George L Mee Memorial Hospital D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in King City, California.
- Location
- 300 Canal Street, King City, California 93930
- CMS Provider Number
- 056443
- Inspections on file
- 15
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at George L Mee Memorial Hospital D/p Snf during CMS and state inspections, most recent first.
The facility failed to complete required elopement risk assessments on nearly all residents, including two residents with alcoholism and significant medical and cognitive conditions, and did not develop or implement individualized care plans for a resident who frequently went to the garden independently. Staff did not use any elopement assessment tool, did not consistently monitor residents’ whereabouts when they were in the garden or off the unit, and relied on residents signing LOA forms as if this released the facility from responsibility. LOA documentation for both residents showed repeated missing time-in entries, incomplete destinations, absent nurse initials, and no documented mental, physical, or functional assessments before leaving or upon return, despite facility policy. One cognitively intact, ambulatory resident with a history of leaving and returning intoxicated eloped from the building without signing out, was later struck by a vehicle as a pedestrian, was found to have an elevated ETOH level, and subsequently died from multiple traumatic injuries, while another severely cognitively impaired, wheelchair-bound resident routinely left the facility alone in the early morning hours without appropriate assessment or supervision.
The facility failed to ensure competent food safety practices among kitchen staff, leading to deficiencies in dish machine sanitizer testing, cool down processes, and produce handling. Staff were unable to correctly test sanitizer concentrations, verbalize proper cool down procedures, and wash melons before cutting, contrary to FDA guidelines and facility policies. The lack of training was acknowledged by the Dietary Manager and emphasized by the Registered Dietitian.
The facility failed to maintain food safety and sanitation standards, with issues including an unclean ice machine, improper plumbing of drainage pipes, and expired food items in refrigerators. The Dietary Manager and Stationary Engineer acknowledged these deficiencies, which also included rust on shelves, dirty equipment, and worn-out cutting boards.
The facility failed to follow its policies for advance directives and POLST forms for several residents. Critical sections of the POLST forms were left incomplete, and there was no documentation of discussions or assistance with advance directives for multiple residents. The chief nursing officer confirmed these deficiencies, highlighting a lack of adherence to established procedures.
The facility failed to develop comprehensive, resident-centered care plans for six residents, including those with chronic kidney disease, dementia, and paraplegia. The care plans did not include specific activities provided to the residents, such as music, television, and social events, as verified by the activity coordinator. This lack of documentation and implementation could impact the residents' well-being.
The facility failed to follow approved menus and lacked a written emergency menu plan. The Dietary Manager admitted to not using a therapeutic menu spreadsheet, and a cook used the wrong ladle size for serving, violating portion control policies. Additionally, the facility did not have a detailed emergency food plan, which could affect residents' nutritional needs during emergencies.
The facility failed to maintain appropriate food preparation and serving temperatures, leading to cold meals and improper textures for pureed diets. Observations revealed that meals were prepared hours in advance, affecting their quality. A resident reported receiving cold meals, and test trays showed non-compliance with temperature standards and recipe adherence.
Two residents with foley catheters had their drain bags left uncovered, compromising their dignity. One resident, with neurogenic bladder and renal cell carcinoma, confirmed the lack of a privacy cover since admission. Another resident, with Parkinson's disease and other conditions, also had an uncovered drain bag. A nurse and the CNO acknowledged the oversight, which violated the facility's policy on patient privacy.
A resident with severe anemia and metastatic cancer was administered oxygen without a physician's order, contrary to the facility's policy. The resident was observed receiving oxygen at 2 liters per minute, despite the order being discontinued over a month prior. Interviews with staff confirmed the lack of an active order, highlighting a failure to verify physician orders before administering oxygen.
A resident was served a meal that did not align with their documented food dislikes and preferences, as observed during a lunch service. The resident's tray card indicated a dislike for carrots and a preference for soup, but they were served carrots and not provided soup. This was confirmed by both a CNA and the dietary manager, who acknowledged the dietary staff's failure to follow the resident's documented preferences.
A registered nurse failed to perform hand hygiene after removing gloves and before preparing medications for a resident, breaching infection control protocols. The resident had diagnoses including alcoholic liver disease and hypertension. The nurse acknowledged the oversight, and the infection preventionist confirmed the breach of facility policy.
Failure to Assess and Supervise Residents at Risk for Elopement and Misuse of LOA Process
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for residents at risk of elopement, particularly two residents with known risk factors, and the failure to complete required elopement risk assessments for nearly all residents. One resident with alcoholic cirrhosis, alcohol dependence, ascites, and hepatic encephalopathy was cognitively intact per BIMS and independent in transfers and walking, and he frequently went to the facility’s garden. Staff reported that he had previously left the facility in the morning and returned intoxicated in the evening, and that this incident should have been reported to management. Despite a physician’s order for an Elopement Evaluation and an order that he could only leave the SNF/hospital property with a responsible party, no Elopement Evaluation Assessment was completed upon admission, and staff confirmed there was no tool in use to assess elopement risk. The nurse manager stated the assessment was not done because the resident was alert, oriented, and independent. The same resident’s preference for frequent independent garden time was documented in his activity preferences, but the activity staff did not develop a comprehensive activity care plan that included objectives, interventions, supervision requirements, or monitoring of his whereabouts during garden time. The activities coordinator and nursing staff acknowledged that the existing documentation did not constitute a true care plan and that there was no constant monitoring of the resident while he was in the garden. In addition, the facility did not follow its Leave of Absence (LOA) policy requiring a complete mental, physical, and functional assessment within 30 minutes before leaving and upon return, documented in the nursing progress notes. Multiple LOA forms for this resident showed times out with no times in, missing nurse initials, and incomplete destination information, and the nurse manager confirmed that nurses did not complete or document required assessments on numerous dates. Staff interviews revealed that nurses and CNAs did not routinely check on residents in the garden, did not sign the resident back in when he returned for medications, and believed that the resident’s signature on the LOA form released the facility from responsibility. On the day of the fatal incident, the resident signed out in the morning to go to the garden, was seen on surveillance video leaving and re-entering the building, and later left again in the early afternoon without signing out. He took his medication early that afternoon, but staff did not verify his whereabouts afterward. Surveillance footage reviewed by the director of quality showed the resident exiting through the lobby doors and heading toward a nearby street, after which he was no longer visible until a truck stopped in front of the hospital later that evening, coinciding with the time of a motor vehicle accident in which he was struck as a pedestrian. He was subsequently admitted to the acute hospital as a trauma patient with extensive injuries and an elevated blood alcohol level and later died; the hospital death summary listed multiple traumatic injuries and alcohol intoxication among the diagnoses and contributing conditions. A second resident, with diagnoses including alcoholism, diabetes mellitus, hemiplegia due to prior stroke, hypercholesterolemia, hypertension, and wheelchair dependence, had a BIMS score indicating severe cognitive impairment. No Elopement Evaluation Assessment was completed upon his admission. The nurse manager stated that such assessments were only done when residents were “triggered” by an elopement incident or a change in condition, rather than upon admission. This resident routinely signed LOA forms and left the facility or went to the garden unassisted, propelling his wheelchair using his left arm and leg, often in the early morning hours. CNA staff reported that he preferred to go out alone to stores to purchase lottery scratcher tickets and that staff did not take his vital signs each time he returned from LOA. Review of his LOA forms showed numerous entries with times out but no times in, missing nurse initials, missing destinations, and lack of documentation of assessments before leaving or upon return, contrary to facility policy. Beyond these two residents, the facility failed to complete Elopement Evaluation Assessments upon admission for 39 of 40 residents reviewed. The report states that this failure could result in not identifying residents’ elopement risk levels and not implementing resident-centered plans of care, with the potential to result in harm, injury, or death for residents at high risk of elopement. The cumulative failures to assess elopement risk, to develop and implement individualized care plans for residents with known preferences for independent outdoor time, and to follow the LOA policy for assessment and documentation led to an immediate jeopardy situation, as the noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents, exemplified by the elopement and subsequent fatal motor vehicle accident involving the first resident.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure that food and nutrition services staff carried out their duties competently, as evidenced by several deficiencies observed during a survey. Two kitchen staff members were unable to properly test the dish machine sanitizer solution concentration. One staff member, identified as DSW E, incorrectly described the normal sanitizer range for the dish machine solution, while another, CK I, demonstrated a misunderstanding of the testing process. The facility's policy required a minimum concentration of 50-100 ppm of chlorine, which was not correctly identified by the staff. Additionally, the Dietary Manager acknowledged the lack of proper training for the staff in this area. Further deficiencies were noted in the cool down process for cooked foods and the handling of produce. CK B incorrectly verbalized the cool down process, stating incorrect temperature ranges and timeframes, which did not align with the 2022 Federal FDA Food Code requirements. Moreover, DA D was observed chopping melons without washing them, contrary to FDA recommendations and the facility's policy. The Dietary Manager confirmed that no in-service training on these critical food safety practices had been provided to the kitchen staff from June 2023 through June 2024. The Registered Dietitian emphasized the importance of proper training to prevent exposure to contaminated foods.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation standards, as evidenced by multiple deficiencies observed during a survey. The ice machine was found to have visible pink slime and tan residue on its ice-making parts, which were not cleaned according to the manufacturer's guidelines. The Stationary Engineer admitted to using an inappropriate cleaning solution and not following the recommended cleaning schedule. Additionally, the ice machine's silver mesh filter was clogged with gray lint, indicating a lack of regular maintenance. Further inspection revealed that two drainage pipes were directly plumbed into floor sinks without air gaps, posing a risk of backflow contamination. The Dietary Manager was unaware of this issue, and the Stationary Engineer confirmed that air gaps should have been present. The kitchen also had three floor sink drains that were visibly dirty with dark stains and food debris, which the Dietary Manager acknowledged should have been cleaned by the evening staff. The survey also uncovered expired food items, including sliced cheese, pears, and cranberry juice, in various refrigerators. The Dietary Manager and a registered nurse confirmed that these items should have been discarded according to the facility's policy. Additionally, moldy bell peppers were found in the walk-in refrigerator, and the Dietary Manager admitted they should have been checked upon delivery. Other issues included rust on metal shelves, a dirty freezer door gasket, unclean serving scoops, and worn-out cutting boards, all of which were acknowledged by the Dietary Manager as needing attention.
Failure to Complete Advance Directives and POLST Forms
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding advance directives (AD) and physician orders for life-sustaining treatment (POLST) forms for seven out of eight sampled residents. Specifically, the facility did not complete the necessary sections of the POLST forms for Residents 9, 22, 24, 26, 31, and 184, leaving critical sections such as those for advance directives and artificially administered nutrition blank. Additionally, there was no documentation indicating that the facility discussed or assisted in executing advance directives for Residents 22, 24, 26, 31, 32, and 184, nor was there evidence of requests for copies of executed advance directives. During an interview, the facility's chief nursing officer confirmed these findings, acknowledging that case management or social service staff should have been involved in discussing and assisting with advance directives, and that nursing staff should have completed all sections of the POLST forms. The facility's policies, revised in 2022 and 2021, respectively, outline the responsibilities of registration/admitting staff and healthcare providers in ensuring that advance directives are documented and that POLST forms are completed based on the patient's expressed treatment preferences. The failure to follow these procedures has the potential to result in the delivery of medical services against the residents' wishes.
Deficiency in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for six out of thirteen sampled residents. These residents included individuals with various medical conditions such as chronic kidney disease, dementia, hypertension, alcoholic liver disease, depression, paraplegia, congestive heart failure, diabetes, and anxiety. The care plans for these residents were not comprehensive and did not include specific activities that were provided to them, as observed and verified by the activity coordinator. For instance, Resident 15, who has chronic kidney disease and dementia, was observed to enjoy activities like listening to music, doodling, and receiving manicures. However, these activities were not documented in her care plan. Similarly, Resident 8, who has alcoholic liver disease and paraplegia, enjoyed watching television and participating in candlelight dinners, but these preferences were not reflected in his care plan. The activity coordinator confirmed that the care plans lacked measurable objectives and timetables to meet the residents' needs. The chief nursing officer verified that the facility's policy required comprehensive, resident-centered care plans that include measurable objectives and timelines. However, the care plans for Residents 3, 5, 1, and 29 also lacked specific activities that were provided to them, such as haircuts, nail care, and social activities. This failure to document and implement comprehensive care plans had the potential to result in the residents not receiving the necessary interventions to maintain their highest level of well-being.
Deficiency in Menu Compliance and Emergency Planning
Penalty
Summary
The facility failed to ensure that approved menus were followed and that emergency menus were developed to properly feed residents in an emergency. During an interview with the Dietary Manager (DM), it was revealed that the facility did not use a therapeutic menu spreadsheet, and instead, cooks used a daily production tally sheet. An observation during a tray line showed that the cook used a 2-ounce ladle instead of the required 4-ounce ladle to serve orzo, which was acknowledged by the DM as incorrect. This failure to use the correct serving utensils was against the facility's policy on portion control, which mandates standardized portions to ensure nutritional content and food cost standards are met. Additionally, the facility did not have a written emergency menu plan. The DM stated that in an emergency, the facility would use existing food supplies, including rehydrated meals stored in an outdoor connex. However, there was no detailed emergency menu or food plan to describe how these foods would be used to meet the nutritional needs of residents on regular and therapeutic diets during emergencies. The Registered Dietitian (RD) emphasized the importance of following approved menus and having a well-defined emergency food and water plan. The facility's policy on disaster planning requires a documented Food & Nutrition Services Department Disaster Plan, which should include guidelines for meal planning during emergencies. The plan should ensure the facility is self-sustaining for a minimum of six days and outline menu plans for various emergency scenarios. However, the facility did not have such a plan in place, which could potentially impact their ability to meet residents' nutritional needs during an emergency.
Deficiency in Food Preparation and Serving Temperatures
Penalty
Summary
The facility failed to ensure that food was prepared and served at appropriate temperatures, which compromised the flavor and nutritive value of meals. During a kitchen tour, it was observed that cooked green peas were left uncovered on warm water, and chili was stored in a food warmer hours before mealtime. The facility's meal preparation schedule indicated that meals were prepared well in advance of serving times, which could affect the quality of the food. Additionally, a resident had previously reported receiving cold meals during a Resident Council Meeting. The facility also did not adhere to approved recipes for pureed meals, resulting in lumpy textures that were not suitable for residents requiring pureed diets. During a test tray observation, the pureed macaroni and cheese was found to be lumpy instead of smooth, and the regular macaroni and cheese was served at a temperature below the required standard. The facility's policies required specific temperature controls and adherence to standardized recipes, which were not followed, potentially impacting the residents' nutritional intake.
Failure to Cover Foley Catheter Drain Bags
Penalty
Summary
The facility failed to ensure that residents were treated with dignity by not covering the foley catheter (F/C) drain bags for two residents. Resident 31, who was admitted with diagnoses including neurogenic bladder and renal cell carcinoma, had an uncovered F/C drain bag secured to their bed frame. This was observed during a survey, and Resident 31 confirmed that the drain bag had been without a privacy cover since their admission. The resident's minimum data set indicated intact cognition, suggesting awareness of the situation. Similarly, Resident 32, admitted with conditions such as Parkinson's disease, frontoparietal cerebral atrophy, and a sacral decubitus ulcer, also had an uncovered F/C drain bag. This was confirmed by a registered nurse, who acknowledged that the nursing staff should have used privacy bags to cover the F/C drain bags to maintain the residents' privacy and dignity. The facility's chief nursing officer also confirmed that the staff should have adhered to the facility's policy on patient confidentiality, which emphasizes the importance of privacy and dignity.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
The facility failed to adhere to its policy and procedure for oxygen therapy by administering oxygen to a resident without a physician's order. Resident 31, who was admitted to the facility with diagnoses including renal cell carcinoma, metastatic cancer of the spine, severe anemia, and was under palliative care, was observed receiving oxygen via nasal cannula at a rate of 2 liters per minute. However, a review of the resident's records indicated that the order for oxygen had been discontinued over a month prior, and no new order had been issued. Interviews with the registered nurse and the chief nursing officer confirmed that there was no active physician's order for the oxygen therapy being administered to Resident 31. The facility's policy, which requires verification of a physician's order before administering oxygen, was not followed. The chief nursing officer acknowledged the oversight and confirmed that the licensed nurse should have verified the presence of an active order before administering oxygen to the resident.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food dislikes and preferences of Resident 30, which was observed during a lunch meal service. On the specified date, Resident 30 was served cut carrot pieces mixed with Italian vegetables, and soup was not provided, despite the resident's lunch tray card indicating a dislike for carrots and a preference for soup at lunch and dinner. This oversight was confirmed during an interview with a certified nursing assistant (CNA H) and the dietary manager (DM), both of whom acknowledged that the dietary staff should have adhered to the resident's documented food dislikes and preferences. The facility's policy and procedure on food preferences, revised in May 2023, outlines the importance of communicating with residents about their food and beverage preferences within 72 hours of admission. This includes documenting food dislikes, preferences, intolerances, and allergies. The dietary manager confirmed that the dietary staff did not follow the policy, as they failed to serve the meal according to Resident 30's documented preferences, which could potentially lead to decreased food intake and negative health effects for the resident.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during medication administration for a resident. Specifically, a registered nurse did not perform hand hygiene after removing used gloves and before preparing medications for a resident. This was observed on two separate occasions during a medication pass, where the nurse disposed of gloves in a trash bin attached to the medication cart and proceeded to handle medications without sanitizing her hands. The resident involved was admitted with diagnoses including alcoholic liver disease, left hip arthritis, and hypertension. The registered nurse acknowledged the failure to perform hand hygiene during an interview, confirming that she should have sanitized her hands after glove removal. The infection preventionist also verified that hand hygiene should have been performed according to the facility's policy, which emphasizes the importance of hand hygiene after contact with inanimate objects and glove removal.
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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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