Golden Sonora Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sonora, California.
- Location
- 19929 Greenley Road, Sonora, California 95370
- CMS Provider Number
- 555736
- Inspections on file
- 75
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Golden Sonora Care Center during CMS and state inspections, most recent first.
The facility removed assist rails from the beds of several cognitively intact residents with documented weakness, mobility impairments, and fall histories, despite existing consents, physician orders, and care plan interventions authorizing assist rails for bed mobility and ADL support. Residents reported that maintenance staff removed the rails even when they objected, and that they had previously relied on the rails to turn in bed, reposition, assist with transfers, and feel secure during incontinence care. After removal, residents described fear of falling, loss of independence, and humiliation related to needing more staff assistance. Nursing staff confirmed that assist rails were removed facility-wide, that residents were upset or devastated, and that the action was driven by corporate concerns about restraint use, while the maintenance director acknowledged he was instructed to remove rails and was unsure whether residents had been informed. These actions conflicted with the facility’s own resident rights policy regarding participation in care planning, dignity, self-determination, and reasonable accommodation of individual needs and preferences.
A resident was administered metoprolol despite physician-ordered parameters to hold the medication for low blood pressure or heart rate. On several occasions, the medication was given when the resident's vital signs were either below the specified thresholds or not documented, leading to an episode of hypotension that required emergency evaluation. Nursing staff confirmed awareness of the parameters but did not consistently follow them, contrary to facility policy.
A resident's responsible party and family were not immediately notified of the resident's death. The facility staff relied on hospice to make the notification, but the responsible party only learned of the death upon returning to the facility. Interviews and record reviews revealed inconsistent practices and a lack of direct communication with the family, despite facility policy requiring notification of the responsible party in such events.
Meal tray tickets containing sensitive personal and medical information for all residents were found discarded in a kitchen garbage can and subsequently transported to an unsecured, publicly accessible dumpster. The tickets included resident names, room locations, diet orders, fluid textures, food preferences, allergies, and special instructions. The CDM confirmed that these documents should have been shredded and that their disposal in the trash violated HIPAA and facility policy.
The facility failed to verify, complete, and implement PASRR screenings and recommendations for four residents with serious mental illness or intellectual disabilities. This included not identifying a resident's SMI on the PASRR, not completing required Level II evaluations due to unresponsiveness to state contacts, and not providing or following up on recommended specialized mental health services.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility did not provide alternate meal options with similar nutritional value to the main entrée for 172 residents. Interviews with residents and the CDM revealed that alternate choices were limited to items like grilled cheese sandwiches, chef's salad, cottage cheese and fruit, and hamburgers, with some residents reporting only snack-type items and reduced portion sizes. Review of recipes showed a significant difference in protein content between alternate and main meals.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not have a program in place to monitor antibiotic use, lacking a system to track or evaluate antibiotic administration among residents.
Multiple flies were observed in the kitchen and dry storeroom, with staff swatting at flies during meal plating and food left mostly uncovered. The door to the dumpster area was found propped open, increasing the risk of pest entry. The Dietary Director confirmed an increase in flies and acknowledged the risk of food contamination, in violation of the facility's pest control policy.
A resident's urinary catheter bag was observed without a privacy cover, and staff confirmed that this did not align with facility policy requiring such covers to maintain resident dignity. The absence of the privacy cover was acknowledged by both nursing and administrative staff, highlighting a lapse in upholding the resident's right to dignity.
Residents who were clinically determined to be appropriate for self-administration of medications were not permitted to do so, contrary to regulatory requirements.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with multiple chronic conditions, including COPD and chronic kidney disease, was admitted to hospice care but did not have a hospice care plan developed as required. Record review and staff interview confirmed the absence of a coordinated plan of care, despite facility policy mandating such plans for residents receiving hospice services.
A resident with multiple medical conditions had a pressure ulcer that was reclassified from unstageable to stage 4 after debridement, with new treatment orders issued. The care plan was not updated to reflect the current wound stage or treatment, as confirmed by nursing staff and leadership, despite facility policy requiring such updates for accurate care delivery.
The facility did not ensure that services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
A resident did not receive appropriate care or interventions to maintain or improve ROM or mobility, and the facility did not ensure services were provided to prevent a decline unless it was medically unavoidable.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents did not receive appropriate urological care as ordered, including missed documentation of catheter care and urine output for one resident, and delayed scheduling and communication of a urology consult for another. Staff interviews and record reviews confirmed lapses in following physician orders and facility policy, as well as inadequate communication regarding outside medical appointments.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Two dumpsters were observed overflowing with garbage, preventing the lids from closing and leaving one lid open. The dumpsters, located near the kitchen hallway, were not maintained according to facility policy or FDA guidelines, as confirmed by the dietary manager during an interview.
Two unlabeled urinals were found on a nightstand next to a resident's bed, and staff confirmed that urinals should be labeled to prevent cross contamination and infection. The infection preventionist and ADON acknowledged this was unsanitary and did not meet infection control standards, as outlined in facility policy.
A resident experienced a change in condition and was sent to the ER, but the facility failed to immediately notify the responsible party as required. Staff left voicemails on an office phone outside business hours, despite having received updated after-hours contact information, which was not added to the resident's record. This led to miscommunication and medical decisions being made without the responsible party's input.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to accepted professional standards, as observed by surveyors during their review of documentation and information handling practices.
A resident with recent subdural hemorrhage, muscle weakness, and impaired safety awareness was left unattended in the bathroom after being transferred to the toilet by a CNA. Despite being identified as a moderate fall risk, the resident was left alone for about two minutes, during which time a fall occurred, resulting in a scalp laceration that required emergency care.
A resident with multiple medical conditions, including dementia and a recent toenail wound, did not receive a physician-ordered podiatry consult. Despite documentation and staff acknowledgment of the order, the consult was not completed, and the omission was confirmed by facility leadership.
A facility failed to create baseline care plans within 48 hours for a resident admitted with multiple health conditions, including UTI, muscle weakness, and aphasia. The necessary care plans for communication, dehydration, skin, and incontinence were not initiated during the resident's stay and were only created five days after discharge. The ADON confirmed that these care plans should have been developed promptly to guide staff actions and meet the resident's immediate needs.
A resident with hypertension and a cerebral aneurysm did not receive proper blood pressure monitoring before administering amlodipine, leading to a stroke. The facility failed to set parameters for when to withhold the medication and did not consistently record blood pressure readings. A critically high blood pressure reading was not acted upon, resulting in the resident's transfer to a hospital for higher care.
A resident's personal belongings were lost due to the facility's failure to properly inventory and label clothing. The resident, who was fully continent, was found wearing an adult brief, and several personal clothing items were missing. The facility's process for managing residents' belongings was not followed, as the inventory list was not found in the resident's record, and clothing was not labeled before being sent to laundry services. Unlabeled clothing was stored in bags and could not be returned unless identified by residents.
A resident with schizophrenia and muscle weakness experienced an incident resulting in a laceration and abrasions. The facility failed to document follow-up assessments and social services interventions for 72 hours post-incident, as required by policy, potentially leaving the resident's injuries and psychosocial needs unaddressed.
A resident with prostate cancer and brain metastases was denied re-entry to a facility after hospitalization, despite being calm and cooperative. The facility failed to document the discharge reason or provide a written notice to the resident, their representative, or the LTC Ombudsman, violating the resident's right to return and appeal the discharge.
A facility failed to implement a care plan for a resident with dysphagia, despite the resident's risk of aspiration. The resident's medical records showed no care plan addressing this risk, confirmed by the ADON. The SLP provided ongoing staff training and posted signs for aspiration precautions, but the nursing staff did not update the care plan with these recommendations, contrary to facility policy.
A resident with dementia and dysphagia was found with a straw in her milk despite a posted sign indicating no straws, posing a risk of aspiration. The SLP had identified coughing with straw use and provided ongoing staff education on aspiration precautions, but the resident continued to be found with straws at her bedside.
The facility failed to provide residents with access to their personal funds during weekends and after hours, affecting 42 residents with funds in the facility trust account. Despite a policy requiring access to funds within 24 hours, several staff members were unaware of the procedures, leading to inconsistencies in cash availability at nurse's stations. This deficiency was highlighted by residents who reported difficulties in accessing their money, and staff interviews revealed a lack of communication and implementation of the policy.
The facility did not serve the correct double protein meals to 10 residents, instead providing double portions of each food item. This was observed during a lunch meal service, and the District Manager acknowledged the error, noting the absence of the Dietary Manager during tray line. A facility document emphasized the importance of tray line accuracy for maintaining nutritional adequacy.
The facility failed to follow proper food handling practices, affecting 171 residents. Food items lacked use-by dates, and expired products were not removed. The kitchen had unsanitary conditions, including a dusty fan and wet-stacked cups. Nursing station refrigerators contained unlabeled food and were unclean, posing a risk of foodborne illnesses.
The facility failed to maintain infection control protocols, including not using enhanced barrier precautions for a resident with a nephrostomy tube, transporting clean linen with an open cart cover, and neglecting hand hygiene during wound care for a resident with a stage 4 pressure ulcer.
A resident with a urinary catheter in a LTC facility was observed to have their urine collection bag uncovered on multiple occasions, which compromised their privacy and dignity. The resident's care plan included the use of a catheter, and both a CNA and the DON confirmed that the bag should have been covered. The facility's policy on dignity requires staff to assist residents in keeping urinary bags covered.
Two residents in a facility were found without their call lights within reach, despite their care plans indicating the necessity due to their medical conditions. One resident, with muscle weakness and difficulty walking, was observed trying to use a TV remote for help. Another resident, paralyzed on one side and on hospice care, was also found without access to their call light. Staff confirmed the oversight, and the DON acknowledged the failure to follow the facility's policy.
A resident's right to self-determination was not respected when they requested a shower instead of a bed bath, but staff did not honor this request due to time constraints. The DON and a CNA could not provide documentation of the resident receiving a shower or bed bath on the designated days, despite the facility's policy emphasizing the importance of supporting residents' rights and well-being.
A facility failed to coordinate PASRR assessments for a resident with schizophrenia, as her mental illness was not included in the PASRR Level I screening. Despite documentation indicating schizophrenia, the screening incorrectly showed no serious mental illness. Staff interviews revealed confusion over responsibility for PASRR accuracy, and the facility's policy was not effectively implemented.
A resident with COPD, pulmonary embolism, and diabetes was observed smoking unsupervised on the sidewalk outside the facility, despite a no-smoking policy. The resident, who used a walker and had an unsteady gait, kept cigarettes and a lighter in a bag tied to her walker. Facility staff, including the Administrator, were aware of the resident's actions and her refusal to use nicotine patches offered by the facility.
A resident with a PICC line did not receive dressing changes as ordered, risking infection. The dressing was not changed on the scheduled date, and staff confirmed it was only reinforced. Facility policy required weekly changes to prevent infection, but documentation showed a lapse in adherence to this protocol.
A facility failed to change a resident's oxygen tubing weekly as per physician's order. The resident, who was admitted with respiratory failure, was observed using oxygen tubing that had not been changed since 6/3/24. Both the LN and DON confirmed that the tubing should be changed weekly to prevent infection, highlighting a lapse in following professional standards of practice.
A resident with end-stage renal disease did not have complete pre and post-dialysis documentation for five out of six treatment days, leading to a communication gap between the dialysis center and the facility. Staff interviews confirmed the absence of necessary documentation, which is crucial for monitoring the resident's condition and responding to potential adverse outcomes.
A resident with pancreatic and lung cancer did not receive prescribed oxycodone for pain management due to a discrepancy in medication administration records. The medication card showed two remaining tablets, contradicting the documentation by an LN who claimed the medication was given. Interviews confirmed the resident experienced pain, and the facility's policy on controlled substance reconciliation was not followed.
A facility failed to document the rationale for extending a PRN order of Lorazepam for a resident beyond the standard 14-day period. The resident was prescribed the medication for agitation over six months without proper justification, contrary to the facility's policy. Interviews with staff confirmed the oversight, highlighting a lapse in following procedures for psychotropic medication use.
The facility failed to properly label and store medications, with spillage and sticky residue found on medication bottles and drawers. An insulin pen for a resident with Type 2 Diabetes was used past its expiration date, risking reduced efficacy. The DON highlighted the importance of maintaining clean and organized medication storage to prevent infection.
Resident Rights Violated When Assist Rails Removed Against Residents’ Wishes
Penalty
Summary
The deficiency involves the facility’s failure to honor resident rights to self-determination, dignity, and participation in care planning when assist rails used for mobility and bed mobility were removed from multiple residents’ beds against their wishes. Five cognitively intact residents, each with documented weakness and mobility impairments, had previously consented to the use of assist rails, had physician orders in place, and in some cases had care plan interventions specifying assist rails for bed mobility and ADL function. Despite this, the facility directed that assist rails be removed, and maintenance staff carried out the removal, including in situations where residents verbally objected. One resident with anxiety, depression, muscle weakness, and a history of repeated falls had a BIMS score of 15, a signed consent form for assist rails, and a physician order allowing assist rails for bed mobility. This resident reported that the maintenance person removed the assist rails three days prior to the survey despite the resident’s request that they not be removed. The resident stated the rails were used to help turn in bed and to hold onto during incontinence care to feel safe and secure, and since removal, the resident experienced ongoing fear of falling out of bed and feeling scared. Another resident with hemiparesis, hemiplegia, difficulty walking, muscle weakness, and wheelchair dependence, also cognitively intact with a BIMS of 15, had consented to assist rails and had a physician order for their use. After a discharge and return to the facility, this resident found the rails had been removed, reported previously using them to pull up in bed, reposition, and stand and pivot, and stated that repeated requests to staff to have the rails replaced had not been honored, leading to concerns about getting weaker and feeling scared during turning and incontinence care without the rails. A third cognitively intact resident with muscle weakness, difficulty walking, and lack of coordination had a consent form, a care plan intervention for assist rails for bed mobility, and a physician order permitting assist rails. This resident reported that the rails were removed on a specific date and remained off until the day before the survey, during which time the resident experienced a near fall when trying to go to the bathroom and reported loss of independence, including no longer being able to change their own incontinent briefs and needing two staff for this care, which the resident described as humiliating. A fourth cognitively intact resident with difficulty walking, muscle weakness, depression, anxiety, and obesity had a care plan for assist rails on both sides of the bed for bed mobility, a consent form for bilateral grab/assist/mobility bars, and a physician order for assist rails. Nursing staff interviews confirmed that assist rails had been removed facility-wide, that residents had used them for mobility assistance and turning in bed, and that residents were upset, with one nurse stating a resident was devastated. The maintenance director stated he was directed to remove assist rails from residents who were not “required” to have them and was unsure if nursing staff had explained the removals to residents, acknowledging that some residents had a problem with the removal. The assistant director of nursing stated that residents who wanted to keep rails had been evaluated, had orders, and had care plans, but she was later told to re-evaluate whose rails were “necessary.” These actions conflicted with the facility’s written policy on resident rights, which includes the right to participate in the development and implementation of the person-centered care plan, to sign after significant changes to the plan of care, to a dignified existence and self-determination, to be treated with dignity and respect, to reasonable accommodation of individual needs or preferences, and to make choices about significant aspects of life in the center.
Failure to Hold Metoprolol per Physician Parameters Resulting in Hypotension
Penalty
Summary
The facility failed to ensure that medications with physician-ordered parameters were safely administered for a resident prescribed metoprolol for hypertension. The physician's order specified that metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 100 or heart rate (HR) was less than 60. On multiple occasions, including specific dates, the medication was administered despite the resident's vital signs being outside of these parameters or not documented at all. For example, on one date, the resident's blood pressure was recorded as 90/66 and 89/65, both below the hold threshold, yet the medication was still given. Additionally, there were instances where vital signs were not recorded on the medication administration record (MAR) prior to administration. Interviews with licensed nurses confirmed that they were aware of the hold parameters and acknowledged that the medication should not have been administered when the resident's vital signs were outside the prescribed limits. The failure to adhere to these parameters resulted in the resident experiencing hypotension, requiring emergency evaluation and observation. Facility policy required medications to be administered as prescribed and in accordance with physician orders, which was not followed in this case.
Failure to Notify Responsible Party of Resident Death
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) or family member about the death of a resident who was under hospice care. The resident's contact list included seven individuals, with one family member designated as the RP. This RP was not contacted by the facility regarding the resident's passing; instead, she discovered the resident's death upon returning to the facility the following morning. The RP confirmed that neither she nor other family members were notified by the facility, and the hospice agency only contacted her after she arrived at the facility and learned of the death. Interviews with facility staff, including licensed nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Service Assistant (SSA), and the Assistant Administrator (AADM), revealed inconsistent practices and expectations regarding notification of family members upon a resident's death. While some staff believed that hospice would notify the family, others stated that it was the facility's responsibility to ensure the RP or emergency contact was informed, regardless of hospice involvement. Documentation in the resident's medical record indicated that the family was present the night before the death, but this was confirmed to be inaccurate by both the RP and the ADON. A review of facility policies indicated that the nursing staff was required to notify hospice and the family in the event of a resident's death or change in condition. However, in this instance, the nurse contacted hospice but did not notify the RP or family, and there was no documentation of attempts to reach the RP or other contacts. The failure to notify the RP and family members directly violated the resident's right to have their responsible party informed of significant changes, including death.
Improper Disposal of Meal Tickets Compromises Resident Privacy
Penalty
Summary
The facility compromised the privacy and confidentiality of all 173 residents by improperly disposing of meal tray tickets containing sensitive personal and medical information. During a kitchen tour, surveyors observed meal tickets with resident names discarded in a garbage can in the dishwashing area. The path of the kitchen trash was traced to outside dumpsters located in an unsecured, publicly accessible parking lot. Review of the meal tickets revealed they included resident names, room locations, meal locations, therapeutic diet orders, fluid textures, food preferences, allergies, and special instructions, all of which are considered protected health information. The Certified Dietary Manager confirmed that the expectation was for meal tickets to be placed in a shred bin and acknowledged that discarding them in the trash violated HIPAA regulations. Facility policy also stated that residents have the right to privacy and confidentiality for all aspects of care and services.
Failure to Complete and Implement PASRR Requirements for Residents with SMI/ID
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Preadmission Screening and Resident Review (PASRR) process for four residents with serious mental illness (SMI), intellectual disability (ID), or related conditions. For one resident, the PASRR Level I screening from the discharging facility did not indicate a diagnosis of SMI, despite the resident having a documented diagnosis of Depressive Schizoaffective Disorder. The facility did not have a process in place to verify the accuracy of PASRR documents received from other facilities, resulting in the omission of critical information. Another resident's PASRR Level I screening indicated the need for a Level II evaluation, but this was not completed because facility staff were unresponsive to multiple attempts by the state agency to schedule the evaluation. Similarly, a third resident required a Level II Mental Health Evaluation after a positive Level I screening, but the evaluation was not completed due to the facility's lack of response to the state's communication attempts. In both cases, the absence of follow-up and unclear staff responsibilities led to the closure of the cases without the required assessments being performed. For a fourth resident, the facility did not implement or follow up on specialized services recommended in the PASRR Level II Determination Report, such as psychotherapy, counseling, and neuropsychology consultation. There was no evidence that these recommendations were reviewed with the medical doctor or incorporated into the resident's care plan. Staff interviews confirmed that the recommended mental health services and consultations were not provided, and the facility's process for ensuring follow-up on PASRR recommendations was not followed.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the labeling and secure storage of medications and biologicals within the facility.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Provide Nutritive Alternate Meal Choices
Penalty
Summary
The facility failed to provide alternate food choices with similar nutritive value to the main meal for 172 residents who received food from the kitchen. During a kitchen tour, the alternate menu was reviewed and found to include chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers. The Certified Dietary Manager (CDM) confirmed these were the only alternate meal choices available. Residents reported that they previously received alternatives like sandwiches but now only receive snack-type items, and that portion sizes have decreased since a new company took over food services. Residents also stated that they are not receiving alternatives to the main meal anymore. Further interviews with the CDM revealed that the menu was provided by an external company and could be changed based on the cook's time constraints. The CDM confirmed that the alternate grilled cheese sandwich meal comes with a vegetable and side dish of the day, but no additional protein is added. A review of the corporate recipes showed that the grilled cheese sandwich provided 14 grams of protein, while the main entrée, sesame chicken, provided 35 grams of protein. This discrepancy in protein content indicates that the alternate meals did not match the nutritive value of the main meals.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. This lack of monitoring could result in inappropriate or unnecessary antibiotic administration, but the report only states the absence of a monitoring program and does not provide further details about specific residents or incidents.
Failure to Maintain Effective Pest Control in Food Preparation Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by multiple observations of flies in the food preparation and storage areas. During several kitchen tours, flies were seen in both the kitchen and the dry storeroom, which was separated from the kitchen by a closed door. Additionally, the door to the dumpster area was found propped open with a rock, potentially allowing pests easier access to the facility. During a lunch plating observation, multiple flies were present in the kitchen, and staff were observed swatting at the flies while food was mostly uncovered. In an interview, the Dietary Director acknowledged an increase in the number of flies over the past few days and recognized the risk of food contamination, stating that meals should have been covered. Review of the facility's pest control policy indicated that all food preparation, service, and storage areas should be regularly monitored for pests, and any concerns should be reported immediately. The presence of flies in food areas was confirmed by both observation and staff interview, and the facility's own policy and external resources highlight the risk of contamination from flies.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident's urinary catheter bag was observed hanging under the bed without a privacy cover. During multiple observations and interviews, both a CNA and a licensed nurse confirmed that the catheter bag was not covered, and acknowledged that it should have been concealed with a privacy cover to maintain the resident's dignity. The Assistant Director of Nursing also confirmed that facility policy requires the use of privacy covers for urinary catheter bags to preserve resident dignity. The facility's policies on resident rights and accommodation of needs emphasize treating residents with respect, kindness, and dignity, and specifically mention the importance of accommodating individual needs to maintain independence and well-being. Despite these policies, the lack of a privacy cover for the urinary catheter bag was observed and confirmed by staff, indicating a failure to uphold the resident's right to dignity as outlined in facility policy.
Failure to Allow Self-Administration of Medications
Penalty
Summary
Residents were not allowed to self-administer their medications, despite it being clinically appropriate to do so. The facility failed to permit self-administration of drugs for residents who were determined capable, as required by regulations.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Develop Hospice Care Plan for Resident Receiving Hospice Services
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive hospice care plan for one of seven sampled residents who was receiving hospice care services. The resident in question was admitted with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and chronic kidney disease. Despite being admitted to hospice care due to a terminal diagnosis of COPD, a review of the resident's records and an interview with the assistant director of nursing (ADON) confirmed that no hospice care plan had been developed for this resident. The facility's own policies require the development of a coordinated plan of care (POC) with hospice providers, including directives for managing pain and other symptoms, as well as a comprehensive, person-centered care plan with measurable objectives and timetables. The ADON acknowledged during the review that the absence of a hospice care plan meant staff might not know what care and services to provide, potentially impacting the resident's care. The deficiency was identified through both record review and staff interview, with verification that the required hospice care plan was missing.
Failure to Update Care Plan After Change in Pressure Ulcer Status
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident with a pressure ulcer after a significant change in the wound's condition and treatment. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, acute posthemorrhagic anemia, and generalized muscle weakness, was admitted with an unstageable pressure ulcer on the right buttock. Following a wound assessment and debridement, the pressure ulcer was reclassified as a stage 4 wound, and new treatment orders were initiated. However, the care plan continued to reflect the previous unstageable status and did not incorporate the updated stage or new treatment interventions. Interviews with nursing staff, a nurse practitioner, and the assistant director of nursing confirmed that the care plan was not updated to reflect the current wound stage and treatment orders. Staff acknowledged the importance of timely care plan updates for accurate communication and guidance in wound care. Review of facility policies and job descriptions indicated that care plans should be revised to reflect changes in residents' conditions and treatments, but this was not done in this case.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, are not provided in the report.
Failure to Provide Care to Maintain or Improve Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that the resident received necessary interventions or services to prevent a decline in ROM or mobility, except in cases where such decline was medically unavoidable. The report notes that the required care was not provided, but does not specify the medical history or current condition of the resident involved.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Timely Catheter Care and Urology Consults
Penalty
Summary
The facility failed to provide appropriate health treatment and services to meet the urological needs of two residents. For one resident with a history of heart failure and urinary retention, physician orders required indwelling urinary catheter care and documentation of urine output every shift. However, review of treatment administration records over several months revealed multiple instances where catheter care and urine output were not documented as ordered. Interviews with nursing staff and the Assistant Director of Nursing confirmed that catheter care and output measurement were expected every shift, and that these tasks were not consistently documented in the resident's medical record. Another resident, admitted with hemiplegia following a stroke and experiencing recurrent urinary tract infections (UTIs), had orders for a urology consult and referral to a urologist. Despite these orders, the consult and referral were not carried out in a timely manner. The resident’s family member repeatedly expressed concerns to staff about the need for a urology evaluation due to ongoing UTIs and a suspected prolapsed bladder. Multiple staff interviews confirmed that the family’s requests were communicated, but the scheduling of the urology appointment was delayed, and there was a lack of timely communication regarding the appointment status to both the family and nursing staff. The facility’s process for scheduling and communicating outside medical appointments was found to be inadequate. The staff member responsible for scheduling did not have access to the electronic clinical record and did not consistently update nursing staff about appointment statuses. This led to a disconnect in communication, resulting in delays in care and lack of timely information for both staff and the resident’s family. The Assistant Director of Nursing acknowledged that the process did not meet expectations and that the facility’s policy for catheter care and timely medical consultations was not followed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to properly maintain its garbage storage area, as observed during a kitchen tour when two out of six dumpsters were found overflowing with garbage. The excess waste prevented the lids from closing, with one lid resting approximately six inches above the bin due to garbage bags and the other lid left open. The dumpsters were located about 15 to 20 feet from the kitchen hallway door. This situation was confirmed during an interview with the certified dietary manager, who acknowledged the importance of keeping dumpster lids closed to limit pest attraction. A review of the facility's policy on garbage and refuse disposal indicated that all trash should be disposed of in external receptacles with lids covered when not in use. Additionally, the US Food and Drug Administration's Food Code was referenced, emphasizing the need for tight-fitting lids to prevent the attraction and breeding of pests. The observed failure to keep dumpster lids closed and prevent overflow was inconsistent with both facility policy and federal guidelines.
Unlabeled Urinals Found in Resident Room Breach Infection Control
Penalty
Summary
The facility failed to implement and follow proper infection prevention practices when two unlabeled urinals were observed on the nightstand next to a resident's bed. During an observation, it was noted that the urinals were not labeled with any identifying information such as a name, initials, or room number. This was confirmed by a licensed nurse, who acknowledged that urinals should be labeled to prevent use by other residents and to avoid cross contamination. The nurse further stated that using a urinal belonging to another resident could cause infection and illness. The infection preventionist and the assistant director of nursing both confirmed that the presence of unlabeled urinals did not meet the facility's infection control expectations and was considered unsanitary. Facility policies reviewed indicated that maintaining a clean, sanitary, and orderly environment is required, and that infection control practices must support prevention and transmission of infection. The failure to label urinals as required was identified as a breach of these policies.
Failure to Notify Responsible Party of Change in Condition and Emergency Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) for a resident who experienced a change in condition and was sent to the emergency room. Specifically, after the resident had an unwitnessed fall, the facility did not contact the RP until the following day, despite having received written instructions with updated after-hours contact information. Instead, staff left multiple voicemails on the RP's office phone, which was only checked during regular business hours. The updated contact information, which included specific after-hours instructions, was not added to the resident's admission record, resulting in staff being unable to reach the RP in a timely manner during an emergency. Interviews with facility staff confirmed that the updated contact information was received but not incorporated into the resident's records. The facility's policies required immediate notification of changes in condition and documentation of such notifications, but these procedures were not followed. As a result, there was miscommunication between the facility, the RP, and the emergency room, and medical decisions were made for the resident without input from the RP.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Resident Fall Due to Inadequate Supervision in Bathroom
Penalty
Summary
A deficiency occurred when a resident with a recent history of traumatic subdural hemorrhage, muscle weakness, and impaired safety awareness was left unattended in the bathroom. The resident had been admitted to the facility only a few hours prior, with documented left-sided weakness, slurred speech, and cognitive impairment. Despite being identified as a moderate fall risk with deconditioning and gait/balance problems, the resident was transferred to the toilet by a CNA, who then left the resident alone in the bathroom at the resident's request for privacy. The CNA was away for approximately two minutes, during which time the resident fell and sustained a scalp laceration requiring emergency medical attention and laceration repair with staples. Interviews and record reviews confirmed that staff were aware of the resident's fall risk and cognitive limitations. The facility's policy and the Director of Staff Development indicated that staff should remain close to residents identified as fall risks, even if privacy is requested, and should stay within reach or just outside the bathroom door. However, this protocol was not followed, resulting in the resident being left unsupervised and subsequently experiencing a fall with injury.
Failure to Provide Physician-Ordered Podiatry Services
Penalty
Summary
The facility failed to provide podiatry services as ordered by the physician for one resident. The resident was admitted with diagnoses including dementia, glaucoma, hyperlipidemia, and depression. A skin/wound note documented an evaluation and treatment for the resident's right toenail, which had mild exudate. Following this, a physician's order was placed for a podiatry consult to address the toenail issue. Despite the physician's order, the resident was not seen by a podiatrist. This was confirmed through interviews and record reviews with the Social Services Director, Assistant Director of Nursing, and the Administrator, all of whom acknowledged that the order for a podiatry consult was not carried out. The staff confirmed that the failure to follow the physician's order could impact the resident's health and well-being.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to create and implement necessary baseline care plans within 48 hours of admission for a resident, resulting in a lack of care plans for communication, dehydration, skin, and incontinence during the resident's stay. The resident was admitted with multiple diagnoses, including urinary tract infection, muscle weakness, aphasia, dysphagia, cerebral aneurysm, and adult failure to thrive. Despite these conditions, the care plans were not initiated until five days after the resident was discharged. The Assistant Director of Nursing (ADON) acknowledged that care plans should have been developed within the first 48 hours of the resident's admission. The ADON explained that care plans are essential for directing staff actions and ensuring that the resident's needs, such as using a whiteboard for communication, are met. The facility's policy requires a baseline care plan to be developed within 48 hours to meet the resident's immediate health and safety needs, but this was not adhered to in this case.
Failure to Monitor Blood Pressure Leads to Resident Stroke
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident diagnosed with hypertension and a cerebral aneurysm. The resident was prescribed amlodipine for blood pressure management, but the facility did not consistently monitor the resident's blood pressure before administering the medication. There were no parameters set in the medication order to guide when the medication should be withheld, and the resident's blood pressure was not regularly recorded. This lack of monitoring and absence of parameters led to the administration of amlodipine without assessing the resident's current blood pressure, which is critical in managing hypertension effectively. The resident's blood pressure was not taken consistently throughout their stay, and a critically high blood pressure reading of 272/114 was not acted upon by the nursing staff or reported to the medical doctor. Despite the resident's medical history and the potential risks associated with high blood pressure, the facility did not ensure that the resident's vital signs were monitored every shift as expected. This oversight resulted in the resident experiencing a stroke and requiring transfer to a hospital for a higher level of care. Interviews with facility staff, including licensed nurses and the Assistant Director of Nursing, revealed an understanding of the importance of monitoring blood pressure and the need for parameters in medication orders. However, these practices were not followed, leading to a significant lapse in care. The medical doctor also emphasized the necessity of regular monitoring and communication regarding the resident's condition, particularly given the resident's aneurysm and the associated risks of elevated blood pressure. The failure to adhere to these standards of care had a direct negative impact on the resident's health and well-being.
Failure to Protect Resident's Property from Loss
Penalty
Summary
The facility failed to protect a resident's property from loss, resulting in the resident losing personal items and potentially experiencing emotional distress. The resident, who was fully continent, was found wearing an adult brief, and their responsible party noticed the absence of several personal clothing items, including boxer briefs and sweatshirts. The responsible party had previously purchased and brought these items to the facility, but they were missing during a visit. The facility's process for managing residents' personal belongings was not followed. An inventory list of the resident's belongings was supposed to be completed upon admission and scanned into the electronic health record, but it was not found in the resident's record. Staff were expected to label clothing with the resident's name using a sharpie, but this was not done, leading to the loss of the resident's clothing. Interviews with staff, including CNAs and the Director of Nursing, revealed that the inventory process was not properly executed, and clothing was not labeled before being sent to laundry services. The Housekeeping Manager confirmed that unlabeled clothing was stored in bags and could not be returned to residents unless they complained and identified their items. The Director of Nursing and the Administrator acknowledged the issue and the lack of an inventory sheet in the resident's medical record. The facility's policy required that residents' belongings be inventoried and documented upon admission and updated as necessary, but this was not adhered to, resulting in the loss of the resident's personal items.
Incomplete Post-Incident Documentation for a Resident
Penalty
Summary
The facility failed to meet professional standards of care for a resident who was admitted with schizophrenia and muscle weakness. After an incident where the resident became enraged and was found on the floor with a laceration, the documentation of assessments and observations post-incident was incomplete. The resident was taken to the emergency room and returned with additional abrasions, but there was no documentation of follow-up care or assessments for 72 hours as required by the facility's policy. The interdisciplinary team recommended social services follow-up, but there was no documentation of this occurring. The lack of documentation meant that the resident's potential injuries, illnesses, and psychosocial needs were not assessed or addressed. The facility's policy required all services and changes in the resident's condition to be documented to facilitate communication among the care team, which was not adhered to in this case.
Failure to Ensure Resident's Right to Return After Hospitalization
Penalty
Summary
The facility failed to ensure the right to return for a resident after hospitalization, which led to a deficiency. The resident, who had been admitted to the facility with diagnoses including prostate cancer and secondary malignant neoplasm of the brain, was sent to the hospital due to aggressive behaviors. Despite being calm and cooperative upon evaluation in the emergency department, the facility refused to accept the resident back after discharge from the hospital. This refusal occurred without documented justification from a facility physician or proper communication with the hospice team. The facility did not provide a written Notice of Transfer or Discharge to the resident, the resident's representative, or the Long-Term Care Ombudsman. The lack of documentation and communication regarding the resident's discharge was confirmed by interviews with the Medical Director, Social Services Director, and the Administrator. The facility's policy required that reasons for transfer or discharge be documented in the resident's medical record, which was not adhered to in this case. Additionally, the facility's failure to provide a discharge notice deprived the resident and their representative of information regarding their rights to appeal the transfer or discharge. The Administrator acknowledged that a written discharge notice was not provided and that the conversation with the resident's representative was not documented. This oversight prevented the resident's family from coordinating care and deprived the Ombudsman of the opportunity to advocate on the resident's behalf.
Failure to Implement Care Plan for Resident with Dysphagia
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with dysphagia, a condition characterized by difficulty swallowing. This deficiency was identified during a review of the resident's admission records, which indicated diagnoses including dementia, generalized muscle weakness, and dysphagia. Despite these conditions, there was no care plan in place to address the resident's risk of aspiration, a serious condition where food or liquid is accidentally inhaled into the airway, potentially leading to pneumonia. The Assistant Director of Nursing confirmed the absence of an aspiration care plan, acknowledging that such a plan is necessary for staff to be aware of the resident's dietary limitations and interventions needed to prevent aspiration. Interviews with staff revealed ongoing issues with compliance to speech therapy recommendations. The Speech Language Pathologist (SLP) had conducted in-services to educate staff on aspiration precautions and had posted a sign above the resident's bed to communicate these precautions. However, the Administrator indicated that the nursing staff was responsible for entering the SLP's recommendations into the care plan, which had not been done. The facility's policy on comprehensive person-centered care plans, revised in March 2022, states that care plans should be revised as residents' conditions change, highlighting a lapse in adherence to this policy.
Failure to Adhere to Aspiration Precautions for a Resident
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards, as evidenced by the presence of a straw in the resident's milk despite a posted sign indicating no straws. The resident, who was admitted with diagnoses including dementia, generalized muscle weakness, and dysphagia, was observed with a straw in her milk during a lunch meal. The Director of Nursing confirmed the presence of the straw and acknowledged that the resident was not supposed to have straws due to the risk of aspiration. The Speech Language Pathologist (SLP) had previously identified that the resident coughed when using a straw and had posted a sign above the resident's bed to prevent staff from providing straws. Despite ongoing staff education on aspiration precautions, the resident continued to be found with straws at her bedside. The SLP's evaluation and treatment notes consistently indicated the resident's need for modified diet and aspiration precautions, including the recommendation against straw use. The failure to adhere to these precautions posed a risk of aspiration, which could lead to serious health complications.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds during weekends and after business hours, affecting 42 residents with funds in the facility trust account. Interviews and record reviews revealed that residents could only access their funds during business hours through the business office. Although the Business Office Manager Assistant (BOMA) stated that cash was available at the nurse's stations after hours, several licensed nurses were unaware of this provision, indicating a lack of communication and implementation of the policy. The facility's policy required that residents have access to funds within 24 hours, but this was not consistently practiced. Specific instances included Resident 28, who reported being unable to access cash on weekends, and Resident 98, who was unclear about the process for accessing funds. Interviews with various staff members, including licensed nurses and the Assistant Director of Nurses (ADON), highlighted inconsistencies in the availability of cash at nurse's stations and a lack of awareness among staff about the procedures for providing residents with their funds. The facility's policy indicated that residents should have access to a certain amount of money within 24 hours, but this was not effectively implemented, potentially impacting residents' ability to engage in activities and meet their needs.
Failure to Serve Correct Double Protein Meals
Penalty
Summary
The facility failed to ensure that the lunch meal served on June 19, 2024, met the nutritional needs of 10 residents who had orders for double protein. Instead of receiving double protein, these residents were served double portions of each food item on their meal trays. This discrepancy was observed during the lunch meal service in the kitchen. The District Manager, during an interview, acknowledged that staff should have prepared and served meals according to the orders and that the Dietary Manager should have been present during the tray line to ensure accuracy. A review of the facility's document titled 'TRAYLINE ACCURACY/MENU COMPLIANCE' from 2010 indicated that the goal of tray line accuracy is to maintain residents' nutritional adequacy.
Food Handling and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food handling practices, affecting 171 residents who received food from the kitchen. Multiple food items in the refrigerator, freezer, and dry storage area were found without labels indicating a use-by date, making them available for resident consumption. Additionally, expired food products, such as balsamic vinegar, lemons, and sour cream, were not removed from the kitchen, posing a risk of being served to residents. The kitchen environment was also found to be unsanitary. A fan above the double coffee maker was observed to have accumulated dust and lint, and the coffee makers beneath it were uncovered. Plastic cups were stacked wet after washing, which could lead to contamination. Furthermore, opened boxes of plastic silverware were left uncovered in the dry storage area, increasing the risk of contamination. In the nursing stations, the [NAME] Unit's refrigerator contained unlabeled food items, and the East Unit's refrigerator was found with hair, spilled liquid, and stains. These conditions were confirmed by the facility's staff, including the Assistant Manager, Licensed Nurse, and Director of Nursing, who acknowledged the potential for foodborne illnesses due to these deficiencies. The Registered Dietitian emphasized the importance of labeling food products with use-by dates and maintaining a clean and sanitary kitchen environment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain its infection control program in several instances. For Resident 126, who had a nephrostomy tube and was at high risk for infection due to ureter cancer and type 2 diabetes, the facility did not ensure enhanced barrier precautions were followed during a dressing change. A licensed nurse performed the dressing change without wearing a gown, which was required under the enhanced barrier precautions. Additionally, the nurse failed to date, time, and initial the new dressing, which is crucial for ensuring that dressing changes occur as scheduled and to minimize infection risk. Another deficiency was observed when a clean linen cart was transported with its cover flap open, exposing the clean linen to potential contamination. This was noted during an observation near the East Unit Nurses Station. The facility's policy required that clean linen carts be covered to prevent contamination, but this protocol was not followed, posing a risk of transferring harmful bacteria to the clean linen. Furthermore, during wound care for Resident 2, who had a stage 4 pressure ulcer and osteomyelitis, a licensed nurse failed to perform hand hygiene between glove changes. After cleansing the wound, the nurse changed gloves without washing hands, which is against the facility's wound care policy. This lapse in hand hygiene could contribute to the spread of infection, especially given the resident's existing severe wound condition.
Failure to Maintain Privacy and Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain privacy and dignity for a resident with a urinary catheter, as the resident's urine collection bag was observed to be uncovered on multiple occasions. The resident, identified as Resident 2, was admitted to the facility with diagnoses requiring assistance with personal care. The care plan for Resident 2, initiated on February 22, 2024, included the use of a catheter and aimed to keep the resident free from catheter-related trauma. Observations on June 18 and June 19, 2024, revealed that Resident 2's urinary collection bag was not covered with a privacy bag, which was confirmed by a certified nursing assistant (CNA) who acknowledged that the bag should be covered to maintain dignity. The Director of Nursing (DON) also confirmed that the uncovered urine collection bag was a dignity issue and stated that the expectation was for the bag to be covered. The facility's policy on dignity, revised in February 2021, indicated that staff are expected to promote dignity by helping residents keep urinary bags covered.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents, Resident 103 and Resident 169, by not ensuring their call lights were within reach. Resident 103, who was admitted with multiple diagnoses including muscle weakness and difficulty walking, was observed sitting at the edge of his bed without a visible call light. Instead, he attempted to use the television remote control to call for help. A Certified Nursing Assistant (CNA) confirmed that Resident 103's call light was on the floor and out of reach, which contradicted the care plan that required the call light to be within reach due to the resident's risk of falls. Similarly, Resident 169, who had a history of stroke, paralysis on the right side, and was on hospice care, was found in bed with the call light on the floor, out of reach. The resident required supervision for daily activities and was dependent on staff for assistance. The care plan for Resident 169 also indicated the need for the call light to be within reach due to the high risk of falls. Both the CNA and a Licensed Nurse (LN) acknowledged the importance of having the call light accessible, especially given Resident 169's condition. The Director of Nursing (DON) confirmed that the facility's policy and procedure for ensuring call lights are within reach was not followed, acknowledging the oversight in care for both residents.
Failure to Honor Resident's Shower Request
Penalty
Summary
The facility failed to respect the right to self-determination for one resident, identified as Resident 150, who requested a shower instead of a bed bath. Despite the resident's request, a Certified Nursing Assistant (CNA) informed Resident 150 that there was not enough time to provide a shower. This incident was confirmed during an interview with Resident 150, who stated that he was not given his shower on his designated shower days. The Director of Nursing (DON) and CNA 2 were unable to provide documentation confirming that Resident 150 received a shower or bed bath on the specified days. The DON acknowledged that the expectation was for CNAs to provide showers if requested by residents. The facility's policy on dignity, which emphasizes care that promotes residents' well-being and supports their rights, was not adhered to in this instance. Resident 150's care plan indicated a need for extensive assistance with showers, which was not fulfilled.
Failure to Coordinate PASRR Assessments for Resident with Schizophrenia
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for a resident diagnosed with schizophrenia. The resident's PASRR Level I screening assessment did not include her mental illness diagnosis, which is a serious mental illness affecting thought, feeling, and behavior. This oversight was identified during a review of the resident's admission record, Minimum Data Set (MDS), care plan, and history and physical documentation, all of which indicated the presence of schizophrenia. However, the PASRR Level I screening, dated several months prior, incorrectly indicated no serious mental illness. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring the accuracy of PASRR forms. The Health Information Services (HIS) staff mentioned performing audits to ensure PASRR forms were received but was unsure who was responsible for verifying their accuracy. The Assistant Director of Nurses (ADON) confirmed the omission of the mental illness diagnosis in the PASRR and explained the process for updating PASRRs when new diagnoses are identified. The facility's policy indicated that the Administrator is accountable for monitoring the PASRR completion process, but this was not effectively implemented in this case.
Resident Smokes Unsupervised Despite No-Smoking Policy
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for Resident 80, who was observed smoking unsupervised on the sidewalk in front of the facility. Resident 80, who has chronic obstructive pulmonary disease, pulmonary embolism, and diabetes mellitus, was seen walking with an unsteady gait using a walker. Despite the facility's no-smoking policy, Resident 80 left the building twice a day to smoke on the sidewalk, keeping cigarettes and a lighter in a canvas bag tied to her walker. The facility staff, including the Administrator, were aware of Resident 80's actions and her refusal to comply with the no-smoking policy, as well as her refusal to use nicotine patches offered by the facility. Interviews with facility staff, including licensed nurses and certified nursing assistants, revealed that residents were informed of the no-smoking policy and offered nicotine patches to help them quit smoking. However, Resident 80 continued to smoke outside the facility, and staff were aware of her non-compliance. The facility's policy on accidents and incidents requires investigation and reporting of such events, but there is no indication in the report that an incident report was completed for Resident 80's actions. This oversight potentially placed Resident 80 at risk for accidental burns and injuries.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC line). The deficiency was identified when the dressing for the PICC line was not changed according to physician orders. The resident, who was admitted with a diagnosis of bacteremia, had a PICC line dressing dated 6/8/2024, which was confirmed by a Licensed Nurse (LN) during an observation and interview. The facility's policy required the dressing to be changed weekly, but the Medication Administration Record (MAR) showed no documentation of a dressing change on the scheduled date of 6/7/2024, with the next recorded change occurring on 6/14/2024. Interviews with nursing staff and the Assistant Director of Nurses (ADON) revealed that the dressing had been reinforced rather than changed, contrary to the facility's protocol and physician orders. The ADON confirmed that the expectation was for daily assessment and weekly dressing changes to prevent infection and ensure the catheter remained unobstructed and properly positioned. The facility's policy on Central Venous Catheter Dressing Changes emphasized the importance of maintaining sterile dressings to prevent catheter-related infections, specifying that dressings should be changed every 5-7 days.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident, identified as Resident 52. Resident 52 was admitted with a diagnosis of respiratory failure and required oxygen therapy. During an observation, it was noted that the oxygen tubing in use was dated 6/3/24, indicating it had not been changed weekly as per the physician's order. The Licensed Nurse confirmed the tubing should be changed weekly to prevent infection. The Director of Nursing also stated that all residents' oxygen tubing should be changed weekly and dated to avoid infection. The failure to change the oxygen tubing weekly as ordered had the potential to negatively impact Resident 52's health and safety.
Incomplete Dialysis Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care had complete and consistent documentation of their pre and post-dialysis assessments. This deficiency was identified for one resident who was admitted with end-stage renal disease. The facility's records showed that the required documentation, which included the resident's weight, blood pressure, temperature, heart rate, and catheter site assessment, was incomplete for five out of six days of treatment. Specifically, there was missing post-dialysis documentation on certain days, and no pre or post-dialysis documentation on others. This lack of documentation resulted in a communication gap between the dialysis center and the facility. Interviews with facility staff, including a Licensed Nurse and the Assistant Director of Nurses, confirmed the absence of necessary documentation and highlighted the potential risks associated with this oversight. The staff acknowledged that without proper documentation, they could not effectively monitor the resident's condition or respond to potential adverse outcomes, such as changes in blood pressure or bleeding at the catheter site. The facility's policy on the care of residents with end-stage renal disease emphasized the importance of maintaining communication between the facility and the dialysis center, which was not adhered to in this case.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to ensure the accurate dispensing and administration of narcotic drugs for a resident diagnosed with pancreatic and lung cancer. The resident, identified as Resident 545, did not receive the prescribed pain medication, oxycodone, for pain management. The discrepancy was discovered during a review of the medication card and the Antibiotic or Controlled Drug Record, which showed that two tablets remained on the medication card when there should have been none. The Licensed Nurse (LN) 13 had documented that the medication was administered, but the remaining tablets indicated otherwise. Interviews with the resident and staff revealed that the resident experienced pain and did not sleep well, suspecting that the medication was not administered. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed the discrepancy, noting that LN 13 had signed out the medication but failed to administer it. The facility's policy on reconciling controlled substances was not followed, as the medication count did not match the records, and the discrepancy was not reported as required.
Failure to Document Rationale for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure the proper use of psychotropic drugs for one resident, identified as Resident 155, by not documenting a rationale for extending a PRN (as needed) medication order beyond 14 days. Resident 155 was prescribed Lorazepam, an anti-anxiety medication, to be taken every 12 hours as needed for agitation over a six-month period. However, the physician did not provide a documented justification for continuing this PRN order past the standard two-week duration, which is required by the facility's policy and procedure. Interviews with the Medical Director, Administrator, Pharmacy Consultant, and nursing staff revealed that the lack of documentation for extending the PRN order was not in line with the facility's policy. The Director of Nursing acknowledged that the policy, which mandates a reassessment and documented rationale for extending PRN psychotropic medications beyond 14 days, was not followed. This oversight could have led to the unnecessary use of medication, placing residents at risk for injury.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during an inspection of medication carts. In one instance, medication bottles, including Liquid Protein, Milk of Magnesia, and Valproic Acid, were found with spillage on them, and a sticky residue was present on the bottom of the medication storage drawers. This was confirmed by licensed nurses during the inspection of the facility's medication carts. Additionally, a bottle of cough syrup was also found with spillage and sticky residue in another medication cart. Furthermore, an insulin pen for a resident with Type 2 Diabetes Mellitus was found to be available for use past its expiration date. The insulin pen was opened on a specific date and was supposed to be discarded 28 days after opening, but it remained in use beyond this period. The licensed nurse confirmed that the resident received the insulin daily and acknowledged the importance of not using an expired insulin pen to ensure the medication's effectiveness. The Director of Nursing emphasized the need for clean and organized medication drawers to prevent the risk of infection.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
