia, had a care plan dated 8/11/24 that included a referral to a podiatrist for foot care. However, the consult was not arranged until 11/14/2024, three months later. This delay in implementing the care plan resulted in the resident not receiving timely foot care, which could lead to podiatric complications due to their diabetes. Interviews with the Assistant Director of Nursing and a Registered Nurse confirmed that the care plan for podiatric consultation was not followed through in a timely manner. The facility's policy indicated that residents should receive podiatry services every 60 days or as needed, especially for those with diabetes and circulatory disorders. The resident's podiatry visit note from 11/14/2024 indicated significant foot issues, including dystrophic toenails and fungal infection, which were addressed during the visit. The delay in care was acknowledged by the staff, who recognized the risk of further injury due to the resident's diabetic condition.
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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